Experiences with the UK National Health Service Reforms: A case of the infernal market?

The 1991 NHS Reforms introduced an internal market within the UK National Health Service. The move to this form of managed competition represented the greatest change to health services in the UK since the NHS was established, with the separation of the responsibilities for commissioning and providing health care. Under the internal market, purchasers (District Health Authorities and General Practitioner fundholders) are responsible for commissioning health care which best meets the needs of their resident populations. Commissioning occurs through contracts made with health care providers (NHS trusts), and providers are allowed to compete for these contracts. The performance of the internal market will be discussed in this paper in terms of four main criteria: quality, efficiency, choice, and equity. Special attention will be paid to key elements of the system, including General Practitioner fundholders, the contracting process, and the extent of competition between providers.