The National Health Service

The focus of this chapter is on the development of new management systems and practices and their effects on the professions within the National Health Service (NHS). In some ways this is a daunting task. The NHS has been cited as the largest employer in Europe, and, with total employees well over one million in recent decades, this is entirely plausible.1 Furthermore, the health service is far from unitary, for much of its history being split into a number of different areas of activity and semi-autonomous services. General practitioner services have always been provided separately from hospital care, and the local authorities for a long time were responsible for some personal health services within the system. Within hospitals themselves, there have been traditional differences between the district hospitals, specialist hospitals and teaching hospitals. In addition, each individual institution within the system has enjoyed considerable clinical and operating autonomy, and has often developed a distinctive culture. Thus, although as we shall see, there have been elements of centralisation and bureaucracy within the NHS, it would be wrong to think of it as being a monolith (Klein, 1995; Rivett, 1997). This remains true despite concerted attempts at rationalising and unifying the service, especially in the last two decades.