Negotiating the dilemmas of health system governance: A decentred analysis of integrating care systems

Across high income countries, policy makers seek to reform their health systems to promote public health, address long-term care needs, and reduce the burden on acute care. Policy narratives articulate a model of health system governance premised on multi-agency collaboration and service integration. Combining decentred theory with the negotiated order thesis, this paper examines how local policy actors interpret and negotiate the dilemmas presented by such reform in the context of their customary ways of working. Reporting on the findings of a three-year study of the introduction of Sustainability and Transformation Partnerships in the English health and care system, we focus on how policy actors negotiate the dilemmas manifest around the vision and priorities for, and the governance of, health system change. In each area, we show that structural interests and governing traditions shape actors’ orientation towards system change. This results in tensions that are resolved (or not) through localised negotiations between policy actors, which vary according to whether they were open or closed, structured or emergent, and whether they had a significant or limited impact on system governance. The paper shows that health systems reform is contingent upon how local policy actors translate and negotiate policy narratives.