Change and Decision-Making in the NHS: The Case of the Care Programme Approach

Using the Care Programme Approach (CPA) as an example, this article examines the difficulties of implementing change within the National Health Service (NHS). A framework is suggested which aims to clarify the nature of change by distinguishing where, when and how decisions are made. It is argued that structural change in the NHS and the related emergence of new institutions, systems, relationships and operational principles, have generated new uncertainties and ambiguities. A fuller appreciation of how the decision-making process operates is necessary to an understanding of how different policy objectives are pursued.