Alexander Fleming House was the home of the Department of Health and Social Security in the 1970’s (photograph by Stephen Richards and available under the Creative Commons License).
Neil Small, Emeritus Professor of Health Research at the University of Bradford , UK.
Keywords: Ministry of Health: structuration: Dr David Owen: health finance: preventative health care: health inequalities.
Changing the NHS.
Before the 2024 UK General Election, the now Secretary of State for Health and Social Care, Wes Streeting, told the New Statesman that the NHS was gripped by a staffing crisis and the lowest level of patient satisfaction since 1997. There was also a funding challenge, the costs of providing existing services left little for innovation. His solution, pay for an expansion in staffing by abolishing the non-dom tax status that was “enjoyed by a privileged few”. But that expanded staff compliment should not be in hospitals, “We spend far too much money in our hospitals, because we don’t focus enough on prevention, early intervention and social care.”(Streeting 2022)
Since taking office Streeting has seen a series of pay demands and strikes from Resident Doctors that highlight how hard it is to resist incremental spending increases. He has also had opportunities to show how he can innovate via using new technology and shift from in-patient hospital care to care in the community. The National Cancer Plan for England, launched on 4 February 2026, commits to these changes and also looks to reducing inequalities in access and in outcomes.
On one of his rare quiet evenings Streeting might want to reach In Sickness and in Health from his bookshelf. Fifty years ago, Dr David Owen argued that to progress the NHS had to address health inequalities and expand the idea of health care from being solely about the episodic treatment of sickness to its being a broad ranging preventative service. Owen believed he needed not only structural changes but an engagement with what the NHS had achieved and could achieve. The NHS had “created an atmosphere of greater security and serenity up and down the country” but to shift to a focus on prevention would mean “we had to talk about altruism and about being a good neighbour” (Owen 1976 p 2-3).
Fifty years ago.
David Owen had been made Minister of State for Health in the Labour Government in 1974. He quickly found how hard it was to redistribute resources when so large a proportion of funds were allocated to meet historic costs and their incremental increases. His plan for change was to effect a geographic redistribution of resources via the Resource Allocation Working Party, set up in 1975. He also found it hard to have his priorities implemented. His Department seemed to him to simply act as arbiters between the claims of various interest groups. They were preoccupied with day to day administration, with little focus on driving forward longer term priorities.
Although he adhered to the then, and still ongoing, orthodoxy that increases of expenditure on health required economic growth he wondered if that would all be soaked up by the incremental spending that restricted the changes he sought. “It is perhaps a practical fact of life that the problems of redistribution can only be faced at a time of economic difficulties, even though theoretically, it must be easier to redress inequalities at a time of economic growth” (Owen 1976: 49).
When appointed Owen was only the second medical doctor to occupy his post. He may have thought this would ease the challenge of gaining doctors’ support. But while Owen was Minister for Health the Secretary of State for Social Services (which had overall responsibility for health) was Barbara Castle. She was not enamoured of a new “wrecking mood” amongst doctors who were taking industrial action with what she called a “reckless disregard of the needs of patients” (Castle 1976, p 9). Like Owen, she was writing about health not getting its fair share of funding, “you can see it in the age of our hospitals” she said.
Like Streeting, Owen was aware of the need for public support and patient satisfaction. He understood an abiding paradox in health policy; how difficult it would be to convince the public that money should be redirected from cure towards prevention. “When healthy we wish to demystify, expose and objectively quantify the Physicians skills. When ill we desperately want to believe in the power of the Physicians skills (Owen 1976, p 89).
Does a Minister of Health make a difference to heath care?
Ministers of Health come and go but the Ministry is always there. A new person is dropped into ongoing structures and routines and they have to interact with long-established personnel for the short period of their tenure of office. They bring a set of their own and of their government’s priorities and they choose to pursue them using different leadership styles. This interface of institution and individual has provided rich material for those politicians who are also diarists. Richard Crossman (1977) and Barbara Castle (1980), who both had responsibility of health policy, provide rich insights into relations of Minister and civil servant, Minister and doctors’ leaders and struggles with the Chancellor of the Exchequer. The relationship of Minister and civil servant has also provided rich material for comedy, Yes Minister and The Thick of It in particular. But it also presents a scenario well suited to study using Anthony Giddens’ “Theory of Structuration”.
Structuration.
Developed in a series of works beginning in 1976, the same year as Owen’s book, Giddens argued that the implementation of policy needs to be understood as social practice ordered across space and time. He argues for “strategic conduct analysis” which focusses on contextually situated actions. Structures are important, as are actions, but they need to be analysed together. The former requires a consideration of how far a structure, in this case the Ministry, is oriented to serve the status quo or to promote change. As to agents, what knowledge do they bring, what is their motivation and how and in what way do they see themselves exercising control? There are variations in style and in values adopted by each Minister.
It is important that Ministers plan for how they will achieve change and make clear the values underpinning it. Owen realised that shifting towards prevention did not just mean changes in the structures of health care but required addressing concerns the public might have, and what impact the changes he sought would have on the public perception of what the NHS was for.
Do we want Ministers who make a difference?
Who the Ministers are matters. The structures they work with can help or hinder their plans. How you feel about this example of social practice will depend on your politics. In the 1970’s one may have been frustrated by the way bureaucracies inhibited the innovations of the Wilson and Callaghan Labour governments and relieved when, after the Conservative victory in 1979, they did the same to Thatcher’s, or of course vice versa!
A quiet night in.
What will Wes Streeting have learned from reading David Owen’s book? He will have been reminded that the things stopping Owen making the changes he wanted are still here today and are likely to be here tomorrow. He will want to break this pattern. How about being a Secretary of State for the future? (Wes Streeting’s next read could be John Lanchester’s new book, it’s very good on this!) He could direct his Department to shape the present in such a way that it helps set up (and does not styme) tomorrow. An item on every proposal and funding decision, “what does this do for our long term goals?”, and a line on every staff evaluation “how have you progressed reducing inequality and promoting prevention?” would be a start.
References.
- Castle, B. 1976. NHS Revisited. London, The Fabian Society. Tract No 40.
- Castle B. 1980. The Castle Diaries 1974-76. London, Weidenfeld and Nicolson.
- Crossman, R. 1977. The Diaries of a Cabinet Minister Vol 3. London, Hamish Hamilton/Jonathan Cape.
- Giddens A. 1976. New Rules of Sociological Method: a Positive Critique of Interpretive Sociologies. London, Hutchinson.
- Lanchester J. 2026. Look what you made me do London, Faber.
- Owen D. 1976. In Sickness and in Health London, Quartet Books.
- Streeting W. 2022. After a decade of decline, the NHS will be fit for the future under Labour. New Statesman Spotlight, 28 Oct pp 4-5.
Biography.
Neil Small PhD FAcSS is Emeritus Professor of Health Research at the University of Bradford , UK. His most recent books are:
- Health and Care in Neoliberal Times. routledge.com/9781032365145
- and Failures in Health and Social Careroutledge.com/9781032365176
In 1976 he was working in the NHS a few miles from Alexander Fleming House.
Neil Small PhD, FAcSS
Emeritus Professor of Health Research.
Faculty of Health Studies, University of Bradford.
Website https://www.bradford.ac.uk/staff/nasmall
Email n.a.small@bradford.ac.uk
@neilsmall.bsky.social