NEARLY everyone born in England after 1948 was delivered into the care of the National Health Service, and most retain an almost filial loyalty to the organisation. The taxpayer-funded service, which provides health care free at the point of use, is so precious in the public imagination that politicians are less likely to talk of improving the NHS than “protecting” it.

Yet this national treasure is looking frail (see article). Nine out of ten of the local trusts which run hospitals are spending beyond their budgets; overall the service faces a funding gap of £20 billion ($27 billion) by the end of the decade. Doctors have gone on strike over a new, less generous contract that the government is imposing on them. And everywhere hospitals are struggling to make ends meet. In recent weeks one trust has abruptly shut an emergency department to children because it was found to be unsafe; another said it was considering delaying all surgery on obese patients.

The diagnosis is simple: rising demand for health care from an ageing population is outstripping supply. But the cure will be hard to stomach for both left and right. Increasing the NHS’s capacity will require a far more ruthless focus on efficiency. Even then, taxpayers will have to get used to forking out more. Managing demand will involve not just uncontroversial measures such as more emphasis on preventive medicine, but toxic ones such as introducing charges for services that have been free. Such is the price Britons must expect to pay for living a decade and a half longer than when the NHS was founded.

Though the NHS is lean by international standards, it still bleeds money through inefficiency. There can be few organisations in England that still use fax machines as often as doctors’ surgeries do. Poor staff planning means that shortages are tackled by expensive overtime. And the English have a romantic attachment to small local hospitals, which are costlier and deliver worse results than big specialist ones. By scaling up, the NHS could offer better care for the same money. In some parts of the country family doctors are leaving their cottage practices to join chains of larger surgeries that share back-office functions such as call centres. Countries such as Germany and Denmark have found that by reducing the number of hospitals that offer particular surgical procedures, they can reduce the incidence of complications.

You may feel some discomfort

Yet even if all such wastefulness can be eliminated, the government’s plan to close the NHS’s entire funding gap through greater efficiency is heroically optimistic. Britain already spends less as a share of its GDP on health care than most other rich countries. It is now on course to shrink that share, from 7.3% to 6.6% by 2021. At a time of steeply rising demand that is unrealistic. Politicians must make plain to voters that if they want to keep the taxpayer-funded model and expect to carry on living into their 80s and beyond, they will have to pay for it.

At the same time as making available more resources, the government needs to rein in demand for NHS services. Patients should, where possible, be diverted from expensive forms of care into cheaper ones. One reason that hospital beds are in such short supply is that budgets for social care have been slashed. It makes no sense to use hospitals as expensive substitutes for old people’s homes. Amalgamating health and social care, as some regions are already doing, would lead to a more sensible allocation of resources. If more doctors dealt with simple queries from their patients by phone or e-mail, they would have more time to devote to tricky ones. Subjecting more services to fees would temper frivolous demand. In-person doctor’s appointments, for instance, could incur a modest charge, as prescriptions and dental work already do.

More fundamentally, the focus must shift away from treating illness and towards preventing it. The NHS was designed with acute conditions in mind; nowadays 70% of its spending is on long-term illnesses. It is cheaper, as well as better for patients, to reduce obesity, say, than to treat diabetes. Yet NHS providers are paid for the procedures they carry out, not for those that they render unnecessary. A better model would be to give health providers a budget based on the population they serve, and pay them according to their ability to meet targets of better public health. This would increase the incentives to use new technology that would give patients more responsibility for their own health. If private outfits can do this with a profit margin to spare, good for them.

Higher taxes, new charges and more rationed services: these are bitter pills for politicians. But the English are ageing, and as long as their leaders promise simply to “protect” the NHS by doing nothing, the service faces only decline.