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IJPSM

11,4 Barriers to transformation


Beyond bureaucracy and the market
conditions for collaboration in health
234 and social care
Su Maddock and Glenn Morgan
Manchester Business School, University of Manchester, UK
There is a process of breakdown and the emergence of gaps not just in understanding but in
terms of how to manage existing relationships. Old rules and frameworks are no longer
working and new ways are being developed which may become established in new
institutions. This process of breakdown is specific to particular social situations, as the impact
of international competition has clearly varied in Britain (Morgan and Sturdy, 1997).
Few now question the fact that the traditions and labour practices within the
bureaucracies made it extremely hard to stimulate new services and innovation.
What is questioned is whether the impact of contracting has improved care and
services. For although the old administrations were undoubtedly unresponsive
and highly inflexible, they did provide accessible and consistent service, and
staff had a sense of security. In the 1970s and 1980s women managers found the
traditions and labour practices within bureaucracies frustrating and innovation
impossible. But, 15 years later, the impact of contracting has left many
searching for new forms of organizations in an even more hostile and often
macho environment. The restructuring of local government and the health
service may have changed management practices and the method by which
resources are allocated, but the underlying male values deeply embedded in the
bureaucratic structures and within the professions remain intact within the
contracting environment. Almost all professionals and policy makers within
health and social care have come to agree that the delivery of quality services is
dependent on the ability of staff to work collaboratively, in partnership within a
framework which facilitates integrated and sensitive care (Audit Commission,
1997; Community Care Act, 1990; Green Paper on Mental Health Services, 1996).
There has been enormous structural change in health and social services
over the last 15 years and what is needed now is a focus not just on
implementation of better practice but on management frameworks which will
overcome the deeply entrenched barriers to interagency and interprofessional
joint practices and communication. For, whilst management theorists
vehemently assert the need for a shift in thinking and practice in organizations,
a shift which will promote active collaboration between professionals and

International Journal of Public


Sector Management,
Vol. 11 No. 4, 1998, pp. 234-251, This paper was presented at the Second International Research Symposium on Public Service
© MCB University Press, 0951-3558 Management, Aston Business School, September 1997.
managers, and which will motivate staff to engage with change, the reality is Barriers to
that although there are many active innovators in the services, there are as transformation
many, more powerful barriers to social change.
Neither the planned centralized administrations nor the market-driven
agencies have delivered forms of organization which bring users and staff
closer together – and future agencies not only require strategic development but
also are managed and organized in a manner which does allow a greater 235
coalition between user and worker (not only through consumer or user activity
and organization) but through management systems which develop
communication between both parties and a recognition of the necessary
connections between staff and corporate values and staff and user interests. Yet,
in Britain and in other countries this form of agency transformation is proving
as difficult – if not more difficult – within the contracting environment.
Contracting market testing and purchasing frameworks have resulted in
many staff having a greater reluctance to collaborate because they are suspicious
of change programmes dictated by central government and senior management.
Resistance to change is understandable in European countries where the
experience of employees, professionals and managers is that the politicians are
using change programmes, restructuring and the reconfiguration of public
services to cut costs and undermine the trade unions. This has created a lack of
trust in those efforts to transform organizations and public bodies in the
interests of the public, users and quality. This is a problem for those seeking to
transform or democratise the services in the interests of users.
The problem for managers is that they need staff not only to accept
restructuring, new job functions and performance measures, they also need
them to actively engage in quality initiatives and in the development of services.
Overcoming structural and cultural barriers to social change and transforming
organizations is much harder than identifying them. It is hard to break down
the barriers generated by professional training, years of working in institutions
and where people are suspicious of the reasons for change, especially if it comes
from the “top” with adequate rationale.
Managers and professionals have not only to overcome their own personal
blocks and organizational problems, they have to drive managerialism and
other systems. There is a tendency to underestimate the psychological and
cultural barriers to organizational transformation and to overlook why
employees behave and interrelate in the way in which they do and which
greatly affects the lack of interest in the gendered nature of management and
fosters resistance to change. Those attempting to develop new forms of public
sector management have an uphill struggle within, not only the centralized
bureaucratic administrations, but also within the contracting framework and
gendered, professional establishments.
There is frequently a mismatch between corporate message and internal
systems and cultures – consequently the real innovation in organizational
transformation is to ground social principles in a broad organizational strategic
framework which is flexible enough to encourage learning amongst all staff
IJPSM and give greater voice to the most junior staff, in order to compensate for the
11,4 power imbalance in organizations which acts as a megaphone for the those at
the top. Managers need to have an awareness of the resistance to the processes
of change so that they can address that resistance. These resistances spring
within both bureaucratic and market-driven organizations from:
• the contracting environment;
236
• managerialism which works against learning;
• insensitive measurement;
• powerful male cultures and professional traditions.

