Cutting the Cord: Mutual Respect,Organizational Autonomy,and Independence in Organizational Separation Processes

Semi-structured interviews

The first author conducted 66 semi-structured interviews with healthcare service contract managers and other individuals directly involved in aspects of community care, mental health, and acute healthcare service contract management between 2010 and 2014. This paper primarily draws on interviews conducted with members of MgmtAgency and CommunityProvider who had some involvement in shaping the emerging interorganizational relationship. We interviewed 12 CommunityProvider managers (executives and senior and middle managers), 16 MgmtAgency senior and middle managers involved in contracting community care services, and nine GP representatives who were affiliated with MgmtAgency and directly involved in co-designing its community care services strategy for the region.

We deliberately kept interviews open, allowing respondents to reflect on the interorganizational relationship, how it had developed, challenges that emerged, and how these were dealt with from their point of view. Later interviews included more-specific questions to gain further insights concerning topics and themes that appeared to be particularly salient for understanding why certain developments had occurred. With a few exceptions, all interviews were recorded, transcribed, and imported to NVivo for qualitative analysis.

During the study, MgmtAgency announced that it would not automatically renew its existing contracts with CommunityProvider and that it was putting the majority of services that it commissioned from it out to bid. This decision generated uncertainty about CommunityProvider’s viability as a separate legal entity, triggering a wave of resignations. It also provided a unique opportunity to observe emotional responses and capture managers’ reflections on why and how the level of interorganizational tension had built up over the years to the point of threatening the survival of the divested organization and of adequate community care service provision in the region. A few managers refused to participate, but others were very willing to share their views and talk about their experiences, including CommunityProvider’s CEO and other members of the executive team.

Observation

After having conducted a few interviews with MgmtAgency managers, the first author negotiated a three-month shadowing study (Czarniawska, 2007), which involved observing MgmtAgency contract managers responsible for non-hospital-based services for three to four full workdays a week. This was subsequently extended by another three months in which the study focused exclusively on the emerging relationship between MgmtAgency and CommunityProvider. Much time during the shadowing studies was spent observing both formal and informal internal MgmtAgency meetings, meetings between MgmtAgency and CommunityProvider representatives, and meetings with other stakeholders.

The shadowing study generated several types of data. First, in formal meetings, discussions were largely captured verbatim and combined with notes concerning observed dynamics. For discussions outside of formal meetings, the first author wrote or typed extensive notes and later enriched them with further recollections of events. Second, directly before and after formal meetings, as well as at other non-obtrusive moments, he conducted informal, ethnographic interviews with MgmtAgency and CommunityProvider members to gauge their reactions to recent events, understand their concerns, and clarify issues. Third, a summary of each day’s observed events was typed up. Fourth, the first author regularly captured personal reflections about witnessed events, with a particular focus on recurring themes and surprises that informed further data collection. These forms of data collection yielded several hundred pages of notes that we imported into NVivo for subsequent analysis.

Archival data

As part of the shadowing studies, we also collected electronic and paper documents that MgmtAgency managers were working on or that were distributed to all attendees at meetings. These included meeting agendas, draft and approved minutes, strategy presentations, service evaluation reports, service specifications, copies of e-mails, formal letters, contracts, and more. Together with interviews and observation, these documents provided insights into the issues that managers were dealing with. In total, we collected over 20GB of data from MgmtAgency, largely consisting of documents produced between 2008 and 2013. We were also given audio recordings of approximately 27 hours of MgmtAgency’s contract oversight meetings, in which issues relating to healthcare service contracts were discussed. Finally, we collected relevant news, independent inspection reports, and trade journal articles mentioning MgmtAgency, CommunityProvider, and community care service procurement in general, along with annual reports and press releases from the two organizational entities.

Communicating across organizational boundaries facilitates developing and demonstrating competence

A newly separated and dependent organizational entity may lack the ability to develop competence on its own and therefore may require access to relevant resources that others control, including knowledge and skills (cf. Oliver, 1991; Pfeffer and Salancik, 2003). It also needs to agree on roles and responsibilities with interdependent organizational entities so it can effectively coordinate with them (Balogun and Johnson, 2004). Both acquiring resources and agreeing on roles, which are beneficial for developing competence and hence positive appraisal, are facilitated by a high level of sustained communication and inhibited by a lack thereof (e.g., Gray, 2010).

