• Market reform;
  • Ideology;
  • Garbage-can theory;
  • English National Health Service (NHS);
  • 25 years


The garbage-can theory of decision-making (Cohen et al. 1972), has been adapted into a perspective on policy-making, with adaptations of the approach placing notable emphasis upon the health sector (Kingdon 2006; Paton 2006). This article creates an adapted ‘garbage-can’ framework to help explain each stage of the reform of the English National Health Service (NHS) over the last 25 years.

The emergence of the key idea and resultant policy at each stage of reform of the English NHS has been arational and indeed sometimes irrational. Policy has reflected advocacy by policy-salesmen (Kingdon 2002), proffering ‘solutions’ to ill-defined problems and answers to unasked questions, and politicians' short-termist responses at each decision-point.

Yet the garbage-can alone is not enough: if arationality rules in policy-making day to day, this does not mean that there is not an overall ideological context, trend or bias in reform. The article also posits that ‘market reform’ has derived from the ideological hegemony of a naive anti-statism (hostility to a misleadingly defined and often mythological ‘centralist state’) in public services and enthusiasm for market competition rather than any evidence-based application of pro-market ideas to health policy.

A question arises: how are these two approaches (short-term arationality and longer-term ideological bias) combined in explanation of how policy over time is biased in a particular direction while seemingly arbitrary and directionless at each messy decision-point. The article attempts to combine the insights of a garbage-can approach with wider explanations of ideological hegemony.