Fittingly, the NHS celebrated its 75^th anniversary in the wake of a major reform. Such ‘once in a lifetime’ reorganisations have been a feature since its creation. In this guest blog, Dr Michael Lambert, an NHS historian and Research Fellow at Lancaster Medical School, discusses how successive politicians have used restructuring to try and overcome recurrent crises in the health service.

The NHS which Labour’s Aneurin Bevan delivered on 5 July 1948 survived for just over twenty-five years without major reform. This was far longer than all that followed. Bevan’s combination of political pragmatism and financial concessions created an uneasy consensus which endured a succession of electoral and ministerial changes. The relative stability this provided meant that a nationalised health service quilt was woven from a patchwork of previously public and private providers. This stability was deceptive, though, as the NHS was not one organisation but three, divided between primary, secondary and community care. Bevan’s uneasy consensus only lasted because few had the appetite to stomach the turmoil necessary to create a more integrated service.

Labour’s Kenneth Robinson finally caved with a 1968 Green Paper. However, negotiations proved as intractable as anticipated, not least because the entire fabric of the uneasy consensus was being unravelled, renegotiated, and stitched back together. The reforms passed through the hands of Conservative radical Keith Joseph, whose term was sandwiched between Labour heavyweights Richard Crossman and Barbara Castle, before implementation in April 1974. But it was doomed to fail. The 1973 oil shocks and subsequent cash limits sealed its fate and  in 1976 Labour PM Harold Wilson announced a Royal Commission on the NHS to deflect attention and blame. Few were satisfied with the outcome of the prolonged process apart from its architects seeking to forge a new consensus.

The failure of 1974 and the following Conservative electoral victory in 1979 ushered in a new era of continuous and more politicised reform for the NHS. Patrick Jenkin moved swiftly to remove an entire layer of bureaucracy created in the 1974 reorganisation. In 1982 a three-tiered system of regions, areas and districts designed to integrate services became two with the abolition of areas. This was not enough, and the NHS was not immune from wider public sector cuts. In 1983, at PM Margaret Thatcher’s invitation, the Managing Director of Sainsbury’s supermarket, Roy Griffiths, helped introduce private sector management in place of consensus decision-making. But again, neither of these produced the desired outcomes in terms of improved efficiency, economy and effectiveness, and the NHS battled through the worst winter crisis it had faced by 1987.

The first that Secretary of State John Moore knew about the next reorganisation was when Thatcher announced it live on Panorama in January 1988. The resulting Prime Ministerial review considered a range of ideological alternatives but produced precious little. It was only with Moore’s replacement by Kenneth Clarke that reform gathered pace; his insider experience as a former junior health minister and characteristic tenacity provided the necessary leadership. Competition, rather than integration, was the purpose of the reforms. In April 1991 an internal market was created within the NHS. This restructured the service, dividing it in two between purchasers and providers of healthcare, ending the last vestiges of the old command-and-control model of the nationalised health service.

Although Labour was outspoken against the market reforms in opposition, they retained them in power after 1997. Like Thatcher, the first that Chancellor Gordon Brown and Secretary of State Alan Milburn knew about the next reforms was when PM Tony Blair spoke on Breakfast with Frost in January 2000, where He committed to increase UK health spending to match European Union levels. The partnership between the public and private sectors underpinned the latest reforms from 2002, although competition remained. Milburn expanded market mechanisms and subjected them to new forms of regulation which continued with further reform in 2006 after his departure. Only Brown replacing Blair in 2007 and the 2008 financial crisis could halt the forward march of markets and private sector partnership which characterised the New Labour era.

The reforms introduced in 2013 are more associated with their instigator than perhaps any other in the history of the NHS aside Bevan. Andrew Lansley, responsible for health under the Conservative-Liberal Democrat Coalition Government took reforms faster and further than before. Market mechanisms were strengthened which drastically expanded private sector competition. Wider austerity and the loss of management expertise exaggerated this effect beyond the intentions of the original White Paper. The ensuing disruption caused by the reforms once again led integration to become universally fashionable across the political and professional divide. Not least to modernise and improve social care. The impact of the 2022 reorganisation, implemented against the backdrop of the Covid-19 pandemic, remains to be seen.

Since 1948, politicians have seen structural reform as the solution to the ills which beset the NHS. Integration was the remedy for inherited division in 1974. Emulating the private sector and competition were lauded against public sector inefficiency in 1982 and 1991. Partnership and market regulation underpinned third way thinking in 2002 and 2006. Maximising market competition once again prevailed in 2013. This, in turn, led to integration being the answer to fragmentation and division by 2022. Time will tell whether the latest chapter in the history of reform, reorganisation and restructure in the NHS will be the last, or the latest well-intentioned attempt to reform a flawed but loved public institution.

ML

Michael Lambert’s current work on the history of the NHS explores what the cumulative impact of workforce shortages means for spatial and social inequalities of health services since 1948. You can read more here.

Further Reading

Michael Lambert, ‘(Dis)integrated Care Systems: Lessons From the 1974 NHS Reorganisation in Morecambe Bay’, Morecambe Bay Medical Journal, 9 (2022), 33-37. View.

Calum Paton, NHS Reform and Health Politics: Revolution, Counter-Revolution and Covid Crisis (Palgrave Macmillan, published 7 May 2022).

Nick Timmins, Never Again? The Story of the Health and Social Care Act 2012: A Study in Coalition Government and Policy Making (King’s Fund and Institute for Government, published 12 July 2012).

Charles Webster, National Health Service Reorganisation: Learning from History (Office for Health Economics, published 1998).