In our context, a lack of competence that inhibited effective performance initially became apparent with regard to managing sexual health services. The most experienced service manager in this area, Melanie, assumed a commissioning role at MgmtAgency when the organizations first separated. Unable to find a manager with direct experience in sexual health services, CommunityProvider hired Margaret, a former veterinary nurse. Margaret recognized that she needed people to “advise and guide me to increase my learning” (Margaret, CP, interview). Hence CommunityProvider initially faced difficulties managing sexual health services autonomously and needed to acquire relevant resources.

Margaret accepted help from Melanie, who was willing to share her knowledge about the service management role. Apart from helping her deal with day-to-day issues and challenges, Melanie also encouraged Margaret to understand the “broader context” (Margaret, CP, interview) and adopt an organization-wide perspective by considering how local service improvements could be implemented across the region and interact with other CommunityProvider services to increase quality or efficiencies. By frequently communicating across organizational boundaries, MgmtAgency (via Melanie) helped CommunityProvider (Margaret and her colleagues) learn which activities they were expected to perform (i.e., agree on the distribution of roles and responsibilities), as well as how to perform them well (i.e., acquire resources, in the form of knowledge, to support competent performance).

We identified similar developments with regard to pediatric services, although here the roles were reversed, as MgmtAgency largely lacked the ability to evaluate these services. CommunityProvider’s pediatric service manager, Richard, met regularly with MgmtAgency members responsible for commissioning children’s services, including Sharon (a trained biologist) and later Jennifer (a part-time general practitioner or GP). Sharon appeared to recognize the need to develop her knowledge concerning pediatric services and was interested in meeting regularly with Richard. By contrast, her successor, Jennifer, was frequently invited to meetings by CommunityProvider but “kept canceling” (Richard, CP, interview). Richard suspected that Jennifer had some very basic knowledge of general children’s services but was not in a position to effectively evaluate the many complex and highly specialized pediatric services that CommunityProvider offered. Mark, CommunityProvider’s clinical director for pediatrics, eventually showed up unannounced at Jennifer’s GP practice to have an impromptu meeting with her:

So, in the end, Mark just . . . plonked himself in the surgery and said, “I want to see you.” And she had no choice basically. Interesting point: one of the comments that [Jennifer] made [was], “Oh, do we commission [all of these] children’s services? I didn’t think we did.” (Richard, CP, interview)

After further meetings, Richard not only helped clarify Jennifer’s role but also successfully negotiated a “memorandum of understanding” (Richard, CP, interview) to improve coordination between MgmtAgency GPs and CommunityProvider clinicians. Hence interorganizational communication provided opportunities for agreeing on the distribution of roles and responsibilities and ultimately for supporting the competent management and evaluation of pediatric services.

Given the shift from directly managing to contracting services, MgmtAgency had to develop the ability to address service issues without becoming directly involved in their management. Conversely, CommunityProvider had to establish formal methods of reporting issues and addressing them without relying on direction and support from MgmtAgency. This transition to new roles appeared to be difficult for both entities. GPs occasionally sent complaints via e-mail to MgmtAgency managers or directly to CommunityProvider managers and expected them to be dealt with. At times, however, the complaints lacked evidence or were related to issues for which CommunityProvider was not responsible. After receiving a series of complaints, Jonathan, one of CommunityProvider’s five regional generalist managers, attended a MgmtAgency board meeting to propose a formal procedure that would clarify the distribution of roles and responsibilities. The attempt appeared to be successful, as both Jonathan and MgmtAgency managers noted that unsubstantiated e-mail complaints subsequently “stopped” (Kevin, MA, interview).

Thus interorganizational communication helped both entities develop competence with regard to performing practices by providing opportunities to access relevant resources that were (temporarily) situated outside formal organizational boundaries, as well as by agreeing on and clarifying the distribution of each organizational unit’s responsibilities and roles to enable effective coordination in the context of continued interdependencies.

We also identified several examples of how a general lack, and purposeful limiting, of interorganizational communication undermined positive appraisal and contributed to negative appraisal and ultimately mutual disrespect (see Miller, 2001). This disrespect emerged from members of both organizations judging each other as unable or unwilling to competently perform particular practices. Instead of providing opportunities to address any lack of competence, a general lack of interorganizational communication limited the entities’ ability to acquire the necessary resources and agree on the distribution of roles and responsibilities as they transitioned toward separation.

Perhaps the clearest example was MgmtAgency’s inability to competently evaluate community care services. Given that MgmtAgency altered its remit from directly delivering community healthcare services for the local population to procuring them, it became responsible for explicitly specifying which services or outcomes it wanted to purchase and for negotiating relevant terms and conditions. Though rudimentary service descriptions already existed, informal and often idiosyncratic arrangements were the norm. To avoid disrupting existing services, the entities agreed that CommunityProvider would continue to perform the services it had historically provided and that an explicit description of the tasks that these services included and excluded, as well as associated costs and performance measures, would be developed over time. But MgmtAgency managers were overwhelmed with the task of making all the informal arrangements explicit and specifying exactly what the organization intended to procure for its local population.

