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 user settings. Using a performativity lens, we show
how policy processes attempt to 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. Our longitudinal study of the interactions amongst the multiple
constituencies the Act attempted to enrol and the existing socio-technical arrangements the Act
aimed to change, generates three contributions: (1) we characterise the performativity of policy
instruments as a process of bricolage that incorporates the principled attitude of making do on
both sides, those who design the policy and those who are charged to implement it; (2) we
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) we document and explicate why specific performances result in misfires and
unintended outcomes. In short, we conceptualise policy performativity as a non-linear,
dynamic process where theories and their effects are constantly being assessed, reconfigured
and fed back into policy making and implementation.