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ISBN 1-84544-442-6

ISSN 1477-7266

Volume 19 Number 3 2005

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
Organization and
Management

ISSN 1477-7266
Volume 19
Number 3
2005

Using critical theories to develop understanding


of health management
Guest Editor
Dr Mark Learmonth

Access this journal online _________________________

179

Editorial advisory board __________________________

180

Guest editorial: Tales of the unexpected? Stirring


things up in health-care management
Mark Learmonth_______________________________________________

181

Shifting the balance of power? Culture change and


identity in an English health-care setting
Ruth McDonald________________________________________________

189

Exhausting management work: conflicting identities


Jane Mischenko ________________________________________________

204

A hermeneutic science: health economics and


Habermas
Neil Small and Russell Mannion __________________________________

219

Examining leadership through critical feminist


readings
Jackie Ford ___________________________________________________

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236

CONTENTS

CONTENTS
continued

WORK IN PROGRESS
MMR: public policy in crisis: whose tragedy?
Laura Stroud _________________________________________________

252

The inception of the National Health Service: a daily


managerial accomplishment
Nancy Harding ________________________________________________

261

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JHOM
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Journal of Health Organization and


Management
Vol. 19 No. 3, 2005
p. 180
# Emerald Group Publishing Limited
1477-7266

EDITORIAL ADVISORY BOARD


Beverly Alimo-Metcalfe
Professor of Leadership Studies, University of
Leeds on secondment to Leadership Research
& Development Ltd, Leeds, UK
Professor Jim Connelly
Professor of Public Health, Centre for Primary
Care and Public Health, University of
Reading, Reading, UK
Neil Goodwin
Manchester Health Authority, Manchester,
UK
Kristina L. Guo
Health Services Administration, University
Park Campus, Florida International
University, Miami, Florida, USA
Professor Stephen Harrison
Department of Applied Social Science,
University of Manchester, UK
Professor David Hunter
Professor of Health Policy and Management,
School for Health, Wolfson Research Institute,
University of Durham Queens Campus,
Stockton-on-Tees, UK

Mark Learmonth
Jubilee Campus, Nottingham University
Business School, Nottingham, UK
Annabelle Mark
Professor of Healthcare Organization,
Middlesex University Business School,
Hendon, UK
Professor John Ovretveit
Professor of Health Organisation and
Management, The Nordic School of Public
Health, Goteborg, Sweden
Jonathan Parry
Chief Executive of Southport and Ormskirk
NHS Trust, Southport, UK
Ceri Phillips
Centre for Health Economics and Policy
Studies, School of Health Science, University
of Wales Swansea, Swansea, UK
Gerald Wistow
Hartlepool, UK

Guest editorial

Guest editorial

Tales of the unexpected?


Stirring things up in health care management

181

Mark Learmonth
Nottingham University Business School, University of Nottingham,
Nottingham, UK
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 authors
personal experiences of being a manager in the UK National Health Service.
Findings The authors 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 dont 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
was in the NHS. The work also reinforced a discovery I had started to make a few years
The author thanks Philip Warwick, Edward Wray-Bliss and Qi Xu for comments on an earlier
draft.

Journal of Health Organization and


Management
Vol. 19 No. 3, 2005
pp. 181-188
q Emerald Group Publishing Limited
1477-7266
DOI 10.1108/14777260510608925

JHOM
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182

earlier that there are a quite considerable number of people across the world who are
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
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 todays
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 ones 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. Im
confident that Im not the only person in the health field who has had misgivings or
discomforts about management. And if Im 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.
Early years: the budding manager
I started working for the NHS in 1981 as a clerk. Then, the organization of the NHS was
rather different from what it is today. 1981 was a good ten years before the first person
called a chief executive was to emerge to lead any part of the NHS and it was still three
years away from the time that manager became commonly used within NHS job
titles. My ultimate boss in those days was called a District Administrator.

But by 1986 things had changed. That was the year I got a place on the General
Management Training Scheme (GMTS), a fast-track promotion scheme for aspiring
NHS managers, intended mainly for graduates but with some places for candidates like
me who had already spent time in the service. Until the previous year, GMTS had been
known as the National Administrative Training Scheme its name change illustrating
two of the wider NHS changes that had both happened by 1986: the sudden demotion
of administration to the relatively low status it continues to have today, and the equally
sudden lionisation of management. By 1986, people called general managers had taken
over from people called administrators and these managers were now officially
(supposed to be) in charge (Strong and Robinson, 1990).
Whilst on the GMTS and until about the early 1990s, I was deeply ambitious to
become a top NHS manager. This ambition and my views of management in those
days are illustrated by what I wrote on my application form for the GMTS. Here is an
extract from the section of the form headed Motivation for a career in the NHS:
The NHS is a highly complex organization providing socially essential services and as such
presents a great management challenge, particularly with the ever increasing need to ensure
its efficiency and effectiveness. Its complexity demands a range of personal skills and
academic disciplines of a manager and brings him/her into contact with staff, patients and the
general public from all social groups. Also, the introduction of General Management has
given the manager an opportunity to take personal responsibility for his decisions, and more
freedom to implement changes creatively and imaginatively.

In the late 1980s especially, I would have unreservedly echoed a phrase I still remember
from the back cover of the recruitment literature for the 1986 GMTS, presumably
meant to illustrate the desired attitude in trainees: I am very committed and I want to
get to the top. And given that I was very committed to getting to the top, it is not
really surprising that I started to ascend the NHS management career ladder. Looking
back on it now, it seems that being an NHS manager was a positive and important part
of my whole personal identity at that time. But the person I then was, was not to last
too long.
The later years: management and its downsides
It was in the early 1990s, when I was a middle-manager, that I started to become
increasingly bemused and concerned by how a particular version of management,
insidiously but powerfully, had come to dominate many parts of the life of the NHS. I
was asked (and generally forced by the logic of my job) to do things to my subordinates
about which I was deeply uncomfortable. I began to see the politics of organizational
life (though typically dressed up to be about improving public services) as often being
cynically oriented to managers own ends. Career success seemed to come through
getting to be known and liked by those who had the power to give you your next job.
And all this was happening to me at a time when, it is hardly contentious to suggest,
the NHS witnessed an unprecedented rise in the influence of managers and
management thinking more generally. As the managerial reforms progressed, I was
becoming more and more uncomfortable and unsettled about it all.
What follows are two brief illustrative examples of the kind of things that over time
contributed to the fundamental change in my attitudes to management and in the
end to the change in my career. A reorientation which happened gradually over a
number of years; these stories are part of an experience of confusion and discomfort

Guest editorial

183

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that played their part, along with many other things, in slowly draining my
enthusiasm for better management.
The first comes from one of the general hospitals where I was a middle-manager. A
substantial part of the job was introducing a computer system into clinical areas.
Crucially, the introduction involved changes to the way that nurses worked. What I
had assumed would be relatively minor changes in nurses working practices for
substantial gains in terms of the administrative systems were seen very differently by
the nurses themselves. Indeed, they argued that their core job looking after patients
would be significantly compromised, to an extent that far outweighed what they
thought were the cosmetic gains in having a slicker administrative system.
Whatever the rights and wrongs of the situation however, it was pretty clear to me
that the political benefits that would accrue to the top managers of the hospital in them
being seen to be leaders in IT systems meant that there was no question of not
implementing it. During the implementation, I happened to overhear two nurses
expressing to one another their strong personal animosity against me. The realisation
of the extent of their hostility left me quite shocked I had not anticipated it, and at the
time could not work out why it should have been so vociferous. Subsequently I read
McCartney, Brown and Bells (1993) survey of health professionals attitudes to NHS
managers, confirming my suspicion that this sort of hostile managerial/clinical
relationship was not unique:
. . . respondents used the survey to rid themselves of a great deal of aggression and distress
they seemed to feel about NHS managers. They gave the impression of being conquered
peoples of a once great civilisation, suffering the indignities and authoritarian brutalities of a
barbarian, occupying power (McCartney et al., 1993, p. 55).