Rather than resulting from interorganizational collaboration, community healthcare services contracting was typically enacted as follows: MgmtAgency received a total healthcare budget from the Department of Health each year; it estimated the costs of hospital services for the coming year and allocated the rest of the budget to the local mental healthcare provider, community care provider, and small voluntary organizations in the region. Formal service specifications that provided the legal basis for the contract between MgmtAgency and CommunityProvider were produced by CommunityProvider managers, not MgmtAgency. The knowledge and skills to develop community healthcare service specifications were therefore not developed at MgmtAgency.

Many CommunityProvider managers deplored MgmtAgency’s apparent inability to understand more than a “fraction” (Amanda, CP, interview) of CommunityProvider’s services, which resulted in a “parochial view” (CEO, CP, interview) by simplistically equating their organization with nurses. The lack of detailed communication and negotiation about individual services and issues inhibited MgmtAgency’s development of the knowledge required to competently evaluate services, as well as to create and implement a coherent strategy for public healthcare in the region. It also inhibited the clarification of the distribution of roles and responsibilities between the organizational entities concerning these practices. MgmtAgency managers acknowledged that their understanding of, and hence their ability to evaluate, many community care services was limited as a result of not communicating enough with CommunityProvider:

When we had the commissioning–provider split it was very much: the provider floated off; we didn’t really know much about the provider or their performance. And there was a lot of conflict in the meetings and mainly that was due to our lack of understanding of the provider, and you know, we were working with a sort of bottom-line contract sum and we didn’t actually have a detailed understanding of the services and what they were delivering. (Kevin, MA, interview)

This ignorance was exacerbated by CommunityProvider managers consciously limiting the information they shared concerning staffing details (CFO, CP, interview) and not attending stakeholder events and strategy meetings set up by MgmtAgency (Dale, MA, interview). This restriction of interorganizational communication limited opportunities for developing shared understandings of which activities should be performed by whom and how, inhibiting the development and demonstration of organizational competence.

Developing and demonstrating competence generates appraisal respect

Competent performance contributes to self-confidence and positively appraising oneself, which amounts to self-respect (Grover, 2014). Continued communication provides opportunities for parties to demonstrate their (growing) competence to one another and thus to make each other aware of it. Appraisal respect is thus developed as members gain confidence in their own and the other unit’s abilities to competently perform relevant practices. For instance, all the executives we interviewed highlighted that they were proud of CommunityProvider’s achievements in sexual health services. Moreover, CommunityProvider members positively appraised Melanie’s expertise and were therefore confident in MgmtAgency’s ability to evaluate these services. Similarly, while Sharon and Jennifer at MgmtAgency gained competence in evaluating pediatric services, Richard’s continued interaction and sharing of information gave them confidence that CommunityProvider was competently performing those services. Finally, not only did MgmtAgency’s adherence to formal complaint procedures signal competence, but Jonathan’s focus on evidence and rigor appeared to impress MgmtAgency members who, in internal meetings, repeatedly highlighted the importance of being “robust” (observation notes).

By contrast, the failure to develop competence—to perform practices in ways that others expect—contributes to behavior that others may interpret as inappropriate and thus not meriting respect. If one believes that another is, or should be, in a position to competently perform a practice but fails to do so, feelings of disappointment and contempt can arise (cf. Ufkes et al., 2012). This dynamic became apparent from interviews in which members of both MgmtAgency and CommunityProvider described the other (and at times their own) organization as “incompetent” (George, MA, interview) and “immature” (CEO, CP, interview). For instance, CommunityProvider managers blamed MgmtAgency for failing to understand the complexity of its services, while MgmtAgency members allegedly likened CommunityProvider to a “fossil” (Lucy, CP, interview) that was unable to change its existing services—without appreciating the difficulty of making substantial changes in a complex system of interrelated services:

There still does seem to be a view that [MgmtAgency members] can change contract definitions willy-nilly. As if I can just turn the tap and change the service focus or give it up, or I don’t know, just because they think it might be done differently. . . . That is the immaturity that I spoke of. (CEO, CP, interview)

MgmtAgency’s inability to develop a holistic understanding of CommunityProvider’s services and challenges resulted in what some CommunityProvider managers interpreted as “ill thought-through,” “knee-jerk” behavior (CEO, CP, interview) that indicated organizational incompetence, which also did not merit respect. This criticism mirrored comments from MgmtAgency members about CommunityProvider, whose management was perceived as inconsistent and “bizarre” (Allison, MA, interview). While these views generated tension between the organizations, members of both entities stressed that they attributed alleged immaturity to the other organization’s management as a whole rather than to particular individuals (CEO, CP, interview) and said that there was no animosity between individuals that would have inhibited the development of a “professional working relationship” (Allison, MA, interview). Hence incompetence was associated with—and disrespect was directed at—the respective organizational unit that was not performing in expected ways.

