Skip to main content Accessibility help

Being Autonomous and Having Space in which to Act: Commissioning in the ‘New NHS’ in England



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.



Hide All
Alexander, E.R. (1998), ‘A structuration theory of interorganizational coordination: cases in environmental management’, The International Journal of Organizational Analysis, 6: 4, 334354.
Allen, P. (2006), ‘New localism in the English National Health Service: What is it for?’, Health Policy, 79: 2–3, 244252.
Allen, P., Keen, J., Wright, J., Dempster, P., Townsend, J., Hutchings, A., Street, A. and Verzulli, R. (2012), ‘Investigating the governance of autonomous public hospitals in England: multi-site case study of NHS foundation trusts’, Journal of Health Services Research & Policy, 17: 2, 94100.
Axelsson, R. (2000), ‘The organizational pendulum: Healthcare management in Sweden 1865 -1998’, Scandinavian Journal of Public Health, 28: 1, 4753.
Bevan, G. and Hood, C. (2006), ‘What's measured is what matters: targets and gaming in the english public health care system’, Public Administration, 84: 3, 517538.
Black, N. and Mays, N. (2016), ‘Sustainability and transformation plans: a troubled start’, BMJ, 355.
Bossert, T. (1998), ‘Analyzing the decentralization of health systems in developing countries: Decision space, innovation and performance’, Social Science and Medicine, 47: 10, 15131527.
Cambridge online dictionary. ( accessed 7/4/17
Checkland, K., Harrison, S., Snow, S., McDermott, I. and Coleman, A. (2012), ‘Commissioning in the English National Health Service: What's the Problem?’, Journal of Social Policy, 41: 03, 533550.
Checkland, K., Allen, P., Coleman, A., Segar, J., McDermott, I., Harrison, S., Petsoulas, C. and Peckham, S. (2013), ‘Accountable to whom, for what? An exploration of the early development of Clinical Commissioning Groups in the English NHS’, BMJ Open, 3: 12.
Checkland, K., McDermott, I., Coleman, A. and Perkins, N. (2016a), ‘Complexity in the new NHS: longitudinal case studies of CCGs in England’, BMJ Open, 6: 1.
Checkland, K., Segar, J., Voorhees, J. and Coleman, A. (2016b), ‘‘Like a Circle in a Spiral, Like a Wheel within a Wheel’: The Layers of Complexity and Challenge for Devolution of Health and Social Care in Greater Manchester’, Representation, 117.
De Vries, M.S. (2000), ‘The rise and fall of decentralization: A comparative analysis of arguments and practices in European countries’, European Journal of Political Research, 38: 2, 193224.
Department of Health (2005), A short guide to NHS Foundation Trusts, London: The Stationary Office.
Department of Health (2010), Equity and Excellence: liberating the NHS, London: The Stationary Office.
Dixon, A., Storey, J. and Alvarez Rosete, A. (2010), ‘Accountability of Foundation Trusts in the English NHS: Views of Directors and Governors’, Journal of Health Services Research & Policy, 15: 2, 8289.
Exworthy, M. and Frosini, F. (2008), ‘Room for manoeuvre?: Explaining local autonomy in the English National Health Service’, Health Policy, 86: 2–3, 204212.
Exworthy, M., Frosini, F., Jones, L., Peckham, S., Powell, M., Greener, I., Anand, K. and Holloway, J. (2010), Decentralisation and Performance: Autonomy and Incentives in Local Health Economies: NIHR Service Deliery and Organisation Programme.
Exworthy, M., Frosini, F. and Jones, L. (2011), ‘Are NHS foundation trusts able and willing to exercise autonomy? ‘You can take a horse to water. . .’’, Journal of Health Services Research & Policy, 16: 4, 232237.
Harrison, S. and Ahmad, W.I.U. (2000), ‘Medical autonomy and the UK state 1975 to 2025’, Sociology, 34: 1, 129146.
Hoque, K., Davis, S. and Humphreys, M. (2004), ‘Freedom to do What you are Told: Senior Management Team Autonomy in an NHS Acute Trust’, Public Administration, 82: 2, 355375.
Klein, R. (2013), The new politics of the NHS: from creation to reinvention (7th edition), London: Radcliffe Publishing Ltd.
Macfarlane, F., Exworthy, M., Wilmott, M. and Greenhalgh, T. (2011), ‘Plus ça change, plus c'est la même chose: senior NHS managers’ narratives of restructuring’, Sociology of Health & Illness, 33: 6, 914929.
Mannion, R., Goddard, M. and Bate, A. (2007), ‘Aligning incentives and motivations in health care: the case of earned autonomy’, Financial Accountability & Management, 23: 4, 401420.
Mosca, I. (2005), ‘Is decentralisation the real solution?’, Health Policy, 77: 1, 113120.
NHS England (2012), Health and Social Care Act 2012: Fact Sheets
NHS England (2013), Draft framework of excellence in clinical commissioning, Nov 2013.
NHS England (2014), Five year forward view, Leeds: NHS England.
NHS England (2015), Delivering the Forward View: NHS planning guidance 2016/17 to 2020/21 Leeds: NHS England.
NHS England (2016), The forward view into action: New Care Models: update and initial support, Leeds: NHS England.
Peckham, S., Exworthy, M., Greener, I. and Powell, M. (2005), ‘Decentralizing Health Services: More Local Accountability or Just More Central Control?’, Public Money & Management, 25: 4, 221228.
Petsoulas, C., Allen, P., Checkland, K., Coleman, A., Segar, J., Peckham, S. and McDermott, I. (2014), ‘Views of NHS commissioners on commissioning support provision. Evidence from a qualitative study examining the early development of clinical commissioning groups in England.’, BMJ Open, 4: e005970.
Powell, M. (2016), ‘Order of change in the ordered changes in the NHS’, in Exworthy, M., Mannion, R. and Powell, M. (eds.), Dismantling the NHS? Evaluating the impact of health reforms, Bristol: Policy Press.
Secretary of State for Health (2000), The NHS plan: a plan for investment, a plan for reform, London: The Stationary Office.
Speed, E. and Gabe, J. (2013), ‘The Health and Social Care Act for England 2012: The extension of ‘new professionalism’’, Critical Social Policy, 33: 3, 564574.
Timmins, N. (2012), Never again? The story of the Health and Social Care Act 2012. A study in coalition government and policy making., London The King's Fund.
Verhoest, K., Peters, B.G., Bouckaert, G. and Verschuere, B. (2004), ‘The study of organisational autonomy: a conceptual review’, Public Administration and Development, 24: 2, 101118.
Walshe, K., Coleman, A., McDonald, R., Lorne, C. and Munford, L. (2016), ‘Health and social care devolution: the Greater Manchester experiment’, BMJ: British Medical Journal (Online), 352: i1495.
Walshe, K. (2017), ‘Sustainability and transformation plans for the NHS in England: radical or wishful thinking?’, BMJ, 356.
Weiss, C.H. (1999), ‘The Interface Between Evaluation and Public Policy’, Evaluation, 5: 4, 468486.


Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed