On the character of the new entrepreneurial National Health Service in England: Reforming health care from within?
| Published date | 01 June 2022 |
| Author | Damian E. Hodgson,Simon Bailey,Mark Exworthy,Mike Bresnen,John Hassard,Paula Hyde |
| Date | 01 June 2022 |
| DOI | http://doi.org/10.1111/padm.12797 |
SYMPOSIUM ARTICLE
On the character of the new entrepreneurial
National Health Service in England: Reforming
health care from within?
Damian E. Hodgson
1
| Simon Bailey
2
| Mark Exworthy
3
|
Mike Bresnen
4
| John Hassard
5
| Paula Hyde
6
1
Sheffield University Management School,
University of Sheffield, Sheffield, UK
2
Centre for Health Services Studies,
University of Kent, Canterbury, UK
3
Health Services Management Centre,
University of Birmingham, Birmingham, UK
4
Business School, Manchester Metropolitan
University, Manchester, UK
5
Alliance Manchester Business School,
University of Manchester, Manchester, UK
6
Birmingham Business School, University of
Birminghamr, Birmingham, UK
Correspondence
Damian E. Hodgson, Sheffield University
Management School Conduit Road Sheffield
S10 1FL, UK.
Email: d.hodgson@sheffield.ac.uk
Funding information
Health Services and Delivery Research
Programme, Grant/Award Number:
09/1002/29
ABSTRACT
Recent health care reforms in England, combined with
financial austerity, have accelerated both corporatization
and commercialization in the English National Health Ser-
vice (NHS) and this has encouraged greater public sector
entrepreneurialism (PSE). We advance this argument by
examining the meaning and experience of corporatization in
this sector, illustrating our argument with qualitative data
from a specialist hospital at the forefront of this trend. We
demonstrate how the policy and practice of corporatization
is entangled with increased commercialism and how this
shapes more entrepreneurial conduct from staff. Framed in
terms of the recursive relationship between organizational
dynamics and individual behaviors, we focus empirically
upon the shifting epistemic boundaries associated with
increased corporatization, describing the dissonant effects
of these shifts upon individuals, their attempts to compart-
mentalize, and the ethical dilemmas that result. Through this
case we draw conclusions about the emerging impact of
corporatization, commercialization, and public sector entre-
preneurialism across public services.
1|INTRODUCTION
The corporatization of public services is an international, cross-sectorial trend that has gathered pace in recent years
(Clifton & Diaz-Fuentes 2018; Grossi & Reichard 2008; Voorn et al.2018). Corporatization in the public sector
involves the transformation of governmental departments and units into semi-autonomous organizations, subject to
Received: 26 June 2020 Revised: 25 October 2021 Accepted: 27 October 2021
DOI: 10.1111/padm.12797
338 © 2021 John Wiley & Sons Ltd. Public Admin. 2022;100:338–355.wileyonlinelibrary.com/journal/padm
private commercial law with independent revenues and managerial independence, but still under at least partial state
control (Andrews et al.2020). This shift exposes public service delivery to greater competition with the aim of driving
efficiency (Lindlbauer et al.2015) and establishing private-sector management practices as standard
(Bourdeaux 2008). Corporatization therefore represents an example of systemic or public entrepreneurship
(Bernier & Hafsi 2007) insofar as it “shifts control of service delivery from politicians and bureaucrats to professional
managers who are motivated to find innovative service delivery solutions”(Andrews et al.2020, p. 485). The reach
of corporatization has extended into key public services (including health care) across Europe, the United States, and
other developed economies (Braithwaite et al.2011; Ferry et al.2018). In this article, we explore how such a shift
takes place through the conduct of individual middle managers within a public hospital in the vanguard of corporati-
zation and commercialization. Our focus therefore is upon the manner in which corporatization and associated entre-
preneurial behavior is understood, contested, and enacted within state-owned corporate entities (as opposed to
privately owned) and the effect upon the frontline of public service delivery.
The roots of European public service corporatization can be found in the series of reforms initiated from the late
1970s onward, often referred to collectively as New Public Management (NPM), which sought to rationalize public
spending by placing pressure on public services to operate in more “business-like”ways (Hood 1991), creating new
executive and managerial roles, and introducing an array of new performance management and auditing practices.
Although it is questionable in the short term how effective a form of rationalization these reforms were (Harrison
et al.1992), viewed over a longer time period, they prepared the ground upon which such an agenda could be
pursued more emphatically (Ongaro & Ferlie 2020). Change has been accelerated by the pressures produced by the
radical cost containment measures introduced in the wake of the 2007–2008 financial crisis in the United Kingdom
and elsewhere (Exworthy et al., 2016b). This has heralded a distinct modality of corporatization in an uneasy alliance
with competition and commercialization, which has driven a more entrepreneurial approach into the workings
of public organizations. In the English NHS, such activity ranges from maximizing revenue from ancillary
services such as car-parking (www.theguardian.com/society/2016/oct/14/car-parking-at-hospitals-in-england-rises-
average-15-since-2014) through to commercial land sales (www.hsj.co.uk/finance-and-efficiency/exclusive-half-of-
land-proceeds-go-into-revenue-despite-reinvestment-pledge/7023770.article) and joint-venture activity (www.
hcahealthcare.co.uk/news/press-releases/new-65-million-pound-specialist-hospital-facility-planned-for-birmingham)
and even investing in music festivals (www.hsj.co.uk/finance-and-efficiency/trust-lost-more-than-360k-over-
cancelled-music-festival/7030504.article). As an illustration, the Royal Marsden hospital which, in 2021, opened the
“first state-run cancer treatment center in the world-renowned medical district”of London, as a form of direct
competition with the private sector (Plimmer 2021). The COVID-19 pandemic has forced the NHS and its myriad of
organizations to address their revenue streams, despite an increase in NHS funding (Charlesworth 2021), further
encouraging organizations to pursue commercial opportunities.
Although corporatization does not necessarily entail commercialization, corporatization certainly enables com-
mercialization by repositioning public service organizations in a competitive setting. Commercialization is accelerated
by the introduction of market mechanisms similar to those introduced in the United Kingdom in the 1980s and
1990s; however, where these were originally concerned with cost-containment, their contemporary use encourages
revenue-seeking behavior among managers (Waring & Bishop 2013). At the same time, corporatization has encour-
aged market entry by a more diverse range of service provider organizations (Gore et al.2018), with a marked
increase in private provision and a shift toward more transactional service provision based on contracts and tariffs
(Sheaff et al.2019). This shift has also been accompanied by a retreat by the state in some areas of health service
provision, such that there has been an increase in out-of-pocket expenditure; in the United Kingdom, this represents
16.7% of all health expenditure (https://data.worldbank.org/indicator/SH.XPD.OOPC.CH.ZS). Together these
changes have produced a complex, “hybrid”system in the NHS (Gore et al.2020; Thynne & Wettenhall 2004)in
which quasi-corporate organizations interact within a quasi-market comprising both public and private bodies
(Exworthy et al.1999), with several semi-autonomous and arms-length bodies outside central government providing
strategic direction and oversight (Hammond et al.2019). Within this hybrid system, the evolution of corporatization
HODGSON ET AL. 339
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