Appraisal respect facilitates continued interorganizational communication

The utility of communicating with others who are deemed competent—or have some knowledge or other relevant resources to share—is apparent: perceiving someone as having access to valued resources attracts interest (Bourdieu, 1986) because one prefers to talk about a subject or problem with those who know and/or can do something about it. This became evident in our study when Richard noted that although he did not approve of interference from MgmtAgency, he “really quite like[d] the fact” that Melanie, who he had “huge respect for,” frequently provided advice “because she understands the service” (Richard, CP, interview). Richard recognized that CommunityProvider benefitted from communicating regularly with MgmtAgency because the divested unit was able to gain access to Melanie’s valuable knowledge. Moreover, improvements in the provision of specialized community care services, including sexual health and pediatrics, were nominated for national awards (archival documents). This unequivocal signaling of competence further encouraged interorganizational communication, as CommunityProvider and MgmtAgency were both keen to showcase their achievements via conference presentations and brochures.

We also observed the opposite dynamic of a perceived lack of competence hampering communication. When asked why the level of communication with certain MgmtAgency members, especially GP representatives, appeared to be low, CommunityProvider managers noted that they believed conversations were meaningless while MgmtAgency was in the midst of reorganizing itself. According to CommunityProvider’s executive team, MgmtAgency’s apparent inability to perform its most basic functions with regard to effectively monitoring, evaluating, and contracting healthcare services was “embarrassing” (CEO, CP, interview) and lacked any “sense of corporateness” (Amanda, CP, interview). The researcher also witnessed one MgmtAgency manager tell the GP representative Jennifer before an internal meeting that he believed CommunityProvider’s inability to innovate warranted measures such as helping the local mental health care provider take over its services—rather than trying to engage with CommunityProvider to collaboratively address problems. We saw evidence in both organizations that communicating with members of a seemingly incompetent or dysfunctional entity was not considered worth the effort.

Communicating across organizational boundaries facilitates developing and demonstrating recognition

Developing and demonstrating recognition require communication that transcends boundaries (Carlile, 2002). Regular face-to-face interaction provides opportunities for actors to share feedback and adjust their understandings (Carlson and Zmud, 1999). This dynamic became especially apparent concerning the management and evaluation of sexual health services and pediatric services and when addressing service issues in the region that Jonathan was managing. For instance, Angela, CommunityProvider’s manager overseeing highly specialized services, including sexual health and pediatrics, noted that due to her many direct conversations with both non-clinical managers and clinicians (GPs) at MgmtAgency, she got “to know them very, very well” and “understand where they are coming from and . . . what they are trying to get at” (interview). The explication of issues provided opportunities to develop a deeper appreciation of the other organization’s concerns or, in the words of one CommunityProvider manager, to “know how someone else works; . . . what they respond to; . . . what will tick them off” (Ella, CP, interview).

A lack of communication inhibits developing recognition because opportunities to share concerns do not emerge. Hence it becomes difficult to develop an understanding of what the other cares about, how the other expects and/or wants to be treated, and on which issues the other expects or wishes to be included. This situation thus maintains boundaries of understanding. For instance, because CommunityProvider “floated off” (Kevin, MA, interview), MgmtAgency members appeared to be unaware of some of the CommunityProvider managers’ key concerns and vice versa, as highlighted by CommunityProvider’s CEO:

It is still very illuminating when you have discussions with GPs [affiliated with MgmtAgency] who talk about “Well, you must’ve got money for this” or “You must’ve got money for that.” And my answer is, “I got absolutely zilch.” QIPP [quality, innovation, productivity, and prevention] money? Zilch in district nursing, etc. And they are shocked when you lay the truth of the funding arrangements out. So, we should have [clarified that we were not] cutting posts out for the sake of it [but instead] trying to live within very meager means. (CEO, CP, interview)

