Implementing Marketization in Public Healthcare Systems: Performing Reform in the English National Health Service

Abstract

To implement marketization in public healthcare systems, policymakers need to situate abstract models of prescriptive practice in complex user settings. Using a performativity lens, we show how policy processes attempt to bring about the changes they presume. Investigating the implementation of the Health and Social Care Act 2012, and the development of policy instruments and ‘Clinical Commissioning Groups’, we explicate the performance of a marketization programme. Our longitudinal study of the interactions amongst the multiple constituencies the Act attempted to enrol, and the existing socio-technical arrangements the Act aimed to change, generates three contributions: (1) we characterize the performativity of policy instruments as a process of bricolage that incorporates the principled attitude of making do on both sides – those who design the policy and those who are charged to implement it; (2) we identify the mechanisms through which the performativity of an envisioned model of marketization operates at multiple scales within a complex and highly distributed system of provision; and (3) we document and explicate why specific performances result in misfires and unintended outcomes. In short, we conceptualize policy performativity as a non-linear, dynamic process where theories and their effects are constantly being assessed, reconfigured and fed back into policymaking and implementation.