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JournalOfHea PDF
JournalOfHea PDF
Journal of
Health Organization
and Management
Using critical theories to develop
understanding of health
management
Guest Editor: Dr Mark Learmonth
www.emeraldinsight.com
Journal of Health ISSN 1477-7266
Volume 19
Organization and Number 3
2005
Management
Using critical theories to develop understanding
of health management
Guest Editor
Dr Mark Learmonth
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Abstract
Purpose – Received wisdom about management and leadership in health care takes it for granted
that better management is, by definition, a good thing. Aims to raise some doubts about this received
wisdom and suggest that perhaps better management may be unconditionally “better” for only a few
people.
Design/methodology/approach – These doubts are raised mainly via accounts of the author’s
personal experiences of being a manager in the UK National Health Service.
Findings – The author’s attraction to some parts of a body of literature called critical management
studies is discussed that was subsequently used to make sense of these experiences.
Originality/value – The accounts are offered in the belief that they will be of interest to other people
who are wrestling with their own ways of making sense of personal experiences in and around better
management in health care.
Keywords Critical thinking, National Health Service, Health services sector, Management theory
Paper type Viewpoint
Introduction
Governments, health care professionals, the public, everyone – we all want “better
management” – don’t we? After all, being against better management in health care (or
anywhere else) seems logically perverse: who can be “for” inefficiency? Could anyone
really want to promote bad practice?
And yet, for quite some time during the 17 years I spent working as a manager in
the UK National Health Service (NHS), I was aware of an increasingly strong feeling
that, for me, there was something wrong with simply (and simplistically) being “for”
better management: at least management in the sense of the business-style way of
organizing things that is now so widely taken for granted in the healthcare of many
countries. After all, from time to time my jobs in NHS management provided me with
privileged insights into some of the less wholesome things done in the name of better
management. Indeed, I sometimes had a hand in helping with these less wholesome
things myself (more on this later).
In 1998 I left the NHS to carry out research for a PhD that turned out to be a critical
examination of health services management (Learmonth, 2003). Doing the research
helped me to articulate some of the misgivings I had had about management when I Journal of Health Organization and
was in the NHS. The work also reinforced a discovery I had started to make a few years Management
Vol. 19 No. 3, 2005
pp. 181-188
q Emerald Group Publishing Limited
The author thanks Philip Warwick, Edward Wray-Bliss and Qi Xu for comments on an earlier 1477-7266
draft. DOI 10.1108/14777260510608925
JHOM earlier – that there are a quite considerable number of people across the world who are
19,3 sceptical about, if not downright hostile to the idea that better management is always
and necessarily a good thing.
Some of these critical ideas about management, specifically in the context of health
services, are collected together in a book I recently co-edited: Unmasking Health
Management: A Critical Text (Learmonth and Harding, 2004). The point of the book
182 was to stir things up in health care and challenge the “need” for management; in
particular, the way in which this so-called need hardly ever gets challenged in today’s
health care environments. The articles in this special edition of JHOM share the aim of
Unmasking, giving readers a further flavour of the potential for health care of critical
thinking about management.
So what I want to do in this introductory essay is to complement both Unmasking
Health Management and the articles that follow by providing one kind of rationale for
the different sorts of critical approaches to management they set out – a rationale that I
think may well make sense to many people currently working in health services. And
not just managers, anyone (including, and perhaps especially health care professionals)
looking for alternatives to the current performance obsessions of health care that is
making it an increasingly unpleasant and unrewarding environment in which to be.
In doing so, I am not primarily going to discuss theory, at least not in an abstract
kind of way. What I want to do is provide a few relatively brief personal experiences
that illustrate parts of the journey that led me to becoming sceptical about the standard
claims made for “better management” in health services. My preoccupation with a
critique of better management has its roots in experiences whilst I was employed
within health care. Academic work that questions, in a health service context, some of
the fundamental assumptions on which many ideas about better management are built
(see for example, Pollitt, 1993; Davies, 1995; Traynor, 1999; Loughlin, 2001) has become
important to me not so much for its satisfaction of intellectual curiosity, but because of
the way such work helps to make sense of these experiences.
Norman Denzin (1998, p. 315) argued that any discussion of interpretive practice:
must become political, personal and experiential. . . . I believe that the methods for making
sense of experience are always personal. . . . One learns about method by thinking about how
one makes sense of one’s own life. The researcher . . . fashions meaning and interpretation out
of ongoing experience.
So the intent in offering some narratives about my experiences is to see whether my
stories resonate with stories that other people who work in health care can tell. I’m
confident that I’m not the only person in the health field who has had misgivings or
discomforts about management. And if I’m right, perhaps my own account may be of
interest to those who are on a similar journey, wrestling with their own ways of
making sense of personal experiences in and around health care management.
Notes
1. Ford and Harding (2003) have shown some of the negative things that can be done – even to
health service managers themselves – in the name of the better management.
2. It might be that that one of my own ways of coping is confessing some of the things that
trouble me in the pages of this journal.
JHOM 3. Fournier and Grey (2000) provide a sympathetic, scholarly analysis of CMS; Parker (2002)
complements this with an accessible and lively (self-styled) polemic aimed at a general
19,3 readership focused on what he thinks the wider implications of CMS are for society as a
whole. Or for a brief overview click on: http://aom.pace.edu/cms/About/Domain.htm
4. And notice how staff at the sharp end of these changes typically speak of them in rather less
appreciative terms, their terms tending to make the management-speak sound hollow and
ironic.
188
5. See for example, Parker’s (2002) discussion of alternative organization (pp. 200-13).
References
Connelly, J. (2004), “Doctors and managers: conflicts, professional self-images and the search for
legitimacy”, in Learmonth, M. and Harding, N. (Eds), Unmasking Health Management:
A Critical Text, Nova Science, New York, NY, pp. 107-16.
Davies, C. (1995), Gender and the Professional Predicament in Nursing, Open University Press,
Buckingham.
Denzin, N. (1998), “The art and politics of interpretation”, in Denzin, N. and Lincoln, Y. (Eds),
Collecting and Interpreting Qualitative Materials, Sage, Thousand Oaks, CA, pp. 313-44.
Ford, J. and Harding, N. (2003), “Invoking Satan or the ethics of the employment contract”,
Journal of Management Studies, Vol. 40 No. 5, pp. 1131-50.
Fournier, V. and Grey, C. (2000), “At the critical moment: conditions and prospects for critical
management studies”, Human Relations, Vol. 53 No. 1, pp. 7-32.
Learmonth, M. (2003), “Rereading NHS management”, unpublished PhD thesis, University of
Leeds, Leeds.
Learmonth, M. and Harding, N. (Eds) (2004), Unmasking Health Care Management: A Critical
Text, Nova Science, New York, NY.
Loughlin, M. (2001), Ethics, Management and Mythology: Rational Decision Making for Health
Service Professionals, Radcliffe Medical Press, Oxford.
McCartney, S., Brown, R. and Bell, L. (1993), “Professionals in health care: perceptions of
managers”, Journal of Management in Medicine, Vol. 7 No. 5, pp. 232-40.
Parker, M. (2002), Against Management: Organization in the Age of Managerialism, Polity,
Cambridge.
Pollitt, C. (1993), Managerialism and the Public Services: Cuts or Cultural Change in the 1990s?,
2nd ed., Blackwell, Oxford.
Strong, P. and Robinson, J. (1990), Under New Management, Open University, Milton Keynes.
Traynor, M. (1999), Managerialism and Nursing: Beyond Oppression and Profession, Routledge,
London.
Willmott, H. (1997), “Making learning critical: identity, emotions and power in processes of
management development”, Systems Practice, Vol. 10 No. 6, pp. 749-71.
The Emerald Research Register for this journal is available at The current issue and full text archive of this journal is available at
www.emeraldinsight.com/researchregister www.emeraldinsight.com/1477-7266.htm
Shifting the
Shifting the balance of power? balance of
Culture change and identity in an English power?
health-care setting
Ruth McDonald 189
National Primary Care R&D Centre, University of Manchester, Manchester,UK
Abstract
Purpose – A recurring theme in Government policy documents has been the need to change the
culture of the NHS in order to deliver a service “fit for the twenty-first century”. However, very little is
said about what constitutes “culture” or how this culture change is to be brought about. This paper
seeks to focus on an initiative aimed ostensibly at “empowering” staff in an English Primary Care
Trust as a means of changing organisational culture.
Design/methodology/approach – It presents findings from an ethnographic study which suggests
that this attempt at “culture change” is aimed at manipulating the behaviour and values of individual
employees and may be interpreted as a process of changing employee identity.
Findings – Employees reacted in different ways to the empowerment initiative, with some resisting
attempts to shape their identity and others actively engaging in projects to bring their unruly self into
line with the ideal self to which they were encouraged to aspire.
Originality/value – The challenges presented by the need to respond to conflicting Government
policies created tensions between individuals and conflicts of allegiance and identity within individual
members of staff. Alternative forms of selfhood did not merely replace existing identities, but interacted
with them, often uncomfortably. The irony is that, whilst Government seeks to promote culture change,
the frustrations created by its top-down target-driven regime acted to mitigate the transformational and
reconstitutive effects of a discourse of empowerment aimed at achieving this change.
Keywords Work identity, Empowerment, Primary care, National Health Service, Organizational culture
Paper type Research paper
Introduction
The NHS Plan, published in July 2000, announced proposals for “far reaching change
across the NHS”, with “radical change” planned at “every level” in order to make the
service “fit for the 21st century” (Department of Health, 2000). A recurring theme in
Government policy documents has been the need to change the culture of the NHS in
order to deliver the vision outlined in the Plan (Department of Health, 2001). Despite
this emphasis on the manufacture and manipulation of culture as a means of achieving
desired outcomes, very little is said about what constitutes “culture” (Ormrod, 2003) or
how this culture change is to be brought about. There are some clues in policy
documents which emphasise “new ways of working” and “shifting the balance of
power” to front line staff. However, imposition of centrally determined targets and
top-down directives raises questions about what this shift in power means in practice.
