I have been sitting in patchy sunshine reading Rejuvenate or Retire? the Nuffield Trust's anthology to mark the NHS 60th anniversary.

I wish I could add "with a glass of wine at my elbow", but I have been reading at dawn and do not start that early.

It has proved a good read, one I have enjoyed in alternation with revisiting Machiavelli's The Prince.

Nick Timmins, who is a King's College London visiting professor of public management as well as a weighty Financial Times scribbler, has put together articles and interviews with key players ranging from every recent ex-secretary of state, starting with Patrick Jenkin (1979-81), to a swathe of senior ex-officials, medics and analysts.

One striking conclusion, as Nuffield director Jennifer Dixon points out in her foreword, is the degree of consensus among the assembled VIPs on key issues. Politicians proclaim the need for consensus, but in a post-ideological, managerialist era like ours, they feel the need to accentuate what are often minor differences.

But it is true. There is basic agreement that it should remain taxpayer-funded, free at the point of use. Even those who believe in the insurance model (like Lord Jenkin) don't think it can happen. "There is no constituency for change," a health official, Sir Ken Stowe, recalls hearing Margaret Thatcher concede.

Top-ups and co-payments

Most witnesses detect growing convergence between world systems. But there are divisions over a UK embrace of co-payments (£5 to see the GP?) or top-up payments (those cancer drugs). Typical of boisterous Ken Clarke - one of the NHS's ministerial "five giants" according to Mr Timmins (the others are Nye Bevan, Enoch Powell, Barbara Castle and Alan Milburn) - he is an opponent, not least because he fears that sick patients would get ripped off by quack medicine. Mr Milburn concedes top-ups may happen all the same: he's right.

Pretty much everyone seems agreed that the purchaser-provider split is vital, that the private sector must provide important competitor services within the NHS and that more decisions should be taken locally and accounted for there.

That does not mean an arm's-length management structure, let alone a constitution, is the answer, most politicians believe. It fails what Stephen Dorrell (1995-97) calls "the Today programme test". In other words, when something goes wrong, who gets the call from the BBC? The minister. Watch what happens to Bank of England "independence" as the financial crisis deepens.

Local pressures

Indeed, Mr Clarke (1988-90), whose disdain for local government is a silver thread in his career, opposes too much localism (like Gordon Brown he wants it on pay) because he thinks local leaders won't stand up to local pressures.

As a very green junior health minister in 1982 he recalls a maternity unit closure row in Ely where the consultants told him privately the unit was dangerous and must close. But none would step outside with him and tell the protesters and TV cameras.

A shocking tale but typical. The failure to engage the medical professions in management is a constant theme, since Sir Roy Griffiths' seminal report of 1983 and before. It has been matched by evasion and irresponsibility by the doctors which endures to this day.

Doctors and managers

"Must try harder" is the lesson. The trouble is that very different sorts of people want to be doctors from those who want to manage. The NHS and its customers are all suspicious of change. Changing medical attitudes and behaviour is at least as important as changing public attitudes to, say, smoking or fitness, if vital productivity gains are to be sustained.

Everyone loves the National Institute for Health and Clinical Excellence. Frank Dobson (1997-99) regrets Keith Joseph's abolition of local medical officers in 1974. Norman Fowler (1981-87) deplores Labour's feeble public health record. William Waldegrave (1990-92) admires Tony Blair's early reforms but says the NHS's basic structure still doesn't work.

Yet the overall tone is upbeat. The challenges of technology, wonder drugs and an ageing population can be met despite familiar NHS doomsters around since the mid-50s.

As Mr Timmins writes: "If ever there was a golden age, it is now."