In 1968 Samuel Huntington wrote that the ‘most important political distinction among countries concerns not their form of government but their degree of government’ (Huntington, 1968: 1). How governance is organised and what governments try to do is not the same thing as the extent to which governments have the tools and information to govern.

The story of NHS governance is most commonly told in terms of its form. Outside the UK, the NHS is often taken as the ideal type of a monolithic, centralised, state-run health system. Endless classes in health policy and systems teach it as the original and purest Beveridgean system, with strong political and administrative control over health services. Students or readers are lucky if there is much recognition of the fact that administrative devolution to Northern Ireland, Wales and Scotland existed for decades before political devolution in 1999, let alone the variable degree of central control that existed within the systems at any given time (Klein, 2003). Sometimes it doubles as an ideal-type for neoliberalism or marketisation, a useful story of a country that had a strikingly unified social democratic system and turned away from it to a series of very visible experiments with markets and ‘neoliberalism’, ‘privatization’ or ‘Americanization’ (Powell, Béland and Waddan, 2018).

Inside the UK, the history of the NHS is often written in much more subtle terms, influenced by a long tradition of research into NHS reforms, their politics and their effects. They are often superficially focused on form, as seen in the organigrammes of the NHS that decorate their pages. But there is a thread of something else, namely an interest in degree of governance. We can see this interest in discussions, reviewed in this volume’s introductory chapter, of the tension between central control and local activity (Klein, 2010), the balance of public and private ownership and finance, centralising and decentralising policies, the relationships between professionals and the state, efforts to understand the different kinds of relations at work in it (Exworthy, Powell and Mohan, 1999) and debates about the conditions under which various central policy tools are effective.