ABSTRACT
New Labour started with the 'ideology of pragmatism'. In health, when Labour became New Labour and moved towards the ideology of first 'central control' and then managerialist markets, it replaced its vague 'modernising' aspirations with a harder agenda. Schools, universities, health services increasingly 'choice' and market rhetoric; increasingly bureaucratic reality. Political agendas hamstring local management, passed down the chain of command by intermediary apparatchiks in the Strategic Health Authorities. In the 1990s, a major political aim of the Conservatives' reforms was to try to devolve responsibility and blame regarding the national health services (NHS) to 'local management'. The NHS in its traditional incarnation was anything but 'Stalinist', even in the very whimsical sense that the word is used by those who object to central planning. Whether in the NHS or in the health services of Africa and Asia, 'devolution' or 'decentralisation' requires both trust in lower tiers and faith in their ability to acquire skills.
