Introduction

The 60th anniversary of the National Health Service (NHS) gives an appropriate time to reflect on progress in conquering Beveridge's (1942) giant of disease. After Bevan, Beveridge is often regarded as a parent of the NHS (coming sixth in the Health Service Journal's ‘Diamond’ list of the most important people in the 60 years of the NHS; Health Service Journal, 30 June 2008). However, Beveridge's role in creating the NHS was limited. As Scrivens (1991, p 27) points out, although a comprehensive health service was a central feature of the post-war reconstruction programme, Beveridge made little reference to its specification.

There are two main ways of defining health: the positive approach, where health is viewed as a capacity or an asset, and the negative approach, which emphasises the absence of specific illnesses, diseases or disorders (Baggott, 2004, p 1). The famous 1948 definition by the World Health Organization of ‘a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity’ (www.who.int/about/definition/en/print/html) clearly stresses the positive (if rather utopian) view. Giddens (1998, p 111) claims that when Beveridge famously declared war on want, disease, ignorance, squalor and idleness, his focus was almost entirely negative. He said that we should speak today of ‘positive welfare’ to which individuals themselves and other agencies besides government contribute – and which is functional for wealth creation. The guideline is investment in human capital wherever possible, rather than the direct provision of economic maintenance. In place of the welfare state, we should put the social investment state, operating in the context of a positive welfare society. Positive welfare would replace each of Beveridge's negatives with a positive: in place of want, autonomy; not disease but active health; instead of ignorance, education, as a continuing part of life; rather than squalor, well-being; and in place of idleness, initiative (p 128). However, Giddens is incorrect in that – at least on paper – the NHS has always been concerned with positive health, but has been concerned in practice with negative health: talking positively but acting negatively. Recent years have seen claims that the NHS is focusing upstream (Hunter, 2008) but, as we shall see, this represents something of a ‘Groundhog Day’ in that similar claims have been made throughout its history.