Recognizing others’ concerns promotes feeling respected

By recognizing what another cares about, one is able to demonstrate respect in the form of appearing to take these concerns into account. If this demonstration is interpreted as genuine and therefore successful, the other feels respected in the sense of being included (De Cremer and Tyler, 2005). In our context, demonstrating respect sometimes involved “show[ing] something tangible” (Jonathan, CP, interview). The regional manager Jonathan not only promised MgmtAgency members that he would listen to their concerns but also began to implement changes. For instance, after becoming aware that local GPs for years had not been able to admit certain patients to beds at a local community hospital managed by CommunityProvider, “within four weeks” Jonathan “ring-fenced these two beds” (Jonathan, CP, interview), which meant that from then onward two beds were reserved exclusively for patients exhibiting certain conditions that were referred by local GPs. Meanwhile, the GP rep Jennifer, who was initially accused of being unwilling to meet with CommunityProvider managers to discuss pediatric services, began to develop a reputation for being a “good listener” (CFO, CP, interview). Her newly hired colleague Tim, a senior, non-clinical manager, also gave CommunityProvider members the feeling that their organization’s concerns were being recognized by agreeing to enter into a dialogue about how CommunityProvider’s performance should be evaluated, rather than simply demanding that certain (potentially unachievable) targets be met, as had apparently been the norm in the past:

When Tim attended [a performance review meeting], we talked about community matron personal health plans [and we] said, “Look, you have given us a 100% target and it is just not doable; there is a waiting list; so, let’s reduce it.” And he went, “Yeah, okay.” . . . And for me that was a valuable conversation. (Margaret, CP, interview)

In his attempts to be as open and transparent as possible, the pediatrics manager Richard shared information even when it revealed internal problems and mistakes. According to Sharon, a contract manager at MgmtAgency, “We have a good and constructive and transparent relationship, and there is no data that I have not seen” (interview). Richard’s willingness to be open and inclusive and to reveal flaws was regarded as helpful for developing a shared understanding and achieving both organizational units’ objectives. As a consequence, some actors in each organization felt that their interests were being recognized by actors in the other.

By contrast, having the impression that one’s legitimate concerns are not being considered by others triggers feelings of injustice that may contribute to anger (Miller, 2001). By not interacting regularly and failing to recognize what another cares about, it becomes difficult to manage and change this impression. Because managers’ work is concerned with effective organizational performance, beliefs that their organization is not being treated seriously may be interpreted as undermining their own work. Hence the apparent dismissal of an organization’s interests may be interpreted as illegitimately questioning the validity of, and hindering the ability to perform, one’s individual role—linking disrespect of a collective with personal feelings of being disrespected (cf. Rogers and Ashforth, 2017).

In our study, members of both organizations accused each other in interviews and internal meetings of “not thinking of how to build a consensus” (CFO, CP, interview), failing to “see the bigger picture” in terms of how their decisions affected others (Martin, MA, internal meeting observation), and behaving in ways that were “unfair” (Jonathan, CP, interview) and “unreasonable” (Helen, CP, interview). Such accusations of not demonstrating sufficient respect were especially linked to disruptions related to closing, changing, or temporarily withdrawing community care services. GP representatives at MgmtAgency believed that CommunityProvider unnecessarily triggered disruptions by making changes to general nursing services without discussing them with the affected parties first: “Suddenly there is a change, and there isn’t any explanation. It appears unilateral, cold, and unfeeling” (George, MA, interview). Mirroring this complaint, CommunityProvider managers believed that MgmtAgency managers disrupted their organization by unexpectedly announcing they would no longer fund certain services. These announcements were especially frustrating when MgmtAgency did not follow through on them, as this signaled a lack of concern that the announcements would generate preventable managerial challenges for CommunityProvider: “[Announcing the termination of a service] always ends up being around Christmas time, so that is a really bad thing to do—consulting with the workforce about whether they’re going to have a job or not” (Angela, CP, interview). Members of both entities acknowledged that they had “caused part of the problem,” contributing to disrespect by unilaterally driving changes (CFO, CP, interview) and “asking them [CommunityProvider] to do more and more” (Felicity, MA, interview) instead of trying to understand and address each other’s concerns.

Recognition respect facilitates continued interorganizational communication

Feeling that one’s concerns are being taken seriously by another party increases the willingness to communicate, because demonstrations of respect generate positive attitudes among the respected actors toward the respectful actors (van Quaquebeke and Eckloff, 2010; Blader and Yu, 2017). This dynamic became especially apparent when CommunityProvider managers were willing to meet with MgmtAgency members who they believed were interested in understanding CommunityProvider’s perspective and working together to help solve complex problems. For instance, although Sharon was not an expert on contracting pediatric services, Richard felt that her “open and honest” approach allowed him to enter into “a much broader conversation” (Richard, CP, interview) that involved sharing information about a range of issues. He consequently made efforts to have monthly face-to-face, one-on-one meetings with her, in addition to frequent telephone calls. Similarly, Jonathan became popular as he developed a reputation for listening and attempting to address concerns, as did the contracting director Tim at MgmtAgency. The first author witnessed Margaret from CommunityProvider leave her office and drive to another town at very short notice, despite a busy schedule, for an unscheduled, informal meeting with Tim at a café after he told her on the phone that he had some time to talk (observation notes).