The other example comes from a few years later, when as a waiting times manager I
manipulated statistics to make them politically acceptable. Part of my job was
collecting the statistical returns from individual hospitals to provide a Region-wide
summary. It was clear that at the time, both the Secretary of State and the Opposition
spokesperson on health took keen personal interests in any summaries that were out of
line with the national government guarantees about maximum waiting times. It was
equally clear that the top managers in the organization did not welcome such interest!
Indeed, although they were aware of the real situation, they would not sanction a
summary being returned unless it represented a picture that would be unlikely to
attract interest from politicians. Thus I became actively involved with (what today is
euphemistically called) adjusting waiting list returns mainly by encouraging the
chief executives of local hospitals to present me with a return that needed no further
adjustment. At the time, these sorts of practice were endemic in the NHS (as many
managers will privately acknowledge) although their existence was publicly denied
until recently presumably when such denials became untenable.
What are we to make of my stories? No doubt todays health care managers are as
aware now, as I was then, of the dilemmas they face they too can tell stories similar
to mine. All surely know that there have been occasions when their own decisions have
made others lives difficult, perhaps even miserable and lets not forget that the need
for better management has often justified managers themselves suffering stress,
unfairness (and worse)[1]. In other words, there was (and is) nothing particularly
unusual about my sort of stories. This goes for others jobs too no doubt most health

care professionals have similar stories to tell about equivalent dilemmas and worries
(for an example from medicine see Connelly, 2004, p. 110).
So then, all of us have things that trouble us about our jobs and we have to make
sense of them in some way or other so that we can continue to do our jobs and live the
rest of our lives[2]. One way is to develop a thick skin and see these sorts of experiences
as something that simply goes with the job. But it started to appear to me that there
was something fundamentally problematic going on in management, that could not be
remedied by simply trying harder at being a manager even trying harder at being a
thick-skinned manager armed with the latest ideas on leadership, reengineering or
whatever!
Unfortunately, my main problem was the lack of a way to make sense of my
concerns. By the early 1990s I had begun to read the official theory of standard
management textbooks and government reports rather less enthusiastically than I had
earlier on, when such ideas strongly influenced the extract from my job application.
Overtly political and self-interested behaviour was simply not supposed to happen in
my reading of such texts. They seemed either to downplay it completely, or when it
was acknowledged, marginalized it by claiming that political conflict might be used to
further organizational effectiveness. Their portrayals of management as essentially a
set of technical activities done in the service of others or of ones organization now
appeared to me to be downright disingenuous.
Looking back with the perspective of ten years, it was probably these discomforts
that were an important part of my sideways move out of mainstream management to
become the chief officer of a community health council. Community health councils
were bodies that were still part of the NHS but were made up of unpaid lay members
who were charged with a watchdog function on behalf of local communities. Their
chief officers were paid as NHS middle-managers but such posts were, to say the least,
not regarded as good career moves for future top managers (indeed, community health
councils were abolished in 2003).
The contribution of critical management studies
It was during my time in community health councils, whilst studying for a Masters
degree in 1996, that I first discovered research in a tradition that had come to be known
as critical management studies (CMS)[3]. Although CMS is far from a unified or
coherent intellectual movement (according to Parker (2002) it is more like a connected
set of debates) many of the people who call themselves CMS researchers seemed to me
to be articulating what I had been trying to think through with little success in the
previous few years. In contrast to standard management theories, government reports
and the people in boardrooms who, as far as I could see ignored (or simply did not
recognize) the fundamental difficulties with management, I began to realise that there
were people in universities who were directly addressing some of the sources of my
own sense of unease.
The official stories told about the NHS are tales of excellence and improvement that
contrast all too starkly with the kind of stories I have emphasized here. If these latter
stories are acknowledged at all in boardrooms and government documents they tend to
be understood as aberrations, things that can be overcome if we do management better
implement codes of conduct more diligently or practice the latest form of leadership
more faithfully. But for many in CMS, the supposed remedy more, better

Guest editorial

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management is in fact the problem. Far from representing individual bad luck or
being readily explicable by my own incompetence, the stories I have told can be
understood not as aberrations at all but exactly the kind of things we might expect to
happen when we set out to manage organizations in the way that has come to dominate
the NHS over the last 20 years or so.
A commitment to CMS does not involve a claim that every single activity we have
come to regard as management is unnecessary or is actively antagonistic towards
creating a better, fairer world. Of course some (perhaps most) of the things managers
do are important and worthwhile. CMS is less of a challenge to management activities
per se than it is a challenge to the dominant ways in which we have come to think about
management in western society. So I am not suggesting that the typical NHS manager
deliberately sets about to be domineering or unethical; nor that if we could only appoint
individuals with integrity to top jobs everything would be OK. What I am suggesting
is that the problems I and others experienced are created primarily by the dominance of
a particular way of thinking about management: in particular, thinking of it in terms of
technique.
In health care today, management is typically understood as a technology of control.
That is to say that the problems of organizing are assumed to be ones that are
susceptible to various techniques that managers can take out of a tool-kit and, with the
right training, use to control the resources of an organization. Of course, the biggest
challenge is usually controlling human resources but this challenge is still thought
of as technical in nature. Apparently humanist affirmations like leadership and
emotional intelligence can be just more tools in the managers tool-kit tools with
value only if they further improve managerial control if they trump the more
traditional approaches to getting things done (Willmott, 1997).
And once we see control as a technical achievement it tends to become an end in
itself. Managers can celebrate the service reconfiguration, the quality enhancements,
the reduced waiting times, the IT systems implementations and so on that they have
achieved. What is more, the depersonalized management-speak in which it is all
dressed up can make these things seem unconditionally positive. So positive that we
are able to rationalize, maybe even forget, the considerable ethical compromises,
inhumanity and inequality that such achievements almost always involve[4].
So, Unmasking Health Management, along with the articles that follow in this special
edition of JHOM, offer accessible introductions to CMS applied to health care introductions
that dont let us so easily forget the less wholesome things done in the quest for better
management. What I hope they do in particular is to challenge forms of management
thinking that see management as purely technical, as simply finding better ways of getting
things done. They show how an exclusive focus on performance has the effect of hiding
phenomena like exploitation, surveillance, manipulation, discrimination and subordination
how this focus provides camouflage for the things that are regularly done in the name of
and under the cover of better management.
Where I believe CMS can have a particularly valuable role is in providing an
alternative to the official stories, to fill in the gaps that have been left by all the
airbrushing that is necessary for us to continue to think about management in
excessively positive ways. CMS is one place (with journalism, novels, films and so on
often providing other places) that gives legitimacy to those people who want to say the
kind of things that need saying about the processes of management but cannot easily

say it through managerially-sanctioned channels. Can you imagine an article like this
appearing in a government-backed publication or a hospital magazine?
To be (perhaps unduly) optimistic for a moment all this just might encourage more
critical reflection about organizational life. Rather than leading to the despair or cynicism
that is often apparent among people who get disillusioned with their work, such
reflection can spur us on to thinking about how else we might do organizing ways that
do not necessarily involve controlling other human beings and using them as resources
in our plans. There are alternatives, though none are straightforward or easy, and have
increasingly been erased or forgotten because of the dominance of business management
as the exclusive form of thinking about how to do organizing[5]. For the time being at
least, we will almost certainly be ploughing fairly lonely and difficult furrows should we
try them; but that is not to say they are not worth trying.
Towards some conclusions
So, I hope that this article may have struck a chord with some of its readers, especially
those who work on the front line in health care (though I recognise that it might equally
have made others angry, even appalled). But I dont want to be accused of misselling
CMS. It is in no way a panacea.
A particular issue is that what academics can actually do in the sense of taking
effective action against dominant forms of management is not entirely clear. Indeed,
leaving the NHS like I did might be interpreted as an act of cowardice in the context of
my views about management, a retreat to an ivory tower of (safe) contemplation rather
than a positive contribution to bringing about change at ground level.
Quite possibly there is more than an element of truth in this. CMS has given me a
way to have romantic notions of myself as a radical at the same time as giving me a
relatively safe, well-paid and (possibly) prestigious job a job that has even allowed
me to transfer my NHS pension! On the other hand, writing and teaching are
potentially ways of staying engaged with practice ways of doing something to
encourage new thinking and forms of resistance however slight that something
might be.
In any event, do not expect CMS to provide straightforward answers that give the
details of viable alternatives to business-style management; indeed, if we want to do
away with the complications and complicities involved in our work its probably best
to stop thinking entirely or at least abandon the sorts of ideas CMS encourages. But
what CMS academics can do (if nothing else) is give space and credibility to
like-minded people to think through things that are important about organizational life,
things that are not just about reproducing the current obsessions with performance,
league tables or efficiency. And so, just maybe, we might start to develop ideas that
enable us to do things differently.
Unmasking Health Management: A critical text (ISBN 1-59033-979-7) was published
by Nova Science, New York in 2004.
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.

