Visible hand or invisible fist? The new market and choice in the English NHS.

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 1990 s' 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.