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IJPSM
22,2 Gendered nature of
managerialism? Case of the
National Health Service
104
Karen Miller
Glasgow Caledonian University, Glasgow, UK
Received 10 August 2007
Revised 4 February 2008
Accepted 5 February 2008
Abstract
Purpose – The purpose of this paper is to argue that managerialism, as applied to the public sector,
contributes to a gendered organisational culture that disadvantages female career progression.
Design/methodology/approach – The research was qualitative in approach and involved
face-to-face interviews with male and female, clinical and non-clinical managers (n ¼ 31) in
Scotland’s health service.
Findings – The main finding is that public sector managerialism, and consequent transactional and
stereotypical masculine styles of management, inhibits female career progression.
Practical implications – Managerialism as currently applied in the public sector creates certain
inefficiencies by limiting the potential of women, which has implications for female career progression
in the public sector, succession management and the sustainability of services.
Originality/value – The paper adds to a growing body of evidence that stereotypical masculine
styles of management create an organisational culture that affects female career progression.
Furthermore, the paper will be of value in understanding the factors that impact on female career
progression within the public sector, which is of importance given that the majority of public sector
employees in the UK, particularly in the health sector, are female.
Keywords Managerialism, National Health Service, Gender, Career development,
Organizational culture, Scotland
Paper type Case study

Introduction
The ideological and socio-economic landscape of the 1980s and 1990s saw the rise of
managerialism in the administration of the public sector. Much has been written about
the reform of the public sector, the integration of managerialism and marketisation,
and new public management (NPM) (see Hood, 1991, 1998; Hughes, 1998; Greenwood
et al., 2002; Massey, 1993; Peters and Savoie, 1998; Pollitt, 1990; Savoie, 1994). The
managerialist model and NPM has created transactional public sector organisations
with a stereotypical masculine management style and organisational culture. It is not
the intention of the paper to explore organisational culture per se (for a more
elaborative discussion on organisational culture within the health service see Scott
et al., 2003; Mannion et al., 2005; Davies et al., 2007) rather to argue that managerialist
International Journal of Public Sector
emphasis on efficiency, effectiveness, economy, performance measures, etc. has created
Management an environment where stereotypical masculine skills such as competitiveness,
Vol. 22 No. 2, 2009
pp. 104-113 command-control behaviours and achievement are valued. These stereotypical
q Emerald Group Publishing Limited
0951-3558
masculine skills are imported from private sector practices to achieve greater efficiency
DOI 10.1108/09513550910934510 and effectiveness for the goal of profit making. There is a growing body of evidence
that masculine organisational culture inhibits female progression to senior managerial Gendered
and leadership positions (see Yoder, 2001). The emphasis on efficiency, effectiveness, nature of
economy and performance measures has created an environment where there are
increased job demands. Public sector employees are now required to meet efficiency managerialism?
goals and performance targets which often result in a long working-hours culture,
stress and competitiveness. These job demands have placed innumerable pressure on
employees, irrespective of gender, to conform to the managerialist model. There is 105
evidence to suggest that the managerialist model and consequent masculinised
organisational culture negatively affect the career progression of female public sector
employees. For example, Coyle’s (1995) research with nurses argued that
managerialism has eroded the professional structure and senior positions which
were previously occupied by women and placed them under the management of
managers.
This paper is based on qualitative research involving face-to-face interviews with 18
female and 13 male, clinical and non-clinical managers within Scotland’s National
Health Service (NHS). Research participants were randomly selected across Scottish
health boards. The research found a consistency of opinions among male and female,
clinical and non-clinical managers that the managerialist emphasis on efficiency,
effectiveness and particularly meeting performance targets has increased job demands,
negatively affects a work-life balance and inhibits female career progression. Research
by Perrott (2002), Lane (2004) and Stivers (2002) has made similar findings that
managerialism in the public sector is a gendered phenomenon with implications female
career progression.

