Street and Maynard (2007) argue the case for refining the system of payment by results currently being introduced for English hospitals. On the basis of international experience, they recommend, among other things, moving away from setting prices equal to average cost towards setting them equal to best practice costs, adjusting them for quality and using them to signal what activities are desirable. They also discuss how to control total expenditure for primary care trusts (PCTs) under payment by results and question the merits of extending payment by results to mental health services, ambulances, community services, and long-term conditions, ‘where it is difficult to describe patient care requirements and cost variations may be high’ (p. 9).

As England (unlike the rest of the UK) retreads the market route in health policy, it is worth asking two questions. Firstly, is the government right that the ‘new market’ (as it refuses to call it, except in private seminars) is fundamentally different from the 1990s’ internal market which New Labour allegedly abolished in 1997? Secondly, given that the new market is clearly not characterized by the invisible hand, should we characterize it as steered ‘economically’ by a visible (facilitating) hand, on the one hand, or managed ‘politically’ by a fist which would like to remain invisible in order to maintain its power? This article goes on to examine choice in the new NHS with reference to Hirschman (1970), arguing that genuflections to the latter by pro-choice advocates such as Le Grand (2003) are just that – genuflections. Hirschman is used as a taxi by which to reach a desired destination rather than a stimulus to critical reflection, Hirschman-style, upon how ‘exit’, ‘voice’, and particular combinations of ‘exit’ and ‘voice’ may produce perverse outcomes.

Over the last two decades, there has been an increased focus among the health policy and research communities upon improving efficiency, in terms of activity levels and health outcomes, in the health care systems of the EU member states. In this article, some of these developments are described and to some extent assessed, and an attempt is made to highlight how they may serve to undermine more fundamental aspects of these systems: namely, that access to health care be universal and affordable at the point of use.

In ‘Visible hand or invisible fist’ Professor Paton asks two specific questions; first, whether the new internal market is different to the one we experienced in the 1990s; and, second, given that the new market is not steered by anything approximating the invisible hand, is it an economic market at all, or some kind of political market instead?

Calum Paton’s article reads like a howl of pain when faced with the history of the past 20 years of ‘market-like’ reform to the NHS and the prospect of what is to come. Typically, he makes some powerful points. Not least, he highlights some of the unresolved tensions in current health policy. It does indeed remain pretty much of a mystery quite how patient choice, practice-based commissioning, and commissioning by primary care trusts will knit together, let alone how all NHS Trusts, foundation or not, are meant to make a profit (surplus) within a cash-limited system. But, while his article contains a litany of the problems, both actual and potential, that the ‘new NHS’ may bring, it is missing a counter factual. It contains an unspoken assumption that these changes are being made, almost willfully, to a system that was functioning, if not perfectly, then pretty well.

The world is a dangerous place, and so is the health system; hospitals in particular.

This was not self evident to this author before observing 20 years of health policy evolution in Western countries, together with some personal experience. This perspective is furthered by the two volumes reviewed here. In the view of this author, health policy is moving beyond, or at least supplementing, the structure and process emphasis, provided mainly by economists, but with under-girding from other disciplines, that has dominated during the last two decades. The new focus in health policy is not only on quality, but on what to do when quality breaks down and we cannot rely, however much we desire, on a clear systematic framework of standards, incentives, regulations, and controls (Chinitz, 2002). How do we go forward in a realm where the stakes are so high? While not providing all the answers, the two volumes examined by this essay certainly lay out the dilemmas and provide some realistic propositions, for moving forward in health policy and management. And, not surprisingly, economics loses its pre-eminence to other disciplines, especially law, organizational theory, and management.

I am grateful for two respondents as perceptive as Ian Greener and Nick Timmins. Greener’s response allows me in turn to extend my argument. Timmins’ response challenges my case, allowing me to defend it – while his sharp political ‘nose’ sniffs out trends in policy with which I agree.

Recent policy developments in public health care systems lead to a greater diversity in health care. Decentralization, either geographically or at an institutional level, is the key force, because it encourages innovation and local initiatives in health care provision. The devolution of responsibilities allows for a sort of ‘deconstruction’ of the status quo by changing both organizational forms and service provision. The new organizations enjoy greater freedom in the way they pay their staff, and are judged according to the results. These organizations may retain financial surpluses, develop ‘spin-off’ companies, and commission a range of specialized services (such as Diagnostic and Treatment Centres in UK) from providers outside the institutional setting in order to have more access to capital markets. However, this diversity may generate a feeling of a lack of commitment to a national health service and ultimately a loss of social cohesion. Through fiscal decentralization to regional authorities or planned delegation of financial agreements to providers, financial incentives are more explicit and may seem to place profit making above a commitment to better health care. An evaluation of the ‘myths and realities’ of the decentralization process is needed. Here, I offer an assessment of the ‘pros’ and ‘cons’ of the health care decentralization process in Spain, drawing on the experience of regional reforms from the pioneering organizational innovations implemented in Catalonia in 1981, up to the currently observed dispersion of health care spending per capita across the regions.

Right-wing health policy is alive and well in the United States. Pro-business and libertarian health policy advocacy groups, generously funded by right-wing foundations (and, in some instances, by the health care industry), produce a continuous stream of press releases, policy-statements, books, articles, and symposia, as well as testimony before legislative and administrative bodies. Their positions are taken very seriously by the American media, who make certain that right-wing policy experts are represented in any discussion of current health policy issues.

As the American right wing’s control of national (and local) politics implodes in the United States, there is the inevitable hope wafting in the air as policy specialists and other political activists on the other side of the divide anticipate capturing the US presidency at the end of 2008 to go with the center-left’s majorities won in the US Congress at the end of 2006. And so, health care reform is once again on the march! Alas, if Max Weber was wise to have observed that ideas run upon the tracks of interests, implying clearly that some good ideas die their death because they do not find the right track of interests, while some tracks of interests go nowhere for lack of the right idea, the health policy debate still provides a Technicolor demonstration that the mish and mash of this and that is not yet pointing the country in any particular direction, regardless of election outcomes in 2006 and 2008. Worse yet, in spite of the great sociologist Reinhard Bendix’s demonstration in his masterwork Kings orPeople (1978) that non-incremental transformations often occur at critical junctures of a nation’s history due to the diffusion effects of ideas from abroad, there is no evidence in the current (or past) American debate that the country has ever learned anything at all or thinks it has anything at all to learn from the way these problems are grappled with, and more successfully, elsewhere. (Oh, let’s just take Japan, France, Germany, Spain, Canada, the UK, and a handful of other countries as quick examples.)