Between central control and local responsiveness: striking the balance.
Authors: R Klein
Journal: BMJ (1980)

Secretary of State for Social Services, is the latest in a long line of ministers to try to find a solution to some of the central dilemmas of the NHS.His consultative document, Patients First,' is one more attempt to find an appropriate balance between centralisation and responsiveness to local circumstances, between democracy seen as accountability to Parliament and democracy seen as participation by repre- sentatives of citizens in NHS affairs.To understand the nature of these dilemmas, it is helpful to start with the Cabinet debate in 1945 when Aneurin Bevan first presented his proposals for the creation of the NHS.*When Bevan produced his plan, it was immediately opposed by Herbert Morrison, the Lord President of the Council and a champion of local government.If the new regional and local management boards were to be "subject to the minister's direction on all questions of all policy," Morrison argued, then they would be "mere creatures of the Ministry of Health, with little vitality of their own."Yet, Morrison pointed out, "it is difficult under a State system to envisage the alternative situation in which, in order to give them vitality, they are left free to spend Exchequer money without the minister's approval and to pursue policies which at any rate in detail may not be the minister's, but for which he would presumably be answerable."Bevan never met Morrison's argument head on: his answer took the form of a counterattack, arguing that handing over health services to local government would not only be inefficient and prevent the achievement of national standards of provision but would also arouse much more opposition than his own plan."Such an alternative," he wrote, "would rouse a tornado compared with any passing thunderstorm my scheme may provoke."In any case, he rejected Morrison's dilemma: "The danger of concentrating police powers in one minister is obvious, but I am sure that the Lord President will not press this analogy.There can be no Gestapo of hospital orderlies.A centralised service must, indeed, be planned so as to avoid rigidity."But though the new regional and local boards would be "the agents (though not, I hope, in any derogatory sense the creatures) of my Department . . .yet it is precisely by the selection of the right men and women to serve on these bodies that I hope to be able to give them substantial executive powers, subject to broad financial control, and so prevent rigidity.Admittedly, this is a field in which there is room for development in the technique of government, but the problems that will arise should not be incapable of solution."In the event, there has not been much "development in the technique of government" in the subsequent 35 years of the NHS's history.The problems that have arisen have proved stubbornly resistant of any solution.For the first 20 or so years of the NHS the dilemma was side-stepped.The Ministry of Health, as it was then, was a "laissez-faire" department2that is, it was content to devolve executive power to the regions and the hospital management committees, with little attempt to *Details of these are available in the Public Records Office and are published here fdr the first time.