“The NHS is under tremendous pressure,” I tell a novelist friend.

“Could it die?” he asks.

“I suppose it could.”

“How would that happen?”

How would it happen? That’s a hard question. I didn’t have a convincing answer, but it’s a question worth examining.

I trotted out to my novelist friend my usual reference by the world’s wittiest health economist, Uwe Reinhardt, that all health systems will eventually be the same: the rich will, as they do now, buy what they want where they want; the middle classes will have to buy insurance; and the poor will be left with a low quality rump service. It’s the health system most of the world has right now.

But how might we get there? “Death,” famously “hath a thousand doors,” but there are three groups that might precipitate the death of the NHS: patients, doctors, and politicians.

The worry of supporters of the NHS has long been that the middle classes would bail out—as they do with education. If they went, there would not be sufficient political and financial support to maintain the current NHS. The poor would be left with the rump service, which would inevitably deteriorate without the sharp elbows and funds of the middle classes. But why would the middle classes go? They’d go because of extreme dissatisfaction with the NHS: increasing difficulty in seeing GPs, long waits for hospital treatment; and, most important of all, a sense that the NHS could no longer offer world class care. The inability to offer the best could come about simply because inflation in the costs of care always runs ahead of general inflation. It may be a race that will inevitably be lost with a service funded from taxation. Data released last week showed that satisfaction with the NHS dropped by a significant 5% in 2015—but 60% are still “very or quite satisfied.”

The middle classes could desert only if there was somewhere to desert to. At the moment the private sector couldn’t begin to offer the extent and range of care needed. In particular there is almost no non-NHS private practice, but most GPs are independent (private) practitioners—and they could decide to abandon NHS contracts and go it alone. They are currently threatening mass resignation. Mass desertion by GPs could potentially happen fast, and there are plenty of global hospital chains that could provide hospital care. It might even be that a company could spot a business opportunity and increase private healthcare capacity. Construction of hospitals might take time, but perhaps many would become available if the NHS was collapsing. Social care and some mental health care are already provided by the private sector. Insurance companies would also be needed, but both local and overseas companies already exist.

The doctors, particularly consultants and GPs, are the other group that could bring about the death of the NHS. Nurses, the biggest group of NHS employees, probably lack the muscle, and managers are unlikely to take the lead, although some of them might enjoy the challenge of setting up the new system—and undoubtedly nurses, managers, and the other professions within the NHS would be needed in a private system.

General practitioners could, as I’ve said, switch to providing services for non-NHS patients, and a body of them are already calling for charges to patients. Consultants are the most powerful group, and many of them currently work at least some of the time in the private sector. A professor of surgery once told me that surgeons innovated in the private rather than public sector because it was so much easier. There have long been mutterings about consultants forming chambers, like barristers, and selling their services to the highest bidders.

I write this on the day that the government has imposed a new contract on junior doctors, and negotiations are also underway for a new consultant contract. Perhaps the consultants could become so alienated, so resentful of heavy handed government that they could desert in large numbers. Again there has to be somewhere to desert to.

Politicians are the final group who have the power to kill the NHS, and some people have long been convinced that that is what right wing politicians want. The Daily Mail, the newspaper with the most influence over politicians, is so persistent in its attacks on the NHS that it’s easy to think it wants to kill it. But politicians are well aware that despite lots of grumbling there continues to be huge public support for the NHS. The current Secretary of State for Health has taken a big gamble in imposing a contract on junior doctors, but a move that seemed to signal the end of the NHS would be far riskier.

Current politicians are unlikely to make any move that might kill the NHS unless they see that much of the public has lost confidence in the NHS. But as recent experiences in Britain and current experience in the US show the unexpected can happen very quickly in politics. Nigel Farage may be “Donald Trump lite,” but he has expressed doubts about the NHS. Perhaps a more strident and effective politician could arise on the right and kill the NHS.

Having been born four years after the launch of the NHS, I hope that it will “see me out.” I’ve never used a private system and hope never to have to, but as I think about the possible death of the NHS I reflect on the First World War. Historians still argue—and always will argue—about how it started, and the death of the NHS might be equally complicated, arising from deep forces, like countries arming themselves, and a particular incident, like the assassination in Sarajevo.

Richard Smith was the editor of The BMJ until 2004. 

Competing interest: RS was employed by UnitedHealth Group, a large health and wellbeingcompany.