ABSTRACT
As the World Health Report 2000 observed, the development of health systems in the twentieth century has been driven in part by the desire to address health needs with efficiency, fairness and responsiveness to expectations.1 Some states pin their faith on market solutions, trusting to the incentives of competition to ensure quality and access. Others depend on a combination of private medicine and social insurance, operating within a statutory framework.2 Since the midtwentieth century Britain has chosen to rely principally on direct, general taxation and hierarchical government control, an approach which, while not unique, is untypical. It differs, for example, from neighbours France and Germany, which rely to a greater extent on social and private health insurance, and from the United States, in which the private sector plays a larger part.3 Nonetheless the National Health Service (NHS) initially proved both popular and successful, in that it was deemed to be meeting the desired health outcomes without imposing an excessive burden on the public purse.4
