The National Health Service

Abstract

The National Health Service (NHS) celebrated its fiftieth birthday in July 1998. It was established to deliver healthcare according to clinical need and is free at the point of use. Essentially it is funded by central government out of general taxation, receiving £45 billion in 1996–7 of which over 70 per cent was spent on the costs of its one million staff. Throughout its 50 years the NHS has been beset by tensions. There is a tension between the government’s wish to constrain public expenditure and its desire to provide a free service to its citizens. This tension is exacerbated on the one hand by an unwillingness of governments to raise taxes and on the other hand by growing public expectations, medical advances and the rising proportion of elderly people in the population. There is also a tension between managers, who generally focus mainly on financial targets and efficiency measures, and clinicians, who focus on professional autonomy; between the requirements of central accountability and discretion for local managers; and between the interests of the professionals/staff who work in the NHS and those who use its services. This chapter sets out to show how the Conservative governments from 1979 to 1997 sought to resolve these tensions, the problems caused and the impact on stakeholders. It then considers the impact of the Blair government and assesses its plans for further reform highlighting the potential difficulties with these proposals. It argues that the tensions inherent in the NHS remain and that the circle is unlikely to be squared.