This view of culture as a controllable variable, which can be manipulated to improve
organisational effectiveness, is reminiscent of the views popularised in the 1980s in Journal of Health Organization and
books such as Peters and Waterman’s In Search of Excellence. Here the creation of shared Management
Vol. 19 No. 3, 2005
values and beliefs is crucial to organisational success and the achievement of excellence. pp. 189-203
Peters and Waterman’s (1985, pp. 318-25) concept of “simultaneous loose-tight q Emerald Group Publishing Limited
1477-7266
properties” entails the rigorous adoption of overarching values with substantial DOI 10.1108/14777260510608934
JHOM autonomy for operational managers in deciding how to enact these values. However,
19,3 although these overarching values are to be internalised by all employees they reflect the
views and goals of those at the top of the organisation. Similarly, despite the emphasis on
autonomy in Government policy documents, the context of top down directives suggests
that current policies aimed at “culture change” represent strategies of control rather than
empowerment. Strategies based upon the internalisation of values appeal to
190 organisational elites since they appear to be more effective and less costly than
methods which require direct control and surveillance (Sewell and Wilkinson, 1992).
Peters and Waterman (1985, p. 74) provide a range of prescriptions for changing
employee values, and strategies for gaining commitment to organisational goals, but the
success of such strategies appears to be based on a characterisation of employees as
social dopes: “the fact . . . that we think we have a bit more discretion (even when we
don’t) leads to much greater commitment” (Peters and Waterman, 1985, p. 81). Although
such strategies are described as changing organisational culture, they are aimed at
manipulating the behaviour and values of individual employees and may be interpreted
as a process of changing employee identity (Strangleman and Roberts, 1999).
This paper focuses on an initiative aimed ostensibly at “empowering” staff in an
English Primary Care Trust (PCT), which may, in common with Government rhetoric
about empowering NHS staff, be seen as an attempt at increasing organisational
control by shaping employee identities. This initiative appears to be based on the naı̈ve
idea that a shift in culture to produce compliant employees can be achieved by the
manufacturing of certain desirable forms of subjectivity by the actions of powerful
senior managers within the PCT. However, this fails to recognise the active role played
by individuals in the shaping of their own identity. What follows is divided into four
main sections. The first provides a brief account of NHS modernisation and the
theoretical framework through which the empirical data is interpreted. The second
presents contextual information about the case study site, the “Investing in Excellence”
(IEE) course that the PCT offered, and data collection methods. The third discusses
findings from the research based on the interviews and observations conducted. The
final section presents concluding remarks, which examine the implications of the
research findings in the context of ethical selfhood and attempts at new forms of
subordination in the guise of NHS empowerment initiatives.
Conclusions
The case study data suggest that participation in the empowerment programme in
Downtown PCT and the observed behaviours arising from it can be understood in the
context of the fashioning of the ethical self. However, these data also illustrate that the
processes of identity formation are fluid, unstable and reflexive, which means that
although the intent of empowerment initiatives might be the creation of new forms of
subordination the result might be rather different (Alvesson and Willmott, 2002).
Certainly many employees reported feeling more content and less likely to complain in
the context of increasing workloads and uncertainty over roles and responsibilities. For
some, particularly amongst those who had been promoted by the organisation, there
were clear expressions of loyalty to the new regime. For others, however, rather than
actively choosing loyalty they chose quiet resistance, engaging in criticisms with
colleagues or applying for jobs outside of the organisation. Some simply chose to
ignore the changes and continued to work in ways which were compatible with their
own ideas of ethical selfhood. Other respondents chose more open forms of resistance
in the face of attempts to secure their compliance, either by opting out of the IIE course
altogether or using the techniques learned on the course to openly challenge senior
managers within the PCT.
The case study suggests that individuals are actively involved in the construction of
their identities bringing their own values, skills and affiliations to bear on the matter of
what constitutes ethical selfhood. In addition, the rules and values (or moral code)
which convey what is expected of an empowered individual in the context of
Downtown PCT, far from being a systematic ensemble, are transmitted in a diffuse and
contradictory manner. They can best be understood as a complex arrangement of
elements that counterbalance and correct one other. At certain points they cancel each
other out providing for compromises or loopholes.
JHOM For example, there are rules which relate to the requirement for individuals to
19,3 display optimism and positive attitudes. These requirements are laid out clearly in the
IIE course materials and supported by the CEO’s comments about the undesirable
nature of those who see the glass as “half-empty”. There is also the public service
discourse which conveys a picture of a vocational, professional, loyal, self-sacrificing
and caring self for whom service is an honour and a duty rather than a chore.
202 Management textbooks and Government policy documents are replete with images
which equate rationality with calculation and lack of emotion. At the same time there
are other rules, some of which are prescriptive, explicit and consistent which outline
what constitutes the required behaviour for caring professionals. The comments made
by Downtown PCT nurses suggest that such rules may conflict with other managerial
codes. For example, the Nursing and Midwifery Code of Professional Conduct
paragraph 8:1 places a duty on nurses to “work with other members of the team to
promote healthcare environments that are conducive to safe, therapeutic and ethical
practice” (NMC, 2002), but staff who refuse to work in what they consider to be an
unsafe environment may be seen as “negative” or failing to cope in adversity. In
addition, modernisation involves attempting to deliver services with inadequate
resources, to achieve at times unrealistic targets and without being permitted to engage
in rationing. The unreasonable and inconsistent nature of what is being asked (exercise
local freedom, but don’t engage in postcode rationing, prioritise waiting lists and
inequalities and access to primary care services and A&E waiting times and
everything else all at the same time) means that it is not possible to provide simple
messages or codes about what constitutes ethical behaviour.
The depiction of the empowered self at the heart of the IIE programme serves to
buttress the comments of the PCT chief executive in relation to desirable “grown up”
behaviour. Well-behaved selves are loyal, positive and embrace change, but as the case
study illustrates, loyalty may be to other constituencies if the individual chooses to
obey other ethical codes and resistance to change may be seen by individuals as a
positive stance if changes threaten such cherished values as patient safety. Whilst
employees ostensibly choose “loyalty” in preference to “exit”, the tensions created by
an emphasis on personal authenticity in the context of top-down directives which
require the individual to subordinate their personal priorities to those of the
organisation means that conflict and resistance are always present even if not always
openly voiced by employees.
For many, the obligation to render one’s everyday existence meaningful as the
outcome of choices resulted in frustrations emanating from the failure of others to
acknowledge the legitimacy of those choices. The expression of ideas and the selection
of goals by individuals represent not merely an administrative process of policy
implementation, but are instead integral components of the construction and
maintenance of the self. A less than enthusiastic reception for these ideas is not merely
an issue on which compromise can be reached or where agreeing to disagree ensures
good working relationships. Rather, many individuals are likely to perceive opposition
or neglect as deeply wounding since it represents an assault on the self. The case study
suggests that that the shaping of ethical selves and the achievement of a culture of
excellence involves much more than the exercise of an empowerment discourse over
inert and compliant employees. The Downtown PCT employees described here are
actively involved in the shaping of their identity and for many, these assaults on the
self are much more likely to provoke resistance than secure compliance. This state of Shifting the
affairs is likely to be exacerbated in a situation where increasing numbers of PCT staff
are participating in the IIE programme, persuaded of the validity of their own opinions,
balance of
but in the context of top-down directives which conflict with the way in which power?
individuals choose to conduct themselves and with the values which they hold dear.
References 203
Alvesson, M. and Willmott, H. (2002), “Identity regulation as organizational control: producing
the appropriate individual”, Journal of Management Studies, Vol. 39 No. 5, pp. 619-44.
Deetz, S. (1998), “Discursive formations, strategized subordination and self-surveillance”, in
McKinlay, A. and Starkey, K. (Eds), Foucault, Management and Organization Theory,
Sage, London.
Department of Health (2000), The NHS Plan. A Plan for Investment, a Plan for Reform, Cm 4818-I,
The Stationery Office, London.
Department of Health (2001), Shifting the Balance of Power within the NHS: Securing Delivery,
Department of Health, London.
Foucault, M. (1982), “The subject and power”, in Dreyfus, H.L. and Rabinow, P. (Eds), Michel
Foucault: Beyond Structuralism and Hermeneutics, Harvester Press, Brighton.
Foucault, M. (1986), A History of Sexuality, Volume 2: The Uses of Pleasure, Viking,
Harmondsworth.
Foucault, M. (1988), “Technologies of the self”, in Martin, L.H., Gutman, H. and Hutton, P. (Eds),
Technologies of the Self: A Seminar with Michel Foucault, Tavistock, London, pp. 9-15.
Gilbert, T. (2001), “Reflective practice and clinical supervision: meticulous rituals of the
confessional”, Journal of Advanced Nursing, Vol. 36 No. 2, pp. 199-205.
Hirschman, A.O. (1970), Exit, Voice and Loyalty: Responses to Decline in Firms, Organizations
and States, Harvard University Press, Cambridge, MA.
NMC (2002), Code of Professional Conduct, Nursing & Midwifery Council, London.
Ormrod, S. (2003), “Organisational culture in health service policy and research: ‘third-way’
political fad or policy development?”, Policy and Politics, Vol. 31, pp. 227-37.
(The) Pacific Institute (1998a), Investment in Excellence, Personal Resource Manual, The Pacific
Institute, Seattle, WA.
(The) Pacific Institute (1998b), Investment in Excellence, Audio Assimilation Guide, The Pacific
Institute, Seattle, WA.
Peters, T. and Waterman, R.H. (1985), In Search of Excellence, HarperCollins, London.
Rose, N. (1996), “The death of the social? Refiguring the territory of government”, Economy and
Society, Vol. 25, pp. 327-56.
