Decisions and resources in the National Health Service in Scotland

Abstract

The thesis reports on a two-year study which looked at decision-making in two Scottish health boards. The research was prompted by: (1) a dearth of knowledge concerning the dynamics of decision-making in the National Health Service (NHS) at local .level; and (2) a desire to understand the factors at local level which might help to explain the persistence of resource imbalances between different sectors of health care despite numerous attempts to remove them. The case study, which forms the core of the thesis, has two aims: (1) to describe decision-making in the two boards in the area of development fund allocations (ie growth monies) in order to discover the process by which priorities are set; and (2) to provide insights into the operation of the management structure introduced when the NHS was reorganised in 1974. Reform was largely about improving the rationality of decision-making and the case study aims to show what this involved in practice. Rational and incremental theories of decision-making are reviewed for their usefulness in understanding events, although no single theoretical perspective is favoured over others. The main study findings were: (1) that, contrary to much popular opinion, decision-making in the NHS is, to a significant degree, decentralised - both boards possessed a large measure of influence over the services they provided; (2) that, despite this discretion, the emphasis in allocation decisions was on policy maintenance rather than on policy change; (3) that part of the explanation for this resided in a number of constraints, both external and internal, operating on decision-makers; and (4) that a number of coping strategies were adopted by decision-makers in order to facilitate the task of allocating resources and to come to terms with the uncertainty inherent in the decision-making environment. The research also revealed a number of tension points arising from the management structure, many of which served to reinforce the obstacles to change through development fund allocations.