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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
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.
5. See for example, Parkers (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,
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The Emerald Research Register for this journal is available at


www.emeraldinsight.com/researchregister

The current issue and full text archive of this journal is available at
www.emeraldinsight.com/1477-7266.htm

Shifting the balance of power?


Culture change and identity in an English
health-care setting
Ruth McDonald

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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
books such as Peters and Watermans In Search of Excellence. Here the creation of shared
values and beliefs is crucial to organisational success and the achievement of excellence.
Peters and Watermans (1985, pp. 318-25) concept of simultaneous loose-tight
properties entails the rigorous adoption of overarching values with substantial

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Management
Vol. 19 No. 3, 2005
pp. 189-203
q Emerald Group Publishing Limited
1477-7266
DOI 10.1108/14777260510608934

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autonomy for operational managers in deciding how to enact these values. However,
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
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
dont) 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 nave
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.
Identity, empowerment and modernization
Under the guise of culture change, organizational elites may seek to mobilise
particular identities and explicitly or implicitly designate alternative or competing
identities as marginal or illegitimate (Alvesson and Willmott, 2002). Acceptance of
these by employees will serve to limit their choice of alternatives to those which are
compatible with affirming that identification and by implication, with organizational
goals. However, the active consent of those who are the targets of such practices is by
no means guaranteed, since individuals are not mere social dopes, but are actively
involved in the construction of their own subjectivity.
For Foucault, subjectivization is a process in which the individual delimits that
part of himself that will form the object of his moral practice, defines his position
relative to the precept he will follow, and decides upon a certain mode of being that will
serve as his moral goal. And that requires him to act upon himself, to monitor, test,
improve and transform himself. (Foucault, 1986, p. 28) This process should not be

interpreted merely as slavish adherence to rules or prohibitions. Rather, technologies of


the self, and the attainment of a certain mode of being involve individuals in making
choices about behaviour, in exercising their rights, their power, their authority and
their liberty (Foucault, 1986, p. 23) This freedom to make choices is important since it
creates conditions for both the exercise of power by others, (since where individuals are
wholly determined there is no relationship of power) and the exercise of resistance to
that power. Freedoms refusal to submit means that attempts to exercise power will
always take place in the context of resistance (Foucault, 1982). In The History of
Sexuality Foucault described the exercise of power, authority and liberty in the context
of moral codes and techniques of the self. The former define desirable (and otherwise)
behaviours and attributes and specify goals to be pursued and pitfalls to be avoided
and the latter refer to the methods by which individuals act upon themselves in order
to transform oneself into the subject of ones ethical behaviour (Foucault, 1986, p.27).
The creation of the ethical self is seen as involving practices of freedom as opposed
to merely an expression of discipline aimed at constraint. However, in the absence of
ethical practices aimed at excavating our own culture in order to open a free space for
innovation and creativity (Foucault, 1988, p. 163), freedom to create oneself may be
seen less as liberation than an obligation to aspire to a certain ethical self. Technologies
of the self as practices of freedom are identified with an ethic of care for the self. These
technologies of the self imply a set of truth obligations since constituting oneself as an
ethical subject involves conducting oneself in accordance with the truth. Truth here
signifies that which is sanctioned by prevailing moral codes and the construction of the
ethical self as an act of freedom involves choosing to reject other discursive
alternatives which offer marginal or illegitimate truths.
The notion of ethics as a form of freedom, as individuals choosing to adhere or
aspire to certain moral codes is taken up by Nikolas Rose, who sees irony in a state of
affairs in which the government of the soul depends upon our recognition of ourselves
as ideally and potentially certain sorts of person, the unease generated by a normative
judgement of what we are and could become and the incitement offered to overcome
this discrepancy by following the advice of experts in the management of the self. The
irony is that we believe in making our subjectivity the principle of our personal lives,
our ethical systems, and our political evaluations, that we are freely choosing our
freedom (Rose, 1999, p. 11). For Rose, freedom to create an individual self is less about
choice or empowerment and may be more usefully conceived as an obligation to be
free. The self is not merely enabled to choose but obliged to construe life in terms of its
choices, its powers, and its values (Rose, 1999, p. 231).
Rose (1996) suggests the discourse of empowerment can be seen as the role of
experts in the coaxing of others who lack the cognitive, emotional, practical and ethical
skills to take personal responsibility and engage in self-management. He describes
how the promulgation of technologies of psychological and moral management based
on psychotherapeutic discourse and practice have been focused upon damaged
individuals with the aim being to remedy their behaviour and bring it within normal
(or ethical) limits. There are parallels with the ways in which individuals are
encouraged to reflect on their own practice as part of empowerment processes aimed at
promoting self-actualisation. The discourse of empowerment therefore assumes the
existence of the damaged or deficient subject requiring what Gilbert (2001, p. 204)
terms remedial work through reflective practice and . . . supervision in order to

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achieve forms of subjectivity consistent with modern forms of rule adaptable to


lighter touch forms of surveillance and capable of self-regulation.
The empowerment of NHS staff is depicted by Government as a key plank of its
modernisation agenda, with the process of creating Primary Care Trusts described as
one of putting front line staff in the driving seat. However, in recent years reforms
aimed at strengthening the ability of Government to make the NHS more efficient and
more responsive to the needs of its customers have been characterised as a process of
command and control, emphasising the implementation of top down edicts and
national standards at local level. In the early years of the Blair Government the
characterisation of those working in the public sector as change resistant, part of the
problem rather than the solution, targets rather than agents of modernisation provided
a rationale for imposing top-down solutions on managers who had hitherto failed to
deliver. More recently, however, there has been a more conciliatory approach with an
emphasis, in the rhetoric at least, of empowerment and autonomy of public sector staff.
At first glance the Governments desire to empower NHS employees whom it had
previously held in such low regard is a surprising volte face and runs contrary to the
command and control style of Government policies. However, the process may be conceived
as an attempt (by Government and by PCT senior managers) to reduce insubordination by
influencing individual identity. The success of such a strategy is by no means guaranteed
since every power relationship implies, at least potentially, a strategy of struggle. Whilst
control in the context of stability is the desired outcome of empowerment initiatives, the
achievement and maintenance of stability is never guaranteed since as we shall see from
events at Downtown PCT, insubordination and resistance are essential components of the
power relations within which self-making takes place.
The case study empowerment in Downtown PCT
Downtown (pseudonym) PCT was created in April 2001. It was formed from two existing
Primary Care Groups and one community health services trust. The latters role was the
provision of community services (such as community nursing, podiatry, speech and
language therapy) while the former were involved in the commissioning of health services
for the local population. In addition staff from the Health Authority were incorporated into
the PCT. The community trust staff formed the vast majority of the new PCT employees
and were located either in clinics within the local community or in Walsingham House, a
mile and a half from the PCT headquarters which housed the PCT chairman, executive
directors and some support staff (e.g. finance, human resources). This geographical
separation of the senior managers from the rest of the staff exacerbated the unhappiness
felt by many members of the former community trust when the chief executive of the
community trust was not appointed as the lead officer of the PCT. Staff at Walsingham
house spoke in pejorative terms of the Palace and its inhabitants and the chief executive
pointed to this them and us state of affairs in one of her briefings to the staff.
The creation of the PCT involved not merely assimilation of existing organisations
but reorganisation of ways of working which involved the creation of new roles and the
disappearance of old ones. Displaced were staff were labelled at risk. The use of the
label was intended to promote some sense of security since these staff would be given
priority in applying for new posts, but it is not clear that labelling employees in this
way was a reassuring process. Reorganisation was a constant feature during the
research and this was initially justified on the basis that the PCT was a new

