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Decentralisation and Performance: Autonomy and Incentives in Local Health Economies

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Decentralisation and Performance: Autonomy and Incentives in Local Health Economies SDO Project (08/1618/125) Decentralisation and Performance: Autonomy and Incentives in Local Health Economies Research report Produced for the National Institute for Health Research Service Delivery and Organisation programme March 2010 Dr. Mark Exworthy, Royal Holloway University of London Dr. Francesca Frosini, King’s Fund (formerly Royal Holloway, University of London) Lorelei Jones, London School of Hygiene & Tropical Medicine Stephen Peckham, London School of Hygiene & Tropical Medicine Professor Martin Powell, Birmingham University Dr. Ian Greener, Durham University Professor Paul Anand, Open University Dr. Jacky Holloway, Open University Address for correspondence Mark Exworthy School of Management, Royal Holloway, University of London Egham Hill, Egham, Surrey TW20 0EX E-mail: [email protected] Queen's Printer and Controller of HMSO 2010 Page 1 SDO Project (08/1618/125) Contents Acknowledgements ....................................................5 Executive Summary....................................................6 Glossary .....................................................................9 1 Introduction:decentralisation in health policy..11 1.1. Setting the scene: decentralisation in contemporary public services............................................................................11 1.2. Decentralisation in English health policy ...............................15 1.2.1. The classic NHS (1948-79).........................................15 1.2.2. Conservative health policy (1979-1997).......................17 1.2.3. Labour health policy (1997-present)............................19 1.3. Contemporary policies on decentralisation in the English NHS..21 1.4. Local health economy ........................................................29 1.5. Conclusion .......................................................................33 2 Literature Review.............................................35 2.1. Decentralisation ................................................................35 2.1.1. Decentralisation in theory ..........................................35 2.1.2. Towards a new framework of decentralisation...............39 2.2. Autonomy ........................................................................43 2.2.1. What is Autonomy and how might it be conceptualised?.43 2.2.2. How is autonomy meant to work in practice? ................52 2.2.3 Autonomy and performance ........................................60 2.3. Performance.....................................................................61 2.3.1. Decentralisation and performance ...............................62 2.3.2. The centrality of performance in public management .....64 2.3.3. A history of performance in the NHS............................66 2.3.4. Performance measurement: assumptions and consequences...........................................................72 2.3.5. Perspectives on performance......................................76 2.3.6. Formal and informal performance explained .................83 3 Methods. ..........................................................90 3.1. Aims and objectives...........................................................90 3.2. Overall methodology..........................................................90 3.2.1. Comparative case-studies ..........................................90 3.2.2. Rationale for case-study selection ...............................90 3.2.3. Case study selection criteria.......................................91 3.2.4. LHE selection ...........................................................93 3.2.5. Tracer selection........................................................98 3.3. Methods in detail............................................................. 101 3.3.1. Secondary data ......................................................101 3.3.2. “Policy ethnography” in LHEs....................................102 Queen's Printer and Controller of HMSO 2010 Page 2 SDO Project (08/1618/125) 3.3.3. Analysis ................................................................104 3.3.4. Advisory Group ......................................................105 3.4. Issues and challenges ...................................................... 106 3.4.1. Revisions to the methodology...................................106 3.4.2. Access ..................................................................107 3.4.2. Ethics and research governance................................110 3.4.3. Limitations of the methodology adopted.....................111 4 Findings. ........................................................113 4.1. Autonomy ...................................................................... 113 4.1.1. Views on autonomy.................................................113 4.1.2. How autonomy is shaped .........................................119 4.2. Performance................................................................... 134 4.2.1. The significance of “performance” in LHEs ..................135 4.2.2. Causes and pathways to performance: ......................136 4.2.3. Performance management .......................................139 4.2.4. Formal performance................................................140 4.2.5. Informal performance..............................................149 4.2.6. The interplay between formal and informal performance ..........................................................155 5 Discussion and interpretation. .......................160 5.1 Introduction .................................................................... 160 5.2 Decentralisation revisited .................................................. 160 5.3 Autonomy ....................................................................... 164 5.3.1 Defining types of autonomy: .....................................164 5.3.2 Ability and willingness to exercise autonomy: ..............170 5.3.3 Freedom from and freedom to:..................................172 5.3.4 Autonomy - conclusions............................................174 5.4 Performance.................................................................... 175 5.4.1 Revisiting the Decision Space Framework:...................176 5.4.2 Formal and informal performance: .............................181 5.5.Concluding words............................................................. 182 6 Conclusions....................................................184 6.1. Summary of key conceptual and empirical contributions of this report ............................................................................ 184 6.2. Implications of research for policy and practice.................... 188 6.2.1. Autonomy..............................................................190 6.2.2. Performance ..........................................................192 6.2.3. LHE ......................................................................193 6.2.4. Political directions in 2009 .......................................195 6.3. Further research ............................................................. 198 6.3.1. The conduct of research in the current NHS................198 6.3.2. Autonomy: further research .....................................199 6.3.3. Performance: further research..................................200 Queen's Printer and Controller of HMSO 2010 Page 3 SDO Project (08/1618/125) 6.3.4. Systems, integration and collaboration: further research ............................................................................201 References .............................................................203 Appendix 1. Hypothetical case-study .....................219 Appendix 2. Case-study profiles .............................223 Appendix 3. Tracer conditions ................................255 Appendix 4. Invitation letter to participants ..........284 Appendix 5. Consent form ......................................285 Appendix 6. Interview schedule/protocol ..............287 Appendix 7. Interim feedback report, 2008............289 Appendix 8. Advisory Group ...................................291 Appendix 9. REC approval ......................................293 Appendix 10. Summary of issues............................298 Appendix 11. Dissemination activities....................300 Queen's Printer and Controller of HMSO 2010 Page 4 SDO Project (08/1618/125) Acknowledgements We thank all the research respondents in the two case-studies and elsewhere for their willingness to participate in this study. We are grateful to the members of the Advisory Group who contributed to the conceptual and empirical development of the study and advised on the implications for policy and practice. We are also grateful NCC-SDO for their support throughout the project. In particular, the NCC-SDO funded a one-day conference in September 2008 which brought together research teams working in the themes of networks and governance We thank the referees who offered constructive criticism of the draft version of this report (July 2009). Queen's Printer and Controller of HMSO 2010 Page 5 SDO Project (08/1618/125) Executive Summary Background This summary presents the findings and analysis from a study commissioned by the NIHR Service Delivery and Organisation Programme (SDO). Decentralisation remains a strong theme within English health policy, most recently focusing on autonomy for high performing local organisations. Policies such as Foundation Trusts illustrate this. The study examined the impact of national policy (especially autonomy) and local organisational collaboration in terms
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