Rose, N. (1999), Governing the Soul: The Shaping of the Private Self, Free Association Books,
London.
Sewell, G. and Wilkinson, B. (1992), “Someone to watch over me: surveillance, discipline and the
just-in-time labour process”, Sociology, Vol. 26 No. 2, pp. 271-91.
Strangleman, T. and Roberts, I. (1999), “Looking through the window of opportunity: the cultural
cleansing of workplace identity”, Sociology, Vol. 33 No. 1, pp. 47-68.
ten Bos, R. and Willmott, H. (2001), “Towards a post-dualistic business ethics: interweaving
reason and emotion in working life”, Journal of Management Studies, Vol. 38 No. 6,
pp. 769-93.
The Emerald Research Register for this journal is available at The current issue and full text archive of this journal is available at
www.emeraldinsight.com/researchregister www.emeraldinsight.com/1477-7266.htm
JHOM
19,3 Exhausting management work:
conflicting identities
Jane Mischenko
204 University of Leeds, Leeds, UK
Abstract
Purpose – The primary purpose of this paper is to critically explore managers’ experience of work
identity in the National Health Service (NHS).
Design/methodology/approach – This paper is unconventional in that it uses an
auto-ethnographic approach and poetry as the empirical data from which the conceptual
framework evolves. The concepts of identity, power and self are analysed in relation to the
narrative utilising a post-structuralist, critical management lens, particularly drawing from Foucault.
Findings – The paper reflects and critiques the challenges of undertaking auto-ethnography, not
least the publication and exposure of a “vulnerable aspect” of the author but also identifies this as a
powerful method to explore how one uses narrative to create meaning and constitute oneself; the
challenges of such textual representation and the various ways one adapts, resists and survives the
challenge of the “multiphrenic” world.
Originality/value – The contribution this paper makes is an “outing” of the dynamics of being a
manager in the NHS and an opening of a debate on current management discourse and practice. The
further value of this paper is the experimentation of critically evaluating an auto-ethnographic
approach to researching management identity work.
Keywords Critical thinking, Managers, National Health Service, Work identity, Narratives, Poetry
Paper type Conceptual paper
Well here I am telling you part of my story, totally queering the modernist take on the
role of an academic author to remain outside of the text. Here I run through it, my
assumptions, emotions, values and conflicting identities intermingle not just in my
story but throughout the text: in my choice of theory to interpret my text, in my choice
and presentation of my experience and in my wish to challenge the assumption that
only ordered, structured and objective prose is worthy output of academic endeavor.
I use autoethnography as an opportunity to be as open as possible about the issues
that influence my research interests. In sharing a recent and for me significant
experience I have a focus, an application from which to explore theories relating to the
self, identity and power.
I feel I need to share with you my fear, my feelings of anxiety; I am consciously
taking a number of risks in this work. I’m putting my story “out there”, in the domain
of “others”, for you to judge and perhaps permanently fix my identity as an
overwhelmed and insecure manager. Once a paper is produced and “out there” the
resulting prose remains fixed and frozen in time:
As long as you read this poem
I will be writing it.
Journal of Health Organization and I am writing it here and now
Management
Vol. 19 No. 3, 2005 before your eyes
pp. 204-218 although you can’t see me.
q Emerald Group Publishing Limited
1477-7266
Perhaps you’ll dismiss this
DOI 10.1108/14777260510608943 as a verbal trick,
the joke is you’re wrong; Exhausting
the real trick
is your pretending management
this is something work
fixed and solid,
external to us both.
I tell you better:
I will keep on 205
writing this poem for you
even after I’m dead (“An exchange of gifts” by Alden Nowlan).
Autoethnography that is published has been described as an “Outing Process” whether
intentional or not, which maybe an uncomfortable experience (Flemons and Green,
2002, p. 93). There are warnings that your profession and colleagues may see you in a
different light that can damage your career: You may “Publish and Perish” (Flemons
and Green, 2002, p. 165). Well here I am, despite this warning, taking a leap of faith; I
open up to your scrutiny one of my vulnerable “selves” and I do this with the
knowledge that therefore I may remain forever in your eyes, pinned down, as a
miserable specimen of a manager.
The experience of telling my story and reflecting on the meaning has at times been
acutely painful and the charge of reflexivity being a warm and comfortable bath
(Parker, 2002) rings hollow. I’ve also decided to express my story through poetry,
another considerable risk. I have chosen not to explore the theory and techniques of
producing good poetry but rather have used poetry as a raw and expressive force. Why
choose such a medium given my lack of experience? I wanted to avoid creating an
overly rational and dry text that over-intellectualised my experience and instead aimed
to capture my heartfelt and embodied experience, especially my emotional responses.
My first stumbling across autoethnographic research was Carolyn Ellis and
Art Bochner’s work (2000) and I was both captured and enraptured: My heart raced, my
head raced, I wanted to read and find out more. These texts didn’t just interest me on an
intellectual plane but fully engaged me. I responded personally on an emotional and
physiological level. I experienced these stories, through application to and reflection of my
own: I read moving personal stories of experiences relating to childhood abuse (Keisinger,
2002) and I reflected on my experience as a health visitor, child and mother; I read of an
experience of sex identity transformation (Dent, 2002) and I reflected on my life as a
woman and of being categorised. I read of a woman dealing with surviving cancer (Ellis
and Bochner, 2000) and felt the fear of possibility; and of those dying of metastatic cancer
(Gray et al., 2002) and I remembered a lost friend and my experience as a nurse.
Given my experience of the above rich and dramatic narratives, a further fear I have
is the knowledge that my story is far more mundane, less dramatic and more routine. It
involves the more chronic and insidious pressure of work and living in the twenty-first
century, with the condition of “multiphrenia” (Gergen, 2000) and the toll it takes. Who
would be interested? How self-indulgent and narcissistic, and yet; worthy
autoethnography is said to move beyond individual introspection or self-therapy
and explores the meaning for others (Pelias, 1999; Ellis and Bochner, 2000).
I should warn you the structure of this paper is intentionally unconventional: the
traditional format of preceding the empirical data with the theoretical framework is
flaunted. Here, I am both researcher and research subject and the paper, reflecting the
research experience, evolves from the acutely personal and deeply emotional, to then
JHOM explore the use of a critical management theoretical lens. The theory is then used to
19,3 understand how social meanings of self, identity and power have created the
possibility of my experience and in fitting with critical research (Alvesson and Deetz,
2000) start to explore ways of resistance.
Given that I strongly believe that language and text doesn’t produce a clear
representation of reality; that in post-structural theory meaning is constantly deferred
206 in reference to further language, and that this story is created by all of us: the
researcher “I”, the researched “I” and you the readers, I suggest we take Gergen’s (2000)
advice: I invite you to engage in free play with both my story and my ongoing
interpretations.
Autoethnography
The reason autoethnography is so appealing to me is that it recognises how the
personal is always social. The private struggles and endeavors of individuals are
always linked to social and cultural values and meanings (Denzin, 2001). Our
understanding of ourselves and our experience is developed through our interaction
with others. I like the ethic of care and concern (Denzin, 1997) and recognise the moral
work and ethical practice inherent in developing a meaningful personal narrative in
our uncertain, changing world (Ellis and Bochner, 2000).
Autoethnography has elements of an autobiographical approach and uses the
personal experience to focus on the vulnerable self and also takes a wider ethnographic
gaze to the cultural, social aspects of that experience (Reed-Danahay, 1997). The
research (graphy) is on the self (auto) in the culture (ethno) and self-other interactions
(Reed-Danahay, 1997; Ellis and Bochner, 2000). There isn’t one way to undertake
autoethnography but a whole continuum of approaches, all of which place a different
emphasis on self, culture and research (Ellis and Bochner, 2000). In my reading I have
come across personal narratives, solo or group performances, art, rap and poetry (see
Bochner and Ellis, 2002 for rich examples of such approaches). However, although
there are many presentations of autoethnography they all hold a core principle of
starting with a personal story, which incorporates the physical feelings, thoughts and
emotional experiences that expose the vulnerability of the self and therefore “challenge
the rational actor of social performance” (Ellis and Bochner, 2000, p. 744). Human
beings are emotional and embodied subjects and discourses and research methods that
place an over emphasis on rationality reduce this richness of human experience
(Knights and Willmott, 1999).
I embrace autoethnography as being in harmony with my philosophical beliefs and
therefore a fitting poststructuralist research method. Autoethnography incorporates a
focus on interpreting the micro practices of everyday life and a critical questioning of
established social order, which are congruent with critical research methods (Alvesson
and Deetz, 2000). Within it there is a clear recognition of my role as researcher (and
researched subject) in determining the research topic, framework and interpretation.
There is recognition of the chaotic, ambiguous nature of life and narrative and that as
the researcher, I both contribute to and experience this chaos. The method demands
high reflexivity and personal accountability so my assumptions and values are openly
stated, rather than the traditional positivist approach, where the researcher speaks in
the authoritative third person, presented as an objective and neutral instrument (Ellis
and Bochner, 2000; Gergen and Gergen, 2002).
Autoethnography is a first person dialogue with a dramatic tension plot line. It is: Exhausting
. . . a form that will allow readers to feel the moral dilemmas, think with our story instead of management
about it, join actively in the decision points that define an auto ethnographic project, and work
consider how their own lives can be made a story worth telling (Ellis and Bochner, 2000,
p. 735).
I enjoy the fact that autoethnography reduces the distance between the 207
researcher, researched and reader is engaging and enables my story to be heard
through your frames (Flemons and Green, 2002). Autoethnography gives me the
opportunity of sharing one aspect of my struggle of “being-in-the-world” and of
performatively constituting myself against a backdrop of social role expectations
(Lockford, 2002).
A meaningful autoethnographic project should move you the reader, initially to
feeling and reflection (Lockford, 2002) and then on to action (Denzin, 1997).
