This working paper takes the ‘long view’ of NHS reform. It uses historical methods to analyse policy documents and speeches by key political actors in order to explore the nature of what became for both the Conservative and Labour Parties a commitment to taking a market approach to NHS reform. The paper focuses on the provision of clinical services.
The belief that taking a market approach will result in both a more efficient and better-quality service has been common to both Conservative and Labour administrations, and there has been substantial continuity in the development of many of the new structural forms that have been introduced (for example, Foundation Trusts) and the mechanisms that have been required (for example, the use of legally binding contracts). The separation of purchasing from provision has been central to facilitating the market in health care. However, the precise nature of the purchaser/provider split and the extent to which external, independent sector providers have been encouraged has been envisaged differently by the main political parties. The paper considers the focus of successive governments in their efforts to implement market-oriented reforms, particularly the importance they have attached to competition on the one hand and to choice on the other.
The paper addresses the debate as to whether the long experiment with the introduction of market principles is best characterised in terms of continuity or change. It argues that while it is possible to read off continuity from the means and mechanisms employed by successive governments, it is important to consider the political ideas informing the desired ‘direction of travel’ of the main political parties; it is not possible to read off ‘ends’ from policies. Crucially, the Labour and Conservative Parties have differed in their thinking about the desired relationship between the state and the market and the extent to which they have wanted to distance the state from governing what is a huge, complicated and often politically troublesome public service.
Key words: English NHS, NHS reform, political ideas, ideas in policymaking