The focus of this paper is on the impact of managerialism and the new public management on the professions within the NHS in recent years. Potentially, this is a large task. It has been suggested that the NHS is the largest employer in Europe - and with total employees of upwards of three quarters of a million in recent decades - this seems entirely plausible. But this sort of measure of scale is misleading. The health service is far from a unitary entity, being split into a number of areas of activity and semi-autonomous services. General practitioner services, for example, have always been administered separately from hospitals, and the local authorities have always provided some personal services for the NHS. Even within the hospitals themselves, there have been traditional differences between the district hospitals, specialist hospitals and teaching hospitals. In addition, each individual institution within the NHS 'system' has, more often than not, enjoyed both considerable operating autonomy and developed an individual culture. Thus, although, as we shall see, there have been distinct elements of centralisation and bureaucracy within the NHS, it would be wrong to think of it as being, at any time, an organisational monolith. This is true despite concerted attempts at rationalising and unifying a host of diverse activities in recent years.
In the following discussion, attention will be mainly focused what has been happening in hospitals in recent decades and, within this, attention will be mainly on hospitals providing acute services. What is said here does relate to some extent to specialist hospitals as well to some extent, and there will be some asides and comments on other areas of the NHS; but, in order to simplify the discussion and make the analysis clear, the impact of management change is considered in the context of acute hospitals. This still makes the total population to which this analysis relates, considerable, potentially including more than two hundred thousand nurses and some tens of t