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Objective Little is known about how to achieve scale and spread beyond the early local adoption of an innovative health care programme. We use the New Care Model – or ‘Vanguard’ – programme in the English National Health Service to illuminate the process, assessing why only one of five Vanguard programmes was successfully scaled up. Methods We interviewed a wide range of stakeholders involved in the Vanguard programme, including programme leads, provider organisations, and policymakers. We also consulted relevant documentation. Results A lack of direction near the end of the Vanguard programme, a lack of ongoing resources, and limited success in providing real-time monitoring and evaluation may all have contributed to the failure to scale and spread most of the Vanguard models. Conclusions This programme is an example of the ‘scale and spread paradox’, in which localism was a key factor influencing the successful implementation of the Vanguards but ultimately limited their scale and spread.

In this chapter we introduce the background and rationale for our historical review of community nursing services through the lens of health policy. We provide the research questions the review is based on and detail the topic themes used to structure our answers to these questions. We have considered policy relating to community nursing services over seven eras from 1948 to the present day and each subsequent chapter details this. A definition of community/district nursing used for the purposes of the review is provided, as well as an outline of the structure of the chapters and the book. Each chapter will follow a consistent format: Historical context The role and function of community/district nursing services The management of community/district nursing services and the population covered Financing community/district nursing services Summary

In this chapter, we detail the first major re-organisation of the NHS since its inception and the consequences for community nursing. The 1974 wholesale re-organisation was born out of frustrations with the management and fragmentation of services resulting from the tripartite system. Services were bought together in a unitary model, centrally controlled but geographically organised. Local Authorities (LAs) were divested of many of their healthcare responsibilities including community nursing, which was transferred under the responsibility of newly created Area Health Authorities (AHAs). There was optimism that bringing community nursing under the NHS umbrella would foster a new era of co-ordinated working between all disciplines in the system, such as hospital nursing. Unfortunately, many of these intended aspirations were not realised despite the importance of the service to policy agendas emphasising integration, out-of-hospital care and prevention of ill health. In terms of managing and financing the district nursing service, this was not simplified by the re-organisation and population coverage continued as a mix of geographical and attachment to GP services. We conclude this chapter by emphasising the increasing demand for community and district nursing services. It became apparent in this era that the re-organisation did not bring any significant improvements and thus the attention shifted again towards organisational and management solutions to the NHS’ problems.

This chapter centres on the publishing of the NHS Long Term Plan in 2019 and subsequent revised Health and Social Care Act (2022), both of which focus on integrated, out-of-hospital approaches to health service delivery. The creation of a layered system across geographical levels is advocated, with nested levels of ‘place’ and ‘neighbourhood’ intended to be the building blocks of Integrated Care Systems (ICS), which replaced CCGs in July 2022. We introduce the concept of newly created, ‘neighbourhood level’, Primary Care Networks (PCNs) of general practices and how district nurses fit into them, especially with regard to their organisation around geographical versus GP registered lists. Whilst not explicitly mentioned in the H&SC Act, it is clear that the Act situates community-based services as essential in the context of the desire to reduce the amount of hospital care, which has implications for district nursing services in particular. This mode of care delivery will require multi-disciplinary team working across all levels of the new system whereby community nurses will be required to liaise and co-ordinate with primary and social care to deliver services. Continuance of case management approaches for patients with complex needs and lack of funding in the social care system, means that we discuss in this chapter, the further strain on already pressured community nursing teams.

The National Health Service and Community Care Act 1990, set in motion by the publication of the 1989 White Papers—Working for Patients and Caring for People, saw an intense time of policy change which would profoundly impact community and district nursing services. These papers ushered in the introduction of the internal market with purchaser/provider split between commissioners and providers of services, aiming for better services, better patient choice and to reduce costs. This chapter focuses on how the NHS was re-structured to facilitate this quasi-market organisation with Health Authorities (HAs), once pivotal, replaced by Primary Care Groups (PCGs) at the end of the decade. We document here the impact of these changes on the district nursing service as well as bringing to the fore that it was a service in crisis and in need of attention. Heavy caseloads coupled with a diminishing workforce led to a review of the grading system and an increasing use of ‘skill-mix’. We also highlight that aligned with internal marketisation ideals, funding of community services was based on a crude count of average number of contacts rather than based on the complexities of the role. As ever, there was a need for district nurses to ‘deliver more for less’ (Audit Commission, 1999, p. 94) at the end of the era.