Managerialism and the NHS

Scholars (see Ham, 2005, Klein, 2001, Ferlie et al. 1996, Massey and Pyper, 2005,
Hughes, 1998; Flynn, 2002) argue that public sector managerialism includes, inter alia:
a focus on financial control and savings with consequent efficiency savings and
privatisation; an emphasis on managerialism with a command-control mode of practice
in order to ensure performance targets are being achieved; an emphasis on
performance management and target driven modes of practice with consequent
financial and performance audits and benchmarking; the integration of markets and
competition to ensure a customer orientation; deregulation of the labour market with
the introduction of pay-performance contracts, fixed term contracts and staff turnover;
a shift from professions to general management; debureaucratisation in terms of less
bureaucratic processes and more entrepreneurial management; and new forms of
governance such as partnerships with the private sector.
The NHS has seen the much of these changes such as the introduction of an internal
market in the 1990s, increased “customer” responsiveness with the Patients’ Charter,
increase performance measures and financial controls, and with New Labour a
retention of the purchaser-provider split in NHS England to ensure efficiency,
performance and quality of service delivery. The New Labour government, as did the
Conservative government, also introduced a system of performance frameworks to
entrench efficiency, quality, performance and responsiveness of service. For example,
New Labour introduced a system of clinical governance that resulted in national
IJPSM service frameworks and institutionalised performance management (Department of
22,2 Health, 1998). The integration and institutionalisation of performance management
was to ensure strategic political objectives were being met, a mechanism to maximise
productivity, to ensure compliance by health professionals, and achieve cost efficiency.
In Scotland, the internal market was abolished and regional health boards were
established in April 2004. Although the policies and structures between NHS Scotland
106 and England diverged (the purchaser-provider split was maintained in the NHS in
England), NHS Scotland nonetheless also incorporated performance assessment
frameworks. In NHS Scotland efficiency and effectiveness was to be ensured more
through the use of performance assessment frameworks than a quasi-market. The NHS
as a whole and in Scotland in particular saw a proliferation of performance frameworks
and audits to ensure efficiency, quality and performance targets were being met.
The new generation of performance management systems in the NHS has seen more
stringent targets which NHS organisations are expected to deliver upon. In NHS
Scotland these performance targets, for example, included the extent to which there has
been a health improvement and reduction in health inequalities; fair assess to services;
compliance with clinical governance and quality standards; the quality of service
delivery including patient experience; the extent to which patients and communities
have been involved in decision making; optimal staff governance; and organisational
and financial performance efficiency. These performance measures some would argue
are in fact a reasonable expectation of what the public and patients are entitled to given
that the NHS is a publicly funded service. There are, however, some concerns about the
increased performance regimes such as overload from the volume of data collection
and analysis with the risk of the performance assessment framework becoming an end
in itself (Scottish Executive Health Department, 2004). In other words the performance
targets are becoming the goal with procedures and processes developed to achieve
targets as opposed to other strategic objectives. There are also concerns about the
weighting of various targets such as waiting times and financial efficiency, which
creates tensions with other objectives such as equity of treatment and delivery of
services (Scottish Executive Health Department, 2004). An aspect of the performance
assessment system which is of concern to many chief executives is the issue of job
security (Scottish Executive Health Department, 2004). According to a Scottish
Executive Health Department (2004, pp. 22-3) report chief executives acknowledge that
poor performance and lack of compliance with the performance assessment framework
could result in the ultimate penalty – job loss.
In Scotland the Health Department (Scottish Executive Health Department, 2004)
found that the average length of office for chief executives was only two to three years
and that of a total of 15 chief executives four had resigned from their positions in the
recent past. The dissolution of NHS Argyll and Clyde, and thereby its executive, in
March 2006 by the Minister for Health and Community Care is widely known to be in
response to its poor financial performance with a £80 million deficit (Simpson, 2006).
Some chief executives, in their assessment of the performance management system,
were concerned that they were being held accountable for performance, which was
perhaps beyond their control such as clinical negligence on the part of a clinician
(Scottish Executive Health Department, 2004, p. 23). The Scottish Executive Health
Department (2004) report highlights that there are concerns on the part of managers Gendered
within the NHS of the application and sanctions attached to the performance nature of
assessment system, and the possible loss of talented persons due to job stress and
uncertainties of job tenure. Thus, the application and sanctions attached to these managerialism?
performance measures are having negative outcomes for those involved in the delivery
of health services. What are the implications for the majority of NHS employees, i.e.
women? 107

Gendered nature of managerialism?