organisation. Further processes of reorganisation included the introduction of locality


teams aimed ostensibly at empowering local staff and communities. In addition as
part of the ongoing modernisation/service redesign agenda which involved building
new community and hospital facilities, there was an ongoing process of redefinition of
roles and processes for patient care.
The measurement of outcomes relating to the work performed by those who deliver
health services in the community has long proved a difficult task. In addition, for those
PCT staff not involved in the direct provision of care, the evolving nature of the PCT
and the problems of meeting Government targets in a complex system where it is
difficult to identify mechanisms for achieving desired ends means that the precise
nature of an individuals work is often uncertain and the quality of their output is
difficult to assess. Under such circumstances work-related roles and identities and
professional competency are actively established in interaction. This means that the
likely success of attempts to persuade staff to adopt new identities and work-related
roles, as desired by the chief executive and outlined in modernisation documents would
be diminished if the interaction between former community Trust staff continued
much as it had done. The moving of staff briefings to a neutral venue (away from the
Palace) in order to encourage attendance from former community Trust staff can be
seen as an attempt to widen this sphere of interaction in order to allow new influences
into the processes which shaped individual PCT identities.
A study commissioned from a third party by the PCT chief executive found low
morale, widespread dissatisfaction with channels of communication and distrust of
senior management of the PCT. Respondents reported feeling vulnerable and
complained of a lack of organisational identity. In a context where their former
organisations no longer existed and the new organisation gave individuals no sense of
what it was or would come to be, it is understandable that respondents did not identify
with the PCT nor did they want to belong to it.
As the researchers reported, however, many employees felt a sense of belonging in
relation to the existing services they provided and their immediate working
relationships. The views expressed by interview respondents in the PCT
commissioned study were at odds with the of modernisation discourse, which
permeated Government announcements and circulars and was promoted at every
opportunity by senior managers of the PCT. In contrast, this alternative and unofficial
nature of the resistant discourse had hitherto bubbled below the surface, until it was
captured and articulated in print by the researchers who summarised the views of the
study. The reporting of such views in a quasi-official publication created the possibility
that once circulated throughout the organisation, such findings would lend legitimacy
to the discourse of opposition and negate attempts by the senior management team to
promote identification with new organisational and individual identities. This may
explain why the report, which had been circulated to senior managers within the PCT
upon its receipt in June 2002, was hastily recalled and shredded.
As part of a process of organisational development, the PCT senior management
team extended an invitation to all staff to nominate people in the PCT who were
influencers. These members of staff were then invited to participate in an Investing
in Excellence (IIE) programme.
Influencers were split into groups and brought together as a group for five days
over the course of approximately 12 months. An external facilitator ran these events

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and during this time participants watched IIE videos and engaged in discussion and
group and individual exercises. In addition they worked through audio materials and
work books provided as part of the IIE course during their spare time at home. They
were also invited to attend an influencers lunch at which influencers were briefed,
given lunch and the chance to mingle with the chief executive, chairman and other
senior officers of the PCT.
The data presented here are part of a two-year study participant observation study
conducted between 2001 and 2003 looking at decision making within the PCT. A
variety of methods were used during the conduct of the case study, including formal
interviewing techniques, participant observation and documentary evidence. In total,
30 formal interviews were conducted with employees who had participated in the IIE
programme from a variety of functions including the management of clinical services
(e.g. nursing, podiatry), the provision of services (e.g. health visiting) training, public
health and service development.
At an open staff briefing which reported on the success of the first waves of the
influencers programme, the chief executive described the rationale for it and
encouraged others to participate:
We set up an influencers group . . . we were kidding ourselves that its the senior managers
who have the most influence, but everyone knows who the managers are who have the most
influence. Everyone knows who the people are with strong opinions and are opinion shapers.
So we did a survey [to identify] the main influencers and people were nominated . . . Its good
to have people who challenge, but it can be quite negative if challengers see everything as half
empty . . . And recently weve been adding to the group. I use this as a way of testing the
temperature of the organisation. The culture of the organisations rarely fed back through
management . . . It [influencers programme] can help our self confidence, standing up and
speaking publicly, our sense of self and who we are . . . some of my colleagues are gonna tell
you a little bit about how the course has helped them.

What seems odd here is the notion that it is the people who are already seen to be
having some influence in the PCT who are being singled out for training which will
empower them. If the desire is to empower staff then why not start with those who are
perceived to have little or no influence? These pronouncements raise questions about
the motives for this empowerment process and its desired effects. They also suggest
that the participants are in some way deficient and in need of development. The speech
is used to establish some boundaries of ethical behaviour. For example, challenge is
acceptable, but within certain parameters. Freedom to act is acknowledged (its good
to have people challenge), but this freedom must be exercised responsibly.
Responsible selves do not choose to engage in negative behaviours or adopt
half-empty perspectives.
The need to behave responsibly and in an adult manner is reiterated later on in the
staff meeting when the chief executive explains in her whistle stop tour through the
coming year that she makes no apologies for not talking about everyone . . . theres
always somebody saying Im not important, well Bloody well grow up. You cannot
focus on everything in every organisation . . . some things are really high priority . . .
The parading of those employees who have undertaken the programme and their
recounting of transformations from unassertive to self-confident self, from
disorganised to self-managed self, from emotional to controlled self and so on,
coupled with the CEOs remarks about the programme on our sense of self and who

we are further serves to underline the notion of a desired ethical self based on some
transformation of the current or existing deficient self.
This theme of the emergent self-directed individual, exercising freedom of choice
but behaving responsibly runs through the IIE course, as this extract illustrates:

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The aims of the course are to help you as an individual and an organisation become unique,
self-directed, accountable. . . . it is vital that you become self-directed . . . you have free will.
You can choose (p. 3).

195

Although what this extract also suggests is that the organisation, as well as the
individual, is engaged in a project of the self and that self-direction should be seen in
the context of the moral codes which govern the organisation in which the individual is
employed.
That self-direction, for the empowered individual, is a matter of choice rather than
slavish adherence to rules is emphasised in the course literature as the following
extract illustrates:
Locus of control: The place where control is perceived to be. This is internal for independent,
self-directed, accountable people. It is external to dependent, other-directed people who have
given up accountability for themselves to others, or worse, to circumstances (The Pacific
Institute, 1998a, p. 2).

