The Eternal Triangle: Sixty Years of the Centre–Periphery Relationship in the National Health Service

The history of the National Health Service in England is marked by a paradox. Even while successive governments used the rhetoric of power to the periphery, the exhort‐and‐hope system of 1948 was transformed into a command‐and‐control system over the next 60 years. The contrast between rhetorical aspirations and policy trajectory can be traced back, this article argues, to a debate in the 1945 Cabinet about the design of the NHS: a debate which set out the tension between three policy goals – equity, efficiency and democracy. The pursuit of equity and efficiency (variously defined) has provided the rationale for centralization, at the expense of democracy seen as control by elected local bodies. The major change over time has been less in central government's policy ambitions than in its administrative capacity. New organizational structures and managerial techniques made it possible to exploit opportunities created by information technology.