The twenty-year war over England's National Health Service: a report from the battlefield.

This article analyzes the latest battle in the twenty-year war to change England's National Health Service (NHS), starting with the internal market reforms introduced by the Thatcher government and now carried one step farther by David Cameron's coalition government. The government's program of change is characterized by (1) its wide scope and the organizational upheavals involved and (2) the fact that it is being introduced at a time when the NHS faces unprecedented fiscal pressures. The legislation faced strong political, public, and professional hostility both from those who saw it as a crime against the founding principles of the NHS and from those who saw it as a disruptive blunder that created more problems than it solved. This article asks three questions. Why did the coalition government embark on a policy course guaranteed to lose it votes? How will the much-amended legislation work out in practice: what are the risks and uncertainties? What will be the program's impact: will it, like previous waves of change, disappoint both the prophets of doom and the visionaries of transformation? The conclusion drawn is that the essential, defining characteristics of the NHS are not under threat. It continues to be a publicly funded service, freely available to all. It is not being privatized. But it is moving toward the kind of pluralistic system that would have been established by Britain's last, wartime coalition government, had not Aneurin Bevan nationalized the hospital service in 1948.