Implementing Marketization in Public Healthcare Systems: Performing Reform in the English National Health Service

To implement marketization in public healthcare systems, policymakers need to situate abstract models of prescriptive practice in complex settings. Using a performativity lens we show how policy processes bring about the changes they presume. Investigating the implementation of the Health and Social Care Act 2012, and the development of a policy instruments and Clinical Commissioning Groups, we explicate the performance of a marketization programme. This longitudinal perspective on the interactions amongst the Act’s aims, the multiple constituencies the Act attempted to enrol and the existing socio-technical arrangements the Act aimed to change, generates three core contributions. We (1) characterise the performativity of policy instruments as a process of bricolage that incorporates the principled attitude of making do on both sides of the divide – those who design the policy and those who are charged to implement it; (2) identify the mechanisms through which the performativity of an envisioned model of marketization operates at multiple scales within a complex and highly distributed system of provision; and (3) document and explicate why specific performances result in misfires and unintended outcomes. Thus, we conceptualise policy performativity as a non-linear, dynamic process where theories and their effects are constantly being assessed and reconfigured.