There is a high level of female employment in the NHS with women constituting
approximately 78 per cent of the workforce (Department of Health, 2002; ISD Scotland,
2005; Welsh Assembly, 2005). However, the majority of women are concentrated at
lower grades of the NHS and on part-time employment contacts. Although there are
women at executive levels, there is persistent gender gap of 30 to 40 per cent with few
women at senior managerial and leadership positions (McTavish et al., 2006). Perrott
(2002, p. 23), in her research, similarly found that increasingly public sector
professional services are dominated by women numerically, but are controlled and
managed by men. In NHS Scotland, for example, nurses constitute the majority of the
workforce, approximately 43 per cent, with 90 per cent being female and 50 per cent of
whom are employed on a part-time basis (ISD Scotland, 2005). The high proportion of
part-time female employment affects the pay and career progression of female
employees within the NHS. Lane (2004) found in her research that managers regarded
part-time employees as less than committed to work and were often overlooked for
promotion.
It could be argued that managerialism with the consequent concerns for public
sector efficiency, quality services, and organisational and financial performance has
created a transactional style of management within the public service. Burns (1982)
characterised transactional style of management and leadership as an exchange
between manager/leader and subordinate on the assumption that people are motivated
by reward and punishment. The transactional manager creates structures whereby
subordinates are rewarded for compliance with instructions (Burns, 1982). These
managers clarify subordinates responsibilities and tasks, monitor their work towards
achieving objectives, and reward subordinates for achieving objectives and correct
them for failing to meet objectives (Eagly and Johannesen-Schmidt, 2001, p. 787). The
transaction or exchange relies upon rewards and discipline to achieve organisational
objectives with subordinates considered responsible for meeting objectives (Burns,
1982). The role of the subordinate is to follow the objectives as set by the manager with
the subordinate conceding to the authority of the manager (Burns, 1982). Thus, the
command-control style of managing with a chain of command and levels of
accountability (Burns, 1982) and managerialist notions such as an emphasis on
efficiency and performance accountabilities towards the centre embodies a
transactional style of management.
Mannion et al.’s (2005) research of the NHS found that there was a strong
relationship between hospital leadership and performance. In fact, “high” performing
hospitals were characterised by top-down, command-control styles of leadership –
IJPSM transactional style (Mannion et al., 2005, pp. 435-6). Mannion et al. (2005, pp. 435-7) also
22,2 found that the transactional leadership style in the NHS often saw senior management
preoccupation with meeting national performance targets. The senior management
were often referred to in terms such as “cabal” or “inner circle” and human resource
strategies focussed on recruiting and retaining staff which could deliver upon the
performance management agenda (Mannion et al., 2005, pp. 436-7).
108 The transactional style of management/leadership is associated with a masculine
organisational culture with stereotypically masculine skills such as competitiveness
being valued (see Fletcher, 2004; Eagly and Johannesen-Schmidt, 2001). By contrast,
occupations which generate perceptions of rapport, supportiveness, congeniality,
nurturance and empathy – stereotypically feminine skills – are less valued (Guy and
Newman, 2004). According to Guy and Newman (2004, p. 293) these feminine skills,
referred to as emotional labour, are conflated in professions such as nursing where
stereotypical qualities of women are seen as skills for the profession. Guy and Newman
(2004, p. 294) found in their research of the public sector that emotional labour,
although a covert resource, is an invisible component of job performance and is often a
negatively valued skill as opposed to productivity as defined in job descriptions and
performance regimes. Furthermore, the lack of recognition for emotional labour reflects
a bias that imbues public sector and civil service performance evaluation (Guy and
Newman, 2004, pp. 294-5). Similarly, Alimo-Metcalfe (2002, 2005) argues for an
alternative perspective of leadership in the NHS with recognition for leadership styles
which value a repertoire of social and interpersonal skills as opposed to transactional
styles of leadership. Arguably, an organisational culture with a transactional
leadership/management style and emphasis on performance management, which does
not value emotional labour but rather stereotypical masculine skills, creates a
disadvantage for women. Thus, if women’s performance is evaluated against
performance agendas which perpetuate masculinity and transactional leadership, their
career progression to management and leadership is adversely affected. According to
Perrott (2002) the rise of managerialism is a gendered phenomenon that has resulted in
women occupying positions subordinate to men.
Thus, transactional leadership/management with an emphasis on performance
management and increased job demands to meet performance targets would create an
environment where a work-life balance would be difficult to achieve. Research with
senior clinical and non-clinical managers (n ¼ 31) in the NHS Scotland revealed the
difficulties in achieving a work-life balance in an organisational culture with a
transactional managerial style and increased job demands. The responses to indicators
of transactional managerial/leadership styles, such as command-control behaviours,
revealed that 78 per cent of the managers (male and female) sampled confirmed the
existence of this style (Miller, 2006). The majority of managers stated that the NHS is
target driven which increased job demands and stress. The increase in job demands
often result in a long working-hours culture. The majority of managers (68 per cent)
sampled, worked longer than 50 hours per week (Miller, 2006). The following
anonymised quotes, reveal a consistency among male and female managers concerning
performance management culture and the consequent increased job demands:
 . . . bureaucracy is systematic, you get things from the . . . Executive and think what a lot of Gendered
nonsense, but if told to comply by the Chief Executive then you have to . . .
nature of
. . . [there is] a blame culture, you have to justify your work because you have to meet managerialism?
performance targets . . . big brother is watching. . .

