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Research has demonstrated that pilots contain multiple shifting purposes, not all of which relate to simple policy testing or refinement. Judging the success of policy pilots is therefore complex, requiring more than a simple judgement against declared goals. Marsh and McConnell provide a framework against which policy success can be judged, distinguishing programme success from process and political success. We adapt Boven's modification of this framework and apply it to policy pilots, arguing that pilot process, outcomes and longer term effects can all be judged in both programme and political terms. We test this new framework in a pilot programme in the English National Health Service, the Vanguard programme, showing how consideration of these different aspects of success sheds light on the programme and its aftermath. We consider the implications of the framework for the comprehensive and multi-faceted evaluation of policy pilots.

This article develops an analysis of population-level priority setting informed by Bevir's decentred theory of governance and drawing on a qualitative study of priority setting for service improvement conducted in the complex multi-layered governance context of English primary care. We show how powerful actors, operating at the meso-level, utilize pluralistic and contradictory elements of complex governance networks to discursively construct, legitimize and enact service improvement priorities. Our analysis highlights the role of situated agency in integrating top-down, bottom-up and horizontal influences on priority setting, which leads to variation in local priorities despite the continuous presence of strong hierarchical influences.

Background With innovation in service delivery increasingly viewed as crucial to the long-term sustainability of health systems, NHS England launched an ambitious new model of care (Vanguard) programme in 2015. Supported by a £350 million transformation fund, 50 Vanguard sites were to act as pilots for innovation in service delivery, to move quickly to change the way that services were delivered, breaking down barriers between sectors and improving the coordination and delivery of care. Methods As part of a national evaluation of the Vanguard programme, we conducted an evidence synthesis to assess the nature and quality of locally commissioned evaluations. With access to a secure, online hub used by the Vanguard and other integrated care initiatives, two researchers retrieved any documents from a locally commissioned evaluation for inclusion. All identified documents were downloaded and logged, and details of the evaluators, questions, methodological approaches and limitations in design and/or reporting were extracted. As included evaluations varied in nature and type, a narrative synthesis was undertaken. Results We identified a total of 115 separate reports relating to the locally commissioned evaluations. Five prominent issues relating to evaluation conduct were identified across included reports: use of logic models, number and type of evaluation questions posed, data sharing and information governance, methodological challenges and evaluation reporting in general. A combination of resource, data and time constraints means that evaluations often attempted to but did not fully address the wide range of questions posed by individual Vanguards. Conclusions Significant investment was made in independent local evaluations of the Vanguard programme by NHS England. This synthesis represents the only comprehensive attempt to capture methodological learning and may serve as a key resource for researchers and policy-makers seeking to understand investigating large-scale system change, both within the NHS and internationally. PROSPERO (Registration number: CRD42017069282).

Chapter 2 provides the context, setting out the organisation and governance of commissioning in the NHS. It includes a short summary of the architecture of commissioning pre-Health and Social Care Act (HSCA12), and highlights the important changes which were brought about by the Act, including the abolition of Primary Care Trusts and Strategic Health Authorities, the establishment of Clinical Commissioning Groups (CCGs), the creation of NHS England, transfer of commissioning responsibilities to different bodies (e.g. public health) and the setting up of local Health and Wellbeing Boards. The chapter also highlights the programme theories underlying the HSCA12, in particular the commitment to competition as a means of improving services and the expected benefits of greater clinical involvement in commissioning.

