. . . a national plan to resolve the problems of the NHS? A laudable concept but plagued with pitfalls for politicians. Rudolf Klein has heard it all before

It was the most ambitious exercise of its kind ever launched. In an unprecedented attempt to shape the future, the national plan set out a comprehensive policy agenda for change. It was designed as 'a guide to action', with a long check-list of the 'main things that have to be done'. Action to improve efficiency. Action to improve the supply of doctors. Action to expand community services. Action to modernise hospital buildings. And so on.

The check-list was to be used by the government 'to review regularly the progress being made in each field, to see whether the various policies are proving effective, whether all those concerned are carrying out their particular part of the job, and whether further action is required'. A new era of purposeful government, determined to modernise Britain, had seemingly begun.

But within six months or so of its launch, the national plan was heading to the shredder. Now it is of interest only to historians as an illustration of the perils and pitfalls of planning.

No, this is not an attempt to anticipate either the contents or the prospects of Alan Milburn's much-touted exercise.

The national plan in quest ion was that produced by Harold Wilson's Labour government in 1965.

1This was an attempt to plan not just the government's own programmes - including the NHS - but the entire economy in the expectation that this would achieve a 25 per cent increase in the national output by 1970.Alas, it was not to be. A sterling crisis overwhelmed the government. The national plan, and its growth target, had become irrelevant. The NHS (among others) discovered that the vision of plenty had turned into a mirage: after a few boom years, it was back on short rations by the end of the decade.

To draw a parallel between the 1965 fiasco and Mr Milburn's plan is not to imply that the latter is destined to a similarly short shelf-life. Short of a global economic crash, the plan is unlikely to be derailed by a fiscal crisis. The example of 1965 carries a rather different and more relevant message. It underlines the political risks to ministers if they over-estimate their own ability to shape the future. Just as the 1965 plan mistakenly assumed that it was possible to predict the trajectory of the private sector - down to estimating the likely labour force and output of each industry - so there is a danger in thinking that it is feasible to lay down what the NHS should and will be doing over the next five years or so.

Mr Milburn can command, but it is less clear that he can also control or what the perverse, unexpected effects will be if indeed he attempts to control activities. So, for example, the government is dedicated to eliminating variations in provision. But what if this results in eliminating variations that are acceptable, or even desirable, because they respond to local circumstances or because they reflect experimental innovation?

The point is further reinforced by two other examples of national planning, specific to the NHS: the two documents on priorities published in 1976 and 1977 respectively.

On the whole these were limited in their ambitions: their concern was how to allocate resources in an era of scarcity, not to raise visions of plenty. Even so, they were at best only a partial success. The planned, substantial cut in the proportion of resources devoted to acute services didn't happen. By the end of the decade, there had only been a slight shift. Further, the two documents underline the enduring nature of the NHS's problems and its organisational recalcitrance to ministerial dictates. The 1976 paper reiterated government policy that all urgent cases should be admitted to hospital within a month and all other waiting-lists patients in less than a year. And the 1977 paper hymned the virtues of 'co-operation at a local level' and the importance of 'joint action'. Plus ca change. . .

The moral of all this is not that changing the NHS is impossible. Indeed, the NHS has been in a constant process of change throughout its history. It is that there needs to be certain modesty of ambition and realism about what can be achieved in the lifetime of a government, even if that lifetime extends to more than one term. Failing that, Mr Milburn's eventual successor may come to wish that the national plan, model 2000, had never been conceived or published.

REFERENCES 1National Plan .London: HMSO 1965.

2Priorities for Health and Personal Social Services in England: a consultative document .London: HMSO 1976.

3The Way Forward: priorities in the health and social services. London: HMSO 1977.

Rudolf Klein is author of The New Politics of the NHS (4th edition just published) and senior associate, the King's Fund.