The state and the profession: the politics of the double bed.

Drawing by E H Shepard (1948) (Reproduced by permission of the, estate of E H Shepard) In retrospect it is clear that those who fought Nye Bevan's plans for setting up the National Health Service were right in at least one important respect. The setting up in 1948 marked a revolution in the relation between the state and the medical profession. But it was not quite the revolution that the critics had anticipated and prophesied. It did not mean the triumph of bureaucracy over professionalism or the subordination of doctoring to ministerial diktat. Instead, it created a situation of mutual dependency. On the one hand the state became a monopoly employer: effectively members of the medical profession became dependent on it not only for their own incomes but also for the resources at their command. On the other hand the state became dependent on the medical profession to run the NHS and to cope with the problems of rationing scarce resources in patient care. The subsequent history of the NHS can, in institutional and political terms, be seen largely as a series of attempts to manage this mutual dependency, to find ways of accommodating the frustrations and resentments of both sides in the partnership, and to devise organisational strategies for containing conflicting interests within the framework ofthe NHS. My theme, in short, is that it is possible to understand what is happening in the NHS today-and indeed what has happened over the past 40 odd years-only if it is seen