Every decade since the 1960s, a major text seeking to popularize the latest trends in academic research has been produced on the long-term development of British welfare policy. Hence Maurice Bruce's pioneering The coming of the welfare state (1961) was followed in 1973 by Derek Fraser's The evolution of the British welfare state (3rd ed., 2003) with its nuanced account of the nineteenth-century accommodation between laissez-faire and collectivism. Then in 1982 Pat Thane's Foundations of the welfare state (2nd ed., 1996) injected a gendered and comparative perspective. Harris ably maintains this tradition by incorporating into the well-known story not only rich new historical detail but also quantitative evidence and theoretical insights gained from the social sciences. It may have taken longer than the standard decade to produce but that is because there is so much more to incorporate. A crisis in both the welfare state and the history profession has questioned the fundamental nature of both.
Some critics may complain that this book is not as good a read as its predecessors. They may question, for instance, why even the preface requires five footnotes and why Charles Webster, let alone some lesser historians, deserves as many index references as Lloyd George. They may also cavil at the density of the text and the lack of any clear overarching theme. Such criticisms, however, are unjustified. Social policy by its very nature is complex. Simplicity can therefore mislead. For instance, the “nuts and bolts” of policy are often far more revealing of both the underlying purpose and actual impact of policy than its professed grand design. Moreover, there is no justification, as in some competing accounts, for policy areas to drop from view when there is no dramatic new legislation. Patients do not suddenly stop being treated in the absence of new health legislation. Significant if subtle shifts in the implementation and financing of policy can also occur. Harris presents the fuller and more satisfying, if necessarily more complex, story.
The lack of an overarching theme presents a bigger problem. Given the opening theoretical chapters and the “restructuring” of the welfare state since the 1970s, the bold question might have been asked: how viable was the “mixed economy of welfare” in 1939 with its apparent accommodation between state, market and voluntary provision? Was this the natural destination of the “welfare escalator” which Victorian society boarded? Was excessive centralization between 1945 and 1976 simply an aberration caused by the temporary social solidarity and faith in “big government” encouraged by the Second World War? The adoption of such a theme, however, might have slanted the selection and presentation of evidence. That would have been unfortunate since one of the book's greatest strengths is its comprehensive bibliography and the breadth of the evidence, both qualitative and quantitative, which it deploys. It is indeed an ideal quarry for others. No library should consequently be without it. All welfare specialists should have it as a reference tool and all serious students should use it as both the grounding and a stimulus for their research.
There are three discrete chapters on health care summarizing changes in policy and practice. Clear, and often novel, quantitative evidence covers principal health outcomes as well as the varied provision of services by, and use of, national health insurance and both voluntary and municipal hospitals. Each chapter challenges some conventional truths and provides a stimulus for further thought. Such thoughts, moreover, may be placed in the context of other policy, if not political, developments through a reading of other chapters. This book, in short, provides both a comprehensive introduction to welfare policy and one further reason why the temptation to write medical history as if it were an academic ghetto can be resisted.