Feeling that one’s concerns are not being taken seriously by another, by contrast, can trigger a range of negative responses. A common way of dealing with this situation is to retaliate by refusing to recognize the disrespectful party (Miller, 2001). In the context of interorganizational relations, this can amount to limiting communication with organization members who do not appear to take the interests of one’s own organization into account. For instance, in response to feeling that MgmtAgency members were treating CommunityProvider as a “junior” partner that was always at the bottom of a “pecking order” (CEO, CP, interview), CommunityProvider managers tried to “stand [their] ground” and justified their non-attendance at meetings convened by MgmtAgency and apparent lack of cooperation in this way: “Why should we have to listen and do as we’re told?” (Robert, CP, interview).

Similarly, in response to feeling excluded when decisions about service changes were made, MgmtAgency members, including executives and non-executive board members, vented their frustration concerning CommunityProvider in both internal and public meetings:

It got so frustrating, and there was such negativity towards CommunityProvider by that stage. . . . And it was just getting beyond a joke. So, everybody was moaning about them . . . and it was becoming, I thought, untenable. I mean in public meetings, MgmtAgency would be badmouthing them and I felt it was unfair. . . . And it was sort of kicking the dog. (Felicity, MA, interview)

Over time, mutual disrespect among some actors escalated to “a ping-pong match of blame” (Jonathan, CP, interview) with several CommunityProvider managers believing that MgmtAgency was seeking to punish them and “get their own back” (CFO, CP, interview). Not surprisingly, very little willingness to interact and collaborate subsequently emerged.

Appraisal and recognition respect enable granting and claiming autonomy

Having confidence in one’s own abilities (and thus developing self-respect) enables one to perform practices without relying on others (Grover, 2014). Believing that someone else is competent enables relinquishing control (Sennett, 2002), allowing him or her to take the lead (van Quaquebeke and Eckloff, 2010). Hence appraisal respect—in the form of respecting oneself or another—enables both claiming and granting autonomy. Furthermore, believing that another person or organization will exercise discretion in ways that recognize the interests of all interdependent parties—in other words, that the person or organization demonstrates recognition respect—also facilitates handing over control (cf. Dirks and Ferrin, 2002). Hence recognition respect enables granting autonomy.

When it came to making changes to general community care services (excluding service areas such as pediatrics and sexual health services), many CommunityProvider staff members seemed resigned to the status quo. Managers confessed that a standard response to change requests had been to provide “101 reasons” why change was “too difficult” (Jonathan, CP, interview). This attitude changed after Jonathan intervened, enabling MgmtAgency’s GPs to admit certain patients to local community care facilities. Not only did MgmtAgency members view the intervention as a signal that CommunityProvider was able to make service changes, but also the success contributed to greater self-confidence that made CommunityProvider staff more willing to “come up with new ideas” (Margaret, CP, interview) and develop a “can-do attitude” (Jonathan, CP, interview). Hence appraisal respect contributed to claiming organizational autonomy.

As CommunityProvider became increasingly confident and signaled competence, MgmtAgency was more willing to grant autonomy by expanding the portfolio of services it contracted from CommunityProvider. MgmtAgency agreed to purchase a new service designed to avoid hospital admissions, and it did not become directly involved in managing the service, such as by demanding that CommunityProvider employ a certain number of nurses (Jonathan, CP, interview; archival documents).

By contrast, not having confidence in one’s own abilities reduces willingness to claim autonomy because actors do not feel ready to assume control (Gist and Mitchell, 1992). And believing that another person or organization is not competently performing practices inhibits relinquishing control over them. Hence a lack of appraisal respect inhibits both claiming and granting autonomy. Furthermore, a lack of faith that another organization will use resources in ways that take into account one’s own organizational interests inhibits handing over control (Dekker, 2004), so a lack of recognition respect also inhibits granting autonomy.

