The United Kingdom National Health Service reforms: where are we now?

In April 1991 the reforms of the United Kingdom National Health Service (NHS) established an internal market, separating the roles of purchaser and provider, established new provider organisations (NHS trusts) and initiated the general practice fundholding scheme, where practices of a given minimum size could opt to manage their own budget. This paper reviews the experience so far and outlines recent developments. It concludes that it is difficult to assess whether, overall, the benefits of the reforms outweigh the costs. This is primarily because of a failure to undertake formal evaluation, either before the reforms were implemented, or since they have been implemented. Also, there have been a number of other changes over the same period, including an increase in funding of the NHS. However, two impacts can be identified. Firstly, there has been a shift in the balance of power from secondary to primary care. Secondly, there has been a growing realisation that very little is known about the costs and effectiveness of health care interventions, whether provided within a market-based system or not.