Decentralisation and Performance: Autonomy and Incentives in Local Health Economies (original) (raw)

Any assessment of the level or nature of decentralisation in the NHS is fraught with difficulty. Different Health Ministers, for example, have held conflicting views. Enoch Powell argued that the centre had almost total control. Richard Crossman maintained that the centre was weak. Barbara Castle argued that the RHAs were 'pretty subservient' (in Ham, 2004, p.174-5; cf. Lee and Mills, 1982, p.105). Similarly, commentators present different views. For example, during the Conservative period of office (1979-1997), it appeared that the NHS was moving in two different directions at once. Some commentators claimed that the national character of the health service was undermined (eg. Mohan, 1995) while others argued that the NHS was effectively nationalised (eg. Klein, 2006). Similarly, Labour health policy (1997 onwards) has stressed the importance of both the national and the local (Baggott, 2004; Klein, 2006; Powell, 1998). As Butler (1992, p.125) writes, it is unclear whether the NHS is a central service that is locally managed or a local service operating within central guidelines. Governments have tended to claim the latter, whilst actually willing the former. This section examines the conventional wisdom on decentralisation in the NHS according to the main health policy and management texts (see also Peckham et al, 2005). It summarises the results of a literature review. The search strategy focused on authored (rather than edited) texts that covered a wide period of time from 1948 onwards. Although it was not a 'systematic review' of journal articles with search terms and inclusion criteria (in part because few texts have 'decentralisation' in the title), it was fairly wide-ranging. The aim was to provide a crude content analysis of decentralisation in the texts, but it quickly emerged that decentralisation (or cognate terms) rarely appeared in the indices, which meant that the texts needed to be read in full. It is clear that, while decentralisation and devolution tend to be the dominant terms, they are rarely defined or measured, or linked to the conceptual literature. Also, the terms tended to be used interchangeably. The discussion is presented by broad period.