Introduction

When the NHS began to provide care in 1948 it comprised of a number of organisational features that were the result of its infrastructural inheritances, of compromises and innovations in the process of designing the new service and of ideas about the role of the medicine within it.

This chapter suggests that three key organisational features are central to understanding the NHS of 1948, and alongside them, three key principles that were, to varying extents, embedded in its organisational form. It aims to answer the questions of where these organisational features and principles came from, and what their implications were. It will do this by outlining the process through which the three organisational features and principles emerged, before going on to examine the logics that each created. Every organisational choice creates tensions between the interests that are promoted or excluded as a result. Organisational choices create inheritances that shape the institutions within which those providing health services have to work, choices that favour some courses of actions over others. By examining the logics of these organisational choices, insights into the dynamics of the NHS can be gained.

Key organisational features of the NHS

Rather than presenting the debates and arguments that led to the creation of the NHS, and then show how key organisational features and principles emerged, it perhaps makes more sense to make clear what these features and principles are, and then to show the debates that led to their appearance. The danger of this approach is that ‘Whig history’ gets presented that only includes the elements that the author deems relevant for the argument at hand. However, in the case of the NHS, there is a strong consensus within the literature as to what the most important organisational elements found in its creation were, so exploring their development will hopefully give the reader additional clarity as well as forming a basis for subsequent chapters that will discuss their development in the period after the NHS's creation.

Three key organisational features dominate discussions over the NHS. They are tripartism (Ruggie, 1996); the ‘double-bed’ relationship between the state and the medical profession (Klein, 1990); and the general taxation funding mechanism chosen for the NHS (Moran, 1999) (see Table 2.1).

Tripartism refers to the split in health services between hospital (acute) medicine, general practice medicine and community (personal) health services.