In this final chapter of the book, we return to our original research questions and draw together our findings, looking across the eras to illustrate how the policy changes of the past have defined the services of today and the future. We show how, over time, there has been a consistent pattern in policy by which community nursing services are rarely the focus of policy. Rather, changes have occurred in policy which have had a knock-on effect on Community Health Services (CHS), and these effects have often been to their detriment. In the conclusion, we offer observations on the incoming policy changes in 2022 (H&CA, 2022) and suggestions for future research. Proposals for the development of Integrated Care Systems (ICS) offer both opportunities and threats to the provision of community nursing/health services—the former from more investment or the latter from being dominated by larger acute services. Our main concern is there is a danger that the voice and needs of CHS will yet again remain unheard and un-regarded.

Taking the first era from the inception of the NHS through to 1974, this chapter documents the establishment of the service as a home nursing service. Known as the ‘tripartite era’ because of the way provision of health services were divided between three types of bodies—Local Authorities (LA), Executive Councils of the Ministry of Health and Hospital Boards—this era would see a split enshrined between LA-provided community nursing services and medical services provided by the others. This split has been a feature of the NHS ever since, despite successive unifying re-organisations of the health service, and has come to define the way community nursing is perceived by policy apparent in this review. In line with the format of the chapters, we start to look at the role and function of district nurses (DNs) and begin to see how the role was focused on home care for the sick, management of infectious diseases and supporting doctors. We also begin to examine how DNs were managed and paid for and identify the enduring tensions in how they are organised—either geographically or attached to GP practices. We conclude this chapter with a brief paragraph summing up that for this era the role of district nurse services, despite becoming a national requirement, is rarely fully set out in policy. In other words, the district nursing service was largely invisible in policy terms.

The new millennium saw the publication of The NHS Plan in 2000, which bought a welcome focus to community health services (CHS) and the role of community nursing. We outline the proposals contained in the plan which furthered the quasi-marketisation of the NHS and increased commissioning of health care at the local level of Primary Care Trusts (PCTs)—replacing Health Authorities (HAs) and Primary Care Groups (PCGs). A further review by Lord Darzi and subsequent policy, Transforming Community Services: Enabling new patterns of provision (DoH, 2009) instigated the separation of commissioning/provision and laid out timetables for how PCTs were to do this. The long held roles of the district nursing service continues in this era, although not always clearly defined, understood or acknowledged and policy attempts to expand their remit feature heavily. This included more clinical tasks as well as focusing on such things as public health/health protection and promotion programmes that improve health and reduce inequalities. This chapter also describes the uncertainty for frontline nurses that the Transforming Community Services (TCS) brought in terms of who their employer would be or what management arrangements they would work under given the establishment of some standalone Trusts, some third sector and some combined acute/community Trusts. The aims of the TCS programme were bold but in reality achieved little by the end of the era.

A change of government in 2010 brought fresh NHS reforms and a new Health and Social Care Act (HSCA, 2012). Both, along with the 2014, Five Year Forward View (NHSE) set the tone for this Chapter. We discuss how the continued emphasis on competition between providers, and the introduction of Clinical Commissioning Groups (CCGs) which replaced Primary Care Trusts (PCTs) as commissioners of community services, impacted on community nursing service management and delivery. Policy shifted in favour of a more co-operative approach to service provision and familiar agendas were set out for keeping people out of hospital with reform based around integration between health care sectors and between health and social care services. There was little change on the ground for district nurses in this era despite increasing emphasis on integrated care, collaborative, cross-sector working (i.e. with LA social care) and multi-disciplinary team management of complex patients. The HSCA 2012 began to unravel almost as soon as it was enacted, with the emphasis on competition undermined by the Five Year Forward View shift towards integration between sectors as a dominant organising principle. Community Health Services (CHS) were, to some extent, protected from the fragmentation associated with the Act, and in terms of district nursing practice, this era generated little change with patterns of service provision remaining very much as they were following the upheaval generated by the Transforming Community Services agenda.

