Published: 07/10/2004, Volume II4, No. 5926 Page 23

Stephen Thornton re-reads a new edition of a seminal book, but is unconvinced by its portrait of Labour's recent health policies

Health Policy in Britain Fifth edition Chris Ham Publisher: Palgrave 0333961765£18.99

Chris Ham has an unassailable reputation among NHS managers for his ability to make health policy accessible and relevant to them.

Over many years he has graced the stage of conferences, contextualising and synthesising trends in health policy for the NHS management community.

The latest edition of his book ably serves the same purpose and should be read by all those starting careers in the service, too young to have experienced the rollercoaster policy ride of the last quarter century.

His account is refreshingly idiosyncratic, reflecting that throughout the period he acted as both commentator and player.He starts by rightly reminding us that during the NHS's first 30 years there was organisational change aplenty but that precious little of it, save the creation of the Health Advisory Service, had any impact on the quality of care delivered at the coalface. It was only in the Thatcher years that things really began to change.

For me, as a young hospital administrator deeply frustrated by the absurdities of 1970s-style 'consensus management', the Griffiths Report of 1983 was a turning point. Professor Ham considers its most important effect to have been 'to lay the foundations for the introduction of the internal market'. But for me the cultural changes it embodied were the most profound: the notion that there were no longer any no-go areas for management and that its reach could now extend into the previous black hole of medicine.

Most important of all was the recognition that engaging clinical leaders in the management process was vital if services for patients were to improve.

Professor Ham may well be right in saying that despite her iconic status as a decisive leader, the early Thatcher years were characterised as a long drawnout sequence of changes from which it was difficult to detect a clear plan.

However, I wonder why he considers it such a problem that 'managers and health service professionals were left to discover the importance of the separation of the purchaser and provider roles in the process of implementation'?

This was surely the one benefit of the internal market reforms.

Free from the yoke of central control and prescription, managers and clinicians were liberated to determine their own solutions to problems.

Never again under subsequent Tory or Labour administrations would the management of the service be free to test policy intention to destruction.

The genuine attempt to extricate ministers from the day-to-day management of the service reached its apotheosis when health secretary Kenneth Clarke told parliament that responsibility for mass redundancies across the river at St Thomas'Hospital were none of his business, but that of trust chief executive Peter Griffiths.

By contrast, Mr Ham offers but gentle admonition to New Labour's first administration.

He understates the negative impact of staying within the Conservatives' spending plans and the pernicious effect of retaining the 15-year-old efficiency saving programme at a time when the service was clearly threadbare.

The author concludes his recent history by reflecting on the golden years, when at last there was government commitment to raise the level of spending to European averages.

He rightly pays tribute to the positive impact on waiting times while raising questions about the longterm cost-effectiveness of this investment.

My one disappointment with his treatment of this period is his failure to reflect on his own experience at the heart of government as head of the Department of Health's strategy unit, but perhaps that is a different book altogether.

I would not, for instance, characterise the period as one of 'jockeying for power between the mandarins and managers'.

Rather, it was a series of skirmishes that have yet to be resolved between civil servants and policy advisers; between spending departments and Downing Street; and between the modernisers and the traditionalists.

Stephen Thornton is chief executive of the Health Foundation.