Public agencies in Britain


Quality services depend on the ability of organizations to generate a
“collaborative” culture rather than a blame culture at work; this process
continues to be hampered not only by bureaucratic administrations (attacked
by the “Right”), but also by forms of managerialism and management systems
which are hostile to staff relationships and morale and the old established
professions where male culture is so dominant. The systems and top-down
directives developed through new public management and managerialism have
oppressed staff and managers, as much as did the classical bureaucracies;
managerialism have allowed the powerful male professions to flourish thereby
undermining women, the “female” professions and junior staff. All of this runs
counter to the conditions necessary for learning and change to flourish.
Although new practices and relationships are evident throughout Britain,
without the removal of institutional and professional barriers, the old practices
of crisis management, “blame” and refusal to engage, thrive.
The future of public organizations and their transformation depends on their
ability to move beyond constraints of professional tradition, bureaucratic
practices and the quasi-markets. There is a need for political change at the top
and for a reappraisal of the way managerialism has developed. For in spite of
the rhetoric concerning local determination, appropriate service-based
performance indicators and the need for a learning and collaborative culture,
managerialism in almost all the public services continues to be centrally and
financially driven. Centrally determined performance measures reduce public
services to crude output and outcome measures which are insensitive to local
diversity, change and time, such that even the most transforming efforts of staff
cannot overturn the effects of such a democracy deficit and lack of “user-
sensitivity”.
Dunleavy (1995) suggests that British administrations were insensitive to
both users and the wider community and that now the New Public Management
(NPM) or forms of managerialism tend to be:
• led by those preoccupied with rapid policy making;
• reinforced by adversarial political system;
• endorsed by an overconfident, removed expert élite; Barriers to
• controlled through a highly centralized state; transformation
• few checks on the implementation of policies (i.e. impact studies).
Transforming the British public sector is constrained by a number of other
factors, notably:
• a British class culture where the “weaker” user and staff voice is ignored;
237
• a Labour Party policy-maker view that they can manage NPM better
than the Tories and do not question its neutrality;
• a rigid divide between “doers” and policy makers (“thinkers”) which
results in a lack of foresight about policy impact and the processes of
change.
The tendency in bureaucratic institutions was to control through hierarchical
line management and rigid standard practices. The bureaucratic institution
reinforced strict boundaries between grades, managers and policy makers –
transactions were regular, habitual and between agreed parties. Such a scenario
made it difficult for innovation of any sort to emerge and when it did it was on
the margins, in the community, in outpost departments located away from
the centre.
The market introduced to dismantle such centralizing control has introduced
disorganized and competitive reactions within arm’s-length agencies, where
managers, like street-wise kids, respond to the immediate and to their
performance targets, also centrally determined. The focus of increased
efficiency has increased the pressure on managers and staff to work harder,
doing more and more administrative tasks and consequently never having the
inclination or time to reflect on longer-term strategies and more appropriate
outcome measures. Competing agencies can become so clan and niche
orientated that their marketing strategy usually services a very small section of
the community. This tendency to service the specialist and the élite is highly
socially divisive, especially when pursued by public sector service providers.
The direction in which the uncontrolled market carries organizations is most
often determined not by quality but by financial gain, and accounting and
performance measures reflect this tendency to control finance. Within a trading
world, where financial interests dominate social relationships at work, reflect
not social values, but macho competitivism. Economic and financial systems
are highly influenced by social, psychological and political forces. The
competitive nature of the stock and trading markets encourage a fast, macho
and gambling culture – more akin to poker than financial strategy. Similarly,
the quasi-mixed markets and purchasing systems within the public sector
appear to be encouraging competition, secretive relationships and an
entrenchment of traditional cultures rather than a breaking down of barriers
and the generation of more socialized and egalitarian relationships at work,
reinforcing not collaboration but competition. The following section outlines
IJPSM the prevalence of dominant barriers to change in British health and social care
11,4 agencies, which are likely to be common to other public services and
organizations generally.

Barriers to change: the contracting environment


The British Conservative Government’s (1979-97) attempts at undermining
238 bureaucratic administrations, through the economic levers of contracting and
the market, have replaced the rigidity of red tape with another administrative
edifice of financial transactions and performance measures and regulations
within health and social care. The post-1990 public sector reforms and the
introduction of quasi-markets and central funding mechanisms in Britain have
influenced the way public sector authorities have changed and the direction of
their current transformation.
There is a growing literature on how centrally determined performance
targets have resulted in individualistic and competitive rather than
collaborative cultures, and on the relationship between contracting models and
service provision and quality within health and social care (Le Grand and
Bartlett, 1993; Walsh, 1995). The processes of contracting have in fact
undermined morale and created a climate of mistrust. Ferlie and Pettigrew
(1996) suggest that the market and contracting context that they introduced in
many public administrations has dramatically affected all staff and their
capacity to engage with transforming processes in a collaborative fashion. The
questions being asked in almost all government agencies is:
• Whether the contracting environment has actually resulted in a
user/customer focus?
• Has purchasing brought client and manager closer together?
• How can purchasers support interagency working?
• Whether the conditions for collaboration and partnership are better or
worse than they were within previous administrations?
The local government chief officers are no longer so convinced that contracting
in itself is going to assist service delivery or development and are beginning to
be more aware of the effect on staff morale and motivation. It is this more
sceptical approach that is leading to a reluctance to extend CCT into
professional services.
Young (1996) suggests that whilst there has been a move away from
centralized services as one facility there is a sharp move away from local
budget-holding cost centres (Table I). Internal charging has irritated people and
burdened them with paper work and left many auditors wondering on what
basis the costings were made. To replace internal charging, service-level
agreements are now widely used. In fact Young ( 1996) shows that the constant
restructuring in local government has reduced strategic thinking. He suggests
that in practice the rhetoric of a revolution is proclaimed but the reality is that
the transformation of local government is limited:
The overwhelming impression given by those findings was of a local government engulfed in Barriers to
a tidal wave of centrally inspired change, with officers wielding limited influence as the local
mediators of the change process (Young, 1996). transformation
This change resulted because both the practitioners persistently argued for
regulating the market and for time for providers to develop better services.
However, their efforts to control the market system has not resulted in any
serious changes in contracting frameworks nor in the way managerialism is 239
developing.