This was another period of churn for the NHS. First, the service endured another restructuring exercise, reducing hierarchical layers to a less rigid bureaucratic structure. Area Health Authorities (AHAs) were abolished in 1982 and replaced by 192 District Health Authorities (DHAs). Second, there was a move away from ‘consensus’ style management towards ‘general management’ following the publication of the influential Griffiths Report in 1983. This marked an important phase in the NHS in which a clearly defined management function was implemented to improve efficiency, planning and accountability but bought shifting sands to the way community nursing services were managed. A review of community nursing services in a similar vein, The Cumberlege Report (1986), also proved significant. We focus on the recommendations of this report for improving the role and function of district nursing services and their geographical deployment to strengthen the concept of a localised, neighbourhood nursing structure. Whilst this was a period of change in terms of the organisation and management of Community Health Services and indeed the NHS as a whole, the core role of community or district nurses remained as one of care in the community but with an emphasis on greater multi-disciplinary team working.

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.

Purpose Neo-liberal “reform” has in many countries shifted services across the boundary between the public and private sector. This policy re-opens the question of what structural and managerial differences, if any, differences of ownership make to healthcare providers. The purpose of this paper is to examine the connections between ownership, organisational structure and managerial regime within an elaboration of Donabedian’s reasoning about organisational structures. Using new data from England, it considers: how do the internal managerial regimes of differently owned healthcare providers differ, or not? In what respects did any such differences arise from differences in ownership or for other reasons? Design/methodology/approach An observational systematic qualitative comparison of differently owned providers was the strongest feasible research design. The authors systematically compared a maximum variety (by ownership) sample of community health services; out-of-hours primary care; and hospital planned orthopaedics and ophthalmology providers (n=12 cases). The framework of comparison was the ownership theory mentioned above. Findings The connection between ownership (on the one hand) and organisation structures and managerial regimes (on the other) differed at different organisational levels. Top-level governance structures diverged by organisational ownership and objectives among the case-study organisations. All the case-study organisations irrespective of ownership had hierarchical, bureaucratic structures and managerial regimes for coordinating everyday service production, but to differing extents. In doctor-owned organisations, the doctors’, but not other occupations’, work was controlled and coordinated in a more-or-less democratic, self-governing ways. Research limitations/implications This study was empirically limited to just one sector in one country, although within that sector the case-study organisations were typical of their kinds. It focussed on formal structures, omitting to varying extents other technologies of power and the differences in care processes and patient experiences within differently owned organisations. Practical implications Type of ownership does appear, overall, to make a difference to at least some important aspects of an organisation’s governance structures and managerial regime. For the broader field of health organisational research, these findings highlight the importance of the owners’ agency in explaining organisational change. The findings also call into question the practice of copying managerial techniques (and “fads”) across the public–private boundary. Originality/value Ownership does make important differences to healthcare providers’ top-level governance structures and accountabilities and to work coordination activity, but with different patterns at different organisational levels. These findings have implications for understanding the legitimacy, governance and accountability of healthcare organisations, the distribution and use power within them, and system-wide policy interventions, for instance to improve care coordination and for the correspondingly required foci of healthcare organisational research.

Objectives To establish how quality indicators used in English community nursing are selected and applied, and their perceived usefulness to service users, commissioners and service providers. Methods A qualitative multi-site case study was conducted with five commissioning organizations and their service providers. Participants included commissioners, provider organization managers, nurses and service users. Results Indicator selection and application often entail complex processes influenced by wider health system and cross-organizational factors. All participants felt that current indicators, while useful for accountability and management purposes, fail to reflect the true quality of community nursing care and may sometimes indirectly compromise care. Conclusions Valuable resources may be better used for comprehensive system redesign, to ensure that patient, carer and nurse priorities are given equivalence with those of other stakeholders.

