This text contrasts the proposals of the Royal Commission of the late 1970s with the very different set of priorities enshrined in the 1989 White Paper and describes how the changes between the two documents came about. It argues that the NHS reforms should be seen not as the inevitable product of technical developments, nor as a consensus response to managerial difficulties within the NHS, but rather as part of a wider political strategy towards state provision of welfare. The book strongly emphasises the uneven geographical impacts of post-1979 changes, a topic usually underplayed by analysts of social policy.