The British quasi-market in health care: a balance sheet of the evidence

OBJECTIVES: To summarise the findings from a comprehensive review of research on the effects of the three main elements of the quasi-market reforms of the UK National Health Service (NHS) introduced in 1991/92: General practices becoming fundholders by volunteering to purchase elective care for their patients; Health authorities becoming purchasers of emergency, unplanned and elective services, together with a range of alternatives to fundholding operating under their auspices; The conversion of providers of hospital and community health services to NHS trusts separate from their local health authorities. METHODS: Published and unpublished studies which included any data on the impact of the three main planks of the quasi-market changes, produced between 1991 and late 1998, were identified using a combination of electronic databases, library catalogues at the King's Fund, London, bibliographies, reference lists of individual studies, a survey of NHS directors of public health and consultations with subject area experts. Each main element of the quasi-market was assessed in relation to its impact on: efficiency (primarily productivity); equity; quality; choice and responsiveness; and accountability. RESULTS: There was relatively little measurable change that could be related unequivocally to the core mechanisms of the quasi-market. CONCLUSIONS: The incentives were generally too weak and the constraints too strong to generate the consequences predicted by either proponents or critics of the quasi-market. On the other hand, the way in which the NHS operates was changed irrevocably by the reforms.