Coping with uncertainty: decisions and resources within health authorities

Summary This article reports on a two‐year study which looked at decision‐making in two Scottish health boards. The study, which focused on the allocation of development funds (growth monies), is about understanding and not about reform. It was prompted by: (1) a dearth of knowledge concerning the dynamics of decision‐making in the National Health Service (NHS) at local level, especially since the 1974 reorganisation of the Service; 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 successive attempts by central government to remove them. The study suggests that, contrary to much popular opinion, decision‐making in the NHS is decentralised ‐ the two health boards featured in the research possessed a large measure of influence over the services they provided. Aside from rational and incremental theories of decision‐making which were of value in compre‐hending the decision process observed, the notion of puzzlement as a factor determining decision outcomes was found to be of particular value in the context of the allocation of development funds. The main study findings were: (1) that a policy of appeasing competing, and equally demanding, interests rendered change exceptional although not impossible, as was shown by the emphasis placed upon community health services; (2) that various constraints, both internal and external, operated on decision‐makers; and (3) that a number of coping strategies were adopted by decision‐makers in order to structure their uncertain and unpredictable environment and to manage the constraints on them.