Can my narrative achieve this? Will you recognise my story, my choices and my
pain? Will it cause you to pause in thought and reflect on your related stories?
A charge often leveled at the autoethnographic approach is that it is (or can be)
vain, narcissistic and self-indulgent, or even an “academic wank” (Sparkes, 2002, p.
212). I find such criticisms frustrating, and based on misplaced assumptions of
individual/social dualism (Mykhalovskiy in Sparkes (2002)); they deny that my
experience, my subjectivity, my “self” are social phenomena saturated with the
voices of others (Church, 1995; Gergen, 2000). Pelias (1999) states that good
autoethnography involves a story that points beyond the self and reminds us of the
consequences of our social context: that politics and the individual are integral.
Through many conversations with colleagues, both within and external to the NHS,
I know that my story is not unique and will trigger recognition. When I write of
myself my voice carries the echoes of my conversations, my reading and my living
with others. As Gergen (1999) states, the self and therefore any narrative of the self
is relationally embedded. Here I (and my others) am blatantly and loudly in the text
rather than the traditional social science approach that alleges and assumes the
researcher is silent.
This mode of research does change the researcher and is maybe a therapeutic
process, though this is not its primary aim, which is more to make a connection with
others (Flemons and Green, 2002). As I write and read I shape and make sense of my
experience, my story and sense of self. The use of narrative does not represent reality
but how we constitute reality and our identities. Narrative helps us gain a sense of
coherence and stability in a fragmented, chaotic and conflicting world (Ellis and
Bochner, 2000).
In order to prevent the perception of a fixed story, or fixed identity
autoethnography should fight the impulse to have an ending or closure to an
issue but instead should present a series of openings and possibilities (Flemons and
Green, 2002). If I can achieve this then I hope I can prevent my identity being fixed
in your mind as that of an insecure and overwhelmed manager. Identity work is an
ongoing dynamic or struggle (Sveningsson and Alvesson, 2003) and this is
excellently illustrated by Keisinger (2002) who describes how she has over time
reframed her response to her experience of childhood abuse, in order to move from a
victim to survivor identity.
JHOM My story
19,3 I present my story as a poem of three sections, entitled “Pressure”, “Escape” and
“The Return”.
Pressure
How did this creep up on me?
208 Me so efficient,
so busy
a deliverer?
Always in control,
always calm.
When did work take over?
Its insidious creep;
staying late,
taking work home,
more and more
hours stolen.
Frustration, anger welling up
trying to catch up:
There’s always more.
Where am I?
My children look to me and sigh,
Where is mum?
My rage starts spilling out
to anyone who’ll listen.
My tears ever near,
my throat a tight constriction.
Where am I?
Escape
The tension eases.
The spring uncoils.
Urgency dissipates
as time goes slow.
I unfurl and stretch out
to possibilities.
I determine not to think of work:
I am soothed
by the orange heat of the sun
and the touch of the turquoise sea.
I am healed
by golden childish laughter,
where time passes gently.
I relax
as I drink full bodied wine
squeezed from lush local vines.
The azure blue sky embraces me
as I eat my rich pasta dish.
Italian chatter dances around me
as my family remember,
well rehearsed stories. Exhausting
In the colour and sensuality of Italy
I find a balanced me. management
work
The Return
Physically I feel the return; 209
like a jolt:
A thudding of the heart.
I resist
going back to that pace,
that rat race.
I’m open and vulnerable;
after my break
but I resist
My chest tightens,
my breathing labours.
Overwhelmingly work looms
but I resist
AND I hurt!
Tears and anguish,
suppressed.
But again that refrain,
the pressure of work,
plugged into our pods,
we feed the machine,
life sucked dry.
Pull on my armour.
Where are my masks?
Toughen up Jane
Back to my lists
of things to do . . .
Tight is my chest,
tight is my smile
How can I resist?
As I have typed this, now I am back into the routine and have normalised the
demands of my work schedule, I am reminded of the effort it took to return: I have
relived some of these emotions and feelings, such as my anger, frustration and a
sense of helplessness. I have experienced a physical remembrance as my throat
constricts and my neck tenses. I wonder what there is in terms of the theory and
previous research that can help interpret my experience and possibly find modes of
resistance.
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www.emeraldinsight.com/researchregister www.emeraldinsight.com/1477-7266.htm
Health
A hermeneutic science: health economics and
economics and Habermas Habermas
Neil Small
School of Health Studies, University of Bradford, Bradford, UK, and 219
Russell Mannion
Centre for Health Economics, University of York, York, UK
Abstract
Purpose – Mainstream health economics labours under a misleading understanding of the nature of
the topic area and suffers from a concomitant poverty of thinking about theory and method. The
purpose here is to explore this critical position and argue that health economics should aspire to being
more than a technical discipline. It can, and should, engage with transformative discourse.
Design/methodology/approach – It is argued that the hermeneutic sciences, emphasising
interpretation not instrumentality or domination, offer a route into the change to which one seeks
to contribute. The article specifically focuses on the way Habermas provides insights in his approach
to knowledge, reason and political economy. How he emphasises complexity and interaction within
cultural milieu is explored and primacy is given to preserving the life-world against the encroachments
of a narrow rationalization.
Findings – The argument for a critical re-imagining of health economics is presented in three stages.
First, the antecedents, current assumptions and critical voices from contemporary economics and
health economics are reviewed. Second, the way in which health is best understood via engaging with
the complexity of both the subject itself and the society and culture within which it is embedded is
explored. Third, the contribution that hermeneutics, and Habermas’s critical theory, could make to a
new health economics is examined.
Originality/value – The paper offers a radical alternative to health economics. It explores the
shortcomings of current thinking and argues an optimistic position. Progress via reason is possible if
one reframes both in the direction of communication and in the appreciation of reflexivity and
communality. This is a position that resonates with many who challenge prevailing paradigms, in
economics and elsewhere.
Keywords Health and medicine, Economics, Economic theory, Research methods
Paper type Conceptual paper
Introduction
“Economics is what economists do . . . and that what economists do is to study
questions that can be handled with their own expertise” (Lipsey and Harbury, 1992).
Economists consider how societies meet wants from limited resources. They consider
both production and distribution. How do you decide to produce what is produced and
how do you then produce it and decide who gets it? Health economics, as an applied
sub-discipline of economics, studies how scarce health resources can be used to meet
needs. In the main it identifies that, “the predominant production function for health is
health care”. But the relevant social want is health, not health care. Health is not just Journal of Health Organization and
the product of health care, at the very least it involves environmental, economic and Management
Vol. 19 No. 3, 2005
social factors. It is also arguable that health is an intermediate good – of no intrinsic pp. 219-235
value in itself save its not insignificant contribution to fulfilment in life (Edwards, 2001, q Emerald Group Publishing Limited
1477-7266
635-4). DOI 10.1108/14777260510608952
JHOM In this paper we explore what economics in general and health economics in
19,3 particular might look like if it adopted a different approach – a hermeneutic rather
than an instrumental one. Doing this might offer a route out of the impasse that Lipsey
and Harbury’s closed system implies. It might also allow health economists to say
more about both the nature of the social want of health and about the complex of
factors that impact upon it. These are areas that require more than a narrow
220 understanding of production and distribution.
Much of what we experience is shaped by the structures around us. These
structures can be responded to and changed by collective action. This possibility is
made more difficult however because of the way knowledge is constructed.
Specifically, the Enlightenment encouraged a belief in the usefulness of knowledge to
effect domination. Habermas calls this the exercise of instrumental reason via the
empirico-analytic sciences. Others have more generally characterised the
Enlightenment as marking the ascendancy of a dominant positivism. But there is
also a science of interpretation – understanding the way we interpret our actions to
each other, the way we understand each other, the way we direct our actions together
in social organisations. These are the hermeneutic sciences, they involve interpretation,
not instrumentality or domination (Craib, 1992)
In considering health care, in order to understand how it is constituted in society, it
is necessary to identify significant institutions and organisations and their relationship
with each other. This includes making some assessment of their relative importance
and considering how they link with other key areas in society. It is also necessary to
examine the internal structure of organisations. These are areas amenable to empirical
examination. But if these are necessary they are not sufficient to understand and to
seek routes to effect change. To do this it is necessary to appreciate the objectives,
intentions and choices of the people who work in these institutions and those who seek
services from them. This is a domain for interpretive inquiry.
In describing the link between historical social development and knowledge,
Frankfurt School theorists used the term, praxis. This encompasses a recognition that
any form of action in the world gives us an experience of what the world is like.
Knowledge is the articulation and working out of that experience. Praxis captures
structures and action in such a way that it allows the sort of practical criticism that can
bring about social change. Knowledge here is intrinsically transformative, not technical.
In what follows we will argue that mainstream health economics labours under a
misleading understanding of the nature of the topic area and suffers from a
concomitant poverty of thinking about theory and method. We will argue that health
economics should aspire to being more than a technical discipline and that it can and
should engage with transformative discourse. This, we argue, may be achieved via
theoretical thinking that questions received axioms, many of which are perverse and
unnecessary, and by recognising that economics should be located within an
intellectual domain that accepts that economic behaviour must be analysed as more
than just physical phenomena (Morrow, 1994, p. 9).
We will develop our argument for a critical re-imagining of health economics in
three stages. First we will review the antecedents, current assumptions and critical
voices from contemporary economics and health economics. Second, we will explore
how health is best understood via engaging with the complexity of both the subject
itself and the society and culture within which it is embedded. Finally, we will examine
the contribution of critical theory and ask what sort of health economics would ensue if Health
it was located in this tradition.
economics and
Orthodox and dissident views in economics and health economics Habermas
Over recent decades both in the UK and in many other Western countries, public policy
questions have become increasingly construed in explicitly economic terms. Arguably,
the main beneficiary of this melding of economics and public policy has been the 221
economics profession. Nowhere is this more apparent than in the UK which has
witnessed an explosion in the number of health economists plying their trade in
academe, government departments and the pharmaceutical industry and where
successive reforms to the National Health Service have drawn increasingly on
economic ideals for inspiration and post hoc legitimation.
