Introduction

The National Health Service (NHS) is a remarkable institution. It represents an experiment in social engineering, an attempt to provide free healthcare to the population of the UK across a comprehensive range of services. In the US, where private medical insurance is the usual means of paying for care, over 40 million people are uninsured either because their employer does not provide it as part of its rewards package or because they cannot afford to purchase it from their own funds. Citizens of the UK, however, tend to take the NHS for granted. On the one hand, it is a national treasure, regarded by policy makers as a welfare service they must treat with extreme caution because of the disastrous electoral consequences that could result from being seen to be privatising healthcare. On the other hand, media stories run most days of sick patients not receiving the care they should have, of dirty wards and of staff shortages. The NHS seems to be the nearest thing the people of the UK have to a national religion, but also an institution portrayed as being in permanent crisis.

The NHS is also remarkable for its sheer size. It is the largest employer in Europe, with around 1.3 million employees (Secretary of State for Health, 2006). However, the name ‘National Health Service’ itself is misleading for a number of reasons. The NHS has not always been terribly ‘nationally’ organised, with significant variations in care existing from one place to another, and with increasingly different policies in place in England, Scotland, Wales and Northern Ireland. Furthermore, the NHS has not always had much of a focus on ‘health’, being perhaps a place where we receive treatment for illness rather than advice on how to stay healthy (Doyal, 1979). Finally, criticisms made of the NHS, especially in recent years, suggest that ‘service’ might be something of an anachronism because of the perception, often propagated in the media, that what it provides is often poor quality, delivered in crumbling, dirty wards with low staff morale.