The policymakers who kept changing the prescription

Margaret Thatcher never liked the NHS and wanted wholesale tax relief for private healthcare when the NHS review started in 1988. John Moore wanted a system in which people could opt out of NHS contributions if they took private cover. Nigel Lawson, the Chancellor, wanted neither, but an extension of charging. Thatcher, however, vetoed that.

When Kenneth Clarke took over from Moore, he helped Lawson to scupper the plans for alternative financing of the NHS, but bought Thatcher's desire for competition between self-managed hospitals in an internal market - and injected the idea of GP fundholders buying care.

Under John Major and William Waldegrave, the language and pace of the reforms were toned down, and Waldegrave put Health of the Nation targets on the agenda. Patient's Charter objectives and centrally funded initiatives to cut waiting lists and improve services took a higher profile. But as Major's administration took a softer line, top NHS management took a tougher one. Peter Griffiths, the deputy chief executive of the NHS, and Eric Caines, its personnel manager, were fiercely pro-market.

Under Virginia Bottomley, the pendulum has swung back and forth. Early encouragement of more vigorous competition - partly at the instigation of Brian Mawhinney, her health minister - has been followed by much more talk of partnership and co-operation. Duncan Nichol, the former NHS chief executive, has been replaced by the more pragmatic Alan Langlands.

Even under Nichol, however, attempts were made to reinstate planning - not just in London - following fears over just how destructive the market could be to the fabric of the NHS. Without that, London hospital closures would have been even more dramatic. The new community care arrived and Mrs Bottomley has pushed mental health up the agenda.

But as some trusts are struggling and fundholding takes on myriad different forms, no one knows whether, three to five years down the road, health authorities or GPs will be buying most care - or which should be. Ministers find themselves denying the ultimate logic of the NHS reforms - that the service could end up publicly funded but privately provided. At the same time, however, they are encouraging the private sector to bid to finance and run NHS services and even entire hospitals. Meanwhile, NHS hospitals are earning record sums from treating private patients.

Nicholas Timmins

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