As an academic sub-discipline, health economics has brought an elegant set of
theories, models and techniques to bear on the topic of health and health care. Indeed, it is
readily acknowledged that theoretical formulations and empirical applications falling
within its purview have contributed significantly to advances in the parent discipline (the
theory of human capital, outcome measurement and evaluation, cost-effectiveness
analysis, principal-agent models, the theory of supplier induced demand, geographical
resource allocation and the study of asymmetric information, to name but a few). Yet,
health economics as a sub-discipline has remained remarkably insulated from important
theoretical and philosophical debates that have traversed the social sciences. If one wants
to assess fully the contribution of health economics one has not only to look at the
techniques used by its practitioners but also the values and implicit philosophical
assumptions that govern the choice of these techniques. What questions are the
techniques brought to bear on and what sense is made of the answers arrived at?
In this section we will:
. Consider the development of economics. Specifically we will review the
contribution of some dissenting voices and we will ask if it is a discipline in
crisis.
.
Review contributions to economics from outside the dominant paradigm.
.
Examine the nature of health economics and consider its span and reach.
Focus The language of economics: the Women ignored or devalued The pursuit of economic and A concern with the citizen in
consequences of economic non-economic goals their community
rhetoric: the way knowledge is
constructed, communicated and
understood: the language of
economics as discourse
Proposes See conventional economics as a Consider costs other than those Consider sociability and social Include shared goods,
text, as a language of persuasion just traded in markets; include approval; the impact of social e.g. health care through
– as metaphor and rhetoric altruism and co-operation relations; the social construction public health measures
of economic institutions
Approach Dialogical research, reflexivity Focus on provision rather than See market participants as social Focus on community
and deconstruction consumption actors who are guided by shared outcomes
experiences and observations of
others
Further Noordhaven, 1995; McClosky, Hall et al., 1995 Granovetter, 1992 Mooney, 1998
reading 1985; Brown, 1994
paradigm
outside the prevailing
Habermas
Health
economics and
Examples of voices
225
Table II.
JHOM economics alongside considerations of complexity and chaos theory, something we
19,3 return too below.
Arising from these assumptions, propositions and maxims we can identify welfare
economic analysis is being based on the Pareto principle. This states that a
redistribution of resources is preferred if it makes some people better off, and makes
none worse off. Such states, when achieved, are known as Pareto optima, and these
secure a distribution of resources in society, which economists refer to as allocative
efficiency. Because of considerable problems in applying the Paretian criteria to their
field, health economists tend to adopt the less stringent notion of the potential for a
Pareto improvement. A potential Pareto improvement occurs when the benefits that
accrue to the gainers from any resource distribution are large enough (at least
hypothetically) to compensate any losers.
When using the neo-classical framework it can be shown that a system of market
competition is the best (but not only) means of securing a Pareto optimum. Most
neo-classical analysis therefore proceeds on the assumption of the existence of
competitive markets rather than a centrally planned or mixed economy.
In practice it is difficult to reconcile the dominance of these principles with the focus
of much health economic activity (Edwards, 2001). Many economists are exploring how
to incorporate factors other than individual utility, and they are considering ways of
developing inter-personal comparisons of utility, the development of quality of life
measures for example. Health economists also consider the impact of supplier-induced
demand, a phenomena that is widespread in health care but that is not amenable to
analysis with the conventional tools of welfare economics (Phelps, 1995). Others are
critiquing the subject focus of health economics (see Culyer, 1991 on extra-welfarism
for example). There is also an engagement with the social and the idea of public goods.
One challenge in terms of the subject focus of health economics is that health care is Health
an intermediate good with no intrinsic value. Its value is in its contribution towards the economics and
production of health. It does this alongside many other things, environmental and
financial circumstances for example. The production of health is also only an enabling Habermas
device that permits a person to achieve other functions, leisure, goal fulfilment, the
potential to work and so on. As Edwards and Boland (1996) argue a problem for health
economics is that most of it is carried out with the relevant social want at its centre 227
being health care and not health (Edwards and Boland, 1996). The result is that
Williams’ summation, made in 1987, that “we have hardly begun to use the discipline
of health economics for the improvement of the people’s health” still holds true today.
Given challenges in the subject focus, problems in the Paretian paradigm and an
observed flexibility on the part of some health economists to stray from the orthodox
what impact has health economics had on policy, and what impact has policy had on
health economics? Hurst (1998) has reviewed the field for the years between 1972 and
1997. He identifies a number of important contributions both to the content of policy and
to the process of appraising the implementation of policy. He is careful, however, not to
seek to claim too much. Health economics is one discipline amongst many that have an
input into the policy arena. There is also a danger of post hoc attribution of impact and an
overall problem in assessing influence in terms of both the detail of policy and the
parameters and language of the policy environment. Yet it is possible to infer that health
economics has had a significant impact on the formulation of health policy at a national
level. The US health economist Alain Enthoven’s influence on the introduction of the
purchaser/provider split as part of the 1991 NHS internal market reforms is the most cited
example of the influence of health economics at a national level (see Enthoven, 1985). But
one can also list discussions of geographical equity and resource allocation, health
technology assessment and investment appraisal as constituting other areas of impact.
It is interesting not only to consider the contribution to shaping a new policy but also
to look at the way that health economics can impact in such a way as to divert policy
from an existing ideologically driven plan. Here Hurst cites Culyer’s impact on the 1991
NHS reforms. There was an inclination on the politicians’ part to explore shifting from a
model of full public funding. Culyers’ work (1976) on “caring externalities”, proved a
powerful factor in diverting the opinions of politicians. Caring externalities – the
importance of public funded services in terms of the impact they have on social
cohesion, are just the sorts of factors that the Paretian paradigm eschews.
However, although health economics has had a major impact on the formulation of
national health policies, there is growing evidence to suggest that it has had
correspondingly little influence over the day-to-day decision making of managers and
professionals working in front-line NHS organisations. The key problems acting
against the impact of health economics appear to centre around, the poor presentation
of economic studies, unintelligible jargon, abstruse maths and the fact that rational
economic frameworks are rarely structured to reflect the context and real world
contingencies in which resource allocation decisions are made on the ground by “street
level bureaucrats” (McDonald and Baughan, 2001; McDonald and Kernick, 2002).
There is a danger that in criticising the Paretian paradigm we are tilting at a straw
man. Has it already been superseded in health economics because of the many
problems it presents? Is there a gap, or a tension, between abstract proposition and
empirical knowledge? Do approaches to the empirical agenda increasingly bypass the
JHOM abstract propositions? If practitioners of health economics are extemporising in such a
19,3 way as to match approach and subject in ways that work for them are we moving, via
these small steps, towards a new theoretical approach that would foster a new sort of
empiricism and what might this look like?
To help us move towards proposing a new approach, we want now to look at
arguments about the ontology of economics and at the way it engages with
228 observations about culture and about complexity. Overall our intention is to consider
how far a different paradigm for health economics could take shape within a critical
theory perspective. We wish to see how far health economics could be incorporated into
the scenario Habermas paints about the transformation of the social sciences. He
argues that the 1970s saw a transformation such that:
Objectifying approaches no longer dominated the field (they) were competing instead with
hermeneutical and critical approaches that were tailored in their field of knowledge to
possibilities of application other than manipulation of self and others (Habermas, 1987,
pp. 272-3).
We can see in Habermas’s development of the nature of the rational and his
identification of the different projects and potentials of science a schema that allows us
to engage with complexity. It also allows us to see shortcomings in an
empirico-analytic science of economics that is designed to shape behaviour towards
specific aims and given ends. Economics’ shortcomings lie in its constriction of the
subject area and in its choice of method. But shortcomings do not mean we have to
abandon economics, rather we can reframe it into the domain of the
historical-hermeneutic or the critical-dialectic.
Conceptualising reason as something located in subject – subject relations of
communicative action rather than in the subject – object relation of the conventional
way of understanding, for example, economic utility allow Habermas to retain that belief
that an accumulation of communicative reason can, and will, enrich everyday life.
Conclusions
We began this article by arguing that both economics and health economics exhibit
major problems in their approach to conceptualising their subject areas and developing
their methodologies. We have presented a series of critical voices who approach their
discipline in ways that make different assumptions and we have observed that, in
practice, economists have at times exhibited a pragmatism that has freed them from
prevailing paradigms and allowed them to impact on the policy making process. We
went on to wonder how the discipline dealt with dissenting voices and with the
shortcomings of the model in terms of prediction and understanding. What was the
evidence for observing/anticipating a paradigm shift and, more generally, how
did/might the discipline change?
At the heart of our criticisms of orthodox economics is a sense that it does not
sufficiently acknowledge the complexity of economic life and the endogenous and
culturally mediated nature of individual preference formation. We have explored how Health
complexity theory adds a crucial dimension to understanding modernity and that economics and
communication and culture are essential ingredients in seeking to understand
economic behaviour. Habermas
In conclusion we are arguing that as a subject area both economics and health
economics has too narrow and static an understanding of the individual; exemplified
by a narrow understanding of choice and utility and an absence of an understanding of 233
the social world that is shaped by reflective, reactive and interrelated people. Likewise
the economy is more complex, socially constructed and unpredictable, than the current
paradigm allows.
The way forward is to build a more complex model around a new ontology of
preference in individuals and change in the system. This involves putting back some of
the concern with the collective and with the moral that early modern thinking had a
close engagement with. It is also about engaging with health economics as a
transformative rather than an objectifying activity. In the final part of this article we
considered how the critical theory of Habermas could offer a way of understanding the
inter-relationship of individual and system.