BackgroundGeneral practices have begun working collaboratively in general practitioner federations, which vary in scope, geographical reach and organisational form.ObjectivesThe aim was to assess how federating affects practice processes, workforce, innovations in practices and the interface with health and social care stakeholders.DesignThis was a structured cross-sectional comparison of four case studies, using observation of meetings, interviews and analysis of documents. We combined inductive analysis with literature on ‘meta-organisations’ and networks to provide a theoretically informed analysis.ResultsAll federations were ‘bottom-up’ voluntary membership organisations but with formal central authority structures. Practice processes were affected substantially in only one site. In this site, practices accepted the rules imposed by federation arrangements in a context of voluntary participation. Federating helped ease workforce pressures in two sites. Progress regarding innovations in practice and working with health and social care stakeholders was slower than federations anticipated. The approach of each federation central authority in terms of the extent to which it (1) sought to exercise control over member practices and (2) was engaged in ‘system proactivity’ (i.e. the degree of proactivity in working across a broader spatial and temporal context) was important in explaining variations in progress towards stated aims. We developed a typology to reflect the different approaches and found that an approach consisting of high levels of both top-down control and system proactivity was effective. One site adopted this ‘authoritative’ approach. In another site, rather than creating expectations of practices, the focus was on supporting them by attempting to solve the immediate problems they faced. This ‘indulgent’ approach was more effective than the approach used in the other two sites. These had a more distant ‘neglectful’ relationship with practices, characterised by low levels of both control over members and system proactivity. Other key factors explaining progress (or lack thereof) were competition between federations (if any), relationship with the Clinical Commissioning Group, money, history, leadership and management issues, size and geography; these interacted in a dynamic way. In the context of a tight deadline and fixed targets, federations were able to respond to the requirements to provide additional services as part of NHS Improving Access to General Practice policy in a way that would not have been possible in the absence of federations. However, this added to pressures faced by busy clinicians and managers.LimitationsThe focus was on only four sites; therefore, any federations that were more active than those federations in these four sites will have been excluded. In addition, although patients were interviewed, because most were unaware of federations, they generally had little to say on the subject.ConclusionsGeneral practices working collaboratively can produce benefits, but this takes time and effort. The approach of the federation central authority (authoritative, indulgent or neglectful) was hugely influential in affecting processes and outcomes. However, progress was generally slower than anticipated, and negligible in one case.Future workFuture work would benefit from multimethod designs, which provide in-depth, longitudinal, qualitative and quantitative methods, to shed light on processes and impacts.FundingThis project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full inHealth Services and Delivery Research; Vol. 8, No. 11. See the NIHR Journals Library website for further project information.

In spite of their widespread use in policy making in the UK and elsewhere, there is a relatively sparse literature specifically devoted to policy pilots. Recent research on policy piloting has focused on the role of pilots in making policy work in accordance with national agendas. Taking this as a point of departure, the present paper develops the notion of pilots doing policy work. It does this by situating piloting within established theories of policy formulation and implementation, and illustrating using an empirical case. Our case is drawn from a qualitative policy ethnography of a local government pilot programme aiming to extend access to healthcare services. Our case explores the collective entrepreneurship of regional policy makers together with local pilot volunteers. We argue that pilots work to mobilise and manage the ambiguity and conflict associated with particular policy goals, and in their structure and design, shape action towards particular outcomes. We conclude with a discussion of the generative but managed role which piloting affords to local implementers.

The optimal balance between central governmental authority and the degree of autonomy of local public bodies is an enduring issue in public policy. The UK National Health Service is no exception, with NHS history, in part at least, a history of repeated cycles of centralisation and decentralisation of decision-making power. Most recently, a significant reorganisation of the NHS in 2012–13 was built around the creation of new and supposedly more autonomous commissioning organisations (Clinical Commissioning Groups – CCGs). Using Bossert's (1998) concept of ‘decision space’, we explored the experiences of local commissioners as they took on their new responsibilities. We interviewed commissioning staff from all of the CCGs in two regional health care ‘economies’, exploring their perceptions of autonomy and their experiences over time. We found significant early enthusiasm for, and perceptions of, increased autonomy tempered in the vertical dimension by increasingly onerous and prescriptive monitoring regimes, and in the horizontal dimension by the proliferation of overlapping networks, inter-organisational groups and relationships. We propose that, whatever the balance between central and local control that is adopted, complex public services require some sort of meso-level oversight from organisations able to ‘hold the ring’ between competing interests and to take a regional view of the needs of the local health system. This suggests that local organisational autonomy in such services will always be constrained.

We use the lens of ‘institutional work’ to explore the implementation of innovative projects within the NHS in England, designed to improve access to primary care services. We report a qualitative process evaluation of their implementation. We highlight the conflicting institutional logics at work across the field, and provide some examples of ‘creating’ and ‘disrupting’ institutional work required to bridge them. We explore the enabling conditions which may have allowed our participants to temporarily transgress the institutional constraints within which they worked. We provide evidence which may be of practical use for those seeking to innovate in this way, and ask whether or not these micro-level acts of creation and disruption may, in the longer term, accumulate towards wider institutional change.

