The first major reorganisation of the National Health Service took place in 1974, twenty-six years after the service had been established. It has long been perceived as a failure. This article draws on archival records and a witness seminar held in November 2016 to provide a more nuanced assessment of the 1974 reorganisation and understand more fully why it took the form that it did. In particular it identifies the reorganisation as an important moment in the ongoing story of management consultants engaging with health policymakers, and explores the role of McKinsey and Co. in detail for the first time. Key explanatory factors for their involvement are identified, including the perceived lack of expertise and manpower inside the civil service and the NHS, and perceptions of their impact and effectiveness are discussed. Many debates about the use of management consultants today were directly foreshadowed during the early 1970s. Alongside this, the role of other groups of policy actors, including civil servants, politicians and medical professionals, are established and the extent to which British health policymakers have had to work within existing cultural, political, legislative and practical constraints when trying to initiate change is demonstrated. The fact that many of the ‘mistakes’ that were made have been repeated in the course of subsequent reforms, speaks to the poor institutional memory of Whitehall, and the Department of Health and Social Care in particular. In the run up to 1974 management consultants could make only a limited contribution to an imperfect compromise.

Who was to blame when a labouring woman or her unborn child died during the early modern period? How was responsibility assessed, and who was charged with assessing it? To answer such questions, this article draws on French obstetrical treatises produced by male surgeons and female midwives between 1550 and 1730, focusing on descriptions of difficult deliveries. Sometimes the poor outcome of a labour was blamed on the pregnant woman herself, but more often a particular medical practitioner was implicated. Authors of obstetrical treatises were careful to assign fault when injuries or deaths occurred in cases concerning them. Chirurgiens accoucheurs (surgeon men-midwives) regularly accused female midwives of incompetence, yet also attacked fellow surgeons as well as those male physicians officially superior to them in the medical hierarchy. Female midwives similarly condemned the actions of male practitioners, without hesitating to censure other women when their mismanagement of deliveries had tragic consequences. Part of authors' eagerness to blame others stemmed from the fear of being held accountable for mistakes preceding practitioners had made. Ascribing responsibility usually went hand-in-hand with defensive claims of innocence, or boastful declarations of having saved a suffering woman from the bungling attempts of less skilled birth attendants.