Our overall approach has been to look at the method of understanding and the
subject of concern – at economics and economy. Habermas offers insights in his
approach to knowledge and reason, specifically via communicative rationality. His
understanding of political economy emphasises complexity, interaction within cultural
milieus and gives primacy to preserving the life-world against the encroachments of a
narrow rationalization. His optimism that progress via reason is possible if one
reframes both in the direction of communication and in the appreciation of reflexivity
and communality resonates with many who challenge prevailing paradigms, in
economics and elsewhere.
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The Emerald Research Register for this journal is available at The current issue and full text archive of this journal is available at
www.emeraldinsight.com/researchregister www.emeraldinsight.com/1477-7266.htm
JHOM
19,3 Examining leadership through
critical feminist readings
Jackie Ford
236 Nuffield Institute, University of Leeds, Leeds, UK
Abstract
Purpose – This paper seeks to explore a critique of the limitations of mainstream leadership research
and publications and offers a critical management analysis through drawing on a feminist reading of
leadership in organizations.
Design/methodology/approach – There has recently been witnessed a growing interest in the
promotion of effective leadership within both organizational studies literature and organisational
policy as the route to ensuring employee commitment and enhanced organisational performance and
the achievement of ever demanding goals and targets. This turn to leadership is represented in both an
upsurge of research studies and a proliferation in the promotion of leadership as the organisational
panacea. An analysis of the literature on leadership was undertaken, giving due consideration to
mainstream and more critical accounts in relation to illustrations drawn from the UK National Health
Service (NHS).
Findings – This paper explores mainstream literature on leadership and finds it wanting, in terms of
its failure to deliver a common understanding of the concept, in its generally uncritical accounts, and
its inability to expose the androcentric nature of the core assumptions within hegemonic discourses of
leadership. Drawing on critical feminist readings in relation to the UK NHS, a more critical account of
leadership is presented.
Practical implications – Greater awareness is required for the adoption of culturally sensitive and
locally-based approaches that take account of individuals’ experiences, identities and power relations
and that allows for the presence of a range of masculine and feminine workplace behaviours.
Originality/value – This paper provides an overview of the dominant themes within the literature
on leadership as they relate to the UK NHS, and presents a feminist critique of the more subtle ways in
which notions of leadership in organisations fail to consider their potential for bias.
Keywords Leadership, National Health Service, Research work, Feminism
Paper type Literature review
Introduction
In recent years, both mainstream management literature and organisational policy
show evidence of a marked turn to leadership rather than management as the means to
enhance organisational performance in contemporary organisations. This is matched
by a growing trend in the UK to attribute ever-greater significance to leadership as a
way of solving organisational problems not only within the private sector, but also
within the public sector more generally, across education (in schools and in
universities) as well as in health and local government organisations. The current
government’s focus on the “modernisation” of our services calls for better management
and better leadership across the public sector services and has resulted in the
Journal of Health Organization and establishment of numerous units dedicated to develop leadership initiatives. As part of
Management this process, the Council for Excellence in Management and Leadership was founded in
Vol. 19 No. 3, 2005
pp. 236-251 April 2000 with the remit of developing a strategy “to ensure that the UK has the
q Emerald Group Publishing Limited
1477-7266
managers and leaders of the future to match the best in the world” (Council for
DOI 10.1108/14777260510608961 Excellence, 2002, p. 1).
This turn to leadership in the UK National Health Service (NHS) has been reflected Critical feminist
in the creation, in 2001, of a Leadership Centre within the Department of Health’s readings
Modernisation Agency. More recently a common set of NHS leadership qualities has
been developed, so as to “set the standards for outstanding leadership in the NHS . . .
which can be used to assess both individual and organisational leadership capacity
and capability” (Department of Health, 2002a, p. 1). This set of standards presents 15
qualities to which leaders in the NHS should aspire, arranged within three clusters – 237
Personal Qualities, which includes such virtues as self belief, self awareness and
personal integrity; Setting Direction, which incorporates political astuteness, drive and
intellectual flexibility; and Delivering the Service, which comprises leading change and
empowerment, holding to account and effective and strategic influencing.
This turn to leadership has generated a proliferation of leadership research and
publications, yet despite this explosion in volume, three fundamental deficiencies are
striking: the lack of clarity as to a common understanding of the concept; in its
generally uncritical accounts, and its inability to expose the androcentric nature of the
core assumptions within hegemonic discourses of leadership. This paper analyses the
foregoing limitations and provides a critical management analysis, through drawing
on a feminist reading of leadership in organisations, drawing particularly on
illustrations within the UK National Health Service.
Defining leadership
Analyses and critiques of the development in leadership thinking abound (see, for
example Alimo-Metcalfe, 1998; Bass, 1990; Grint, 1997; 2000; Yukl, 1994). Indeed, as
many writers have remarked, it is ironic that despite attempts to trace the development
in leadership thought, a clear definition of the concept continues to evade us. As has
been written almost ad nauseam, there are as many (if not more) definitions of
leadership as there are people who have attempted to define it. As Bennis (1959, p. 259)
noted in his survey of the literature:
Always it seems, the concept of leadership eludes us or turns up in another form to taunt us
again with its slipperiness and complexity. So, we have invented an endless proliferation of
terms to deal with it . . . and still the concept is not sufficiently defined.
Writing in the field continues to multiply, but an acceptable universal definition of
what leadership is continues to be problematic for both practitioners and academics.
Having reviewed in excess of 5,000 published works on leadership neither Stogdill
(1974) in the 1970s nor Bass in the 1980s succeeded in identifying a commonly agreed
definition. As Bennis and Nanus (1985, p. 4) concluded:
Decades of academic analysis have given us more than 350 definitions of leadership. Literally
thousands of empirical investigations of leaders have been conducted in the last 75 years
alone, but no clear and unequivocal understanding exists as to what distinguishes leaders
from non-leaders and, perhaps more importantly, what distinguishes effective leaders from
ineffective leaders.
Some quarter of a century later, the position seems remarkably unchanged. Indeed,
Grint (2000) refers to the increasing abundance of literature in the last two decades,
articulating that in the 1980s, some five articles a day were being published on
leadership in the English language and by the 1990s this had doubled to ten a day.
Yukl (1994) acknowledges that different theories of leadership have evolved as a result
JHOM of the different perspectives of the researchers and the aspect of the phenomenon of
19,3 most interest to them. Thus differences amongst researchers in how they conceive
leadership will lead to variations not only on the selection of phenomena to investigate,
but also into how these phenomena will be interpreted.
Rather than adding to the profusion of leadership definitions, this paper aims to
present a critique of the concept of leadership based on a feminist analysis. The
238 following section explores the dominant discourses of leadership and proffers a
discussion of the limitations to these accounts.
Concluding thoughts
Becoming aware of the various discourses and subject positions that constitute our
subjectivity enables us to see multiple constraints that inhibit our thoughts and actions
and those oppressive discourses and subject positions that we should seek to eradicate
(Best and Kellner, 1991). This paper has considered the dominance of mainstream
positivist approaches to the concept of leadership, and has suggested that the
perpetuation of such research and organisational practice has reified the very concept
of leadership into an objective reality. These dominant conceptions of leadership are
then taken up and adapted at organizational level and they continue to perpetuate the
hidden masculinist assumptions of the attributes of the model of leadership that is
required to be adopted by the organisation. The turn to leadership continues to be
promoted within organisations generally, and within UK public sector organisations
specifically, as a means to address the increasing pace of change and development.
However, much of the research and exploration to date within leadership studies has
failed to challenge the systematic privileging of masculine behaviours and norms as
the basis for defining effective leadership within these organisations. Where models
have suggested a more feminine-informed range of behaviours, their presence seems
confined to organisational rhetoric or statements of espoused practice rather than
organisational reality.
Understanding leadership calls not only for the consideration of social processes
and cultural context (Alvesson, 2002, p. 104). The perpetuation of a single model of
univocal and patriarchal leadership behaviours and the ever-continuing drive within
the NHS to create leaders, perpetuates a model that is exclusionary, and which forces
those ever-increasing numbers of people called leaders into this iron cage of the
personality inventory. I proffer a plea for a research agenda that aims not only to adopt
a culturally sensitive and locally-based approach, that takes account of individuals’
JHOM experiences, identities, power relations and intersubjectivities; but also one that allows
19,3 for the presence of a range of masculine and feminine workplace behaviours.
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Taylor, S. and Yates, S. (Eds), Discourse Theory and Practice: A Reader, Sage, London.
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The Emerald Research Register for this journal is available at The current issue and full text archive of this journal is available at
www.emeraldinsight.com/researchregister www.emeraldinsight.com/1477-7266.htm
Abstract
Purpose – To explore the issues surrounding the falling rates of MMR vaccination following the
publication of a controversial study by Wakefield et al.
Design/methodology/approach – In order to take a fresh look at the MMR crisis, the Greek
tragedy, Antigone, was used as a “strong plot” to de-contextualise the underlying social and political
issues. In this short paper, two themes are explored that emerge from reading Antigone with respect to
the unfolding crisis of public confidence in the MMR vaccine: first, the challenge to government in the
form of a decrease in public trust in government and government policies; and second, how such a
challenge assumes significance and, arising from that, the question of how one might respond to the
challenge.
Findings – The MMR debate throws issues of importance to society into relief – for example, public
trust in government and science; and notions of public good versus rational choice in public policy on
vaccination, However, much of the debate has been polarised into good versus evil – good and evil
being subjective positions that are interchangeable, depending on the side one favours. It is argued
that the issues are more complex than this, and are as much to do with political consent and the
bargain between citizen and state.
Originality/value – Using “strong plots” to theorise about current issues is powerful because it
allows one to explore them from different angles and challenge one’s understanding. Antigone
provides us with a way of standing back from the MMR crisis and re-conceptualising the issues to
capture the essence of the underlying debate.
