Decentralisation and performance: Autonomy and incentives in Local Health Economies

This project will examine the inter-relationship between governance mechanisms, autonomy and incentives in local health economies (LHEs). This interaction shapes decentralisation policies in the NHS and is thought to shape LHE performance. Recently, English health policy has been implementing new forms of decentralisation (eg. earned autonomy, Foundation Trusts) by altering the mix of governance mechanisms (command, collaboration and competition) and making explicit use of autonomy and incentives, thereby aiming to improve NHS performance. Local contextual factors might also shape performance outcomes. The project involves a synergy between the multi-disciplinary teams involved in 2 previous NCC-SDO funded studies. The aim is to investigate the inter-relationship between decentralisation and performance in LHEs. The project has 5 objectives: a. To examine the impact of decentralisation upon performance through analysis of selected 'tracers (as examples of current priorities) in 3 case-studies; b. To describe the local interaction of governance mechanisms; c. To evaluate the degree of autonomy available to local health-care organisations; d. To assess the (financial and non-financial) incentives associated with different policy initiatives; e. To provide lessons for policy-makers and managers at all levels in implementing decentralisation, managing the implications of autonomy and incentives, and addressing performance management through incentives. The study will use mixed methods. First, analysis of policy and performance data will generate the broad pattern of decentralisation and performance across England. Analysis of these data will aid selection of case-studies and 'tracers (examples within case-studies). Second, three case-studies will be selected which represent a maximum variety of pre-defined criteria. Longitudinal, comparative case-study methods include (a) 'mapping LHE performance and organisational characteristics (using local performance and activity data, and published reports); (b) a survey of senior staff in 3 LHEs (n=c.180) to provide their perceptions of current LHE issues and constraints (especially relating to tracer examples); (c) interviews with a sample of stakeholders (n=c.120) will identify the strengths and effects of organisational relationships across the LHE (such as the impact of service developments in the tracer examples); (d) observation of local planning meetings. Parts (a) and (b) will be conducted in year 1, parts (c) and (d) in years 2 and 3. Quantitative analysis will provide descriptive statistics of broad patterns and association. Qualitative analysis will provide thematic comparisons by LHE, organisational type and tracer example. Analysis will identify the pathways by which governance, autonomy and incentives can facilitate improved performance and also the conditions under which the optimal balance of these may be achieved in different contexts. The study will also consider conceptual frameworks (including 'decision space , resource dependency and principal-agent) to improve understanding of the inter-relationships within LHE and the intersection of national/vertical and local/horizontal pressures affecting performance. The study will engage decision-makers at all stages (via data collection, formative and summative feedback and as members of an Advisory Group). Formative feedback to LHEs (and NCC-SDO) will help validate emergent findings and sharpen subsequent fieldwork. Final dissemination will include such (oral and written) feedback, NCC-SDO report, presentations and publications to practitioner and research communities.