The National Health Service (NHS) is a remarkable institution. It represents an experiment in social engineering, an attempt to provide free healthcare to the population of the UK across a comprehensive range of services. In the US, where private medical insurance is the usual means of paying for care, over 40 million people are uninsured either because their employer does not provide it as part of its rewards package or because they cannot afford to purchase it from their own funds. Citizens of the UK, however, tend to take the NHS for granted. On the one hand, it is a...

When the NHS began to provide care in 1948 it comprised of a number of organisational features that were the result of its infrastructural inheritances, of compromises and innovations in the process of designing the new service and of ideas about the role of the medicine within it.

This chapter suggests that three key organisational features are central to understanding the NHS of 1948, and alongside them, three key principles that were, to varying extents, embedded in its organisational form. It aims to answer the questions of where these organisational features and principles came from, and what their implications were....

The story of the tripartite split in the NHS is one of policy makers’ and doctors’ attempts to overcome, or use to their advantage, the organisational separation between health services resulting from the organisational compromises present in the founding of the NHS in 1948. This chapter considers the development of the tripartite split one service at a time, but also in terms of the boundaries of the services in relation to one another.

The creation of the NHS split health services into three largely separately administered services. First, there were the hospitals. Hospitals were nationalised under Bevan’s plan, brought into...

This chapter explores the relationship between the state and the medical profession characterised by Rudolf Klein (1990) as the ‘double-bed’. It is one of the distinctive organisational features of the NHS identified in Chapter Two.

The ‘double-bed’ relationship between the state and the medical profession is one of mutual dependence (Klein, 1990). The creation of the NHS gave the state an effective monopoly on the employment of the medical profession because of the relatively small size of the private healthcare sector. As such, the medical profession became effectively dependent (as a group) on the state for its employment. On the...

The third distinctive organisational feature of the NHS comes from the choice policy makers made at the time of its founding in terms of the way it would be financed. The general taxation method of funding health services means that those on higher incomes make a greater financial contribution to the cost of their treatment than those on lower incomes, but with no guarantee of better access or superior treatment. The principle of funding health services from general taxation is therefore redistributionary – the richer in society are helping to subsidise those who might not otherwise be able to afford...

Managers are now among the most high-profile actors of all those working within the NHS today. They are often cast as its villains. They do not cure people, as doctors do, or care for patients, as nurses do. Instead they are often accused of cutting services, or as taking up money that could be better spent on care. Managers are overheads in health organisations, blamed by politicians when budgets are overspent (BBC News, 2006a) or wards not clean (BBC News, 2001), and reviled by the media as being responsible when things go wrong in health organisations (BBC News, 1999). They...

The role of nurses has been largely absent from the account of health policy and organisation so far presented in this book. This is no accident. It is hard to see what role nurses, as a professional interest group, had in shaping the discussions leading up to the creation of the NHS. They were positioned into the new health service in a role providing most of the care that patients required, but having very little say in how health services should be organised. Nursing is significant in discussions in the 1950s in terms of the relationship between GP and local...

In the past 10 years, there has been a significant increase in interest in the way that policy has positioned the users of public services in relation to professionals and managers (Deacon and Mann, 1999; Le Grand, 1999; Greener, 2002b). From being overlooked in much analysis in the 1970s, which often focused on the relationships between the state, managers and doctors, an interest in the experience of the user of health services has come along with a new emphasis on both consumerism and citizenship in healthcare. The central question this chapter examines is how the NHS, and how NHS policy,...

This chapter brings together the analysis from other chapters of this book to consider health policy since 1997, when Tony Blair’s Labour government was elected. It takes the account of health policy and organisation through to the end of 2007, shortly after Blair retired as Prime Minister and Gordon Brown took over.

During the 1997 election, Labour campaigned to ‘save the NHS’, but its approach to welfare policy during its first term in office faced a significant problem in that, in order to gain credibility with the financial markets, Chancellor Gordon Brown made it clear that he was going to...

This final chapter of the book has two parts. The first part reviews the book’s argument with the aim of exploring what the NHS is like today, summarising the previous chapters’ analysis in the process. The second part considers how health services may be reformed to deal with the problems identified in the first part of the chapter. It presents the author’s view of what the NHS should become.

This book began by claiming that the creation of the NHS in 1948 put in place key organisational features that, to varying extents, are still present 60 years later. These features...