The recent growth of medicine sales online represents a major disruption to pharmacy markets, with COVID-19 encouraging this trend further. While e-pharmacy businesses were initially the preserve of high-income countries, in the past decade they have been growing rapidly in low-income and middle-income countries (LMICs). Public health concerns associated with e-pharmacy include the sale of prescription-only medicines without a prescription and the sale of substandard and falsified medicines. There are also non-health-related risks such as consumer fraud and lack of data privacy. However, e-pharmacy may also have the potential to improve access to medicines. Drawing on existing literature and a set of key informant interviews in Kenya, Nigeria and India, we examine the e-pharmacy regulatory systems in LMICs. None of the study countries had yet enacted a regulatory framework specific to e-pharmacy. Key regulatory challenges included the lack of consensus on regulatory models, lack of regulatory capacity, regulating sales across borders and risks of over-regulation. However, e-pharmacy also presents opportunities to enhance medicine regulation—through consolidation in the sector, and the traceability and transparency that online records offer. The regulatory process needs to be adapted to keep pace with this dynamic landscape and exploit these possibilities. This will require exploration of a range of innovative regulatory options, collaboration with larger, more compliant businesses, and engagement with global regulatory bodies. A key first step must be ensuring that national regulators are equipped with the necessary awareness and technical expertise to actively oversee this e-pharmacy activity.

The English National Health Service (NHS) constitutes a unique institutional context, which combines elements of hierarchy, markets and networks. This has always raised issues about competing forms of accountability. Recent policy has emphasised a move from quasi market competition towards collaboration in the form of new regional organisational arrangements known as Sustainability and Transformation Partnerships (STPs). We explore accountability relationships in STPs, focusing on the challenges of increasing horizontal accountability given existing vertical accountabilities, most notably to national regulators. We utilize a case study approach concentrated on three Clinical Commissioning Groups (CCGs) in urban and rural settings in England. We conducted in-person interviews with 22 managers from NHS organisations and local authorities and examined local documents to obtain information on governance and accountability structures. The fieldwork was undertaken between November 2017 and July 2018. We analysed results by considering which actors were accountable to what forums and the nature of the obligation (vertical or horizontal). We found that individual organisations still retained vertical accountabilities and were reluctant to be held accountable for the whole STP, given they were responsible for only part of the joint effort. Moreover, organisations did not feel accountable to STPs and instead highlighted vertical accountabilities upwards to their own boards and to national regulators; and downwards to the public. But while local commissioning organisations, CCGs engaged with their members and the public, STPs failed to engage adequately with the public. Nevertheless, there were indications that horizontal accountability was starting to develop. This could become complementary to vertical accountability by facilitating mutual learning and peer review to anticipate and defer regulatory intervention. While vertical accountability is necessary to provide oversight and apply sanctions, it is not sufficient and should be accompanied by horizontal accountability.

COVID-19 has thrown NHS procurement into the limelight, but the shortage of personal protective equipment (PPE) has complex origins. This article explores the long-lasting struggle for centralisation in NHS procurement and its impact on the current PPE crisis.

Policy driven change is challenging, with a significant gap between theory and practice. A key tension in enacting such change is achieving a balance between bottom-up development of local, context-specific approaches, and top-down, centrally determined policy solutions and their mutual sequencing. Ideal type models of the policy-making process envisage a rational ordered approach, driven by evidence and accompanied by ongoing evaluation of outcomes (Parsons, 1995, p77); however, the reality is far more complex. We examine the implementation and early operation of the New Care Models (NCM) Vanguard programme in England, using Matland’s (1995) ambiguity-conflict model, to explore the aims and expectations of the programme. We consider the relationship between top-down and bottom-up approaches to policy development and draw attention to the pressures coming from what was initially perceived as a permissive policy approach of encouraging experimentation, whilst also requiring rapid learning, scale and spread. We suggest that future programmes for large-scale policy implementation initiatives could be crafted differently to take account of the environment of implementation and render ambitions more realistic. Rather than aiming to create a set of definite products and templates, it may be that a set of principles for design and implementation should be developed and spread.

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.

Chapter 7 reports two aspects of research on contracting in the NHS. The first investigates how the policies to use contractual mechanisms including financial risk allocation work in practice. Most of the contractual relationships between NHS owned acute providers and commissioners were characterised by the use of general annual financial settlements outside the terms of the contract. This behaviour appeared to be increasing over time. The second study comprises a review of the evidence concerning new forms of contract being introduced into the NHS: alliance and outcome based contracts. These are aimed at facilitating the integration of services and improving quality of care. Evidence from other sectors indicates that new models of contracting may result in cost savings including a reduction in capital costs, the development of innovations and benefits in relation to time. But there are high transaction costs in relation to the process of contract negotiation and specification. The evidence base regarding improvements in the quality of services is not convincing. These models carry a number of potential governance issues in relation to their implementation in the NHS, and are at risk of failing to satisfy public sector governance objectives including accountability, integrity and transparency.

