The recent pace of administrative change in the NHS has been rapid, culminating in the October 1993 decision to abolish the Regional tier of management and merge DHAs and FHSAs. This paper by William Laing is a timely and successful attempt to put these changes in context. It sets out the history of administrative change in the NHS since its inception in 1948, and the concerns that successive reform measures have been designed to address. As the paper shows, the internal market reforms cannot be seen simply as an aberration in the administrative development of the NHS. In many respects they can be seen as the logical consequence of a long series of government initiatives to give strategic direction to the service.

The paper discusses the challenges of the technology induced reconfiguration of services, demographics, patient expectations and rationing. It identifies those issues that remain unresolved by the October 1993 decisions, outlining the future options available for managing the internal market in a way that is accountable, ultimately, to the public.

The paper is intended to be analytical and descriptive. It does not seek to judge the effectiveness of the 1948 administrative structure or of subsequent changes, including the management structures put in place for the internal market. Rather it sets out objectively where we have got to, how we got there, and where we might be heading.