Learning from the NHS internal market

The last government's NHS reforms were frequently criticised for the absence of a well-funded, comprehensive programme of evaluation research from the outset. The position was partially remedied later, although most of the research focused on GP fundholding.

A large number of more modest studies looking at aspects of the changes and employing a range of methodologies sought to fill the vacuum, but serious gaps remained.

This useful volume provides a meta-analysis of nearly 200 published studies, including reports from the Audit Commission and the Commons health select committee. The review of evidence focuses on the three main components of reform - health authority purchasing, GP fundholding and trusts - and considers lessons for the future.

But the review is, in the main, inconclusive. Measurable changes were small, and attributing change to the reforms themselves proved problematic in that some developments, such as increased activity levels, were already occurring before the reforms. Less overall change than predicted could be detected, but rather than blaming the internal market for the generally disappointing results from so much effort and investment, the editors take the view that, arguably, a true market never existed in the NHS. What passed for one was subject to constraints and few incentives.

Although this is a generally well-balanced account, the editors perhaps betray their own bias in implying the reforms might have achieved more had a market been allowed to flourish. There is no conclusive evidence for such a view. Indeed, the available evidence suggests strongly that markets and medicine do not mix well if the policy objectives are aimed at securing equitable coverage of care that is integrated and is affordable and accessible to all social groups.

The real dilemma facing researchers trying to evaluate the 1991-97 NHS reforms was the turbulence of the policy environment. As the editors note, evaluation studies have been hampered by both the rapid pace of change and the number of other changes in the healthcare system that have been proceeding in parallel.

In offering lessons for the future, the editors go beyond the evidence in applauding the government's commitment to a primary care-led NHS through the creation of primary care groups. Drawing on the available evidence, it would be possible to reach a set of conclusions which questioned the desirability and sustainability of the reforms now under way.

The stock of evidence allows very different conclusions to be reached. Such a pick and mix approach to evidence-based policy is not satisfactory and raises deeper questions about the values underpinning research, the theories, concepts and methods employed, and the rigour with which it is conducted.

David Hunter Professor of health policy and management at the Nuffield Institute for Health, Leeds University