Political masters set targets which encourage action orientated style of management . . .
Ministers are accused of bullying . . . allowing public expectations to formulate targets . . . 109
staff surveys indicate an increased level of stress.

My work-life balance is appalling. I work 60 to 65 hours per week and normally on most
weekends and three to four evenings a week.

Political masters are fixated upon waiting times, activity figures, performance . . . it is
impossible to do what is expected within contracted hours . . . it is the sure bloody volume of
stuff coming from the . . . Executive and the turnaround creates pressure . . . we are
overwhelmed and stressed.
The result of the transactional management/leadership style and organisational
culture is that for the majority of NHS employees, i.e. women, career progression to
senior positions appears to require overwhelming job demands which may not be
conducive to a work-life balance. For many the increase in job demands and stress in
order to meet performance targets is a disincentive to seek promotion, given other
demands beyond work. The following anonymised quotes from male and female
managers illustrate this point:
. . . [there is a] . . . new generation of clinical and professional staff who do not find career
progression attractive because of little reward.

There is more of a huge issue about size of the jobs. People often work 12 hours a day, it’s
hard to balance work life . . . there is also an issue of salary, for example, there is not enough
money . . .

It is easier for men to become managers in the sector . . . people have to balance family, there
are little rewards – why would they want to do it [management].

Expectation that seniority of ranks comes from dedication and commitment, females could
potentially be dissuaded from attempting advancement due to conflicts between work
commitment and work-life balance, particularly considering that senior positions require
work beyond the organisation.
The pressure to meet efficiency, quality and performance targets creates a disincentive
for NHS employees in seeking career progression. This should not be considered as a
“choice” (Hakim, 2000) by women but rather “rules of organizations which militate
against women” (Lahtinen and Wilson, 1994, p. 18). Thus, it could be argued that
managerialist objectives of efficiency, quality of services and performance,
implemented by a transactional management/leadership style, create disincentives
for female career progression. Maddock’s (2002) research came to a similar conclusion
that public sector employees continue to be dominated by a masculine organisational
culture with a transactional management norm in public services which marginalises
women. In other words, the command-control behaviours of managers dissuade
women from career opportunities and progression. Moreover, Maddock (2002) argues
IJPSM that male transactional management is rewarded and explains the persistence of the
22,2 culture and career progression of men as opposed to women in the public sector. Male
career trajectories results in men achieving strategic, decision-making leadership levels
reinforcing transactional management/leadership behaviours. Thus, it is men at the
senior administrative and political echelons, making decisions in pursuit of
managerialist objectives, which perpetuates disincentives for female career
110 aspirations. This creates a masculine organisational and transactional culture to the
disadvantage of women.
According to Coyle (2002) women are “kept in their place,” out of power and
influential positions by more complex and discursive processes that question their
competencies to manage. Furthermore, Coyle (2002, p. 130) argues that sustained
competitive and command-control management or “macho” management associates
