1. 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 programme http://www.sdo.lshtm.ac.uk/sdo1252006.html Paper presented to the European Health Management Association conference, Athens, 25-27 June 2008

2. Outline  Conceptual background –Vertical and horizontal autonomy –“Decision space” in local health economies  Empirical study from the English NHS –Emerging findings 1

3.  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 Background Vertical 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.1513-1527 Exworthy 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

4. Conceptual background: “Decision Space Framework” Central Policies Decision Space/ Vertical Autonomy Social and Institutional Embeddedness Local Choice InnovationNo Change Performance 3 Local Level Outcomes Government IncentivesDirected Change Performance

5. The structure of the NHS

6. 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 Relationships Vertical Autonomy Clinical Networks Financial Flows

7. The Study Methodology  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

8.  Dilution of management energy and resources  Diversion of energy and resources to most pressing issues Findings 2 Multiple contradictory policies Rapid pace of change

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

10. 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

11.  Loyalty of patients to local providers  Resistance by purchasers to threaten viability of local providers  Market-based reforms  Restructuring  Reconfiguration  New staff Disruption of social and institutional relations Findings 2 Persistence of social and institutional relations

12. Loyalty 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

13. Disruption of social and institutional relations New 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)

14. Disruptions of social and institutional relations Reconfiguration...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

15.  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