The reforms to the NHS following the White Paper, Working for Patients
, were presented by the Conservative government as promoting devolutio
n, defined as ''decisions . . . taken at the lowest possible level'' b
y Douglas Hurd (1991) - reflecting a senior Minister's interpretation
of the overall policy agenda, including health. It was further claimed
that such policies (''reforms in hospitals, in schools and in housing
'')were a way to ''empower citizens''. This approach was naturally an
attempt to present the Conservatives' policy as pro-community and 'pra
ctical' rather than 'ideological' or free-market obsessed. It is worth
renewing the debate about whether power and/or responsibility were de
volved in the NHS - or, indeed, to the NHS from the Department of Heal
th. Rudolf Klein, in the first edition of his The Politics of the Nati
onal Health Service (1983), had no sooner pointed to the 'devolution'
inherent in the 1982 reorganiZation of the NHS (based on the document
Patients First (HMSO, 1981) when the Griffiths Inquiry recommendations
were accepted. As a result, he was soon to observe that the pendulum
- at that time - had quickly swung back to centralism, an observation
reiterated after a few years when The Politics of the National Health
Service came out in its second edition (Klein, 1989). In other words,
there may be a cycle from centralism to devolution and back, or at lea
st an interpretation of events as such in health policy, which makes a
current reassessment timely. Which direction did the AHS Act of 1990
and related initiatives embody?