The aim of this book is to bring together in one volume the most important research which the Policy Research Unit in Commissioning and the Healthcare System (PRUComm) has undertaken during the period 2011 to 2018. PRUComm is a multicentre research unit based at the London School of Hygiene & Tropical Medicine, the University of Manchester and the University of Kent. PRUComm is funded by the Policy Research Programme of the English Department of Health and Social Care from 2011 onwards to provide evidence to the DHSC to inform the development of policy on commissioning and the healthcare system. The analytical work supports understanding of how NHS commissioning operates and how it can improve services and access, increase effectiveness and respond better to patient and population needs. The structural changes introduced by the Health and Social Care Act 2012 pursuant to the twin policies of increasing clinical involvement in commissioning and accelerating market forces have had large effects on the practice of commissioning across the NHS. There has been a great increase in the complexity of health system governance. The number of bodies undertaking commissioning has increased and there has also been a proliferation of other NHS organisations required to regulate the complex system. The effect of this increase in complexity in the governance of the NHS has been wide-ranging. As a result, local autonomy is severely limited and the original policy aspirations to deliver freedom from government control and greater accountability to patients and greater democratic legitimacy have not been realised to any significant degree. In addition, the fragmentation of commissioning roles has been damaging to the planning and delivery of services which are subject to several commissioning regimes. Not only is there evidence of deterioration in patient outcomes, but the research has also demonstrated that significant effort, and thus opportunity cost, is required from commissioners to ‘knit back together’ pre-existing systems of service planning and delivery. The issue of accountability of commissioners is closely related to the problem of increased complexity of commissioning and system governance. Local Clinical Commissioning Groups are stated to be membership organisations whose primary accountability is internally to their GP members. But in fact the strongest form of accountability would seem to be their hierarchical upwards accountability to NHS England, the national body running the NHS. In addition, the delegation of responsibility for commissioning of primary care to CCGs presents a risk that groups of GPs will commission themselves to provide services, creating a structural conflict of interest, which may undermine their public stewardship role in respect of commissioning budgets. The complex regulatory structures of the NHS required to police the marketised system introduced by the HSCA 2012 have effects on the efficiency of the system as a whole. Inappropriate use of market institutional structures, as opposed to integrated hierarchies, can decrease overall efficiency by increasing costs of undertaking transactions. A further effect of the changes to commissioning introduced by the HSCA 2012 has been on clinicians in primary care. Despite the fact that the research has indicated that they can make a useful contribution to commissioning by CCGs, the workload associated with such involvement is substantial, with a potentially damaging effect on the working lives of GPs, who are already under stress from excessive demands on their time. This makes the sustainability of the model of GP involvement in CCGs dubious. Despite the problems associated with the HSCA 2012, we argue that there will always be a role for planning, and thus a degree of commissioning in the NHS, as a publicly funded system. Strategic decisions need to be made about the allocation of public resources between different services in order to optimise population health and wellbeing. It is also necessary to monitor the performance of providers of care and make improvements where care is substandard. Thus, the core activities of commissioning are necessary whether pro-competitive quasi-market aspects of the English NHS are retained or not. But commissioning in its current form is unlikely to continue, given plans being developed at national level merge CCGs and introduce intermediate tiers of supervision.

The coordination of public services is an enduring challenge and an important policy priority. One way to achieve collaboration across organizational boundaries, which is being considered in public services such as the English National Health Service (NHS), is through the adoption of alliance contracting, prime provider contracting and outcome-based contracting. This article reviews the cross-sectoral literature concerning the characteristics of these new contractual models, how they function, their impact, and their relation to public sector governance objectives. These new contractual forms are characterized as models which, in line with the New Public Management (NPM)/post-NPM agenda, seek to incentivize providers through the transfer of risk from the commissioners to the providers of services. Key findings are that the models are likely to incur high transaction costs relating to the negotiation and specification of outcomes and rely heavily on the relational aspects of contracting. There is also found to be a lack of convincing cross-sectoral evidence of the impact of the models, particularly in relation to improving coordination across organizations. The article questions the reconciliation of the use of these new contractual models in settings such as the English NHS with the requirements of public sector governance for transparency and accountability. The models serve to highlight the problems inherent in the NPM/post-NPM agenda of the transfer of risk away from commissioners of services in terms of transparency and accountability.