Keywords Public health, Immunization, Government policy, Literature
Paper type Conceptual paper
Introduction
Since the publication of Andrew Wakefield’s research into a form of bowel disease and
autism in children and a possible link with the MMR vaccine (Wakefield et al., 1998),
rates of immunisation with MMR have fallen dramatically. There has been much
debate, and some research into possible reasons. Reasons given have included: rational
choice, failure of altruism, lack of trust in government, science, and medicine, lack of
childhood epidemics in recent years, and parental panic induced by selective media
coverage (Hobson-West, 2003; Petts and Niemeyer, 2004; Vernon, 2003). Public health
policy makers see the issue as one of great importance – the success of immunisation
Journal of Health Organization and policies in the UK are dependent on collective action rather than individual
Management self-interest. Sides have been taken and media debate is polarised into good versus evil
Vol. 19 No. 3, 2005
pp. 252-260 – good and evil being subjective positions that are interchangeable, depending on the
q Emerald Group Publishing Limited
1477-7266
side one favours. The issue is also fraught with ethical issues, including consent.
DOI 10.1108/14777260510608970 However, little attention has been given to other philosophical viewpoints.
Government policy response to the MMR crisis has been to formulate policy from a Public policy in
top-down perspective – that is simply to re-iterate messages that the vaccine is safe crisis
and to emphasise the risks for children who contract the diseases. In contrast, there has
been little attempt to understand why people are not vaccinating and thus develop
policy from a bottom-up perspective (Hobson-West, 2003; Vernon, 2003). Furthermore,
Andrew Wakefield himself has been vilified by the medical and government
establishment, and alternately praised and demonised in the press. Meanwhile, MMR 253
vaccination rates are at an all-time low (Horton, 2004). From a health organisation
perspective, how can we make sense of this situation, and what can we learn from it?
One of the questions I am interested in pursuing is how do issues achieve agenda
status? Not all issues that might be considered to be important from a health
perspective are taken up by the media. Yet the publication of an obscure early
case-report in a technical medical journal has led to a major debate on the safety of one
vaccine, and a significant fall in public confidence. How and why did this happen?
My starting point for exploration of the MMR crisis is a Hegelian one – suppose the
problem is not that of good versus evil but that of good versus good? Like Hegel, (and
others) I turned to Antigone to see if her story could help me theorise the public health
crisis surrounding the falling rates of MMR vaccination in the population at risk.
Concluding remarks
From a public health perspective, mass childhood immunisation is one of the great
twentieth-century medical success stories. Children no longer suffer and die from
diseases such as diphtheria, whooping cough and polio that were once common, and
some diseases such as smallpox have been eradicated entirely. However, the publicity
surrounding Wakefield’s work has led to a loss of public confidence in the vaccination
programme, certainly for MMR and possibly for other vaccines. The issue certainly
stayed in the public eye long enough for the government to produce various
information leaflets “reassuring parents about the FACTS”, and to initiate media
campaigns designed to restore public confidence in the MMR vaccine.
Are these what we could characterise as the “facts of the matter”? That the “good”
government seeks to protect the most vulnerable, whilst the “bad” Wakefield
conducts bad science and opens up the possibility of an epidemic? Or, is Wakefield
“good” – championing children damaged by vaccination and upholding their rights, Public policy in
and the public right to know what has caused the damage – whilst the “bad” crisis
government uses its organs (including the media) to discredit him and his work?
From one perspective, public health policy on vaccination is in crisis because of a
maverick doctor who published a flawed study. However, it is equally clear that from
another perspective, Andrew Wakefield is a “saviour”, a doctor who listens to parents
and their fears for their children after diagnoses of autism, post-MMR vaccination: 259
. . . the establishment is trying to vilify the one person who truly believes us [. . .] he
(Wakefield) wanted to help me whereas others just saw me as the mother of a damaged child,
and an “inconvenience” (quoted in Horton, 2004).
Furthermore, the MMR debate throws other issues of importance to society into relief
– for example, public trust in government and science; and notions of public good
versus rational choice in public policy on vaccination. Or at least this is the acceptable
terrain from the traditional public health perspective, although as we have seen, the
issues are more complex than this, and are as much to do with political consent and the
bargain between citizen and state. These are some of the arguments that I intend to
pursue in further work.
In conclusion, Antigone is a tragedy – a dramatic device by which the human
condition is explored through the person of a tragic hero. But whose tragedy is the
MMR crisis? Is it the children whose parents claim they have been damaged? Is it
Andrew Wakefield’s? Is it un-vaccinated children? Is it children in the developing
world who are most at risk of dying from measles? Or is it some future occurrences
about which scientists are reluctant to make known their findings because of the
ramifications from this affair?
Antigone can’t help us to answer these questions, but it does provide us with a way
of standing back from the MMR crisis and re-conceptualising the issues to capture the
essence of the underlying debate.
References
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of Agriculture, Fisheries and Food, London.
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New York, NY.
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Premodern Narratives for Our Times, Oxford University Press, Oxford, pp. vii-viii.
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Gabriel, Y. (Ed.) (2004), Myths, Stories, and Organizations: Premodern Narratives for Our Times,
Oxford University Press, Oxford.
Greenwood, L. (2001), “Do the right thing”, NHS Magazine, March.
Hegel, G.W.F. (1975), Lectures on the Philosophy of World History, Cambridge University Press,
Cambridge.
Hobson-West, P. (2003), “Understanding vaccination resistance: moving beyond risk”, Health,
Risk & Society, Vol. 5, pp. 273-83.
Horton, R. (2004), MMR Science & Fiction, Granta Books, London.
JHOM Markell, P. (2003), “Tragic recognition – action and identity in Antigone and Aristotle”, Political
Theory, Vol. 31, pp. 6-38.
19,3 Peltola, H., Patja, A., Leinikki, P., Valle, M., Davidkin, I. and Paunio, M. (1998), “No evidence for
measles, mumps, and rubella vaccine-associated inflammatory disease or autism in a
14-year prospective study”, The Lancet, Vol. 351, pp. 1327-8.
Petts, J. and Niemeyer, S. (2004), “Health risk communication and amplification: learning from
260 the MMR vaccination controversy”, Health, Risk & Society, Vol. 6, pp. 7-23.
Sophocles (1994), Antigone (trans. by H.D.F. Kitto, edited by E. Hall), Oxford University Press,
New York, NY.
Taylor, B., Miller, E., Farrington, C.P., Petropoulos, M.-C., Favot-Mayaud, I., Li, J. and Waight,
P.A. (1999), “Autism and measles, mumps, and rubella vaccine: no epidemiological
evidence for a causal association”, The Lancet, Vol. 353, pp. 2026-9.
Vernon, J.G. (2003), “Immunisation policy: from compliance to concordance?”, British Journal of
General Practice, Vol. 53, pp. 399-404.
Wakefield, A.J., Murch, S.H., Anthony, A., Linnell, J., Casson, D.M., Malik, M., Berelowitz, M.,
Dhillon, A.P., Thomson, M.A., Harvey, P., Valentine, A., Davies, S.E. and Walker-Smith,
J.A. (1998), “Ileal-lymphoid-nodular hyperplasia, non-specific colitis, and pervasive
developmental disorder in children”, The Lancet, Vol. 351, pp. 637-41.
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No. 1, pp. 75-88.
The Emerald Research Register for this journal is available at The current issue and full text archive of this journal is available at
www.emeraldinsight.com/researchregister www.emeraldinsight.com/1477-7266.htm
The National
The inception of the National Health Service
Health Service
A daily managerial accomplishment
261
Nancy Harding
Nuffield Institute for Health, University of Leeds, Leeds, UK
Abstract
Purpose – It is commonplace to talk of the UK’s National Health Service (NHS) as having its
inception in 1948 in an Act of Parliament which brought together many hundreds of widely dispersed
organisations into one, new organisation, “the” NHS. This paper aims to challenge the concept of “a”
National Health Service and to argue that the (seeming) accomplishment of this “organisation” is the
daily task of health managers.
Design/methodology/approach – The paper develops a theoretically-based analysis of how an
“organisation” is accomplished through ongoing processes of construction. First, critiques of the
ontological status of this thing called “organisation” are considered. Then Laclau and Mouffe’s
discourse theory of political action, inspired by Derrida and Gramsci is used, to try to understand this
apparent “thing” and the work of those charged with its management.
Findings – There has been little application of this theoretical perspective to understanding
management in general and health management in particular but, given the highly politicised nature
of health management, their theoretical perspective seems more than apposite. Application of Laclau
and Mouffe’s theory to the NHS leads to the conclusion that there is no such “thing” as the NHS. There
is, rather, a presumption of the thingness of the NHS and one of the major tasks of managers working
“within” this organisation is to achieve this sense of thingness.
Research limitations/implications – This is “work in progress” – these ideas continue to evolve,
but feedback from readers is necessary.
Originality/value – This is the first time that Laclau and Mouffe’s work has been used to analyse
health organizations. The value of the paper is mostly for people working to develop
critically-informed understandings of how organizations work.
Keywords Social processes, National Health Service, Critical thinking, Clinical governance
Paper type Conceptual paper
Introduction
It is commonplace to talk of Britain’s National Health Service (NHS) as having its
inception in 1948 in an Act of Parliament which brought together many hundreds of
widely dispersed organisations into one, new organisation, “the” NHS. In this paper I
challenge the concept of “a” National Health Service and argue that the (seeming)
accomplishment of this “organisation” is the daily task of health managers. To do this I
draw firstly upon critiques of the ontological status of this thing we call “organisation”.
I then use Laclau and Mouffe’s (1985) discourse theory of political action, to try to
understand this apparent “thing” and the work of those charged with its management.