Background The 2012 Health and Social Care Act in England replaced primary care trusts with clinical commissioning groups (CCGs) as the main purchasing organisations. These new organisations are GP-led, and it was claimed that this increased clinical input would significantly improve commissioning practice. Aim To explore some of the key assumptions underpinning CCGs, and to examine the claim that GPs bring ‘added value’ to commissioning. Design and setting In-depth interviews with clinicians and managers across seven CCGs in England between April and September 2013. Method A total of 40 clinicians and managers were interviewed. Interviews focused on the perceived ‘added value’ that GPs bring to commissioning. Results Claims to GP ‘added value’ centred on their intimate knowledge of their patients. It was argued that this detailed and concrete knowledge improves service design and that a close working relationship between GPs and managers strengthens the ability of managers to negotiate. However, responders also expressed concerns about the large workload that they face and about the difficulty in engaging with the wider body of GPs. Conclusion GPs have been involved in commissioning in many ways since fundholding in the 1990s, and claims such as these are not new. The key question is whether these new organisations better support and enable the effective use of this knowledge. Furthermore, emphasis on experiential knowledge brings with it concerns about representativeness and the extent to which other voices are heard. Finally, the implicit privileging of GPs’ personal knowledge ahead of systematic public health intelligence also requires exploration.

In this essay, I explore the rise of the concept of ‘leadership’ in the English NHS, highlighting the similarity with a previous shift from (bad, old) ‘administration’ to (good, new) ‘management’. I take a critical look at this discursive shift and highlight some of the overblown claims made for the value of ‘clinical leadership’. I argue that, rather than turning all NHS staff into leaders, we should perhaps tone down the level of our rhetoric and instead emphasize the need for a service full of good followers who will maintain a relentless focus on care, quality and efficiency.

The English NHS is currently organised around a split between the ‘commissioning’ and the ‘providing’ of health care. There has been considerable critical comment about commissioning, focusing upon perceived inadequacies of the regulatory structure and a perceived lack of competence of the managers concerned. In this paper, we use empirical data from two detailed studies of commissioning to propose a third explanation of the difficulties that have been observed in making commissioning work. We apply Scott's institutional analysis to the issue, arguing that far from reflecting managerial incompetence, some of the difficulties experienced are inherent in the normative and cultural/cognitive pillars of the NHS institution, so that there is a lack of ‘fit’ between commissioning and the institutional characteristics of the NHS. We conclude by exploring the potential impact of the latest round of NHS changes on this institution.

Central policies that are only loosely specified might be expected to result in local variations in interpretation and implementation, and practice-based commissioning in the English National Health Service (NHS) is no exception. We show how local ‘sensemaking’ in relation to this policy has been influenced by local histories and by conceptual schemata derived from earlier reorganisations of the NHS. Changes to organisational formalities do not necessarily, therefore, result in reappraisals of sensemaking on the part of local actors. We also employ our data to address issues raised by commentators critical of the way the concept of sensemaking has been previously employed.

With the recent publication of The Engagement Cycle (DH, 2009a), exploring the issues surrounding patient and public involvement (PPI) in World Class Commissioning, it seems timely to look at how this type of involvement/engagement has developed in recent years. Set against official rhetoric that emphasises the importance of PPI in the NHS, this paper is informed by evidence emerging from a three‐year research project into the development of practice‐based commissioning conducted at Manchester University. It is suggested that commissioners (primary care trusts and practice‐based commissioners) need to think deeply about the meaning of public involvement in their context, while at national level strategies should be flexible enough to allow a diversity of approaches which may ultimately allow PPI to flourish.

Alford's theory of structural interests has been used as a framework within which to analyse health systems across the world. However, authors have often been uncritical in their acceptance of Alford's original analytic categories. In this article we use data from a detailed qualitative study of the introduction of Practice Based Commissioning in the UK NHS to interrogate Alford's work more critically. Disrupting Alford's original categories of ‘professional monopolisers’ as dominant interests, challenged by management ‘corporate rationalisers’, we suggest that the new structures established in the NHS since 2002 systematically privilege an interest that we call ‘corporate monopolisers’, and that this is under challenge from ‘professional rationalisers’.

