The first major reorganisation of the National Health Service took place in 1974, twenty-six years after the service had been established. It has long been perceived as a failure. This article draws on archival records and a witness seminar held in November 2016 to provide a more nuanced assessment of the 1974 reorganisation and understand more fully why it took the form that it did. In particular it identifies the reorganisation as an important moment in the ongoing story of management consultants engaging with health policymakers, and explores the role of McKinsey and Co. in detail for the first time. Key explanatory factors for their involvement are identified, including the perceived lack of expertise and manpower inside the civil service and the NHS, and perceptions of their impact and effectiveness are discussed. Many debates about the use of management consultants today were directly foreshadowed during the early 1970s. Alongside this, the role of other groups of policy actors, including civil servants, politicians and medical professionals, are established and the extent to which British health policymakers have had to work within existing cultural, political, legislative and practical constraints when trying to initiate change is demonstrated. The fact that many of the ‘mistakes’ that were made have been repeated in the course of subsequent reforms, speaks to the poor institutional memory of Whitehall, and the Department of Health and Social Care in particular. In the run up to 1974 management consultants could make only a limited contribution to an imperfect compromise.

Over the last three decades, Norway has experienced two fundamental reforms in hospital organization and direction. In 1970 the nineteen county authorities took over ownership and budget responsibilities for hospitals within their areas, replacing a highly varied and complex structure of ownership, typically generated locally. In 2002 hospitals were transferred to the state and amalgamated into five regional government enterprises. These, in turn, have organized all hospitals in their region under local health enterprises. Both regional and local enterprises are separate legal entities, with their own executive boards and managing directors. The Minister of Health appoints the boards of the regional enterprises, while their directors and the boards of the local enterprises are appointed by the regional boards. Both regional and local enterprises are supposed to have full autonomy for day-to-day operations, while being subject to strategic and political decisions by the Minister of Health as the ultimate authority of the enterprise assembly (foretaksmøte). The “enterprise” concept is, of course, borrowed from private business, modelled on companies of limited liability. The choice of this organizational model must be understood at least partly within the context of a general politico-administrative reform, inspired by the worldwide New Public Management movement. Each enterprise is a separate economic entity with a clear responsibility for balancing its budgets. Privatization (or part-privatization) and bankruptcy, however, are out of the question, as the state in the end retains full economic responsibility.

Since 1974 the National Health Service (NHS) has been subject to successive reorganisations which have shaped and reshaped patterns of administration, clinical care and services. This paper uses two sources of oral evidence: a Witness Seminar with a group of administrators who attended the NHS National Administrators’ Training Scheme in the late 1950s and a collection of interviews with doctors and managers who have played key roles in the health services of Manchester and Salford between 1974 and 2007. It surveys the day-to-day interactions between doctors and administrators/managers in hospital settings and analyses what these reveal about relationships within the broader context of shifting organisational structures and management styles. It suggests that the evidence challenges the historical stereotyping of the two groups and that strong working relationships have been determined as much by the values of respect and association as by changes to structures or management styles.