The impact of reforms on public sector staff


The impact of contracting generally has been to create a smaller core of better
paid managers who have a strategic role in commissioning and purchasing;
service practitioners are undermined by intrusive measurement and increased
workloads; support staff have, in general, lost security and are now often on
short-term contracts. The flexibility required by new developing agencies has
been introduced at the expense of staff security and morale. Public sector staff
experience a loss of control over their lives; professionals and managers also
tend to work longer hours.
The morale of staff in the social and health services is extremely low. There
is a huge sense of job insecurity amongst all levels of public sector staff, but
particularly amongst those who are on part-time and short-term contracts. In
fact, the stress levels are so high amongst teachers that they are flocking to
retire early, in such numbers that the then Secretary of State for Education,
Gillian Shepherd, accused them of fraudulent claims of ill health in January
1997. Qualified nurses are not applying for jobs, junior doctors are leaving the
country, psychologists, physiotherapists and occupational therapists are in
very short supply (Nursing Times, 1997). There are shortages of junior doctors,
general practitioners and some consultants in almost all the major cities. The
medical profession is experiencing its biggest spillage from training ever. The
contracting culture has had a dramatic effect on staff and their confidence in
internal and external relationships (Hoggett, 1996).
Precise figures on the number of job losses which have resulted from
restructuring are difficult to find but they are considerable. Managing the
internal market required an increase in managers and business administrators

Strongly agree
1992 1994
(%) (%)

Managing competition requires new skills 95 90


Competition has reduced morale 34 49 Table I.
Competition has changed management processes 91 84 Impact of contracting
Competition is encouraging cross-department working 52 51 on organizational
Source: Young (1966) processes
IJPSM and the exact consistency of these contracting mechanisms is still not
11,4 established. Restructuring and organizational change has involved real job loss
and the fear of job loss. Nurses are experiencing the greatest changes and
express their feeling of loss as being due to:
• a loss of role identity;
240 • loss of job satisfaction with patients;
• a questioning of their professional role and values;
• a lack of confidence in their working environment and a development of
mistrust.
This lack of confidence bodes ill for those attempting to introduce new joint
working practices. Whilst there is a greater awareness of “user” interest and the
need to consider service quality as well as routine staff, many public sector staff
are fearful and sceptical that their managers or the Government are really
concerned about service quality:
But for many staff the talk of shared organisational mission, commitment to quality and
customer responsiveness flies in the face of their experience of increased class sizes,
inadequate nursing cover, disappearing job security, voluntary and compulsory redundancies,
etc. (Hoggett, 1996).
Young (1996) reports that, in local government, managers have lost their
appetite and interest in service development – they are too demoralized by
constant change and no longer think it is worth thinking about future services
or how they are organized. Local government social service staff, in particular,
express a feeling of loss because they felt that they had lost status and direction
in their work. They felt deskilled rather than reskilled. Clearer job definition
resulted in many not being able to do the function they had previously done.

Consequences: the loss of social capital


The impact of contracting and managerialism on staff is accepted as common
knowledge within the services and also by some policy makers, and yet how
this affects care, management and service objectives tends to be overlooked.
The market was intended to stimulate the growth of the private sector and
create a mixed economy of “care”; the fragmentation of service providers would
stimulate development and stir the providers into responsive services. However,
it also had the effect of creating patchy service, competitive agencies and a
desire for efficiency saving which forced practitioners and support staff into
mechanical relationships with clients and closed “in-the-box” relationships
between themselves. The lack of time for informal communication results in an
even greater alienation amongst staff and users than was generated by the
former bureaucratic departments.
Charlesworth et al. (1996) showed how internal markets dramatically affected
the relationships between agencies, between local authorities and the voluntary
sector, between health and social services, and between managers and
professionals. The contracting system, when it operated as a purely economic
market system, resulted in the measurement of the quality of tasked efficiencies Barriers to
rather than care. This works against the social and humane relationships transformation
required in social care. The effects of managerialism:
… have had a dramatic effect on staff-morale and relationships. Because the analyses so far
have been directed primarily to discovering the logic of such markets (the prevailing form of
competition, contracting regulation and organisational strategies), they have tended to reduce
the complexities of relationships and social processes involved in mixed economies to their 241
specific economic dimensions (Charlesworth et al., 1996).
“Marketized forms of relationships” have developed (Wistow, 1995) which
encourage competitive and combative forms of behaviour, and prioritizes
immediate results rather than development. Non-contractual forms of
relationships were permitted within the purchasing or commissioning wing of
services, but there continued an assumption that “provider agencies” should be
“entrepreneurial” and combative in their approach to clients and contractors.
What is emerging is that various types of entrepreneurial organizations, driven
only by “efficiency”, undermine relationships and the quality of work cultures:
Mixed economies of care need to be analysed in terms of the prevailing patterns of
relationships – and models of co-ordination – both within and between organisations. The
concept of mixed economy does not differentiate between forms of relationship. The idea of
modes of co-ordination points to the dimensions of power, principles and knowledges (of those
involved) which shape structures, cultures and relationships both within and between
organizations (Clarke and Newman, 1994).