PurposeThe purpose of this paper is to discuss the impact of contracts on general practise in the UK National Health Service. In particular, it is concerned with the response of practitioners to the apparent flexibilities offered in the new contract with its focus on outcomes rather than processes.Design/methodology/approachEthnographic studies of two general practices, using non‐participant observation, documents and interviews with staff over a five‐month period.FindingsConclusions suggest that the new contracts, far from encouraging flexibility and responsiveness from general practitioners, have tended to strengthen bureaucratic forms in the way the contract is implemented.Originality/valueThe new contract has introduced greater clarity regarding roles and responsibilities within practises. At the same time, when operating in financially tight conditions, the contract can make rationing more explicit. Decisions are made not in accordance with the targets but in light of local pressures and constraints, causing tensions between primary and tertiary care.

The Local Government Act (2000) introduced new Overview and Scrutiny Committees, composed of elected non‐executive councillors, that can respond to proposals from the NHS for changes in services and also set their own agendas for more detailed scrutiny, including of the NHS. Limited capacity has meant that the focus of scrutiny has often been on statutory consultations from the NHS, service provision, NHS organisations and only occasionally on wider issues. However, it is commissioning that is officially seen as the main vehicle for shaping NHS services, so health scrutiny ought logically to address itself more to commissioning than to investigating providers. Practice‐based Commissioning (PBC) was introduced in 2004 with the aim of engaging front‐line clinicians in commissioning health care, though most such commissioning is being undertaken by groups of practices joining together to form consortia, rather than by individual GPs. In principle, this makes it more practicable for health scrutiny to include PBC, but consortia are not statutory bodies and cannot be compelled to participate. We suggest ways in which this omission might be addressed.

In 2004 a new contract was introduced for General Practitioners in the UK, which introduced a significant element of 'pay-for-performance', including both clinical and organisational targets. The introduction of this contract has caused interest across the world, particularly amongst those responsible for commissioning primary care services. It can be argued that the clinical targets in the contract (known as the Quality and Outcomes Framework, QOF) represent a move towards a more biomedical model of health and illness, which is contrary to the ideal of providing holistic (or biopsychosocial) care that has been traditionally espoused by GPs. This paper reports results from two linked studies (in England and Scotland) investigating the early stages of the new contract. We describe the way in which four practices with different organisational approaches and espoused identities have all changed their practice structures, consultations and clinical care in response to QOF in ways which will result in patients receiving a more biomedical type of care. In spite of these observed changes, respondents continued to maintain discursive claims to holism. We discuss how this disconnection between rhetoric and reality can be maintained, and consider its implications for the future development of GPs' claims to a professional identity.

This paper examines the responses of primary health care clinicians (doctors and nurses) to an invitation to enterprise contained in a new contract which offers financial rewards for meeting targets. We suggest that far from being swept along by a hegemonic enterprise discourse or having `no choice but to comply' (Cohen and Musson, 2000: 45), the engagement of our study participants in enterprising behaviours can be understood in terms of a more active process, albeit one characterized by new bureaucratic forms. Rather than riding roughshod over cherished traditional identities, part of the attraction of enterprise in our case study can be understood in terms of its role in assisting enterprising clinicians in managing the tensions inherent in these identities.

PurposeThe authors' aim was to investigate mechanisms and perceptions of control following the implementation of a new “pay‐for‐performance” contract (the new General Medical Services, or GMS, contract) in general practice.Design/methodology/approachThis article was based on an in‐depth qualitative case study approach in two general practices in England.FindingsA distinction is emerging amongst ostensibly equal partners between those general practitioners conducting and those subject to surveillance. Attitudes towards the contract were largely positive, although discontent was higher in the practice which employed a more intensive surveillance regime and greater amongst nurses than doctors.Research limitations/implicationsThe sample was small and opportunistic. Further research is required to examine the longer‐term effects as new contractual arrangements evolve.Practical implicationsIncreased surveillance and feedback mechanisms associated with new pay‐for‐performance schemes have the potential to constrain and shape clinical practice.Originality/valueThe paper highlights the emergence of new tensions within and between existing professional groupings.

The new General Medical Services contract was introduced into general practice in the UK in 2004, and it links pay to performance far more than in the past. As a result, accurate data collection about patients and the care that they receive is now not only important for good patient care but also to prove that targets are being met. The use of electronic records and information technology has thus become much more sophisticated. This article reports the results from an ethnographic study of the early stages of the new contract in two general practices. As expected, electronic data collection had increased in importance in both practices, with consequences both for clinician–patient interactions and for the structures and processes in the practices, as uniform data collection instruments are put in place that privilege ‘hard’ biomedical data that can be easily coded above ‘softer’, more patient-centred information. Roles and responsibilities had been changed to reflect the needs of the new systems, and new software applications allowed increased surveillance of both doctors’ and nurses’ performance; both of these had an impact on patterns of authority in our study practices. Furthermore, the structural changes that were found acted to embed the new ways of working, ensuring their reproduction in the future. In spite of these effects, we found little opposition to or critical reflection on the changes, and the doctors in our study continued to view their improved computer systems as neutral recording devices. The implication of these findings is discussed.