According to Margaret, the manager of sexual health services, confidence among CommunityProvider staff was generally lacking, which inhibited efforts to make service improvements and amounted to what she termed “feeding the beast” (interview)—simply reacting to what others (including MgmtAgency) were demanding. This lack of confidence in its own competence inhibited claiming autonomy, which was particularly evident in community nursing: several CommunityProvider nurses allegedly continued to “bow down” to MgmtAgency GPs and do what they were told rather than demand that their organization’s autonomous status be respected (Lucy, CP, interview). And in at least a few instances, nurses spoke openly with GPs about what they perceived as managerial failings at CommunityProvider rather than attempting to resolve them internally first (Catherine, CP, interview).

We also identified attempts to restrict the autonomy of the other organizational unit. For instance, several CommunityProvider managers appeared to be concerned that MgmtAgency would use its powerful “monopsony” position (CFO, CP, interview) as the sole purchaser of these health services in the region to the detriment of CommunityProvider’s interests. They thus judged that it was in their interest to “have some protection for ourselves” (Amanda, CP, interview) by sharing limited information about some of its services and continuing to produce service specifications rather than let MgmtAgency specify terms and conditions. This inhibited MgmtAgency’s ability to competently monitor and evaluate services, as well as to produce its own service specifications. CommunityProvider managers restricted its autonomy based on their beliefs that MgmtAgency would not adequately take into account their organization’s concerns (i.e., demonstrate recognition respect).

MgmtAgency’s members grew concerned that their interests were not being taken into account, so they also engaged in attempts to restrict autonomy. The growing feeling that CommunityProvider was being “very deceptive” (George, MA, interview) by consciously hiding information concerning services triggered demands for it to commit to always having a certain number of staff available for each service in each region—and thus for MgmtAgency to influence CommunityProvider’s resource allocations—rather than simply commit to providing specific service outcomes. In internal MgmtAgency meetings, such restrictions were justified on the grounds that MgmtAgency’s payments to CommunityProvider apparently “got lost in a black hole” rather than being used to improve contracted services (Joe, MA, observation notes).

Claiming and granting autonomy reinforce appraisal and recognition respect

Granting autonomy signals that the other person or entity is entitled to exercise discretion and that one has some degree of confidence or faith in the other’s abilities to make valued contributions by competently performing certain tasks (Sennett, 2002). If the other accepts this autonomy, he or she feels valued (Rogers, Corley, and Ashforth, 2017), and subsequent competent performance further supports appraisal respect.

A few CommunityProvider managers, including Jonathan and Lucy, developed a reputation for addressing issues instead of complaining about them or demanding additional financial resources. The GP representative Jennifer attributed what she regarded as positive developments at CommunityProvider to efforts by “the manager in that area” (Jennifer, MA, interview), while regional manager Lucy commented that her ability to “deliver” rather than “run to mommy” was met with appraisal respect in the form of MgmtAgency members stating “you are very good” (Lucy, CP, interview).

Meanwhile, although CommunityProvider’s managers at times expressed frustration about MgmtAgency’s apparent lack of support for their organization, they also appeared to respect MgmtAgency when it did not interfere. Contract manager Amanda noted that MgmtAgency’s decision not to provide any transition funding to help CommunityProvider set up its own governance arrangements “really was a school of hard knocks from a financial perspective at the beginning of the relationship with MgmtAgency” but was also “very helpful because . . . it really focused the mind of CommunityProvider on what it needed to do to be well run and effective” (Amanda, CP, interview). In other words, by forcing CommunityProvider to manage itself, MgmtAgency recognized its need to shape its own future.

Yet dynamics that reinforced mutual disrespect when autonomy was not claimed or granted were also prevalent in our study. Just as incompetent performance can trigger feelings of disappointment and contempt, the apparent unwillingness to take full responsibility can trigger negative evaluations. Here the issue is not one of perceived incompetence but of unnecessarily relying on, and thereby disrupting, others. CommunityProvider was accused of behaving “like the adolescent who has basically left home and gone to university but keeps coming back because they want the washing done” (Richard, CP, interview) because its response to many issues was to “constantly run to mother” (Lucy, CP, interview) and “come up with the same old sob story that we haven’t got enough money and we can’t do it” (Richard, CP, interview). A notable example was CommunityProvider’s request for financial support to upgrade information systems, which MgmtAgency dismissed on the grounds that the upgrade was a “background process” that should “be happening anyway” rather than an issue requiring MgmtAgency’s support or attention (CFO, CP, interview).

Mirroring these complaints, CommunityProvider’s managers expressed their disappointment about MgmtAgency “lacking any appetite for risk” (CEO, CP, interview) and apparently being “frightened” of making any radical changes to the local health economy that could upset other stakeholders, such as the local hospital, despite increasing financial pressures (Lucy, CP, interview). MgmtAgency did not appear to be claiming autonomy in addressing healthcare system management challenges, despite being responsible for doing so. This further inhibited the development of appraisal respect.