The systems mismatch


There is, in effect, a mismatch of management and contracting models and the
policy desire for partnership and collaboration between individual staff and
individual agencies. The reality is that the effect of annual contracts and
competition between providers has been to generate mistrust, low morale and
hostility (Coote and Hunter, 1996). A recent IPPR report argues that the current
market ground rules or purchasing structures actually result in low trust or
hostile relationships and high transactions costs (Coote and Hunter, 1996).
Demoralized staff were completely mistrustful of both manager and
government intentions. Even some government ministers have recognized that
a pure market system cannot work within health and social care, and have
shifted away from their original emphasis on private market agencies and pure
and distinct purchasing, where annual contracts were supposed to keep
provider units on their toes and purchasers were to actively stimulate the
private market. This position has been considerably toned down, to one where
purchasers within health and social care are now encouraged to work with
providers and told to develop “mature relations” within a commissioning
framework (Ferlie and Pettigrew, 1996).
Whilst many in senior management may be able to differentiate between
positive and negative aspects of the way managerialism is working within their
service, most staff are totally mistrustful of any change programmes and feel
vulnerable, witnessing the focus of their work changing from “social care” to an
IJPSM overemphasis on defined tasks. The impact of care management and
11,4 managerialism appears to be unobserved by many executives and politicians
who continue in their belief in the rationality and logicality of contracting (in
the same way that the bureaucratic procedures in public administrations were
viewed as indisputable).
The competitive model has been found lacking within health and social care.
242 Too often, management systems are working diametrically in opposition to
public policy objectives which, in Britain in most services, are calling for
increased agency partnership and interprofessional working and greater
collaboration generally. Yet, the Labour Party debate on the public sector
reforms has also neglected the impact of managerialism on staff and their
ability to collaborate and has instead tended to focus on the impact of the
structural levers of privatization, market testing and contracting mechanisms.
New Labour, in a socialist tradition, again concentrated on constitutional and
structural reforms leaving public sector management, its framework and
measures, to local managers as if management were a neutral matter. Although
there is talk of shifts in thinking about welfare and the public sector generally,
these debates avoid the major problem of making policies a reality, neglecting
cultural as well as structural barriers to change.
There is a need to bridge the gap between policy and practice and to focus on
process rather than models. New policies need to be negotiated with the public,
with staff and practitioners as well as with managers; there is a need for a new
public sector management framework as well as a policy framework – which is
not merely the softening of the American private sector management model. In
spite of the need for decentralized decision making and more democratic
internal practice, the new Labour Government continues to speak in terms of
targets, standards, performance measures, and budget rationing, which
undermine the ability of local politicians and managers to develop appropriate
service configurations and a more positive (learning) culture amongst public
sector staff.
Without considering how central government and policy makers are
affecting people, we need to be aware of the impact of managerialism on staff
and their ability to deliver responsive services and care. Many of the existing
performance measures and targets are acting as disincentives for the very
policy changes that senior politicians and managers espouse. This is because
they interfere with the capacity of people to reach agreement, work together
and therefore assist the process of change. There are very concrete examples of
this in the health service where senior managers have, on paper, endorsed a
policy which strengthens joint commissioning, training and practice but the
accounting and measurement systems work against such practices.
For instance, a nurse director had brought together nurses, therapists and
managers in groups to devise new roles and staff relationships – unfortunately,
at the same time, national directives called for occupational standards and
protocols which completely worked against this process, and those in the
working groups felt betrayed and demoralised (Worsley, 1996). Similarly,
although some chief officers encourage service development and management Barriers to
innovation, they continue to use performance measures which do not register transformation
the new processes, activities and staff involved, and instead reinforce activities
separating practitioners.
Finance is needed to develop processes; it is not an add-on for staff and
managers. There is need for greater face-to face communication and time for
developing new thinking, new measures and new relationships. Whilst there are 243
calls for interagency working and multi-professional collaboration, there are
still too few commissioning bodies willing to pay for new partnerships, for new
strategy implementation and innovation. Too often, innovative practitioners
report that their collaborative work is undervalued because it is bypassed by
inappropriate management measures and is on very short-term funding.
The contracting environment has created an “Alice in Wonderland” scenario
where those with least power are expected to be strategic, innovative,
responsible and collaborative whilst government and executives monitor them
on financial performance criteria which do not measure this work and make
claims of how they are employing staff by devolving their own responsibility
for strategy. A major international problem is that senior managers are
reinforced for controlling staff, reducing financial expenditure and increasing
either profit or efficiency. What they should be rewarded for is creating a
framework which facilitates a sustaining environment or collaborative culture
and stimulate social development innovation. The gender imbalance as regards
senior management is one of the factors which has resulted in too few managers
who recognize the need for a match of systems with corporate objectives, and
who recognize the necessity of looking at the impact of top-down restructuring,
new management fads, structural conditions on staff morale, motivation
and trust.

