Published: 02/06/2005, Volume II5, No. 5958 Page 14 15

Designed to make the NHS more devolved and decentralised, SHAs are under threat of abolition or reorganisation. But have they been successful? Kieran Walshe and colleagues report

Strategic health authorities may have felt a bit lonely in the run-up to the election - and for good reason.

All the major political parties promised some form of reorganisation or abolition of SHAs if they were elected, and not many voices were raised in their defence.

Now that Labour is back in power, it has to decide what - if anything - it wants to do to reconfigure the SHAs it created three years ago.

SHAs are the latest incarnation of the intermediate tier in the NHS - successors to regional, district and area health authorities and regional offices - stuck between the Department of Health on the one hand and acute and primary care trusts on the other.

But when they were created, in the Shifting the Balance of Power reforms in 2001, they were part of an ambitious attempt to re-engineer relationships and accountabilities in the NHS to make it more devolved and decentralised.

So did it work? In 2004 we set out to research the evolving role and function of SHAs with five authorities and their health communities through a combination of one-to-one interviews, reviewing documents and observing meetings, and a questionnaire survey of senior managers in acute and primary care trusts.

We began with four questions.

First, how did SHAs define their own role and function, and what differences were there in approach?

Second, what roles were SHAs performing in the eyes of their local health communities, and how were they perceived?

Third, what impact did SHAs have on the performance of the NHS in their area?

And fourth, how was the role of SHAs changing, and what might happen in future as current reforms - foundation trusts, private provision and payment by results - were implemented?

What are SHAs for?

Although these SHAs were superficially very similar in function and structure, they differed fundamentally in their approach, with very different cultures, priorities, ways of working, leadership styles and relationships with their health communities.

This seemed to be largely a product of their chief executive and his or her senior team - and people often personalised their comments about the SHA to individuals within it.

SHAs have a lot of scope to shape and define their own role - setting the boundaries and terms of their relationships with their health communities and establishing a distinctive approach to leadership.

Shifting the Balance of Power set out three main functional roles for SHAs - performance management, capacity improvement, and setting strategic direction.

We found that, especially initially, SHAs had focused on their performance management responsibilities, recognising the political imperative to deliver on access and other targets. At this stage they also needed to ensure that performance was on track, to make space for other responsibilities.

Despite the title, we found strategy-setting was not as central to the work of SHAs as expected. There was some debate about what kind of strategy remit they actually had, given the fairly detailed level of national policy coming from the DoH on many issues.

Most felt that SHAs had the opportunity to shape and tailor national policies to local needs.

But while NHS organisations often wanted a service strategy, offering a blueprint for service development, SHAs felt it was more their role to act at a system level, and saw the detailed development of service strategy as the responsibility of the health community.

SHAs clearly played an important role in communicating DoH strategy to their communities, and there was some consensus that this worked better and faster than it had in the past. This was due to SHA chief executives briefing their health communities on the meaning and direction of policy directives - not just their content - within days of them being announced.

The 'top team' - bringing together SHA chief executives with the most senior DoH managers in for a monthly meeting chaired by NHS chief executive Sir Nigel Crisp - was seen as an important forum in which SHAs had some opportunities to have a voice at national level and some input into policy development.

SHAs and their health communities

SHAs have had to have a different relationship with their health communities to that of some of their predecessors, if only because their span of control is so much greater - dealing with around 20-30 acute trusts and PCTs.

Collective relationships

There was evidence of a shift away from bilateral relationships, with individual organisations moving towards more collective relationships with health systems or localities. There is also effort to engage health communities more directly in collectively leading on key policy initiatives like patient choice.

But SHAs' ability to do this has been constrained by the maturity of local NHS organisations and the relationships between them. In settings where organisations are not robust and there is a history of conflict and tension, it has been much more difficult for SHAs to step away from the traditional health authority role.

Of course, SHAs have still had to step in at times to deal with conflicts or tackle performance problems - and finding the right threshold and mechanism for this has been difficult. Having taken control, SHAs have then had to find new exit strategies, to let them step back again from directing organisations.

You could caricature them as occupying the leadership roles of team captain, coach, and referee in different contexts - sometimes directly engaged in the game, at others setting the pace and determining the direction of play, and at other points trying to set the rules of the game and ensure fairness. The difficulty may be that other stakeholders find this roleswapping hard to follow.

