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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. [ABSTRACT FROM PUBLISHER]

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. [ABSTRACT FROM PUBLISHER]