The new national plan for the NHS, due to be launched tomorrow, is being hailed the biggest overhaul of the health service since its creation in 1948. It signifies a fresh start in the government's modernisation campaign, designed to boost confidence in the ability of the NHS to raise standards to levels our fellow Europeans take for granted. But in the light of hard experience, people will wonder, understandably, whether once again they are being handed a false prospectus. They will need some convincing that this latest overhaul is superior to all those past efforts that governments would rather like them to forget. The historical record confirms that such scepticism is justified. The 20th century was littered with botched refits of the service, with the time intervals between them growing progressively shorter. This galloping instability of policy has been damaging to morale within the NHS and to public confidence.
The characteristics of the healthcare problem have long been familiar. As far back as 1920, the Dawson report identified the challenge and provided a cogent outline of a scheme for a modern health service. Dawson acknowledged that "insufficiency of organisation" was already preventing the advantages of modern medical knowledge reaching the people.
That report proposed a remarkably far-sighted plan for a co-ordinated system of primary, secondary and tertiary care, based on a system of health centres and involving the unification of preventive and curative medicine. Despite the acknowledged wisdom of this scheme, in major respects it still remains largely unrealised.
Tragically, the Dawson scheme was left to gather dust, with the important consequence that already during the interwar period, Britain was begin ning to slip down the league tables of healthcare. Even at the start of the second world war, when action to modernise healthcare was inescapable, the government failed to take decisive action. Its hand was finally forced by William Beveridge, who insisted that his scheme for social security must be underpinned by his "assumption B", entailing commitment to a comprehensive health service.
This broke the log jam, but the government squandered its opportunity and spent the rest of the war squabbling with the British Medical Association over the shape of a future health service. Horsetrading ended with a blueprint of impossible complexity that was incapable of implementation. By supreme good fortune, however, the health portfolio of the 1945 Labour government went to Aneurin Bevan, the youngest member of Clem Attlee's cabinet. Bevan had the audacity to scrap the previous plans and adopt an entirely different framework. Although his scheme was very much a hasty contrivance, involving some important concessions to vested interests, it proved an adequate working arrangement that persisted for some 25 years.
The main problem during this period was resource starvation, a difficulty that set in at an early stage and famously led to Bevan's resignation from the government.
From the mid-60s on, a decade of deliberation over reorganisation represented a staggering record of ineptitude on the part of both Labour and Conservative governments. The result was a worst-of-worlds blueprint in the form of the 1974 reorganisation.
This promised "a fully integrated health service" capable of making up for lost time and realising the ambitious humanitarian objectives adopted in 1948. This goal was to be attained through imposition of a "sound management structure created at all levels". Governments were initially confident that the management solution would clear up the problems of the NHS without calling for additional resources. And, at least initially, the new system attracted a positive response from within the service.
However, outside critics were sceptical, seeing the reforms as what the independent office of health economics called a "political device intended not to alter standards of health care but to impress the public with merely symbolic changes". At first, the government and NHS establishment fought to preserve the essence of the new system, but support melted away and it soon became evident that the 1974 reorganisation was a gigantic mistake.
This was a watershed. From the 70s on, every year was dogged by crisis. Cosmetic changes were tried, but under the relentless pressure of resource starvation it became evident the creaking system was under intolerable strain. Despite growing public alarm, however, no attempt was made to achieve a new consensus on the way forward. Instead, as a response to the winter crisis of 1987, the Thatcher government embarked on a confidential review, which launched the NHS into its "internal market" reforms.
Announced as the biggest overhaul of the NHS since its creation, these offered all the benefits that had been claimed for the 1974 reorganisation. The internal market blueprint was sold in 1991 with a far more sophisticated public relations campaign than that used 17 years previously, and an appearance of success was achieved by a short-lived burst of additional spending. This secured temporary relief from the relentless cycle of crisis, but the spending controls were soon reapplied and no amount of public relations spin was able to prevent collapse of public confidence.
The Labour opposition deftly exploited the public mood and in this undoubtedly contributed to its massive electoral success in 1997. Within a matter of months, the new government - with Frank Dobson at the helm of health - came up with its own blueprint for the future. Conscious of the momentous changes it was introducing, the white paper of December 1997, The New NHS, borrowed its title from Bevan's leaflet describing the NHS in 1948.
Dobson announced that his scheme was a 10-year programme of modernisation. And Labour invested so much confidence in its own form of "integrated care" that it felt able to commit itself to the Tories' parsimonious spending plans - with the inevitable consequence that the NHS once more plunged back into its cycle of crisis. Now, with Dobson thrown overboard, health secretary Alan Milburn is starting afresh with yet another 10-year modernisation programme, promising a more radical approach than previously adopted.
Milburn, however, possesses one incomparable advantage denied all of his predecessors. For the first time in the history of the health service, he is promised that the level of resources will rise commensurately with the massive scale of the task to which he is committed. To stand a chance of success, he must demand that the promise is fulfilled and renewed.
• Charles Webster is a fellow of All Souls College, Oxford, and is official historian of the NHS
