The 1989 white paper Working for patients set out radical options for reform including the introduction of an internal market in the NHS. One of the central themes in the white paper was to delegate operational responsibility away from Whitehall. The government’s proposals were to leave responsibility for strategy with an NHS policy board chaired by the secretary of state. Operational decisions would be for an NHS management executive chaired by a chief executive. The board would set objectives for the NHS management executive and monitor achievement against those objectives. Centrally, the policy board and the management board were established by Len Peach, who was NHS Chief Executive between 1986 and 1989.
The white paper also set out plans for independent audit. The government proposed giving the Audit Commission responsibility for the statutory external audit of NHS organisations in England and Wales. Working for patients also introduced the concepts of clinical audit, both in hospitals and in primary care, as an intrinsic part of management rather than as a professional add-on. Money was made available to ease its introduction.