Professional boundaries are barriers


The paradigm shift from “closed” to “open” is dependent on the two traditions
of professionals and managers coming to recognize each other’s value and
negotiate more balanced relationships. To some extent this can be summarised
as a balancing of the forces between those who tend to think in terms of
“systems” and those who are more likely to see change as being the result of key
“individuals”, and their personalities. The separation between organization and
specialism is extreme and acts as a major barrier to collaboration. Whereas
previously the two traditions of management and professional training could
operate side by side in larger bureaucracies, in the smaller organizations and
the new contacting agencies, this is more difficult. The manager has to think in
corporate terms not in the interests of one profession or one department.
Unfortunately, in the Western world, professionals have the capacity to
reinforce their status by demonstrating certainty and claims to “truth” by way
of bogus scientific measurement. Junior professionals attempt to entrap their
work by crude measurement in order to bolster their own status. Under-
confident professionals have created a prison for themselves within their
IJPSM establishment thinking and practices and consequently are frequently closed to
11,4 learning. Those in power tend to assume that they are right, are remote from the
realities of those outside of their social group and have a tendency to deny
information that does not conform to the thinking patterns learnt in lengthy
training. As many of the systems and criteria used in management, economics,
and development reflect professional élites it is unsurprising that professional
244 group members tend to appraise the world around them and package it neatly
into these same dimensions.
The problem remains that many individual doctors are the gatekeepers of
health care and, whilst they may protect existing practices, they also impede
new developments especially outside their own speciality and sector, and most
often this affects the development of community and primary health care. The
medical profession guards its members and its traditions, cementing the
establishment through the royal colleges, universities and British Medical
Association.
A major obstacle to bringing professionals and agencies together tends to be
a combination of a medical resistance to managerialism and the medical
establishment’s traditional codes of practice. Professional boundaries, although
specific to the profession, are well protected and guarded by specialist
knowledge which is reinforced by research agendas. The contracting
environment has not removed doctors’ power to say “no” – consultants still
continue to be major barriers to initiatives; sometimes this is understood to be
positive – for instance they stay “financial cuts” – but often they also refuse to
engage with joint working arrangements and only relate openly to other
doctors. Performance management is understood by many doctors to be a direct
attack on the medical and other professions. Whether the reforms have been as
successful in undermining medical élitism is debatable.
Within this context some doctors are loathe to delegate and fear any nurse or
therapist role extension; however, this is changing. The need to reduce doctors’
hours has created opportunities for doctors and nurses, but new flexibilities, if
decreed rather than negotiated, add to the doctors’ fear of “loss of control” and
the nurses’ fear of that they are being used as cheap doctors. Whilst policy
makers and managers want the move towards role-extension, seeing it as good
sense and a step on the road to improve patient care, they are also clearly
pushing new skill-mix and role changes through organizations fast because
such changes solve both the problem of how to reduce junior doctors’ hours and
reduce the pay-roll costs.
Many professionals make judgements on the basis of their specialist service
training and are sceptical about new staff roles and the use of generic
management to oversee very different services. The distinction that separates
the specialists from the corporate manager is the “management” emphasis on
technical systems and the faith in systems over and above individual people.
This position is very different from the individualist professional position
which tends to place value not on staff as a group but on individual users and
the status of individual staff.
The managerial preference for systems is often associated by the public, staff Barriers to
and consumers as one which places management systems and finance above transformation
service and value (Gray and Jenkins 1993; Harrison, 1992). The functionalist
approach within managerialism tends to exacerbate this problem. Functional
mapping, over-formal and logistic planning and project management all rely on
agreed and visible tasks and objectives. Yet, within the service sector,
education, training and development the real impact of service delivery is 245
experienced by people who are themselves reacting, responding, and adjusting
to the care, teaching or development process. Their engagement and
participation in the processes, if successful, almost invariably leads to a shift
away from the original framework and its anchors. This has been recognized by
many within evaluation and development but inflexible management systems,
such as care management, force staff into relationships and activities which
further compartmentalize and separate staff rather than bring them together in
more open relationships.
Managers and professionals do have different priorities. Managers tend to be
“organization” people who refer to “corporate” objectives and are looking to
improve overall performance, whether that be in terms of service development
or financial performance. Generalists too often have no knowledge of the
services they manage and consequently do not recognize how management
systems can impact on service delivery. Too many managers control finance,
staff and care rather than think about how to develop organizational systems
which support users and staff. One health executive said she could only think of
one purchasing chief officer, in her region, who understood the need for
management to be solidly grounded in service and user detail or need and on
service development.
This bodes ill for the future of health service strategy in that region:
A major problem for those of us working in the NHS Regional executives is that only one of
the chief executives of purchasing authorities has any professional background and few are
women – they cannot easily predict the outcomes of their thinking and systems on services or
staff. This is frustrating because the NHS reforms could be made to work to the advantage of
the disadvantaged, but this will not happen unless the purchasing managers are driven by a
knowledge of social need and service. Those graduates who are fast-tracked through the NHS
on general management schemes and who grew up in the early 1980s do not have this
knowledge nor in general a commitment to social change – they are careerists (Director of
Priority Services).
On the other hand, professionals are often as narrow, neglecting to consider
health needs and intent upon protecting their traditional practices, they are
unwilling to share knowledge and status. The BMA is probably now the
strongest trade union left in Britain. It was the only group in the NHS to remain
outside of the local pay deals and to have protected its national pay
negotiations. Salter (1993) and McKewitt and Lawton (1996) argue, “it’s ironic
that the very reforms which were intended to transfer power from the doctors to
the consumers, seem to have transferred power from one group of the medical
profession the another”. Other professional associations such as the Royal
IJPSM College of Nursing are vocal in their opposition to NHS reforms on local pay and
11,4 generic workers, but are more open to moves towards joint practices where they
do not appear to involve an erosion of nursing status. The traditional roles and
functions within nursing and psychology are also guarded by professional
association and in many cases enshrined in authoritarian management
structures (Worsley, 1996).
246 Practitioners or professionals continue to be threatened by managerialism
and forms of performance management, which they think will remove their
autonomy and power and does not reflect the needs of service users, whether
they be clients, patients or students. This tension is felt much more strongly in
services which have developed from previous professional provision. Mintzberg
(1995) noted flashpoints between managers and doctors express the traditional
tensions between the “agency” versus “system” approaches:
• where the managers dominate who are obsessed with budgets and
meeting activity targets;
• where the professionals (doctors) dominate and the service continues to
reflect professional tradition rather than the users;
• where the professionals dominate but they have developed a user and
joint practice focus;
• where managers dominate the organization but they are developing a
corporate culture which embraces or is being driven by organizational
behaviour learnt in the previous systems and culture.
Senior managers are driven by narrow financial targets and general standard
performance measures whilst the professionals, committed to their individual
“clients”, are sometimes blind to the wider world of power relationships within
organizations. The conclusion is that managers need to trust and be more
confident of practitioner and staff judgement and experience for it is they who
come into contact with local detail. This will enable them to develop with the
professionals more sensitive forms of measurement and relationships.
In spite of the very different mind-sets and traditions in management and the
professions they also endorse male gender cultures. The established career-
route through the professions is not dissimilar from the linear promotion
progression of managers. Whistleblowers and dissenters suffer the same fate of
exclusion, marginalization and are often bypassed for promotion. The problem
for all social innovators, whether they be professional or manager, is that they
challenge accepted practices or systems in order to develop new relationships.
They are breaking out from established boundaries and are therefore
threatening to their colleagues. Innovation is often named as sabotage before it
is accepted by a critical mass within the organization.