Objectives: To investigate how general medical practices in the UK react to bureaucratic initiatives, such as National Health Service (NHS) National Service Frameworks (NSFs), and to explore the value of the metaphor of 'barriers to change' for understanding this. Methods: Interviews, non-participant observation and documentary analysis within case studies of four practices in northern England. Results: The practices had not actively implemented NSFs. At interview, various 'barriers' that had prevented implementation were listed, including the complexity of the documents and lack of time. Observation suggested that these barriers were constructions used by the participants to make sense of the situation in which they found themselves. Conclusion: The metaphor of 'removing barriers to change' was of limited use in a context where non-implementation of policy was an emergent property of underlying organizational realities, likely to be modifiable only if these realities were addressed.

In seeking to prevent a reoccurrence of scandals such as that involving cardiac surgery in Bristol, the UK government has adopted a model of regulation that uses rules and surveillance as a way of both improving the quality of care delivered and increasing confidence in healthcare institutions. However, this approach may actually act to reduce confidence and trust while also reducing the moral motivation of practitioners. Accountability in health care is discussed, and it is suggested that openness about the difficult dilemmas that arise when practitioners have a duty to be accountable to more than one audience may be an alternative means of restoring trust. A greater emphasis on the sharing of information between individual health professionals and their patients would increase trust and would allow patients to hold their doctors to account for the quality of care they receive. Concentrating more on developing trust by the sharing of information and less on the futile search for complete confidence in systems and rules may improve the quality of care delivered while also nurturing the moral motivation of professionals upon which the delivery of high quality health care depends.

Objective: One of the key goals of the current reforms in the English National Health Service (NHS) under the Health and Social Care Act, 2012, is to increase the accountability of those responsible for commissioning care for patients (clinical commissioning groups (CCGs)), while at the same time allowing them a greater autonomy. This study was set out to explore CCG’s developing accountability relationships. \ud \ud Design: We carried out detailed case studies in eight CCGs, using interviews, observation and documentaryanalysis to explore their multiple accountabilities.\ud Setting/participants: We interviewed 91 people,including general practitioners, managers and governing body members in developing CCGs, and undertook 439 h of observation in a wide variety of meetings.\ud \ud Results: CCGs are responsible to a managerial, sanction-backed accountability to NHS England (the highest tier in the new organisational hierarchy), alongside a number of other external accountabilities to the public and to some of the other new organisations created by the reforms. In addition, unlike their predecessor, commissioning organisations, they are subject to complex internal accountabilities to their members.\ud \ud Conclusions: The accountability regime to which CCGs are subject to is considerably more complex than that which applied their predecessor organisations. It remains to be seen whether the twin aspirations of increased autonomy and increased accountability can be realised in practice. However, this early study raises\ud some important issues and concerns, including the risk that the different bodies to whom CCGs are accountable will have differing (or conflicting) agendas, and the lack of clarity over the operation of sanction regimes.

PurposeThe purpose of this paper is to explore the practical daily work undertaken by middle‐level managers in Primary Care Trusts (PCTs), focusing upon the micro‐processes by which these managers enact sensemaking in their organisations.Design/methodology/approachThe research took a case study approach, undertaking detailed case studies in four PCTs in England. Data collection included shadowing managers, meeting observations and interviews.FindingsThe research elucidated two categories of enactment behaviour exhibited by PCT managers: presence/absence; and the production of artefacts. Being “present” in or “absent” from meetings enacted sensemaking over and above any concrete contribution to the meeting made by the actors involved. This paper explores the factors affecting these processes, and describes the situations in which enactment of sense is most likely to occur. Producing artefacts such as meeting minutes or PowerPoint slides also enacted sense in the study sites in addition to the content of the artefact. The factors affecting this are explored.Practical implicationsThe study has practical implications for all managers seeking to maximise their influence in their organisations. It also provides specific evidence relevant to managers working in the new Clinical Commissioning Groups currently being formed in England.Originality/valueThe study expands the understanding of sensemaking in organisations in two important ways. Firstly, it moves beyond discourse to explore the ways in which behaviours can enact sense. Secondly, it explores the distinction between active and unconscious sensemaking.