Refusing to grant autonomy when it is expected risks triggering resentment because it may be interpreted as illegitimately curtailing one’s freedom (Shera and Page, 1996). CommunityProvider’s managers frequently complained about MgmtAgency routinely interfering in operational matters concerning community care services and compared it with an estranged father who “every so often . . . comes in and is critical and gives us a good kicking and says: ‘You’re not doing it well enough! You need to do this, this, and this!’” (Richard, CP, interview). CommunityProvider’s CEO complained about MgmtAgency being “paternalistic” and “controlling,” such as by questioning the establishment of an autonomous community care organization even several years after the decision had been made (CEO, CP, interview). Interestingly, CommunityProvider’s CFO noted in an interview that his organization, by refusing to agree to certain requests, could be seen as “helping to disempower” MgmtAgency. Both organizational units appeared to be disrespecting each other by restricting each other’s expected degrees of freedom.

Autonomy enables substituting organizational dependencies over time

CommunityProvider’s confidence in its own competence helped managers bid for contracts from other management agencies and persuade them of its ability to manage specialist services. Successful bids resulted in receiving income from multiple sources, reducing (but not eliminating) CommunityProvider’s dependence on MgmtAgency. CommunityProvider won a contract to provide sexual health services in a neighboring region within a couple of years of its establishment—and in three other regions across the country shortly after. It also successfully expanded its provision of pediatric services outside the region administered by MgmtAgency (archival documents).

Despite such successes, less than three years after CommunityProvider became a separate legal entity MgmtAgency announced that it was putting the majority of its services (excluding sexual services and pediatrics) out to bid. And after an unsuccessful attempt to merge these services with the largest local hospital, MgmtAgency again assumed direct responsibility for managing them less than a year later. This triggered feelings of failure among CommunityProvider’s managers for “not keep[ing] a good enough relationship” with MgmtAgency, “never prov[ing] that we are different,” and not “doing the smart things and really demonstrating quick changes” (CFO, CO, interview). CommunityProvider’s failure to develop autonomy was associated with the disrespectful interorganizational relationship and its inability to signal competence.

Autonomy reduces the need to communicate extensively over time

The perceived development of CommunityProvider’s competence in some areas and the impression that MgmtAgency’s concerns were being acknowledged with regard to specialized services and addressing service issues in the region that Jonathan was responsible for reduced the need for the organizations to interact concerning these practices. Tim, the contract director at MgmtAgency, emphasized the benefits of frequent interorganizational communication in interviews and meetings but acknowledged that its necessity decreased when the organizations competently performed the practices expected of them and in ways that acknowledged each other’s concerns: “if you’ve got a community care provider that’s getting on and sorting it out, you leave it until there’s a row [conflict]” (Tim, MA, interview).

Only after it became apparent that MgmtAgency would not renew contracts for general community care services with CommunityProvider did conversations take place to clarify roles and responsibilities and understand concerns and complexities related to the competent performance of certain practices. Our notes from the last meeting observed (in 2013) indicate a stark contrast with previously formal and often tense interorganizational performance review meetings that had resulted in participants allegedly “crying in the corridor.” Attempts to understand and support each other now seemed to emerge instead:

Jennifer (MA): The importance of transparency of information is what this is bringing out. We didn’t have it in the past. We should be much more mature—rather than relying on anecdotes.Nathan (CP) notes that nursing staff would like more information about what will happen now that community services are being put out to bid.

Tim (MA): I think we have held back on communication because certain things have not yet been agreed.

Nathan (CP): But any communication is better than nothing. . . . What GPs are saying is that it is worse hearing nothing rather than that things are in progress.

Jennifer (MA): It’s about managing expectations.

Tim (MA): Should we commit to some kind of communication by the end of next week, regardless of any agreements? . . .

Jennifer (MA): We should be doing this regularly; I hope we move to a much more collaborative way of working rather than being confrontational, which is the direction we have been going.

Fred (CP) laughs, stands up, walks over to Tim, smiles, and hugs him. Several meeting participants also laugh.

While the eventual reintegration of most local community services into MgmtAgency suggests that both executive teams failed in their mandate to divest CommunityProvider from MgmtAgency, CommunityProvider did survive as a (much smaller) legal entity with operations in multiple regions. Although it lost the majority of its services, it ultimately became a provider of specialized community services predominantly related to pediatrics and sexual health—the practices in which mutual respect, autonomy, and increased independence had developed.