Gender, managerialism and women managers


In the 1980s one of the reasons why female managers were more likely to
embrace the new thinking of public sector management was that it looked as if
it would undermine the traditional male professions and macho management. Barriers to
The shift in performance assessment to “task” from the role and status culture transformation
created openings for many women in middle management. But the situation
was complex and varied and by the 1990s women managers were beginning to
get disgruntled about the lack of concern for the very values and traditions of
public service within the performance and contracting management systems.
Many women saw the advent of managerialism as a liberation from the male 247
professional establishments. The market was introduced into the public
services to undermine professional autonomy and shift more power towards
corporate managers who could make decisions on the basis of overall service
objectives rather than merely reinforcing professional practices. In fact,
although new public management may have successfully undermined
individual professionals as innovators, it has not undermined the male
professions such as medicine and their establishments, which if anything are
becoming more entrenched. The threat presented by corporatism and generic
management to the medical professional have had a unifying effect, bringing
those consultants previously in conflict closer together. The effect of this is to
reinforce many of the outdated professional boundaries which tend to
marginalize female members.
Lawyers, academics and the medical establishment are concerned to protect
their members and their clients/patients and their liberal education often leads
many to become involved in issues of social justice. But the male professions
also breed individualists who are very slow to recognize the importance of more
collaborative and egalitarian relationships, and lack respect for users. The
professional entrenchment against central government and managerialism also
makes it more difficult for juniors and women to change working practices.
The professions are founded on class male authority and authoritarianism
which undermine women’s activities (Davies, 1995). Each profession is a guild
and a club, with its own closed culture, codes and professional boundaries,
reinforced by long training and institutionalization at work. Where personal
adjustment and collaboration are necessary the professional ethos is out of
place, the professional establishment is by its nature divisive; it protects its
members and its boundaries zealously (Stacey, 1988). Expert knowledge sets
the boundaries for professional roles and responsibilities and limits learning
and self-expression. Many women working in the health services (Maddock and
Parkin, 1994) still perceive the medical establishment as more of a barrier to
collaboration and joint practice than either bureaucratic practices or “market”
competition. This is because even senior managers continue to avoid managing
medics.
Because so many women managers (Maddock, 1998) were frustrated in
public administration by what they saw as a lack of interest in management
and implementation on the part of managers themselves and politics, they were
initially enthusiastic to endorse clear and transparent performance measures.
At first the quality movement and the introduction of clarity in performance
measures appeared to open doors and create possibilities for developing more
IJPSM new collaborative ways to work. Many women thought that the introduction of
11,4 managerialism and performance measurement would assist them in developing
more egalitarian practices, although more transparent measures and practices
continue to reflect macho values. Contractual relationships are based on
specifications relating to the old professional boundaries of expertise and job
function, and budgets are allocated to known activities not service development.
248 Managerialism, which appeared to women as a liberation from red-tape and
bureaucracy in the 1980s, has degenerated into an efficiency culture which
rewards cheap activities, fast results, macho and individualistic behaviour and
administrative and evaluation systems which reinforce the systems in use
rather than develop quality of care:
New managerialism involves challenging and questioning the current aggressive style of
interaction. … it assumes that money is the main motivational currency. The performance
culture demands this, everyone is aware that individual appraisal and performance review are
never far around the corner … some writers have begun to refer to a clutter of mistrust
(Harrison et al., 1997) and have questioned the appropriateness of it for healthcare. Certainly
it would seem that the very factors which often bring nurses into nursing – commitment,
altruism, service ideals, the same ideals that encourage them to come in early, go home late
and work their breaks – are without a place in this model (Davies, 1995, p. 169).
Davies (1995) and Pollitt (1990 ) suggest that the contacting environment has
resulted in a more macho culture which merely mirrors that of the male
professions. Celia Davies (1995) suggests that managerialism in health has
resulted in even more detached managers who are devoted to the “new rough,
tough manager” model, and to generic systems which can be applied in any
type of organization anywhere in the world. The globalizing trend has not made
management or managers more sensitive to local or user needs; he or she seeks
to control through performance management and because of more transparent
