Dr Catherine Calderwood's plan for a team of top managers to travel round Scotland to discuss the future of the health service with staff, patients and the public may not be the same as a public debate on the matter, nor reach the same conclusions about the priorities and desirable provision.

Either approach will miss the benefit of significant knowledge if it does not debate and learn the lessons from the past and will risk repeating mistakes that have led to the impasse between demand and resourcing in the NHS.

Reasons for the inefficient working of the NHS are multiple and the consequent lessons that could be learned go back a long way. Although the NHS was created in law in July 1948, health care for people nationally has existed for centuries. Its form was subject to alteration as a result of political and social changes as far back as the 16th century. It may seem that nothing can be learned from history but the changes in the centuries from Henry VIII on have been driven by the opinions of political power brokers without reference to the people. The question to be asked is whether it is efficient to vest responsibility in the government of the day for the adaptation to healthcare provision or if better alternatives exist to meet evolving medical and social needs.

Health care developed from that provided by religious bodies through to the pre-NHS local arrangements, paving the way for further developments: the Beveridge Report in 1942 moving on to the White Paper and the decision to bring in the NHS. The Second World War brought socio-political change in interpersonal relationships inconceivable in any other circumstances. Civilians sacrificed their lives for one another at home as forces personnel did in battle. Such was the selflessness and sense of unity that Aneurin Bevan, given responsibility for establishing the NHS, was able to use the tide of public support to bring earlier developments together in support of egalitarian access to health care, unburdened by considerations of cost. As a result of parliamentary practice of the time, matters deserving more time and debate were hurried and many of the present problems in the NHS stem from the compromises reached and errors made.

For example, it had been thought that the health of the people would improve and that the cost of the service would reduce as a result. The consequence of that misjudgment may be out with the scope of even "top managers" to resolve but must be among the topics of debate with the public on priorities and provision because at least some of the solution is in their hands only.

The budget sets a ceiling on the money available for health care (the global sum) but there is no national process for managing public demand. The rationing that covertly exists as a consequence is a tug-of-war between individual and collective patient demands and an NHS trying to meet medical and social need.

For example, research leading to medical discovery feeds into clinical teaching, which extends into what is possible by way of service provision. Pressure groups exist to influence this in the direction they favour and consequently sway the provision and structures of the service.

For example, the principles of care "free at the point of delivery" and registration with an individual doctor have led to a public perception that GPs' primary responsibility is to his or her patients. Government introduction of changes to GPs' responsibilities in response to developments in medicine without accompanying management of public perception has affected the doctor-patient relationship in a way that is prejudicial to efficient primary care.

The NHS is the largest employer in the country, with personnel from all social strata. Those personnel possess the widest range of skills, are engaged in work of the highest complexity and deliver care with the greatest compassion. The work they do affords top managers, patients and the public the opportunity to support them fully by debating the lessons from the past so that we achieve a service that is efficient, affordable, adaptable and solidly founded on democratic process.

Gordon Gaskell is a retired Edinburgh GP who began working in the NHS in 1949 and practised in primary care for 30 years.