Introduction

For much of the history of the NHS, individual hospitals, GP surgeries and community health providers have been only indirectly linked to the Department of Health. The government has set the budget of the NHS, and put in place new organisational structures (as it did in 1974 and 1990), but for the most part, the day-to-day activities of most health organisations have been remarkably insulated from the control of influence of the organisational tiers above them, or from government itself. The previous chapter explored how this changed during the 2000s, when a performance management system was put in place that imposed a great deal more central control on both hospitals and GP practices, to varying degrees of success. This chapter explores how policy-makers attempted to get health organisations to improve by putting in place what we have called ‘local dynamic’ mechanisms to attempt to drive improvements.

‘Local dynamic’ mechanisms differ from central control reform mechanisms in that, although they are imposed centrally by government, they attempt to create locally based dynamics that may vary in operation from context to context, but that seek to generate improvement in a self-sustaining way. Central control mechanisms such as performance management require a central department to put in place incentives to improve by monitoring the activities of organisations, measuring them, and responding appropriately by either rewarding good performance or penalising bad. Local dynamic mechanisms, in contrast, attempt to generate mechanisms by which organisations can become selfimproving, and so do not need the continual intervention of a central department.

The two mechanisms are summarised below, in Table 5.1.

Chronologies of health policy during the 2000s, and indeed the accounts of government advisers (Warner, 2011), suggest that the early part of the decade was dominated by central control measures, after which a more concerted attempt was made to introduce local dynamic mechanisms (often alongside the central controls) (Greener, 2004b; Stevens, 2004). The director of the Prime Minister's Delivery Unit suggested that by the mid-2000s top-down performance management systems (central control) were running up against their limits, and further improvements needed a new, bottom-up philosophy of improvement instead (local dynamic) (Barber, 2007).