systems wants to measure every activity rather than generate learning:
The new manager turns out to have many of the same characteristics of the old. He remains
distant and controlled. He takes a critical stance towards the arguments and established
practices of others, asking constantly for outcome data, cost information and performance
measures, he follows his own convictions, is tough minded in that he must take hard decisions
about “what the market brings” without being swayed by the appeals of sympathy or
particular cases. Above all he is a strong and active decision-maker who will not dodge
controversy and confrontation, be it with staff or the public (Davies 1995, p. 169).
And in so far as it is an improvement, it is because the more aggressive style
and transparent performance measures make the male gender culture more
visible and therefore more vulnerable to change. This was also the suggestion
of many women managers in the health services. However many women, in
their efforts to make systems work, appreciate the new task-orientated culture
but they can at least compete within it – whereas in traditional patriarchal
culture the very fact of their sex barred them from serious status. The effect of
management by objectives has made many gender stereotypes and
assumptions more visible. Pollitt (1990) called managerialism the invasion of a
foreign body into public administration, but in fact the values and hence the
measure proves that bureaucracy and market are based on the same old male Barriers to
culture left free to be more entrepreneurial and aggressive in its transactions. transformation
Managers are judged on whether they are willing to work round the clock, be
detached, cool, and decisive. These characteristics are not dissimilar from the
desired characteristics of managers in the private sector in the 1970s, the “solo
player”, “macho-man”. Although these particular manager traits are said to be
a little out of date in the private sector, they are “alive and kicking” in many 249
NHS agencies around Britain.
The macho culture in the public sector is common – this culture, rather than
encourage openness and managers to take risks, perpetuates the “blame”
culture to an extreme extent. Managers, men and women, develop the idea that
they have to prove themselves to be tough. Women, often feeling they fail on
this score ,attempt to gain credibility by proving they can work more efficiently
and effectively than their colleagues. It is not only performance-related pay that
pushes managers into demonstrating that they can meet unrealistic
performance targets such client contacts, research output, waiting times, etc.
This pressure to be more and more efficient forces managers further and further
away from new partnerships, holistic and user-based quality assurance.
There is a new tension between those women who seek to challenge the
management framework and its criteria as well as male cultures, and those who
are reinforced for their skill in managing systems. Although this could be seen
as the difference between “challenging” and “coping” women this would be too
negative and divisive a comparison. It will be interesting to see how such a
tension develops around the new development of new organizations in the
public sector for, in general, most women are searching for service quality
improvements and adding social value – it is their views on how to achieve such
change that divides them and the gender management strategies they employ
to do so.
Those committed to equal opportunities policies have become disillusioned
by the number of women who have become such efficiency-driven managers. It
would be churlish to blame them for conforming to the efficiency culture – they
are merely adopting the accepted stance of the traditional public bureaucrat of
abdicating responsibility and uttering “what can I do within the system?”
Unfortunately, by adapting to new public management, many women have lost
a sense of what many women managers (Maddock, 1993) are committed to –
that socially connected, inclusive management and services be transformed in
the direction of added social value not reduced financial input.
Unfortunately too few managers appear ready to recognize the necessity of
looking at the impact of managerialism on staff, users and the community –
something which many women traditionally brought to the public sector. Their
role as innovators is much needed in the transformation of the public sector, in
creating a management framework for the public sector and in bringing the
concepts of process, social value and trust into organizations. Sustaining the
innovation in social relationships has proved to be much more difficult than
IJPSM generating it and requires a framework for embedding innovation as well as
11,4 supporting individuals and pilot schemes.
The transformation process is an everyday process and already at work –
but the innovators remain under the stones struggling on the margins of the
professions, of management and in organizations, attempting to introduce
social value and social connectedness to management and their work
250 relationships. These challenging people, often women, are working towards a
more collaborative culture at work – they are often in middle-ranking positions,
outside the centre and working across boundaries. They are frequently
maligned to justify their further marginalization. Social transformation is
dependent not just on necessary financial and structural change but also on the
reversal of values in many measurements and an inclusion of those on the
margins.