Our survey and interviews in acute trusts and PCTs brought out very mixed views of SHAs' performance. As the graph opposite shows, senior managers rated them highly on performance management, innovation and external relations, but were less impressed by their decision-making, strategic direction and leadership style. There were some also some marked differences in the performance profiles - compare SHAs B and C for example.

In some places, SHAs were strong leaders and influencers, and in others they were much less dominant. Similarly, some health communities had the maturity and relationships to exercise a kind of collective leadership for themselves, while in other places organisations were not robust enough for this, or poor relationships prevented them from acting collectively.

The interaction of SHA and health community leadership creates four possible types or models (see figure, right).

Command and control - what might perhaps be seen as a traditional health authority approach, with the SHA showing strong performance management and having a detailed oversight and review function for acute trusts and PCTs.

Decentralised and devolved - with the SHA taking much more of a co-ordinating and networking role, and leadership emerging from the health community as a whole.

High engagement and partnership - with strong leadership being shown both by the SHA and its health community, meaning there is both a robust debate about issues and effective mechanisms for reaching decisions.

Laissez faire - with the SHA offering limited or low-profile leadership, but without the health community being able to take on the leadership role collectively, probably meaning that the agenda becomes dominated by a small number of powerful health community players.

We found that though SHAs differed considerably, as noted above, all were moving away from the 'command and control' style to some degree. In well-developed health communities, this led to either the decentralised or devolved model. In more dysfunctional communities it risked the chaos of laissez faire. When major problems surfaced, especially in areas like access or delivery, all SHAs tended to revert to a command and control style to get things done.

Looking to the future

One of the goals of Shifting the Balance of Power was to devolve decision-making and control to the local level and reduce DoH influence. Although this may not have gone as far as some would hope, three elements of the policy do appear, from this research, to have been successful.

First, the single intermediate tier seems to have had the pace and the proximity to the front line to make essential changes quickly. There has been clarity of roles and leadership and good enough communication to achieve desired improvements (for example, in relation to waiting times and capacity) at a remarkable speed.

Second, there has been a greater degree of 'NHS ownership' of problems and policies. SHAs have been seen as part of the NHS rather than part of the DoH and have had the influence both 'upwards' and 'downwards' to shape policy and achieve change.

Third, although SHAs would not say that it has been their primary function to 'hold the ring' in local disputes, they have nevertheless had the ability to lead change and reform, and mediate in difficult situations.

Their geographical patch has also been large enough for them to have an impact on long-standing strategic and structural challenges.

If these have been the successes, there are another three areas in which Shifting the Balance of Power has had less impact. First, although the DoH has shrunk in numerical terms and has changed its role, many of the unhelpful DoH behaviours have not changed, and that remains a dominant, centralising force in the NHS.

Second, other developments in the NHS - particular the creation of foundation trust regulator Monitor and the Healthcare Commission - have led to increased fragmentation in oversight and regulation and have made the role of SHAs more ambiguous.

Third, the promised devolution and decentralisation have not fully materialised. Although the mantra may be about national standards and local delivery, many NHS organisations feel that the level of national direction has not reduced and the efforts of SHAs and local organisations to manage the system to meet local needs can still easily be overridden.

Centre of networks

Our research highlights the need for organisations like SHAs, but as the current reforms take effect, their role seems likely to change, from being at the intermediate level of a managed hierarchy to being at the centre of a network of organisations with more complex and less direct governance relationships. This will be increasingly relevant as foundation trusts and non-NHS providers enter the picture.

As market management replaces line management, SHAs will not be able to revert to 'command and control' to resolve crises and deal with performance problems.

Increasingly, their ability to influence, negotiate and broker - in other words, to function in the high engagement or decentralised models - will be more important.

Overall, the current size of SHAs - each covering around 2 million people and 20-30 NHS organisations - seems to fit well with the pattern of secondary and tertiary clinical service provision.

On the down side, they do not match local or national government boundaries.

An although there is probably no case for immediate reconfiguration along these lines, over time it may be that fewer, larger SHAs will emerge, with a better correspondence to the organisation of local and regional government. .

Kieran Walshe is professor and director, Donna Bradshaw is a senior fellow and Joan Higgins is a professor at Manchester Business School's centre for public policy and management.

www. mbs. ac. uk/cppm