The impact of a quasi-market on sexually transmitted disease services in the UK

This article reports the results of a study of the impact of quasi-market reforms on sexually transmitted disease (STD) services in one UK health region. An internal or quasi-market was introduced into UK health care in the 1991 reforms of the National Health Service (NHS). Health authorities (HAs) and general practitioner fundholders were given major new responsibilities for purchasing (later called commissioning) health services. The NHS quasi-market was designed to address recurrent difficulties in acute health services by promoting efficiency and consumer choice. The arrangements for commissioning STD services are important because these diseases are major threats to public health and HAs face a number of constraints in bringing about service changes through market mechanisms. In the UK, STD services are provided on a self-referral and confidential basis; patients experience STDs as stigmatizing and often have low expectations of service and little desire for involvement in commissioning decisions. HAs have only limited routine intelligence about STD services and little or no choice of local providers. This study adopted a qualitative case-study approach to examine HA commissioning of STD services. The study found that the introduction of the NHS quasi-market did not equip HAs with mechanisms for bringing about change in STD service provision or STD-related health outcomes. The findings are consistent with other recent studies of HA commissioning and provide further cumulative evidence of the limits to HA leverage in the NHS quasi-market. The study concludes that the commissioning of STD services is likely to remain a low priority in the new NHS structures based on primary care groups.