managerial competencies with qualities of masculinity. Eagly and Johannesen-Schmidt
(2001) argue that stereotypical masculine skills are associated with transactional
management/leadership styles such as aggression, ambition, confidence and
competitiveness. Marshall (1995 as cited in Wilson, 2002) similarly argues that
masculine management style and work cultures create barriers to equality with career
success dependent on stereotypically masculine characteristics as being “tough” and
“ruthless.” Male and female NHS managers stated that to achieve career success and
promotion in the NHS, one has to be aggressive and tough in order to meet the job
demands. The following anonymised quotes are illustrative of this point:
. . . [you have to be] aggressive in taking on the job and management style . . . there has been a
failure in appointing chief executives . . . select people who are tough-minded, but given the
nature of the NHS it beggars belief for men and women that they [chief executives] are so
aggressive.

. . . here is [sic. ] high achievers, always have to be first here. It worries me; if we achieve this
then expectations are high and they keep pushing things.
It would appear that in achieving the objectives of efficiency and organisational and
financial performance, transactional management/leadership and masculine
organisational cultures develop, are rewarded and perpetuated to the disadvantage
of women. It would appear that managerialism has created management/leadership
behaviours and organisational cultures in the public sector that adversely affect the
career trajectories of female employees and may therefore partly explain the high level
of part-time female employment and low level of female representation at senior
managerial levels despite the numerical majority of women in the NHS. It could be
argued that for women there is a cycle of disadvantage: women’s emotional labour is
not valued, nor is their part-time employment, which adversely affects their career
progression to senior management and leadership positions, and in turn it is the
management and leadership of the NHS, which is predominately male, that determines
the performance agenda and skills which are valued.

Conclusion
Managerialism as applied in the public sector creates a gendered organisational
environment that creates career disincentives for the majority of female employees in
the public sector. In an effort to achieve efficiency, quality and performance gains, for Gendered
example, in the NHS, the majority of employees (women) are marginalised by a nature of
masculine organisational culture that has implications for managerial career
progression and succession management. Women’s career trajectories are frustrated
managerialism?
by a transactional managerial/leadership style and organisational culture which
entrenches masculine notions of managerialism. There is a paradox of public sector
managerialism; in an effort to achieve efficiency and performance, managerialism 111
creates organisational dynamics, which limits the talents and potential of employees, in
particular women, and frustrates career aspirations and the progression of future
managers – important for the sustainability of service delivery. Managerialism may be
creating long-term or future inefficiencies by limiting the full potential and productive
capacity of the majority of public sector employees.

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About the author

Karen Miller (BSoc. Sc., BA Public Admin (Hons), MPA and PhD) is Senior Lecturer in Public
Policy and Management and a member of the Centre for Public Policy and Management at
Glasgow Caledonian University. Karen Miller can be contacted at: K.Miller@gcal.ac.uk

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