Introduction

We opened this book (Chapter 1) by observing that the NHS was in a parlous and unprecedented position. Now that the contributors have surveyed the period across a range of domains, there seems to be very little evidence to revise that verdict. Over its 75 years, the NHS has seen a number of ‘big bang’ reforms and many more, smaller incremental reforms (Tuohy, 2018). While there has been a great deal of analysis on the former (Robinson and Le Grand, 1994; Le Grand, Mays and Mulligan, 1998; Thorlby and Maybin, 2010; Exworthy Mannion, 2016), there is a danger that the smaller but cumulative changes of the latter may be missed (Powell, 2016).

Cumulative incremental changes are harder to detect and assess and receive less publicity than large-scale (big bang) reforms which are often heralded with much fanfare and public debate. Large-scale reforms of health systems such as the NHS may be somewhat constrained by its own logics (Tuohy, 1999) but they might also have a negative impact on the resilience of the NHS. Individual reforms (or a programme of them) may not necessarily lead to a loss of resilience at that time but repeated reforms may undermine the cohesion of its structures and processes. The rapidity of such change might only serve to weaken such cohesion further (Thorlby and Maybin, 2010; Exworthy and Mannion, 2016: 8; Timmins, 2012; Exworthy and Mannion, 2016: 8). Without a comprehensive and longitudinal evaluation programme, the cumulative impact of healthcare reforms will remain uncertain or unknown.

In this book, we have sought to offer a comprehensive analysis of the state of the NHS in its 75th year. The four analytical axes (governance; public/private, central/local, and profession/state; introduced in Chapter 1 and reprised next) provided an overarching framework which applied, more or less, to the individual chapters. The subjects of these chapters enabled, we argue, a comprehensive coverage of the main dimensions of the NHS in its first 75 years. We note, however, the absence of topics, such as workforce wellbeing and diversity, and environmental sustainability (among others), from our analysis but we urge others to engage with these topics in future research.