Other reforms were also introduced by the Conservative government in the period after 1987. The general management changes of the mid-1980s were strengthened and doctors became more accountable through general managers. New contracts for G.P.s came into effect in April 1990 after being proposed in the White Paper ‘Promoting Better Health’ (1987). These contracts included targets for preventative work, obliged practices to produce annual reports and information for patients amongst other things. The scope of managers in the NHS to contract out in-house services was increased. Whereas prior to 1987 the private sector has only been able to tender for ancillary services, by the late 1980s quasi-clinical services such as sterile supplies and then clinical services such as pathology were opened up to tenders from the commercial sector (BUTLER, 1993, p57).
Undoubtedly Conservative policy on the NHS was a good deal more radical in the period after 1987 than it had been in the period before 1987. However, a large measure of continuity still existed. Proposals to change the method of funding the NHS were again considered and again rejected. There were no proposals to expand the role of the private sector. Furthermore, despite the underfunding crisis which had prompted the 1988 review, there were no proposals to increase the resources to the NHS, at least until it could be seen whether the reforms would lead as expected to a more efficient use or resources. The continuity of health policy is typified by the foreword to ‘Working For Patients’ written by Thatcher which said that the NHS would “continue to be available to all, regardless of income, and to be financed mainly out of general taxation” (LE GRAND et al, 1991, p93).
The question of why Conservative policy towards the NHS remained relatively pragmatic, even after a wholesale review in which one might have expected a radical overhaul of the system along the lines proposed by the ideological New Right, must be addressed. I believe that the primary reason for lack of fundamental change was the strong public support and sympathetic media coverage of the NHS.
The Conservatives could not be seen to be threatening the existence of a universally available, ‘free’ service given the politically sensitive nature of the issue. Thus, despite Mrs Thatcher’s perception of the NHS as a ‘blackhole’ into which public money was poured without any perceptible gain in performance, the options for reform were limited. It might have been expected that a government committed to free market principles and aiming to cut public expenditure would have given greater encouragement to the growth of the private sector whilst paring down public provision to a bare minimum. However, this did not occur and policy remained firmly committed to a comprehensive public health service.
In conclusion, many parallels can be drawn between the Conservatives’ policy on the NHS in the periods before and after 1987. In both periods, the government attempted through changes in the management structure to improve efficiency – a conventional approach, and throughout it remained committed to a universal service funded from general taxation and mostly free (despite increases in prescription and other charges) at the point of use.
Although the reforms introduced after 1987 were more fundamental than anything that had gone before and undoubtedly led to the greatest cultural change in the history of the NHS, they were not particularly Thatcherite and they did not address the increasingly pressing problem of underfunding. Thus, I would argue that there are differences between policy pre- and post-1987 with the latter period seeing greater change. However, the remarkable feature of Conservative policy towards the NHS during the 1980s and 1990s has been its continuity and the extent to which New Right philosophy and proposals have had relatively little impact.
J. Le Grand, D. Winter & F. Woolley, ‘The National Health Service: Safe in Whose Hands?’, in J. Hills ed., The State of Welfare, 1991, Clarendon Press
C. Ham, Health Policy in Britain, 1992, MacMillan Press
C. Paton, Competition and Planning in the NHS, 1992, Chapman & Hall
W. Ranade, A Future for the NHS?, 1994, Longman Group UK Ltd
J. Butler, ‘A Case Study in the National Health Service: Working For Patients’, in R. Taylor-Gooby & R. Lawson eds., Markets and Managers, 1993, Open University Press
I. Holliday, The NHS Transformed, 1992, Baseline Books