Introduction

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.

Part One: what the NHS is like today

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 have persisted by various means, putting in place mechanisms for their self-reproduction and resisting attempts at change through waves of health reform.

Organisational features

Tripartism

The tripartite relationship between the three areas of NHS provision – GPs, consultants, and health services run by local authorities – remains remarkably in place 60 years after the NHS was founded. Depending on which of the tripartite elements employs a particular member of staff, differences in pay and conditions still exist, even for those working in what appear to be similar jobs. The 1970s saw attempts to work across common boundaries in the first NHS reorganisation, alongside new discourses of community care and primary care leading to a greater emphasis on the provision of local services. Policy confusion in the 1980s resulted in an explosive growth of private residential care for older people and for home visiting, and eventually local authority care managers and social care. Social care is technically outside the scope of the NHS, but lies along the boundaries of health services, and in the eyes of influential commentator (and also recent governmental health policy adviser) Julian Le Grand, presents a template for the way in which health services may be organised more competitively in the future. Hospital services remain dominant in the NHS, but are increasingly under threat as the budget for services is devolved to Primary Care Trusts and GPs, and a greater emphasis on delivering health services in the community emerges. Hospitals also face a number of potential problems in the future because of their difficulties in competing in a healthcare marketplace where they have disadvantages in terms of both higher overheads and providing a comprehensive range of services at a time when specialist, small-scale providers are competing with them.