Devolution and Centralism in the National Health Service

Abstract

Abstract The reforms to the NHS following the White Paper, Working for Patients, were presented by the Conservative government as promoting devolution, defined as “decisions … taken at the lowest possible level” by Douglas Hurd (1991) — reflecting a senior Minister's interpretation of the overall policy agenda, including health. It was further claimed that such policies (“reforms in hospitals, in schools and in housing”) were a way to “empower citizens”. This approach was naturally an attempt to present the Conservatives' policy as pro‐community and ‘practical’ rather than ‘ideological’ or free‐market obsessed. It is worth renewing the debate about whether power and/or responsibility were devolved in the NHS — or, indeed, to the NHS from the Department of Health. Rudolf Klein, in the first edition of his The Politics of the National Health Service (1983), had no sooner pointed to the ‘devolution’ inherent in the 1982 reorganization of the NHS (based on the document Patients First (HMSO, 1981) when the Griffiths Inquiry recommendations were accepted. As a result, he was soon to observe that the pendulum — at that time — had quickly swung back to centralism, an observation reiterated after a few years when The Politics of the National Health Service came out in its second edition (Klein, 1989). In other words, there may be a cycle from centralism to devolution and back, or at least an interpretation of events as such in health policy, which makes a current reassessment timely. Which direction did the NHS Act of 1990 and related initiatives embody?