This paper falls into three parts. In the first part I will briefly review the current process of reform that the United Kingdom National Health Service is undergoing. Two fundamental motivations for reform, the desire for increased efficiency and for an increased responsiveness to patients' needs and preferences will be discussed in greater detail. The second part attempts to provide a perspective on the moral debate concerning health care reform by introducing the distinction between ‘civil association’ and ‘enterprise association’ as proposed by the political philosopher Michael Oakeshott. In the final part, this distinction will be used to analyze the moral and political constitution of the National Health Service, in order to establish the relevance and scope of concerns with efficiency and patient and public accountability. A framework within which the current reforms can be assessed is thereby outlined.