Self-direction involves a recognition that most of our limitations or obstacles are


internal and can be quickly removed by affirming their opposite. However, although
choosing to reject these negative thoughts is part of achieving a new way of life or
becoming a self-actualised individual, it is also important to recognise the existence of
external obstacles that should not be fought against since the constraints they impose
upon us will release more energy and creativity to achieve our goal (The Pacific
Institute, 1998b, p. 231). The freedom (or obligation, in Roses words) to make choices
about ethical behaviour is in part a matter of distinguishing between what is within the
control of the individual and what is not. In the context of dominant discourses on the
inevitable logic of modernisation (where modernisation covers a whole raft of practices
and change management initiatives) it may be that self-actualising individuals choose to
aspire to those behaviours which are consistent with this discourse. Alternatively, those
who would previously have engaged in resistance may now interpret constraints as
external, recognise the futility of resistance and choose to accept the inevitability of
change. This may necessitate a degree of ethical work (travail ethique, Foucault, 1986,
p.27) to bring ones conduct into compliance with the PCT rules or moral code and to
attempt to transform oneself into the ethical subject of ones behaviour.
Whilst the IIE course encourages participants to recognise the existence of external
obstacles which may prevent them from achieving their goals, it is stressed that the
exercise of free will means that nobody can be forced to do anything against their
wishes. Work processes are active choices not burdens imposed by others. A related
implication is that since the possibility of resistance or departure exists for individuals,
complaining about ones lot or engaging in negative thought processes is not the
behaviour to which the ethical individual aspires.
The shaping of the empowered self in Downtown PCT
Participant attitudes towards the IIE course fell in to three categories, with the majority of
people praising the course and a small number either expressing ambivalence or being

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openly critical of it. Most enthusiasts saw themselves as changed and becoming more
confident or content in their work as part of the process. Many of those who were critical
pointed to tensions between the rhetoric of empowerment and the reality of what they saw
as a top-down controlling environment and even amongst those who were wholeheartedly
in favour of the programme there were inconsistencies in the accounts presented. For
example, most respondents described how as an empowered individual they enjoyed a
great deal of autonomy in respect of their workload and objectives yet these same people
also complained that although they saw attendance at IIE sessions as extremely
important they had not been able to attend all of them due to pressure to work on must
dos. This suggests that respondents are subject to pressures beyond their control and are
forced to grudgingly accept the priorities which others impose upon them. Certainly some
respondents expressed resentment at having to miss out on what they saw as time for
their development because of unreasonable demands made from on high:
A couple of occasions when something very major came up at work I had to drop everything
and do this . . . it meant that I couldnt go on 2 of my days. I was furious that this important
part of my personal development had to be put on hold because this big piece of work
trumped it.

The responses of IIE participants serve to underline Foucaults comments on the way
in which individuals decide on a mode of being that will serve as their moral goal.
Many respondents outlined areas of personal conduct or behaviour, which, as a result
of the programme, they had become aware were in need of modification. Amongst
enthusiasts most participants reported acting upon themselves, monitoring their
conduct and improving their performance in an effort to transform themselves.
Lucy was one of those who spoke enthusiastically at an open staff meeting of how the
IIE programme had transformed her. She explained having learned how to look at her
workload and prioritise more effectively. You look at where you spend most of your time
. . . If youre organised you should be spending 80% in the URGENT and IMPORTANT
box. She explained how the IIE programme had helped her identify her own
shortcomings You realise that what you end up doing is the stuff thats not urgent.
Lucy appears to have taken on board the IIE message about self-determination and
accountability and has come to see the root of problems as located within herself rather
than her environment. Problems were conceptualised in terms of deficient individuals
but seen as easily resolved through the use of IIE techniques. During the research
period Lucy was seconded for two years as a project manager but as her original job
was not filled she was currently juggling both roles. However, although Lucy admits in
my interview with her to working long hours and acknowledges that having two jobs
creates tensions, her comments suggest that she perceives the problem as being located
within her deficient practice youve just got to try and get your work part in control
cause you could just be here 24 hours a day really so youve got to try and cut the hours
down and try and be more effective.
Comments by Lucy and other respondents who outlined progress in addressing
deficiencies were often made in the context of some ideal self to which they aspired. For
example, suggestive of a self in transition, is Lauras comment that:
Before [the programme] I would just react to something and sometimes quite inappropriately
as well maybe lose my temper and slamming and banging . . . Im not where I want to be but
Im getting there . . .

The implication is that outward displays of emotion are quite inappropriate


behaviour for the ethical self to which she aspires.
Similarly, the tales told by other respondents about transformed selves exercising
restraint and suppressing anger and resentment as a direct result of their participation
in the IIE programme suggest that respondents are exercising tighter control over their
feelings and behaviours in their journey to becoming their desired ethical self.
Several respondents reported how the IIE programme had taught them that they
did not have to do anything and that they were free to choose although
non-compliance would carry consequences. For Sally, working long hours, often being
the only person left at the health centre when everybody else had gone home was
previously a source of resentment. The realisation of her freedom to choose had
transformed her perception so that she was happy to stay, since it was her choice to do
so. Although elsewhere in the interview she describes feeling pressured to choose
certain courses of action over others:
My own director only went on one of the [IIE] courses. She never said anything but when she
was also missing sessions I didnt feel strong enough to go . . . I think a few people felt like
that. I suppose we should have been stronger but we werent.

In Hirschmans terms, employees who are deeply dissatisfied with an organization may
choose to leave or exit (Hirschman, 1970). Those who stay display varying degrees of
loyalty or voice. Conceptualising choices in terms of freedoms to choose between
loyalty or exit but not voice, closes off certain discursive options, suppressing conflicts
and alternative courses of action. As Deetz writes, in choosing loyalty individuals
gain membership, clarity, status and specific identities, but they also re-enact a
dominant set of power relations with costs (Deetz, 1998, p.170).
Not all participants were comfortable with the consequences of their empowered
status or becoming the self to which they felt they were being encouraged to aspire:
Ive been a little bit unhappy because Ive heard comments from friends that a couple of
managers have commented that Jackie has changed but yes Jackie has changed as a
consequence of the programme . . . to me that was the whole point of the programme. You do
change as a person professionally and personally . . . I should have changed otherwise the
programme would not have been a success. . . . I realise that my comments and opinions are
as valid as anybody else in the organisation and your manager or the boss may not
necessarily always be right and Ive got a right to have an opinion. Ill challenge things but
the point is its not liked if you challenge something.

Of course choosing not to voice criticisms openly does not mean that participants are
choosing loyalty. Instead it may be that they are aware of the consequences of openly
challenging and choose to engage in subtler forms of resistance. Those employees who
had previously been or were currently involved in the front line delivery of services to
local people reported tensions which were highlighted by the obligation to becoming an
empowered ethical self, with all that that implied. The picture painted by evangelistic
participants of ideal selves is one of unemotional, rational, positive and self-contained
individuals. Getting the potentially emotional and unruly self to behave is an important
part of the IIE programme and the remarks by one health visitor that the IIE has
taught her its about focusing your mind and taking away the emotion highlight the
emotional/rationality dualism. For those engaged in caring for patients this lack of
emotionality can cause problems. One respondent who had seen her ability to

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empathise with staff at grass roots level as a strength reported when expressing
anxieties about the ability to deliver safe and effective care with dwindling staffing
levels being instructed to stop thinking like a District Nurse, since it was seen as
incompatible with her status as a manager. The link between emotion and what has
been seen as an irrational clinging to traditional values goes back a long way. As
ten Bos and Willmott point out in their discussion on the dominance of rationalist
assumptions in business ethics, such assumptions privilege reason over emotion: This
is not an ethics that is close to actual human beings. Indeed to be too close to actual
persons risks becoming less ethical (ten Bos and Willmott, 2001, p. 775).
This sense of conflict about identity is heightened for those respondents whose
sense of self is linked to the former community trust which no longer exists:
The impression that is given at the moment is that any old community trust staff are not
really worth anything and the jobs that they did werent and in all this mad rush to change
everything it seems as though any good work that has been done in the past are just being
ignored . . . There are an awful lot of good things in the old organisation including . . . [my]
service.

These inconsistencies and tensions open up space for criticism or resistance, but
empowered individuals may choose other more conformist paths, as this quote
illustrates:
It makes you more aware of what you can do and more aware of yourself . . . I think that I can
cope with things better . . . One of the exercises we did a couple of times throughout the course
was to draw pictures of what was going on in your life . . . and one of the last pictures I drew
was two people sitting opposite each other smiling at each other cos its all about thinking
positive . . . and behind the figure that was me there was this huge black swirl of chaos and I
said that is whats going on in the trust at the moment and Ive got my back to and Im
ignoring it . . . rather than worrying about it . . . and not getting het up about things that are
happening that I have no control over at all.

