Accounts of the NHS reforms: macro-, meso- and micro-level perspectives

The purpose of this paper is to review the various strands of academic commentary on the origins of the reforms of the British NHS announced in Working for Patients and implemented from 1991. The intention is to point to the very different ways in which this major event was interpreted and to question some of the interpretations advanced of the reforms. Ranging the various perspectives along a continuum from macro-level accounts (at the level of global or international trends) to micro-level perspectives (which concentrate on developments internal to health care systems), the paper draws attention to the multifaceted character of the various explanations that have been advanced and argues that no one perspective can satisfactorily account for the reforms. A degree of ecleticism may therefore be involved in producing a comprehensive explanation, and the paper draws attention to some parallels between accounts written from rather different ideological perspectives.