Performing reform in the English National Health Service

Araujo, Luis and Mason, Katherine Jane (2016) Performing reform in the English National Health Service. In: Interdisciplinary Market Studies Workshop, 2016-06-08 - 2016-06-10, St. Andrews University.

Abstract

This paper investigates the relationships between states and markets, through an explication of the role of public policy in introducing quasi-markets in the health sector in England. In an extended qualitative study, we followed the development and implementation of the Health and Social Care Act 2012. The paper focuses on the controversial distinction between providers and purchasers through the introduction of a new type of actor, clinical commissioning groups. First, our analysis revealed how the State performs a strong interventionist role by regulating and de-regulating economic activity, promoting the expansion of markets into novel domains and changing competition rules of health services provision. In contrast with other scholars, we argue that states and markets are not mutually exclusive alternatives. Rather they are entangled through the duality of the state’s involvement in marketization processes and practice, and as regulator. Second, our analysis suggests that transformational quasi-market reforms are failing because of how a programme of intervention was conceived; the policy instruments they deploy were used and reinterpreted in practice, and because of a more nuanced form of performativity of ‘quasi-markets’. Our findings show that whereas the notion of quasi-markets sees no apparent clash between classic economic notions such as choice and competition, and public service ideals such as universal accessibility and uniform quality of care, others disagree. In practice, turning GPs into hybrid subjects equipped to balance objectives embodying a set of disparate and often conflicting values (e.g. value for money, improving clinical outcomes) has proved difficult. Similarly GPs have struggled in defining and qualifying what is to be exchanged. The reforms that envisaged commissioning as market-like exchanges, more closely resemble high-trust networks than markets.