The cost of the National Health Service : problem definition and policy response 1942-1960
The thesis examines how public expenditure on the National Health Service (NHS) was constituted as a political 'problem' resulting in expenditure constraint throughout the 1950s. It argues that the 'problem' related to the influence of estimates made during wartime planning which were frequently used to judge current expenditure from the beginning of the Service to 1960. Such estimates understated the costs of a future NHS and gave an exaggerated view of the extent to which expenditure was 'out of control'. This approach to evaluating Service expenditure was challenged by 'social accounting' reflected in the Guillebaud Report (1956). Social accounting situated NHS expenditure in the context of National Income and demonstrated that NHS expenditure increases were modest in real terms. However, such findings were resisted, particularly within the Treasury, and forms of financial control inherited from the inter-war period, continued to be used in the 1950s. The thesis explores two responses to this 'problem'. Firstly, capital expenditure is examined as a case of expenditure control. It is demonstrated that, while increased investment in hospitals was seen as promoting operational efficiency, the Treasury concern with restraining current expenditure created resistance to a larger capital programme in the 1950s. Secondly, 'managerial' techniques to promote efficiency are examined by looking at attempts to change accounting practice in the Service during the 1950s. It is argued that this experiment was constrained by criticisms of the appropriateness of applying such techniques in health; and because of their implications for medical autonomy. The overall conclusion of the thesis is that there was a disjuncture between the radical shift in health policy which led to the creation of the NHS and the perpetuation of conservative approaches to financial control.