Introduction

Since the early part of the 20th century there has been a continuing debate in the UK about the nature of a national health service. The establishment of the NHS in 1948 did little to end this debate that has continued over the past 60 years. The NHS was itself a compromise of interests – both political and medical – and discussion has repeatedly returned to whether the NHS should be a local or centralised service, what relationship it should have with local government, whether doctors, managers or politicians should run the service, whether it is affordable as a tax-funded service and so on. These debates remain as potent today as they were in 1948 and while it is unlikely that such debates will go away in the future it is perhaps a good time to examine the nature of the NHS 10 years after the election of the Labour government that has introduced political devolution, and towards the end of a three-year period when there has been substantial investment in NHS resources.

In 2006 the Welsh Assembly received devolved authority, providing the potential for wresting policy control of the Welsh NHS from Westminster and highlighting the increasing importance of political devolution in the UK. In addition, 2006 saw calls from the Conservative Party for an ‘independent NHS’ and from within the Labour Party for an independent NHS board and constitution. Health policy in England emphasised developing the role of the private and not-for-profit sectors in healthcare and further embedding a healthcare market, and so highlighted continuing debates about autonomy for, and within, the NHS. Yet, at the same time, in Northern Ireland, Scotland and Wales the emphasis has been on partnerships, professional engagement and central planning – often to overcome fragmentation and improve integration. Contributions to Social Policy Review over the past two years by Rudolf Klein (2005) and Ruth McDonald (2006) highlighted the development of patient choice and marketisation of healthcare. Developments through 2006 suggest that these are continuing themes, certainly within the English healthcare system. Recently there has also been an increasing concern with the relationship between the NHS and patients, service users and carers with an emphasis on self care and the role of health systems and the professionals who work within them in supporting self care (Kerr, 2005; DH, 2006a).