An analysis of the role of state, economy and civil society in the development, management and reform of the NHS 1948 - 1997

The NHS is the centrepiece of the UK welfare state. For fifty years it has provided the majority of health-care in the UK. However the running of the service has not been marked by a smooth operation. Repeated reforms have occurred since 1948 in attempts to increase the efficiency and effectiveness of the service. These reforms have been credited with varying degrees of success. Even the most radical reforms, initiated in 1990, have been marked by some failures - particularly in respect to the provision of services to 'at risk' groups such as the elderly, leading to criticisms of a lack of coherent policy making. The reasons that underlie the success of the NHS in the midst of failure are complicated, but one hypothesis is that the structure of the NHS does not reflect its basic functions. Those functions can be broken down into 2. First is the relief of suffering from illness; second is the support of the industrial and economic base of the UK. The existence of this pluralistic purpose implies that the management of the service requires balancing the forces of economic, state and civil society requirements for the NHS. This management is embodied in a complicated institutionalisation of care, covered in chapter 1. The empirical evidence gathered in the thesis, in chapters 2 and 3 both from literature and case studies, would indicate that at least part of the problems seen in the NHS result from a failure to balance this institutionalisation. However, the situation is made more complex as the result of this imbalance creates further increased demands from some of the elements in the management of the service. Therefore the failure to balance the interactions that surround the NHS increases the pressures on it which in turn increases the imbalance leading to a feedback loop magnifying the problem. The source and problems of this feedback are best exemplified by a case study of the most recent reforms -covered in chapters 4-11 of this thesis. This case study demonstrates that the way in which the 1990 reforms were formulated and implemented took little notice of the impact of the changes on the street level NHS managers - with the results that the reforms did not represent a coherent policy. The result of the lack of coherence is that the changes have not generated efficiency gains, and in some cases have diverted resources away from those most in need. The underlying cause of this is the predominance of non- market forces in the decision making process - i.e. the values of the purchasers and the power of the providers to influence decision making. The linkages between these features of the post reform NHS are described in chapter 12. It is likely that the only way in which the circle of problems in the NHS can be addressed is re-establishing the corporate relationship that surrounds health care. However unlike previous relationships the evidence suggests that the relationship should be established at a policy level, rather than the current trends for a local level relationship. The NHS is not unique in this aspect, as this is the pattern of change seen in many European Countries