The emphasis on recognising ones own limitations and sphere of influence may have the
effect of transforming disciplinary power into a benevolent aid which helps the individual
to appreciate the futility of engaging in areas where they have no control. Yet securing
compliance and turning ones back to the rest of the organisation does not necessarily
equate to enthusiastic support for the PCT agenda or identification with its aims.
The need to remain positive is emphasised throughout the course and was raised
by many participants. The IIE audio assimilation guide compares the use of positive
forethought in efficacious people who look forward and see success with negative
forethought of inefficacious people who look forward and see the future with fear and
misgivings. Given the emphasis on positive thinking in management texts, self-help
books and a range of TV and radio programmes dealing with self-improvement, it is
hardly surprising that employees do not readily admit to being frightened or having
grave misgivings.
The picture of the self as cheerful and coping in adversity without complaint
was one which was presented repeatedly. Many interviewees reported staff
shortages (euphemistically capacity issues) which placed greater burdens on
employees, but almost all interviewees described themselves as positive. Part of
this willingness to express a positive attitude appears to relate to norms about
what is expected of managers and this may be interpreted as putting on a brave

face. An hour after I interviewed Natasha, who described herself as always seeing
the glass as three-quarters full, motivated and autonomous I learned from a third
party that she was unhappy in her existing role and was applying for another job
at a salary of 5,000 less than her current post. Experiencing negative emotions
may result in individuals perceiving themselves as an imperfect rendition of the
positive model. Engaging in a positive discourse may reflect the effort invested in
self-surveillance aimed at getting the self to conform (Deetz, 1998). However,
expressions of allegiance to the positive ideal may be seen as dramaturgical with
employees appearing to toe the line in taped interviews, but behaving differently
outside of those settings. For example, Charlies who described himself as
positive and feeling privileged to be doing this job in the interview spent much
of his time bemoaning his fate and frantically searching the Health Service Journal
every week for a new job outside of the interview setting.
Others actively resisted the notion that being positive implied loyalty to the new
order. A health visitor who reported feeling positive about my outlook also describes
feeling very demoralised about life in the PCT. The tension between what Jenny sees
as the behaviour contained in moral codes relating to the sphere of management and
Jennys own perception of an ethical self, perhaps drawn from her nursing background
is illustrated in her comment:
Youve gotta care about people. You cant do it if you dont care about them and youre
thinking its just one step up to being a manager. A lot of people have thought Ill do health
visiting and then Ill become a manager . . . So theyve done that and theyve time served. I
think its frowned upon to want to carry on in your job. I think people would say Im an
underachiever because I should be somewhere else . . . but I dont want to be where people
think I should be . . . I dont feel like were a unified whole that we feel part of a PCT. For us
our attachment is to our community that we serve and that the PCT is distant . . . thats like
your employer . . . Theres nobody taking a professional interest in what you do . . .

This last remark is important since selves are above all social. The making of the ethical
self involves the existence of rules, but it also involves modes of subjectification; that is
the way in which individuals establish their relation to a rule and recognise themselves
as obliged to conform to it. Praise for key influencers paraded at staff meetings,
invitations to influencers lunches and opportunities to plan future staff communication
meetings with the chief executive provide positive feedback and a means of encouraging
some of those involved in the IIE programme to identify more closely with the values
espoused by PCT senior managers, and hence to comply willingly with PCT ethical
codes. However, as Jennys remarks illustrate, individuals who participate in such
processes may resist attempts to shape their identity if those attempts are seen as lacking
validity in terms of their view of what constitutes ethical selfhood.
A small number of respondents left the course before the end and reported
dissatisfaction with its messages. As one IIE evangelist explained:
I think if you look at the drop out rates the ones who dropped out are the ones who thought
the glass was half empty and the ones who have stayed are the ones who see it as half full.

Whilst judgements about the half-full or half-empty status of individuals are in the eye
of the beholder, IIE dropouts were different from those who participated fully in the
course inasmuch as they were far less inclined to embrace the notion of themselves as
deficient or in need of empowering as this quote illustrates:

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. . . people had nominated us as people that could bring about change and so I wasnt quite sure
why we were then thought to need a development programme . . . We already were
[empowered] cos people were saying we were effective. It just seemed an odd thing to do to me.

Angie, who has worked in the NHS and been involved in managing change for over 25
years hated every second of the IIE programme on the grounds of its evangelical
and patronising manner. Her description of how her willingness to challenge the
corporate line had made her unpopular with PCT management suggests that she has
no regrets about her failure to conform:
If I dont agree then I will challenge . . . There was an incident where I was asked to do
something that I didnt feel competent to do . . . Because Ive challenged things in the past Ive
had senior managers come up to me and say I thought you were really frightening cos youve
got a terrible reputation . . . I said Do you not think I was right to challenge? Theyve said
yeah.

The statement also highlights tensions reported by several interviewees between


complying with managerial edicts and managing risk in the delivery of care,
suggesting that in the context of conflicting ethical codes, the making of the ethical self
can be a tricky and uncomfortable business.
The comments by Angie and others suggest that far from conforming to a PCT norm
or identifying with PCT values many respondents located their sense of self in some
other constituency. For some their loyalty was to the community or to patients, for
others the PCT identity was described in terms which conformed to the territory of
selfhood which individuals had staked out as their own. Organisational goals were
constructed in such a way as to prioritise the specific goals of interviewees and the
descriptions of the ethical PCT selves (positive not negative, deficient but improving not
static, rational not emotional and so on) were overlaid with a veneer, which reflected the
work objectives of individual respondents. This emphasis on individual goals is hardly
surprising given the assumption in the IIE course that individuals are a seething mass of
unfulfilled goals which they are constantly striving to achieve. These are not imposed
from above but freely chosen as representing the individuals true aspirations. What is
not clear is how, when different PCT employees have goals which conflict with those of
other PCT employees, these are to be prioritised or reconciled. The focus on successful
outcomes with the empowered individual considering alternatives and choosing the
correct course of action may explain why interviewees see the organisation in terms of
the goals which relate to their sphere of interest. In effect, employees appear to be
rewriting organisational goals in terms which reflect their own values and priorities
rather than conforming to some top-down notion of what counts as important. Tension
arises from the subordination of individual beliefs and values in the interests of
achieving short-term targets imposed by Government and prioritised by senior
management. In addition, for example, the Deputy Director of Public Health was
dismayed by the fact that others in the PCT choose to prioritise waiting lists rather than
tackling health inequalities. Although both are the subjects of organisational targets, the
timescale for achieving waiting list targets is more short term. Furthermore, the
imposition of many short-term targets from central Government means that PCTs are
unable to prioritise competing goals, with the result that managers may perceive their
departments status as marginal and undervalued. The Deputy Director of Teaching and
Learning was disappointed by the way in which the PCT top level had failed to

appreciate its importance as a core function underpinning the PCTs work ascribing to it
a discrete and peripheral status. Yet training or research initiatives that may involve
granting study leave or secondments and serving long-term organisational goals may
conflict with short-term targets. Similarly, the Deputy Director of Modernisation feels
frustrated that other departments do not afford appropriate recognition to the
importance of her directorate we are the PCT and for a long time its felt like primary
care was just that bit bolted on to the side. With so many targets relating to hospital
performance the PCT board is unlikely to be able devote as much time as it would like to
the development of primary care.
Such frustrations may act to mitigate the transformational and reconstitutive
effects of a discourse of empowerment (exercised responsibly as promoted by the IIE
course) aimed at increasing commitment and contribution to the PCT. The emphasis in
the IIE course and the empowerment discourse on individuals achieving goals which
map on to organisational goals assumes that such goals are internally consistent and
compatible. Government proclamations that staff are now in the driving seat, ignores
the fact that empowered staff members may try to steer the vehicle in many
directions at the same time, creating tensions amongst employees. This tension
appears to manifest itself in disappointment with the attitudes of others and a
willingness to redefine what is important in the organisation rather than in any
attempt to modify ones own notion of what is ethical behaviour.
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.

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For example, there are rules which relate to the requirement for individuals to
display optimism and positive attitudes. These requirements are laid out clearly in the
IIE course materials and supported by the CEOs 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.
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 dont 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 ones 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
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,
but in the context of top-down directives which conflict with the way in which
individuals choose to conduct themselves and with the values which they hold dear.

