Introduction

In a triumphalist pre-Christmas message to the National Health Service (NHS), Sir Nigel Crisp proclaimed 2004 to have been “a very good year of sustained progress” (Crisp, 2004, p 1). Not only had the dividends of investing in the NHS become apparent, the NHS’ Chief Executive reported, but waiting lists had been further reduced, premature deaths from cancer, heart disease and suicide had continued to fall, and a record number of people had quit smoking. Most importantly, though, the foundations had been laid for the transformation of the NHS: “We are changing the whole way the NHS works to ensure that everything we do fits around the individual needs of our patients and public” (Crisp, 2004, p 1). New policy initiatives in 2004 included the first wave of Foundation Trusts (“local organisations to address local needs” [Crisp, 2004, p 1]), a wider range of providers (“to bring in new ideas and create flexibility” [Crisp, 2004, p 1]), new employment contracts (“enabling us to have more staff, working differently” [Crisp, 2004, p 1]) and the introduction of a new inspectorate (“which will … drive up standards and enable patients to be assured of the quality of care they receive” [Crisp, 2004, p 1]).

The transformation has, of course, been long in the making, as last year's Social Policy Review noted (Allsop and Baggott, 2004). It has involved a step-by-step retreat from Labour's 1997 model of the NHS: a model which, for the first time in the history of the NHS, allowed central government to command and control instead of merely exhorting and hoping (Klein, 2001). It has meant, conversely, a move towards a pluralistic, quasi-market model driven by consumer choice and shifting power to the periphery, where the role of central government increasingly becomes regulatory rather than managerial: setting priorities and targets, but allowing local discretion in the way these are achieved. In 2004, the two models were still coexisting: the Department of Health (DH) was in effect using its command and control powers to drive through the changes meant, in theory at any rate, to make these powers largely redundant – much as Mrs Thatcher's administration centralised in the 1990s in order to introduce its mimic market.