Markets, politicians, and the NHS

Enthoven's analysis still illuminates the NHS

In 1985 Alain Enthoven, a visiting American professor, published a monograph that introduced the idea of “an internal market model” for the National Health Service,1 a phrase that was to resonate over the coming years. He has now returned to report on what has happened to the idea, drawing on 120 interviews with people working in the NHS. In the 1999 Rock Carling lecture, commissioned and published last week by the Nuffield Trust,2 he gives his conclusions. The result is a scholarly analysis of the implementation of the 1991 NHS reforms. On the one hand, it helps to make sense of the past: the reasons why the 1991 reforms disappointed both the hopes of their advocates and the prophecies of their critics. On the other, its arguments and insights feed into the continuing debate about the NHS's future.

One myth, however, first requires exploding. This is the view that the 1991 reforms represented a systematic attempt to translate an “internal market model” into practice. They did not. The …