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Implementing market-based reforms in the English NHS: Bureaucratic coping strategies and social embeddedness


  • Jones, Lorelei
  • Exworthy, Mark
  • Frosini, Francesca


This paper reports findings from an ethnographic study that explored how market-based policies were implemented in one local health economy in England. We identified a number of coping strategies employed by local agents in response to multiple, rapidly changing and often contradictory central policies. These included prioritising the most pressing concern, relabelling existing initiatives as new policy and using new policies as a lever to realise local objectives. These coping strategies diluted the impact of market-based reforms. The impact of market-based policies was also tempered by the persistence of local social relationships in the form of ‘sticky’ referral patterns and agreements between organisations not to compete. Where national market-based policies disrupted local relationships they produced unintended consequences by creating an adversarial environment that prevented collaboration.

Suggested Citation

  • Jones, Lorelei & Exworthy, Mark & Frosini, Francesca, 2013. "Implementing market-based reforms in the English NHS: Bureaucratic coping strategies and social embeddedness," Health Policy, Elsevier, vol. 111(1), pages 52-59.
  • Handle: RePEc:eee:hepoli:v:111:y:2013:i:1:p:52-59
    DOI: 10.1016/j.healthpol.2013.03.010

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    References listed on IDEAS

    1. Gaynor, Martin & Laudicella, Mauro & Propper, Carol, 2012. "Can governments do it better? Merger mania and hospital outcomes in the English NHS," Journal of Health Economics, Elsevier, vol. 31(3), pages 528-543.
    2. Fulop, Naomi & Walters, Rhiannon & 6, Perri & Spurgeon, Peter, 2012. "Implementing changes to hospital services: Factors influencing the process and ‘results’ of reconfiguration," Health Policy, Elsevier, vol. 104(2), pages 128-135.
    3. West, Peter A., 1998. "Market--what market? A review of Health Authority purchasing in the NHS internal market," Health Policy, Elsevier, vol. 44(2), pages 167-183, May.
    4. Petsoulas, Christina & Allen, Pauline & Hughes, David & Vincent-Jones, Peter & Roberts, Jennifer, 2011. "The use of standard contracts in the English National Health Service: A case study analysis," Social Science & Medicine, Elsevier, vol. 73(2), pages 185-192, July.
    5. Sabatier, Paul A., 1986. "Top-Down and Bottom-Up Approaches to Implementation Research: a Critical Analysis and Suggested Synthesis," Journal of Public Policy, Cambridge University Press, vol. 6(01), pages 21-48, January.
    6. Paton, Calum, 2007. "Visible hand or invisible fist?: the new market and choice in the English NHS," Health Economics, Policy and Law, Cambridge University Press, vol. 2(03), pages 317-325, July.
    7. Ian Greener & Russell Mannion, 2009. "Patient choice in the NHS: what is the effect of choice policies on patients and relationships in health economies?," Public Money & Management, Taylor & Francis Journals, vol. 29(2), pages 95-100, March.
    8. M Exworthy, 1998. "Localism in the NHS quasi-market," Environment and Planning C: Government and Policy, Pion Ltd, London, vol. 16(4), pages 449-462, August.
    9. M Exworthy, 1998. "Localism in the NHS Quasi-Market," Environment and Planning C, , vol. 16(4), pages 449-462, August.
    10. Mark Dusheiko & Maria Goddard & Hugh Gravelle & Rowena Jacobs, 2008. "Explaining trends in concentration of healthcare commissioning in the English NHS," Health Economics, John Wiley & Sons, Ltd., vol. 17(8), pages 907-926.
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    Cited by:

    1. Matt Andrews & Lant Pritchett & Michael Woolcock, 2016. "Scaling PDIA through Broad Agency, and Your Role," CID Working Papers 315, Center for International Development at Harvard University.
    2. Matt Andrews & Lant Pritchett & Michael Woolcock, 2016. "Managing Your Authorizing Environment in a PDIA Process," CID Working Papers 312, Center for International Development at Harvard University.
    3. Jones, Lorelei & Exworthy, Mark, 2015. "Framing in policy processes: A case study from hospital planning in the National Health Service in England," Social Science & Medicine, Elsevier, vol. 124(C), pages 196-204.


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