Introduction

While there is an underlying view that the state has provided health services since the creation of the National Health Service (NHS) in 1948, the NHS Act 1946 placed an overlay on existing arrangements rather than creating new structures and institutions (Baldwin, 1999). In the UK, health services have always been provided through a mixed market model. Before 1948, general practitioners (GPs) and dentists were paid by fees sometimes covered by personal insurance schemes or charities. After 1948, GPs and dentists remained as individual practitioners and not employees of the NHS and primary care has remained in the mixed economy (Propper et al, 2002). Doctors provide most services that are free to users at the point of delivery and charging for others such as travel immunisation or medical certificates to confirm sickness absence to employers. The NHS is an arm's length organisation responsible directly to ministers, and since 2012, public health has been the responsibility of local authorities (DoH, 2012). Public Health England (PHE) was established as an agency in April 2013 and had had executive responsibilities for health protection primarily through the management of its laboratories and research. It provided advice to local authorities and directors of public health who were appointed by local authorities when they took on these responsibilities. PHE reported to the Secretary of State for Health and Social Care and had some autonomous powers. The Department of Health and Social Care (DHSC), generally referred to as the Department of Health, was founded in 1988 and its responsibilities, apart from public health, have remained consistent. Social care is managed through a mixed market that is in part run by local authorities and in part by the private sector (Cunningham and James, 2014). Health is a devolved matter and managed separately in Scotland, Wales and Northern Ireland.

The application of the Government Procurement Agreement (GPA), the General Agreement on Trade in Services (GATS) and the Single European Market (SEM) within the health and social care sector has been undertaken in a variety of ways that reflect the market's involvement in different parts of the service. Early approaches to the implementation of a private finance initiative (PFI) for the provision of hospitals and the GP model included some privatisation but these were not seen as relating to the provision of secondary care in hospitals (CEC, 2015b).