The cost of the National Health Service : problem definition and policy response 1942-1960.
Cutler, Antony John;
(2000)
The cost of the National Health Service : problem definition and policy response 1942-1960.
PhD thesis, London School of Hygiene & Tropical Medicine.
DOI: https://doi.org/10.17037/PUBS.01520135
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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.