Autonomy and local relationships in the English NHS

Mark Exworthy - M.Exworthy@rhul.ac.uk

Francesca Frosini – Francesca.Frosini@rhul.ac.uk

Lorelei Jones - Lorelei.Jones@lshtm.ac.uk

Research funded by NHS SDO R&D programmehttp://www.sdo.lshtm.ac.uk/sdo1252006.html

Paper presented to the European Health Management Association conference, Athens, 25-27 June 2008

Outline

Conceptual background– Vertical and horizontal autonomy– “Decision space” in local health economies

Empirical study from the English NHS– Emerging findings

1

Central policies determine the “decision space” available locally

Central policies determine the set of incentives

Exercise of choice is “shaped” by and is “interdependent” with other local actors

Horizontal Autonomy

Conceptual BackgroundVertical and horizontal autonomy

Bossert T. (1998). ‘Analyzing the decentralisation of health systems in developing countries: decision space, innovation and performance’. Social Science and Medicine, 47, 10, pp.1513-1527Exworthy M. and Frosini F. (2008).’Room for manoeuvre? Explaining local autonomy in the English National Health Service’. Health Policy, 86, pp204-212

2

Vertical Autonomy

Conceptual background: “Decision Space Framework”

Central Policies

Decision Space/Vertical Autonomy

Social and InstitutionalEmbeddedness

Local Choice

Innovation No Change

Performance Performance

3

Local Level

Outcomes

Government

Incentives Directed Change

Performance

The structure of the NHS

Vertical and Horizontal autonomy in the NHS: the Local Health Economy

13

Restructuring

Market-based reforms

Targets and terror

Public participation

Guidelines and recommendations

Non local PCTs

Foundation Trust

Local PCT

NHS Trusts

Non local PCTs

Local Gvt

Horizontal / Local RelationshipsVertical Autonomy

Clinical Networks

Financial Flows

The StudyMethodology

Comparative longitudinal case-study of 2 contrasting LHEs (2006-2009)

This presentation reports from phase 1 in one LHE

Data collection• Interviews with 23 clinicians and managers• Observation at public and private meetings• Documentary / secondary data analysis

13

Dilution of management energy and resources

Diversion of energy and resources to most pressing issues

Findings

2

•Multiple contradictory policies

•Rapid pace of change

Findings

In the context of policy turbulence and upheaval, organisational performance is associated with long-standing relationships that engender trust

Performance associated with long-standing relationships

[Forest Hospital] has also been very reluctant to give up the OG cancer which I talked about, so

there's lots of tensions between our organisations but the clinicians just kind of, just get on with it

really, you know just … so a few little chats in the room together and man- it's the management that

find it difficult

Cathy, General manager - surgery, County General

Loyalty of patients to local providersResistance by purchasers to threaten

viability of local providers

Market-based reformsRestructuringReconfigurationNew staff

Disruption of social and institutional relations

Findings

2

Persistence of social and institutional relations

Persistence of social and institutional relationsLoyalty of patients to local providers

We will offer a patient five places to go and appointment times at those five places- that's what it says, it doesn't mean it's going to be within your county, or within you district, it's anywhere within the country, so- so all she does is she logs out of the Choose & Book screen and writes me a letter and sends it in, so I mean, so that's all that's happening, there is no choice- patients don't want choice, patients want to be

treated in their local hospital

Bob, Clinical Director of orthopaedics, Forest Hospital

Disruption of social and institutional relationsNew Staff

Well it's difficult because you- you just have to you know, new people come and you end up with a different set of

relationships, sometimes that's been helpful, sometimes it's been less helpful but you know, it has caused some

difficulties where you develop some strategic alliances and you know, new people come in and want to change those alliances for all sort of you know, reasons and you know,

that can disrupt continuity

Chris, CEO, Forest Hospital (FT)

Disruptions of social and institutional relationsReconfiguration

...and I mean it- it brought out I think in that situation often brings out the worst in people and sours relationships

which then take a long time to recover so I think it's been very detrimental to the area and probably the reason why we're now thinking about joining with [the other hospital] as opposed to- some might say the more logical thing is for us to join with County hospital first and then go West, sorry

go East towards [the other hospital] is that the relationships between us and [County] hospital have been

soured by, I think, by the whole process, so it wasn't a particularly constructive or useful thing to go through.

Bob, Clinical Director of orthopaedics, Forest Hospital

Policy does not have intended consequences Referrals patterns are maintained Providers negotiate market share

Policy has unintended consequences Conflict between actors Lack of trust leading to inefficiencies

Local autonomy is highly contingent on relationships within local health economies and national policy

Disruption of social and institutional relations

Consequences

2

Persistence of social and institutional relations

Autonomy and collaboration