The 2004 new General Medical Services (nGMS) contract exemplifies trends across the public services towards increased definition, measurement and regulation of professional work, with general practice income now largely dependent on the quality of care provided across a range of clinical and organisational indicators known collectively as the 'Quality and Outcomes Framework' (QOF). This paper reports an ethnographically based study of the impact of the new contract and the financial incentives contained within it on professional boundaries in UK general practice. The distribution of clinical and administrative work has changed significantly and there has been a new concentration of authority, with QOF decision making and monitoring being led by an internal QOF team of clinical and managerial staff who make the major practice-level decisions about QOF, monitor progress against targets, and intervene to resolve areas or indicators at risk of missing targets. General practitioners and nurses, however, appear to have accommodated these changes by re-creating long established narratives on professional boundaries and clinical hierarchies. This paper is concerned with the impact of these new arrangements on existing clinical hierarchies.

It is now accepted in general practice that we should incorporate the evidence derived from biomedical research into our practice, and both current contractual and proposed governance arrangements are designed to encourage this. The paper in this issue of the BJGP by Hewitt et al 1 reminds us of the additional importance of applying evidence to the overall service that we provide as well as to the narrow medical content of our consultations. Focusing on the detail of receptionist–patient interactions, Hewitt and her co-authors point to some of the contexts in which misunderstanding, miscommunication, and ultimately dissatisfaction may arise. They demonstrate that receptionists tend to use a limited repertoire of styles of communication, and that some of these styles are more prone than others to generate misunderstandings or miscommunications. This is important because such miscommunications, especially if repeated in subsequent visits to the practice, may build up to generate significant patient dissatisfaction; in the competitive environment currently facing general practice this could become a real problem. The obvious approach to address this danger would be via staff training, and the paper by Hewitt et al …

Key messages The Quality and Outcomes Framework (QOF) has been efficiently and effectively incorporated into practice routines. One possible negative effect of this has been a move towards a more biomedical form of practice. There has been patchy but real engagement with practice-based commissioning (PBC), with significant moves in some areas towards GPs acting collectively to improve services across the health economy, including engaging in performance management of each others' practice. Together, responses to QOF and PBC suggest that GPs may be willing and able to act both individually and collectively to try to mitigate the negative impacts of future spending reductions Why this matters to me General practice will be under a great deal of pressure in the next few years. Understanding the impact of past policy changes is essential if we are to ensure that the core values of general practice are maintained.

National Service Frameworks are an integral part of the government's drive to 'modernise' the NHS, intended to standardise both clinical care and the design of the services used to deliver that clinical care. This article uses evidence from qualitative case studies in three general practices to illustrate the difficulties associated with the implementation of such top-down guidelines and models of service. In these studies it was found that, while there had been little explicit activity directed at implementation overall, the National Service Framework for coronary heart disease had in general fared better than that for older people. Gunn's notion of 'perfect implementation' is used to make sense of the findings.

Objectives To examine the managerial behaviours adopted by commissioning managers in English primary care trusts (PCTs), and to explore the impact of these behaviours. Methods Qualitative case studies were undertaken in four PCTs, focusing on staff engaged in the commissioning of hospital services. Both formal and informal observation were undertaken (150 hours), and 41 in-depth interviews conducted with managers and general practitioners (GPs). Results Managers adopted many managerial behaviours familiar from the literature, including sharing information, and networking inside and outside the organization. Multiple organizational layers and unclear decisionmaking processes hindered this activity. In addition, some managers with responsibility for facilitating practice-based commissioning (PbC) adopted a managerial mode that we have called being an ‘animateur’. This approach involved the active management of disparate groups of people over whom the manager had no authority, and appeared to be a factor in determining success. It was facilitated by managerial autonomy and was more prevalent where managers were seen to have legitimacy. Some organizational practices appeared to inhibit its development. Conclusions From 2012/13 it is planned that GPs will be taking more responsibility for commissioning in the English NHS. This research suggests that managers of the new commissioning organizations will require a deep and contextualized understanding of the NHS and that it is important that organizational processes do not inhibit managerial behaviour. Legitimacy may be an issue in contexts were managers are automatically transferred from their existing appointments.