Purpose The purpose of this paper is to investigate the perceptions of key informants on a national support programme for the development of new care models (NCM) in England (2015/2016–2017/2018). It focuses on the perceived facilitators and barriers affecting the development and implementation of the NCM programme and offers some insight into the role of national level support in enabling local integration initiatives. Design/methodology/approach A set of 29 interviews were carried out with a variety of respondents at the national level (including current and past programme leads, strategic account managers, advisors to the programme and external regulators) between October 2017 and March 2018, and analysed thematically. Findings A set of facilitative elements of the programme were identified: the development of relationships and alliances, strong local and national leadership, the availability of expert knowledge and skills, and additional funding. Challenges to success included perceived expectations from the national Vanguard programme, oversight and performance monitoring, engagement with regulators, data availability and quality, as well as timetables and timescales. Crucially, the facilitators and challenges were found to interact in dynamic and complex ways, which resulted in significant tensions and ambiguities within the support programme. Research limitations/implications While the sample was drawn from a range of different senior players and the authors ensured a diverse sample associated with the NCM support programme, it inevitably cannot be complete and there may have been valuable perspectives absent. Originality/value The paper demonstrates that the analysis of facilitators and challenges with respect to the national support of implementation of integrated care initiatives should move beyond the focus on separate influencing factors and address the tensions that the complex interplay among these factors create.

Since 1990, market mechanisms have occurred in the predominantly hierarchical National Health Service (NHS). The Health and Social Care Act 2012 led to concerns that market principles had been irrevocably embedded in the NHS and that the regulators would acquire unwarranted power compared with politicians (known as ‘juridification’). To assess this concern, we analysed regulatory activity in the period from 2015 to 2018. We explored how economic regulation of the NHS had changed in light of the policy turn back to hierarchy in 2014 and the changes in the legislative framework under Public Contracts Regulations 2015. We found the continuing dominance of hierarchical modes of control was reflected in the relative dominance and behaviour of the sector economic regulator. But there had also been a limited degree of juridification involving the courts. Generally, the regulatory decisions were consistent with the 2014 policy shift away from market principles and with the enduring role of hierarchy in the NHS, but the existing legislative regime did allow the incursion of pro market regulatory decision making, and instances of such decisions were identified.

Metaphors are inescapable in human discourse. Policy researchers have suggested that the use of particular metaphors by those implementing policy changes both influences perceptions of underlying reality and determines what solutions seem possible, and that exploring ‘practice languages’ is important in understanding how policy is enacted. This paper contributes to the literature exploring the generative nature of metaphors in policy implementation, demonstrating their role in not just describing the world, but also framing it, determining what is seen/unseen, and what solutions seem possible. The metaphor ‘care pathway’ is ubiquitous and institutionalised in healthcare. We build upon existing work critiquing its use in care delivery, and explore its use in health care commissioning, using evidence from the recent reorganisation of the English NHS. We show that the pathways metaphor is ubiquitous, but not necessarily straightforward. Conceptualising health care planning as ‘designing a pathway’ may make the task more difficult, suggesting a limited range of approaches and solutions. We offer an alternative metaphor: the service map. We discuss how approaches to care design might be altered by using this different metaphor, and explore what it might offer. We argue not for a barren language devoid of metaphors, but for their more conscious use.

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.

Since the beginning of the 1990s the public healthcare system in England has been subject to reforms. This has resulted in a structurally hybrid system of public service with elements of the market. Utilizing a theory of new institutionalism, this article explores National Health Service (NHS) managers' views on competition and cooperation as mechanisms for commissioning health services. We interrogate the extent of institutional change in the NHS by examining managers' understanding of the formal rules, normative positions and frameworks for action under the regime of the Health and Social Care Act 2012. Interviews with managers showed an overall preference for cooperative approaches, but also evidence of marketization in the normative outlook and actions. This suggests that hybridity in the NHS has already spread from structure and rules to other institutional pillars. The study showed that managers were adept at navigating the complex policy environment despite its inherent contradictions.