I’ve just been listening to a report on the radio about people with learning disorders dying 20 years prematurely because the NHS doesn’t treat them adequately. The Care Quality Commission says that a fifth of hospitals don’t provide dignified care for elderly people. A London professor said at the weekend that 20 000 people may have died prematurely in a group of NHS hospitals. The Global Burden of Disease study reported last week that the UK lags behind other developed countries in indicators of ill health. This all comes soon after the report of Mid Staffordshire NHS Trust describing appalling, abusive care, and 2000 premature deaths. So is it time for radical change?

The NHS is clearly failing in many ways and is under tremendous financial and demographic pressure. There are three options for a failing organisation: tweaking, radical reform, or scrapping. What will be best for the NHS?

I’m writing this 13 days before the NHS is about to undergo the most radical reform in its 65 years. So is radical reform the answer? Some sort of radical reform might be the answer, but almost nobody within the NHS believes that the reforms about to be introduced are the answer. Perhaps that’s because those within the NHS are too attached to the old system, but it’s very hard to reform  radically an organisation when most people in the organisation—those who deliver the service everyday—don’t believe in the reforms.

Tweaking doesn’t seem to be the answer. One of the main arguments of those who opposed the current reforms was that there wasn’t a problem to which the reforms were the answer. In other words, tweaking would suffice. That argument is much harder to sustain now than a year ago.

So what about scrapping? The NHS is greatly valued by the British, particularly the older ones, and so politicians try to outdo each other in their commitment to it. No politician would scrap the NHS. But there is something called “extrapolation of commitment” whereby people go on with commitment to something long after it would have been more sensible to quit. An example is when it has taken you ages to get through to a telephone number and then you are asked to hold: it’s very difficult to hang up.

But what would scrapping the NHS mean? The answer depends on what you think the NHS is. For some it is the whole caboodle of hospitals, doctors, community services, and all the rest provided free by the state at the point of care and funded from income tax. For others it is simply a social contract, commitments to universal coverage, the service being free at the point of delivery, and equal quality care for all.

It’s unimaginable to almost everybody in Britain that those commitments could be abandoned. They apply in virtually every developed country, and even the US is being dragged towards universal coverage. Many developing countries much poorer than Britain have achieved universal coverage or are working towards it.

But maybe the contract could be changed. One way to change it might be to abandon the position that healthcare is free and social care means tested. This arrangement made sense in 1948 when much of healthcare was about fixing people with infections or broken bones, but it makes much less sense when most of the health expenditure is on frail elderly people with multiple problems for whom staying at home and out of hospital is more important than having expensive drugs to keep them alive an extra three weeks. The snag here is that all of health and social care being free is unaffordable, so where might a new line be drawn between what is free and what is mean tested? Might it be by need or ability to pay?

Another major change, which is more a radical reform than a change in the contract, might be to accept that an NHS that covers the whole of England and is still largely centrally driven is now unmanageable. Supporters of the current reforms might argue that having a more locally responsive NHS is part of the intention of the current reforms, but we still have a National Commissioning Board. Chopping up the English NHS into Scotland sized pieces would inevitably mean that some parts of the country got better services than others, but that is the case already.

I’m thinking out loud here, and my title is deliberately provocative. It’s hard to think of scrapping or radical reform when we haven’t even yet experienced the next wave of recurrent organisations, but who believes that the reforms about to be introduced will solve the problems listed in my first paragraph? Not me.

Competing interest: Although he works mainly with people in low and middle income countries and has no responsibility for the British part of the organisation, RS is employed by the UnitedHealth Group, which might (or might not)  benefit from big changes in the NHS. He is also the chair of a start up, Patients Know Best, which might benefit from further reform. It is, however, arguable that those who are employed by the NHS are much more conflicted than RS.

Richard Smith was the editor of the BMJ until 2004 and is director of the United Health Group’s chronic disease initiative.