Competing institutional logics in public-private hospital arrangements in England

There has been an increase in partnership working between the NHS and the private healthcare sector in recent years, particularly for elective surgical care. The private sector now delivers a increasing share of NHS-funded services and alongside this privately funded healthcare has continued to grow. As consultants increasingly work across the NHS and the private sector, they must deal with complex and sometimes conflicting institutional demands. This paper explores how competing priorities, pressures and incentives are negotiated across and within the NHS and the private sector, using institutional logics theory to consider the interaction between the different logics of professionalism, bureaucracy and markets. We conducted 84 interviews between 2023 and 2025 with medical consultants, senior leaders and governance leads working across NHS and private healthcare providers in England. We identify three institutional logic dualities: professionalism and market, professionalism and bureaucracy, and bureaucracy and market. We show how these dualities shape opportunities for private work, clinical decision-making, professional identity, oversight mechanisms and governance structures. Our analysis highlights how institutional logics are merged, contested and managed in clinical and organisational practice and we consider the implications for accountability, transparency and professional autonomy. Our study contributes to institutional logics theory by considering how consultants' decisions and practices are constantly renegotiated as professional values, bureaucracy and markets interact.