Autonomy is currently seen by policy-makers in many countries as a possible mechanism for enhancing public sector performance. The authors examine a service reform (the National Health Service in England) in which more autonomy was given to better performing hospitals. Drawing on data from interviews with senior managers, the research suggests that despite being enmeshed in a politicized culture of regulations and guidance, autonomy is increasingly perceived positively and appears to depend on the extent to which organizations have the incentives and the capacity to respond to increased autonomy. The article presents findings that will be of value to policy-makers in many countries.