Why bad policy persists: examining finance practitioners’ views of the English NHS internal market

Outhwaite, Lee

Abstract

This thesis evaluates the reasons for the longevity of the English NHS internal market policy, which challenged the post-1948 public provision model for healthcare services. It reviews the intellectual underpinning of the policy, derived from New Public Management thinking, and describes phases in the evolution of the NHS internal market: “Working for Patients” (1989); “Creating a Patient Led NHS” (2005); and then the 2012 Health and Social Care Act. The policy had considerable longevity considering the various calls and moves to supersede elements of the internal market and replace it. These calls have led to the English Health and Care Act (2022) which seeks to enable healthcare (and wider partner) organisations to work together more easily, but does not abolish the internal market, but incorporates more place-based structures alongside it.

The research examines the views of the epistemic finance practitioner groups involved in administering the NHS internal market, along with the reflective and reflexive practice of the author who has worked in senior roles in NHS finance since 1993. The funding approach for English NHS provider organisations is discussed via quantitative research with fellow practitioners. This research suggests that practitioners do not believe the general approach, or the funding mechanisms were sufficiently robust to run a market.

The thesis then reviews senior finance practitioners’ views on the internal market policy itself using questionnaire-based research with a wide sample of NHS finance practitioners. The research assesses the extent of support for the internal market policy and views on its reform. Access to practitioner networks was made possible via the author's positions within the Healthcare Finance Management Association (HFMA) and the Chartered Institute of Public Finance and Accountancy (CIPFA). The research assesses the extent to which the bottom-up views of practitioners may have influenced policy.

The research then moves on to addressing the nature of the use of evidence for public policy formulation and adoption. This action research phase explores the appetite of practitioners to influence English healthcare finance and NHS system management. It suggests reasons why the market approach to the NHS survived for so long and suggests why there was indecision on what should replace it. It concludes that despite the changes introduced in the 2022 Act, there are improvements to NHS finance and structures that could be made and that English NHS finance practitioners should have a policy determination and implementation role. It suggests finance practitioners, as an epistemic community, should propose more integrated working and policies that focus on population health and closer ties with local government to ensure an integrated system works more effectively, to deliver a higher value health and care system.

Citation

Outhwaite, L. Why bad policy persists: examining finance practitioners’ views of the English NHS internal market. (Thesis). Keele University. https://keele-repository.worktribe.com/output/884969

• Thesis Type: Thesis
• Deposit Date: Aug 16, 2024
• Public URL: https://keele-repository.worktribe.com/output/884969
• Additional Information: Embargo on access until 26 July 2028 - The thesis is due for publication, or the author is actively seeking to publish this material.
• Award Date: 2024-08