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The Emerald Research Register for this journal is available at


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The current issue and full text archive of this journal is available at
www.emeraldinsight.com/1477-7266.htm

Exhausting management work:


conflicting identities
Jane Mischenko
University of Leeds, Leeds, UK

204
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. Im 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:

Journal of Health Organization and


Management
Vol. 19 No. 3, 2005
pp. 204-218
q Emerald Group Publishing Limited
1477-7266
DOI 10.1108/14777260510608943

As long as you read this poem


I will be writing it.
I am writing it here and now
before your eyes
although you cant see me.
Perhaps youll dismiss this
as a verbal trick,

the joke is youre wrong;


the real trick
is your pretending
this is something
fixed and solid,
external to us both.
I tell you better:
I will keep on
writing this poem for you
even after Im 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. Ive 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 Bochners 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 didnt 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

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explore the use of a critical management theoretical lens. The theory is then used to
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 doesnt produce a clear
representation of reality; that in post-structural theory meaning is constantly deferred
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 Gergens (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 isnt 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:
. . . a form that will allow readers to feel the moral dilemmas, think with our story instead of
about it, join actively in the decision points that define an auto ethnographic project, and
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
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.

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My story
I present my story as a poem of three sections, entitled Pressure, Escape and
The Return.
Pressure

208

How did this creep up on me?


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:
Theres always more.
Where am I?
My children look to me and sigh,
Where is mum?
My rage starts spilling out
to anyone wholl 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.


In the colour and sensuality of Italy
I find a balanced me.

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The Return
Physically I feel the return;
like a jolt:
A thudding of the heart.
I resist
going back to that pace,
that rat race.
Im 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.
Power, self and identity
The following theoretical section explores what I perceive to be key concepts running
through my story; those of power, self and identity. These partially mirror those used
by Knights and Willmott (1999) in their text that explored the complexity of
management lived experience as expressed in novels. Knights and Willmott (1999)
particularly emphasised the insecurity of identity and the complexity of power. I use a

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poststructuralist perspective to inform this theoretical framework, which acts as my


lens to focus and reflect. Poststructuralist theory emphasises language as not
representative of reality but a place where social organisation and reality is constantly
created and our individual subjectivity continually, socially construed (Weedon, 1987;
Deetz, 2003). I weave my story in and out of the theory to illustrate the potential
interpretations of my poem. Although little in depth research has taken place on
identity work in organisations (Sveningsson and Alvesson, 2003), I utilise what I have
found to compare and contrast with my experience.
In our present world technology has changed how we relate and interact: we now
have constant social stimulation and interaction through mobile phones, the internet,
electronic mail and the increasing growth in media communication such as 24-hour TV
(Gergen, 2000).
E-mails are a new, relentless and incredibly time-consuming method of
communication in management. As described by Parker (2004) managers are copied
into everything and a considerable chunk of time is spent each day deciphering the
important from the routine. Managers also need to be available to staff, to answer any
queries and deal with any crisises. E-mails and mobile phones are the means by which
one is always accessible, or plugged into my pod. The term pod is used in our
organisation to describe the small cubicle defined as my space within the large open
plan office of the headquarters. There, constantly visible, self-consciously exposed, my
eyes locked onto my screen or plugged into my pod. The design of the office is said to
evolve from a cultural context (Hofbauer, 2000) and the open plan office design
facilitates the panoptical gaze (Foucault, 1977) an effective control device (Foucault,
1977) where one eventually interiorises a monitoring supervisory gaze (Hofbauer,
2000).
I have recently begun to imagine it as analogous to the scene in the Matrix film.
Here the real fate of humans is seen for the first time by the hero Neo: all humans are
in incubators (pods?), wired up and plugged into a false consciousness, a representation
of the world, whilst being used to fuel and feed the machines. Men and women always
at work, kept compliant by powerful, illusionary but taken for granted discourses: we
are the ultimate commodity.
The anger in my poem suggests that I do feel compelled by some other to perform
and produce, though not at an individual other level. There is a combination of
conflicting organisational discourses: of the need to be the best, of the need to survive,
and therefore the need to achieve all my objectives, which feed directly into the
directorate and organisational objectives, versus (hollow laugh) the rhetoric of
improving working lives. Then there is the clash with my personal discourses of
spending time with my family or of taking my study leave. The time in Italy exposed
me more to the need for the latter and partly explains my resistance on my return.
There is the organisational practice of regular one-to-ones with my line manager,
which underpins the discourse of achieving my objectives; the practice of being
constantly visible in the open plan office and the lack of space to have a break for
lunch, which helps promote the culture of putting in long hours.
Excuse me a moment as I slip into my academic I and present some theory
relating to power: Luke (in Knight and Willmott, 1999, p. 95) conceptualises power as
having three dimensions which progress from the overt to the subtle:

(1) The power/authority to determine a decision in a situation where there is visible


conflict.
(2) Power that is utilised to determine what is or isnt on the decision-making
agenda.
(3) Institutionalised power that defines social reality, which then becomes
normalised by people, even if its in conflict with their best interests.
Though I can identify organisational examples in fitting with Lukes theory I do
identify it as a crude, rather simplistic theory: it suggests that there are these dominant
few that do power at the expense of others and that there is a clarity of the others best
interests (Knight and Willmott, 1999).
Returning to my Matrix metaphor/analogy then, however potent it appears, there is
within it a similar simplistic implication that there is a clear known enemy, someone in
control, a puppet master of this grand narrative. This is a seductive and enduring
fantasy/storyline, which is echoed in hero(ine) and villain organisational stories
(Jeffcut, 1993) and the them and us rhetoric of everyday language.
Foucaults understanding of power would suggest that this is a naive view and that
whilst there maybe individuals and groups who promote specific discourses in their
own interest, within any given time there are myriad differing, often conflicting,
discourses which compete in every relationship, communication and social practice
(Weedon, 1987; Smart, 2002; Mills, 2003; Deetz, 2003), and it is this complexity that
contributes to the exhausting nature of (management) identity work. Power then is
seen as a verb rather than a noun (Mills, 2003): it is continually performed by people,
with people, in a complex interplay of numerous discourses, practices, institutions and
interactions, like a fluid network that constantly forms and reforms. Within my setting
then the directors, managers, clinicians and support staff are caught in a similar web of
varying organisational and personal discourses.
Although Foucault has been critiqued as promoting a passive subject, a vessel that
responds to and is constituted by powerful discourse and practice (Smart, 2002; Mills,
2003), his later work claims the possibility of positioning oneself creatively against the
discourses and therefore incorporates the potential for and suggestion of resistance
(Foucault, 1984). The same subject is in a constant dynamic interplay with discourses
and practice that creates them as powerful one moment and powerless the next
(Leonard, 2003).
In the work context my current play at resistance involves using the electronic
mail with a network of similarly minded others to exchange humorous e-mails; to dress
symbolically to resist the corporate code, for example I wear a colourful purple scarf
and black nail polish and a male colleague chooses not to wear a tie, and, arrange every
meeting possible to be out of headquarters to escape! Thus we resist the acid bath of
core corporate values that works to dissolve our colourful diversity (Willmott, 1993,
p. 534):
I never saw sad men who looked
with such a wistful eye
upon that little tent of blue
we prisoners called the sky,
and at every happy cloud that passed
in such strange freedom by (The Ballad of Reading Gaol (part), Oscar Wilde).

