The limits of market-based reforms

Introduction Every health and social care system around the world is concerned with how it can provide care in a way that ensures both high quality and cost-effective care for people. The English system is no exception and over the last few decades there has been increased interest in the use of markets within the context of health and social care [1]. Although local government in the UK has a longer track record of developing a market for care services (especially since the passage of the 1990 NHS and Community Care Act), a series of NHS reforms have followed suit, also drawing on market-based approaches (see [2,3]). The initial introduction of an internal market into the English NHS in the 1990s saw the separation of the functions of service delivery (provision) and the purchasing and planning of these (commissioning). The context has since developed and today commissioners are being asked to strengthen the market further and enable the diversification of provision in a mixed economy of care. The recent passage of the Health and Social Care Act 2012 requires commissioners to ensure good practice and promote and protect patient choice. The legislation seeks to make the NHS more responsive, efficient and accountable by putting clinicians at the forefront of commissioning and, most controversially, opening up the field of provision to encourage more entrants to the market and, ultimately, greater competition [4,5]. Thus, market-based competition is one of the main tools that are available to health care commissioners working within the NHS in England. These changes echo those which are going on in other parts of the globe as national governments seek to develop and extend markets in health and social care. Market based reforms have a central role within the English government’s plans for health and social care, however; they have not been warmly welcomed by all (to put it mildly). There has been considerable critique of the introduction and expansion of market-based reforms in health and social care [e.g. [6-8]]. Most recently there has been considerable debate about the Health and Social Care Act, generally and specifically in terms of the Section 75 regulations which on the face of it are concerned with ‘good procurement practice’, but which many feel open the NHS up to competition. Against this background the Health Services Management Centre at the University of Birmingham and the Nuffield Trust jointly convened a seminar to explore the ‘limits of market-based reforms’ in health and social care and the papers that comprise this supplement are a product of the presentations, discussions and debates from that day. Questions addressed during the day included: • What are the theories that have underpinned the study of commissioning? • What are the ways in which we can investigate commissioning? • What does it mean to do commissioning? • What is the evidence base for commissioning? • What is the future of commissioning? Ultimately, this seminar was particularly concerned with understanding what we know about the effectiveness of market-based reforms and from a variety of disciplinary and methodological perspectives.