References
Audit Commission (1997), Reviewing the Social Services, June, London.
Charlesworth, Clarke, J. and Cochrane, A. (1996), “Tangled webs? Managing local mixed
economies of care”, Public Administration, Vol. 74, Spring, pp. 67-88.
Clarke, J. and Newman (1994), “Going about our business. The managerialisation of public
services”, in Clarke, J., Cochrane, A. and McLaughlin, E. (Eds), Managing Social Policy, Sage.
Coote, A. and Hunter, D. (1996), New Agenda for Health, IPPR, London.
Davies, C. (1995), Gender and the Professional Predicament in Nursing, Routledge, London.
Dunleavy, P. (1995), “Policy disaster: explaining the UK’s record”, Publ ic Pol icy and
Administration, Vol. 10 No. 2, pp. 52-70.
Ferlie, E. and Pettigrew, A. (1996), “Managing through networks”, British Academy of
Management, Special issue, Vol. 7, March, pp. S81-S99.
Gray, A. and Jenkins, B. (1993), “Markets, management and the public sector: the changing role of
a culture”, in Taylor-Gooby, P. and Lawson, R. (Eds), Markets and Managers: New Issues in the
Delivery of Welfare, Open University Press, Buckingham.
Harrison, S. (1997), “Health: the agenda for an incoming government”, Public Money and
Management, April-June.
Hoggett, P. (1994), “New modes of control in the public sector”, paper to ERU conference, Cardiff.
Le Grand and Bartlett, W. (Eds) (1993), Quasi-markets and Social Policy, Macmillan, Basingstoke.
McKewitt, D. and Lawton, A. (1996), “The manager, the citizen, the politician and performance
measures”, Public Money and Management, July-September.
Maddock, S. (1993), “Women’s frustrations with local government management in the UK”,
Women in Management Review, Vol. 8 No. 1, pp. 3-9.
Maddock, S. (forthcoming), Gender and Transforming Organisations, Sage, London.
Maddock, S. and Parkin, D. (1994), Barriers to Women Doctors in the NWRHA, MBS, Manchester.
Mintzberg, H. (1995), “Managing the care of health and the cure of disease”, paper presented to
conference in Massa.
Nursing Times (1997), January.
Pollitt, C. (1990), Managerialism and the Public Services; the Anglo American Agenda, Blackwell,
Oxford.
Salter, B. (1993), “The politics of purchasing in the National Health Service”, Policy and Politics,
Vol. 21 No. 3, pp. 171-84.
Stacey, M. (1988), The Sociology of Health and Healing, Unwin Hyman, London.
Stewart, J. and Walsh, K. (1994), “Performance measurement: when performance can never finally Barriers to
be defined”, Public Money and Management, Vol. 14, pp. 45-9.
Walsh, K. (1995), Public Service and Market Mechanisms: Competition, Contracting and the New
transformation
Public Sector Management, Macmillan, London.
Wistow, G (1995), Local Government and the NHS. A New Agenda, Local Government
Management Board, Luton.
Worsley, M. (1996), personal communication.
Young, K. (1996), “Reinventing local government? Some evidence assessed”, Public Admin,
251
Vo1. 74, Autumn.

Further reading
Clarke, J., Cochrane, A. and McLaughlin, E. (1995), Managing Social Policy, Sage.
Glazer, P. and Slater, M. (1991), “Between a rock and a hard place: women’s professional
organizations”, Gender and Society, Vol. 5 No. 3, pp. 351-72.
Hennessey, P (1996), Muddling through: Power, Politics and the Quality of Government in Postwar
Britain, Victor Gollancz, London.
Hunter, D. (1997), “Wrongly held to account”, Health Service Journal, 8 May.
Jervis and Richards (1997), “Public management; raising our game”, Publ ic Money and
Management, April/June.
Mackintosh, M. (1997), “A socially inclusive management”, paper to the International Conference
on Public Sector Management, IDPM, Manchester, June.
Maddock, S. (1995), “Is macho management back?”, Health Service Journal, Vol. 105 .
Maddock, S. and Parkin, D. (1993), “Gender culture: women’s strategies and choices at work”,
Women in Management Review, Vol. 8 No. 2, pp. 3-10.
Mintzberg, H. (1987), “Crafting strategy”, Harvard Business Review, July-August.
Mintzberg, H. (1989), Mintzberg on Management, Macmillan, New York, NY.
Morgan, G. and Sturdy, A. (1997), “Strategic discourse and the management of change”, paper to
Warwick Conference on Modes of Organising, April.
Osborne and Gaebler (1992), Reinventing Government, Addison-Wesley, Reading, MA.