Steering whilst rowing: governing and managing health services from the centre

The article seeks to explore the practical and theoretical implications of the ways in which senior figures in the National Health Service (NHS) interpret the role of the centre in relation to the delivery units of the health service. This is important in the light of recent plans for reorganisation of the NHS advanced by the new Conservative-Liberal coalition government.

The article is based on interviews with civil servants and NHS staff at senior levels in the centre and in the strategic health authorities (SHAs).

It is found that, in practice, despite numerous attempts to separate out policy making from implementation/management, the two continue to be closely coupled and intertwined. Central staff and regional officials are found to be both steering and rowing.

Only a small selection of senior officials at the centre and only a small proportion of SHA senior managers and directors were interviewed.

The implications are far-reaching. Unless special steps are taken, it seems likely that these senior officials, despite the creation of some new institutions and the curtailment of others, will continue to behave in broadly similar ways to those described here.

Empirical studies of the thinking, assumptions and behaviour of very senior officials in the health service are rare. The analysis in this paper explores the organisational conditions that shape the actions of these senior players.