There has been little application of this theoretical perspective to understanding Journal of Health Organization and
management in general and health management in particular, but given the highly Management
Vol. 19 No. 3, 2005
politicised nature of health management their theoretical perspective seems more than pp. 261-272
apposite. Application of Laclau and Mouffe’s (1985) theory to the NHS, using the q Emerald Group Publishing Limited
1477-7266
evidence in those papers, leads to the conclusion that there is no such “thing” as the DOI 10.1108/14777260510608989
JHOM NHS. There is, rather, a presumption of the thingness of the NHS and one of the major
19,3 tasks of managers working “within” this organisation is to achieve this sense of
thingness.
Nodal points, i.e. privileged signifiers or reference points in a discourse, allow elements
to become structured so as to form a meaningful system of moments and thus a
JHOM discourse. The acceptance of management as the way of organising health services
19,3 required that a new meaning be given to a number of pre-existing and available
signifiers, such as “the patient” who becomes not a passive recipient but active
consumer of medical services; or “the doctor” who becomes not a saintly,
self-sacrificing and all-knowing expert but a fallible, accident-prone and
over-powerful worker. Such meanings become internal moments of organisational
268 discourse only through their being articulated around the signifier “management” as
the nodal point. Medicine still exists as another nodal point, but in political opposition
to that of management.
Laclau and Mouffe’s logics of equivalence and of difference allow us to interpret this
co-existence of two nodal points. The logic of equivalence functions by creating
equivalential identities which result in the institution of a political frontier between two
opposed camps (in our example management and medicine). The logic of difference
works in the opposite way, to dissolve existing chains of equivalence and incorporate
the now disarticulated elements into an expanding order (thus medicine can be argued
to be being incorporated into management as management becomes the
taken-for-granted method of organising health services). However, there is always a
complex interaction between these two logics, with each needing the other and thus
preventing the emergence of a totalising discourse. Individual experience is thus
inevitable.
Hegemony is the final aspect in this overly-brief summary of Laclau and Mouffe’s
theoretical perspective. Fundamental to their theory, hegemony here is based upon the
understanding of hegemony, now stripped of any essentialist aspects such as “a”
homogeneous working class. Hegemony has two aspects: hegemonic practices, which
involves the articulation of various identities and subjectivities into a shared project;
and hegemonic formations, or the outcomes of the resulting endeavours to create new
forms of social order. Hegemony, in short, is a collective social imaginary in which
various nodal points appear to be relatively stabilised. Hegemony is never fully stable
and never complete.
In terms of the arguments of this paper, I suggest that “health” has achieved
hegemonic status – we never question its existence, its value and the possibility for its
improvement. Health services are the politico-hegemonic articulations designed to
encompass the practices we wish will bring about achievement of this collective social
ideal – complete physical, social and mental well-being, to paraphrase the famous
World Health Organisation declaration. The organisations in which such practices are
brought together are the empty signifiers encompassing our desire for this thing
signified by the word “health”. Medicine, nursing and other professional identities
which had been regarded as capable of fulfilling the mythical objectives of full health
were seen to have failed. Crucially, however, their practices of cure and care are not
challenged (we still visit the doctor when we are ill and seek the care of nurses when
hospitalised), rather only the way in which they are organised is confronted. But
another logic has emerged which now has taken on hegemonic status – “good”
management or the bringer of order. Once a health service can be classified as
disordered the space opens for the introduction of management to bring about the
desired order.
However, management has failed to achieve its promise – that elusive thing, full
health, is not available, and so governments, academics, management consultants and
senior managers, turn not away from management but to a search for ways of The National
improving management. These include leadership (Ford, 2004) and evidence-based Health Service
medicine (McLaughlin, 2004). Both these “turns”, to leadership and EBM, presuppose
several universals, those of “a” health service, of management and of medicine. Yet the
universal is impossible, as Laclau and Mouffe have shown, for to define a universal
requires that we endow it with a “presence” which is predicated upon that which is
excluded, its Other. Similarly, the opposite of the universal, the particular (in our case, 269
the manager), is impossible. Identity claims are therefore possible only from “points of
articulation between the two polar extremes” (Harvey and Halverson, 2000, p. 154).
Therefore, all collective identities will have “remainders” arising from the differentially
situated experiences within which identities are practised.
Harvey and Halverson (2000) ask how we may conceptualise this remainder. They
argue that we can both be an identity (Algerian and Jewish) and yet not be that identity. In
such a case one is and is not that/those identity category/ies, giving a remainder which is
a “sense of in-betweenness, of ‘otherness’ that comes from living within a multiplicity of
discourses”. Ford (2004) shows how models of leadership, although ostensibly being
based upon supposedly female character traits, elide the female with the male, so that for
women leaders their gender identity is such a remainder. Greener (2004) reveals how
women managers are conscious of moving in and out of a female identity, so that they are
“other” both to their female gender identity and to their identities as managers. His male
interviewees also demonstrate a movement between various male identities although,
masculinity being the dominant pairing in the binary male/female, they can take their
masculine identities for granted. Lee’s (2004) research reveals how managers who
self-identify as gay also are and are not gay. All these aspects of gender are what is called
“the secret”, defined by Harvey and Halverson (2000, p. 156) as “the portion of lived
experience that escapes being categorised into universal narratives of identity and at the
same time cannot be purely limited to the individual”. This means there are neither
absolutes nor secure foundations within which identities can be made. Just as Laclau and
Mouffe had argued the impossibility of a working class, so Harvey and Halverson argue
that there can be no single way of defining such grand concepts as citizenship, democracy
or feminism. There can, it follows, be no single way of defining either management or
managers. To paraphrase Harvey and Halverson (2000, p. 157), the definition of “the
manager” is contingent upon the negotiations that occur between a multiplicity of
singular experiences.
Greener (2004), Lee (2004) and McDonald (2004) show the complex manner by which
NHS managers both absorb and resist, define and redefine, the identity of manager.
The identities that are experienced are not articulated through the definitions of
management but through practices and cultures of management, involving
assumptions of dominance over others and over the self. Managers “in” the NHS,
Greener (2004) shows, are knowing subjects who will deliberately adopt a stance to
present themselves as managers, in charge and able, they hope, to get others to do what
they, as managers, wish. For these managers, doctors are their alter, their Other by
which they know themselves as managers. Lee’s (2004) interviewees know themselves
as managers through reference to the mythical community of men who have sex with
men (MSM). While they may enter into this “community” out of working hours and
then self-define themselves as gay, during the working day MSM (and thus one aspect
of their own identities) are their alter, their Other, over whom they seek some form of
JHOM dominance in order to achieve the aims of sexual health promotion. There is a major
19,3 emphasis in these interviews upon having achieved, upon having made the
organisation in their own image. Here we see how dominant is the discourse of
masculine, heterosexual discourse in identity formation, and also note, by its absence,
the reference to “official” discourses of management, which are more concerned with
efficiency, effectiveness, leadership, etc. Traynor (2004) illustrates the exquisite
270 dilemma of the subordinated gendered identity of an entire profession (although we
must be careful of using such a designation in the context of Laclau and Mouffe’s
critique), when this profession is the Other, the suppressed half of the binary.
All managers are both managers of others and themselves managed. McDonald
(2004) illustrates how managers, through practices of the self, both accept and resist
attempts at control over them. She further illustrates how the local organisational
context is not that rule-governed, systematically-organised object presumed in policies
and in textbooks. Rather, the “rules” which define this organisation are transmitted in a
diffuse manner, are contradictory and open to interpretation by managerial
participants. Managers try to make sense of this chaos. They are therefore, as Lee
(2004) and Greener (2004) also show, active participants in the constitution of both the
organisation and themselves.
Conclusion
Health, I have suggested, is a hegemonic, collective social ideal. We have erected
complex social networks, known as the NHS, whose concern is officially the
achievement of this ideal. But the term “organisation” is a master signifier which
retroactively constitutes into “an organisation” the multifarious activities and
individuals concerned with achieving this ideal. The resulting coalescence is to be
ordered through the auspices of management, an empty signifier that signifies
something that is sought but is always absent. Managers are the individuals whose
task it is to achieve management. In terms of Laclau and Mouffe’s basic categories, we
thus have:
.
health as the articulation which establishes a relation among elements such that
their identity is modified as a result of the articulatory practice;
.
organisations and management as inter-related but distinct discourses, i.e. “the
structured totality resulting from this articulatory practice”;
.
managers as the moments, or the “differential positions” which “appear
articulated within a discourse”; and
.
the individuals who occupy the subject position “manager” as the elements.
Here management is an empty signifier present only in its absence, and yearned for by
government/politicians. It is experienced very differently by those given the task of
achieving management. Today’s health service manager is charged with the function
of being the rational, organised but deracinated leader who ensures all tasks are
evidence-based and exposed to (successful) audit. This manager, the manager of
reason, must manage a health service that should resemble an efficient machine. This
is the to-be-aspired-to managerial identity to be donned when working within an
aspired-to organisation. However, both this identity and “the” organisation forever slip
away. They refuse to be introjected, and are always just out of the grasp of the anxious
seeker. Rationality and reason are here the surplus which oversteps the boundaries of The National
the possible, i.e. they can never be achieved. The manager experiences this lack, this Health Service
yearning, but also experiences both other dominant identities (such as gender) and,
inescapably, practices of the self. This health manager is fluid, seeks and also refuses
structure, and is a being in the process of becoming, in the process of doing, but of
never arriving. The manager responsible for the management of health services is thus
a manager who strives to become an unattainable Other, the rational manager. 271
Analysing “the NHS” using the lens of Laclau and Mouffe’s theories therefore
reveals a manager involved in multifarious activities concerned with being the
manager, constituting the identity of manager, and, along with all others, practising
the on-going constitution of “the” organisation. Management represents order but
managers do not make order but participate in practices of the organisation. Through
representing order they represent this thing called “organisation”. One of
management’s major tasks is, rather than getting things done through other people,
to embody the master signifier, the NHS, giving it the appearance of an actual, material
presence.
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