As men, women and children queue for the NHS, they take part in what is almost a lottery for life itself. Prompt medical diagnosis and care is often a matter of luck; treatment, a matter of queuing - for the specialist, for the hospital bed, for the operation, even though the condition requires immediate attention. It is a matter of life or death, not of anything "extra". (The extras which are standard beyond this island, would seem an unbelievable luxury here: clean, single rooms for hospital patients as in France, a second medical opinion, as in Germany).

The problem with the NHS is the system itself. Designed as a gigantic monument to post-war collective central planning, the NHS is owned by the state, a nationalised monopoly run by fiat from Whitehall by officials, managers and bureaucrats. From the start it suffered from two fatal flaws, inadequate tax funding and a Stalinist structure. The tax funding on which it depends has never been enough and never will be. No matter how prosperous the country may be, other worthy calls make rival claims, and there are always limits to the levels of tax the public - or the economy - can tolerate. From the start a scarcity of funds has led either to cuts - in capital expenditure, specialists, medical research, medicine and of course salaries - or else to charges. Similarly the structure has defeated every government. Each decade since 1948 a major restructuring has been planned, aiming for greater efficiency, or smoother management, or a more rational system or a change in ethos. None, despite the expense, has been successful.

The upshot is a system in crisis, failing the patients and the doctors and nurses who work in it; and a government, like many of its predecessors, faced with a crisis - though this time it seems as if the NHS is about to collapse under its own weight. The prime minister promises, as others have done, to "save" the system. More funds through higher taxes are announced and more restructuring, with private partnerships involved to run and provide services or good hospitals allowed to run themselves. These attempts to counter the worst features of a monopoly state system may help superficially, but hardly tackle the fundamental problem of a bloated, centrally planned bureaucratic system, where plans replace patient. It is hardly likely that present proposals for change from the top or at the edge will affect the NHS iceberg of 850,000 employees of whom a miserable 2.7 per cent are specialists (seven per cent hospital doctors) and 30 per cent qualified nurses. The new plans will more likely go the way of previous attempts to reform, with more targets, more managerialism, more bureaucracy and failure for the patients.

Instead, what is now needed is a radical change, which puts the patient first and where public funding goes directly to the patient in the form of a health premium. This premium would guarantee, as the NHS is supposed to do, comprehensive health care to each individual irrespective of ability to pay. Each person would then be able to choose the best hospital or doctor for treatment, from a mixture of providers, private, voluntary or state. This was the model planned during the Second World War when Britain prepared its post-war social services. Then politicians from all parties agreed on a post-war national health service, available to all and funded publicly, but provided by a mixture of providers. Beveridge himself had suggested a publicly funded system, where tax and some social insurance covered the main costs. He looked to additional extra funds through schemes for extras. Beveridge's plan for free health care was adopted by the wartime government, and plans were prepared to introduce a national health service after the war using mixed providers, and allowing for more independent funding into the system as a whole. This was a truly mixed model allowing proper partnership where the patient had the choice of provider, the state ensured the best system of finance and an overall national framework, and the medical teams and hospitals were accountable to patients.

This is the model of many successful health systems today, but it was one rejected by the 1945 Labour government in a fit of ideological correctness. Bevan instead dictated that all hospitals should be nationalised, and the health service run, provided and owned by the state - and funded by tax alone. The rest is history - and the problems with which the sick contend in Britain today. There is some small hope for them in the government's timid move to use a range of providers. But we need more radical change, a real mixture, where the notion of partnership is based on equality between the providers, and where the patients are given the means to choose those who they consider will provide the best health care for them.