Reforming a Health Care System in a Big Way? The Case of Change in the British NHS

There is a significant literature on change in health care systems, but much of this has little explicit discussion of conceptual approaches, measures or explanations of change. This article examines studies of the British National Health Service (NHS) focusing on the what, how much and why of change. It sets out the main approaches to studying continuity and change: institutional continuity and path dependency (PD); incremental change; punctuated equilibrium; gradual institutional change; ideational analysis; paradigm change; and institutional logics. It briefly critically discusses each of these approaches, and then examines the main studies in chronological order. With reference to the three main questions of this article, the ‘what’ of change suggests that, in terms of the number of studies, PD and ideational approaches appear to be dominant. The ‘how much’ of change question remains problematic due to unclear dependent variables and conflicting conclusions. Lastly, the ‘why’ of change remains unresolved. In short, studies of change in the British NHS tend to be overly descriptive and under-theorized, and do not fully address issues of theories and concepts, measures and explanations; or the what, how much and why of change.