| Summary: | This thesis investigates the factors involved in the processes of health policy change. It questions the validity of path dependency theory in the context of changes observed within the United Kingdom health system under the Conservatives between 1979 and 1997. The development of the National Health Service (NHS) ‘internal market’ reforms is considered together with five specific cases of change affecting public-private boundaries. The research combines literature research, including biographical and archival sources, with a selection of interviews with important actors from the health policy arena of the time. The cases are mapped using an adapted version of the three policy streams developed by Kingdon for the analysis of agenda-setting processes, as a structured basis for comparison. The research finds little evidence of the self-reinforcing processes that are required to generate path dependency, or that a change of path can take place only at a critical juncture.It shows that small changes can produce substantive and enduring changes of path. It also identifies that the factors involved appear to go beyond Kingdon’s three streams, and attaches importance to the potential for disloyalty to the status quo. Cultural or technical change, as well as policy change, can generate disloyalty amongst those who deliver services. The presence of the potential for disloyalty is, therefore, an important factor in the achievement of a change of path. Taken together the changes between 1979 and 1997 show a notable consistency of purpose in pursuit of a dual agenda of consumerism and public spending control. Whilst analysis of individual cases of change can suggest an absence of strategy, each case plays a part within a remarkable consistent Conservative programme of change the roots of which predate the National Health Service.
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