Change in the British National Health Service: policy paradox and the rationing issue

The National Health Service of the United Kingdom is trapped in a policy paradox. On the one hand, the 1990 reforms encourage the devolution of power to local purchaser and provider units through the operation of the "internal market." On the other, mechanisms of control and accountability are being revamped to produce a centrally managed system bound together by corporate contracts. The political frictions generated by this paradox are exacerbated by the problem of rationing health care in the face of apparently unlimited demand. This article examines the political problems faced by a single Health Authority as it sought to implement the changes required of it by the conflicting policies.