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Within our world there are various recognised social roles, ways of being projected
and re-run millions of times via the media, soaps and films. We are exposed to multiple
possibilities, as identities have become the new marketable commodity (Gergen, 2000).
This constant exposure to multiple points of view challenges the modernist absolutes
of truth, objectivity, authority and knowledge. Everything has become messier,
contestable, chaotic and incoherent (Gergen, 2000), though modernist assumptions,
discourse and practice have not waned (Parker, 1993) but compete against the plethora
of others.
The irony is that within this increasingly incoherent, insecure and chaotic world
and the resulting increasing sense of destabilisation, there is a growing search for
answers and a demand for heroic leadership. However, all leaders, solutions and
truths are then viewed with suspicion, perceived of as disingenuous and identified as
performances (Gergen, 2000). Examples of this in action can be seen in Western
political leader election processes, the recent furor in relation to the MMR vaccination
and in the fickle nature of politicical and managerial flirtations with new
organisational models in the NHS.
In a critical management approach to knowledge we need to be critical of our own
intellectual assumptions (Lawson in Hassard and Parker, 1993). Is my relentless
pursuit of alternative forms of knowledge, my interest in the poststructuralist theorists
any less nave? Rather than a leader I look to theory to assist my search for answers. It
is necessary to remember that any one answer is one possibility of being, which
potentially precludes a number of others.
In the midst of all this turmoil is the ongoing identity work of the individual subject.
It certainly consumes a great deal of my time as I recognise the pull of the work ethic, to
always achieve my objectives, to lead and motivate others and always do my best; a
trite yet compelling echo of my childhood that I now hear myself recite to my children.
The mantra of always doing ones best is not achievable though in all relationships
and contexts: they can be in direct conflict, such as when I set to achieve my work
objectives and bring more and more work home I fail to be the best mother, wife and
daughter I could (ought to) be, something always has to give. The multiphrenic
condition multiplies our inner critics (Gergen, 2000), and I think particularly for women
creates a chaotic confusion of possibilities.
Leonards (2003) feminist poststructuralist study into the ambiguities of how
doctors and nurses positioned themselves in relation to the discourses of their NHS
organisation found that, though organisational discourses are powerful, the interplay
with discourses of profession, gender, home and performance destabilises and
undermines them. She also found that individuals interpret and re-write these various
multiple discourses differently. Leonard (2003) identified that women managers either
enjoyed playing more traditionally masculine roles of leadership or utilised their
position to introduce the more female styles of relatedness as leadership into
organisations. Clinicians further away from the top of the management hierarchy were
least likely to be influenced by organisational discourses (Leonard, 2003).
Within a great deal of the management literature there remains a myth of one fixed
and stable identity (Sveningsson and Alvesson, 2003). Other literature claims the
existence of a fixed organisational identity that the individual then complies with or
resists, depending on their personal narrative of self identity (Sveningsson and
Alvesson, 2003). However, any one organisation has a series of influential discourses,

often competing against each other, which create the possibility of conflicting
organisational identities. Coupled with this confusion is a range of possible identities,
as illustrated in Leonards (2003) study, which are created through our further social
networks and institutions, such as marriage, family, university and the mass media.
The postmodern self (according to Foucault, 1984) therefore has no coherence; there
is no centred, authentic essential element removed from society and the discourses of
power (Gergen, 2000; McNay, 2003a). We are exposed to multiple points of new frames
of reference, which populate the self with multiple possible identities, resulting in a
multiphrenic condition (Gergen, 2000). In this incoherent world identities are
destabilised and always tied to discourse (Sveningsson and Alvesson, 2003). Discourse
here refers to a rationale; a way of thinking that impacts on us and through us in
language and practice (Sveningsson and Alvesson, 2003). I find it useful to think of any
one discourse as a lens that highlights a particular version of the social world: As any
particular discourse is in focus, it is to the detriment of others, which are blurred or
silenced. In our multiphrenic state we are bombarded by many conflicting discourses, a
kaleidoscope of rationales, which undermine any certain, fixed or stable sense of self.
As the kaleidoscope turns many alternative identities potentially, temporarily come
into being.
Self and identity were often used interchangeably within the literature I searched.
Identity(ies) construction is the conscious work of the individual to attach to ourselves
and others a socially constructed identity (Knights and Willmott, 1999; Sveningsson
and Alvesson, 2003). Although we wish to have a stable, secure and unique sense of
identity (Knights and Willmott, 1999; Ellis and Bochner, 2000; Sveningsson and
Alvesson, 2003), our social relatedness, the constant intertextuality of discourses
(Leanord, 2003), our multiphrenic condition (Gergen, 2000) render this an illusion that
we constantly struggle to maintain through our narrative endeavors.
The individual is conditioned to strive for continual self improvement and to do
self work, develop self awareness, personally develop and undergo self construction,
particularly in the work context where the individual is encouraged to work towards
the path of self fulfillment (du Gay in Leonard, 2003).
The constant exposure to multiple perspectives has encouraged an explosion of
responsibilities, objectives and expectations (Gergen, 2000). We have numerous
internal critics, and advisors often in conflict but the voices of others are always
present. We live in a time of increasing self consciousness and self construction. This
has a great deal of face validity for me, within my work context where I have
participated in a number of leadership development programmes and organisational
away-days. These always include some form of self analysis often using
psychometric tools, organisational tools to encourage identity work (Garrety et al.,
2003) and the need to then develop learning objectives. Through these I have also been
exposed to a number of allegedly ideal leadership traits, which promote certain
(gendered) archetypal leadership qualities (Sinclair, 1998 in Olsson, 2002); an example
of this is the NHS Leadership Qualities Framework, which is developed from
interviews with chief executives and therefore inevitably advocates white, middle-aged
masculine styles of leadership such as ambition, self belief, competitiveness and
driving forward change.
In contrast to this image of a powerful, confident, consistent and rational leader
(fixed organisational identity): there is increasing recognition that identity work is

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ongoing (Ashforth, 1998; Sveningsson and Alvesson, 2003; Parker, 2004), always a
process of becoming and often a struggle (Knights and Willmott, 1999; Sveningsson
and Alvesson, 2003).This is why narrative is so powerful, in life or as a research
method. It is a means by which we make sense of our world, and achieve a sense of
coherence in our story(ies) (Ellis and Bochner, 2000). I think the struggle (and
exhaustion) of identity work is very apparent in my poem. I allude to a self-identity,
as someone who is efficient, busy but always in control and delivers my objectives; this
is in direct conflict with the apparent stress I was experiencing due to an ever
increasing workload and therefore contributed to further stress.
The need to let go of the reassuring illusion of a coherent self is not easy we are
conditioned to believe everything originates in the individual; it is a challenge to
recognise the self as relatedness, populated by a plethora of selves, saturated with
fragments of others and changing moment to moment.
Self as insecure manager
Individuals create several, precarious, unstable and contradicting managerial
identities/identity positions rather than one fixed secure one (Leonard, 2003;
Sveningsson and Alvesson, 2003) and identity work is always social rather than
individual (Knights and Willmott, 1999). The dominant discourses and practices
determine the possible identity positions we can create for ourselves and others, and
further influence how we judge and stereotype others (Knights and Willmott, 1999;
Butler, 2004).
As a relatively new manager of others I recognise Parkers experience of becoming
a manager (Parker, 2004) and his transitional insecurity, illustrated by anticipating
the expectation of others, always being available and looking for approval (Parker,
2004).
Sveningsson and Avesson (2003) recognising the lack of in-depth research on work
identity undertook a single case study of a female director. The study identified several
competing, influential organisational discourses and conflict between these and her
narrative of self identity. The narrative self identity is the identity work we
undertake to create a sense of coherence over time as reflexive agents (Sveningsson
and Avesson, 2003; Ellis and Bochner, 2000). Our personal narrative incorporates our
ethics, values and moral work, which relates to our self esteem. When our narrative of
self identity doesnt fit with our potential work identities, the process of becoming
(our identity work) becomes increasingly painful and a struggle (Sveningsson and
Alvesson, 2003). The more fragmented and changing our work situation is the more
identity work we need to do and the more dissonance between the possible work
identities and our personal narrative of a self identity, the more painful that identity
work becomes (Knights and Willmott, 1999, Svengingsson and Alvesson, 2003). This
intuitively feels informative for my situation. My diverse portfolio of responsibilities
reflects the wider context of the increasing fragmented nature of manager roles
(Sveningsson and Alvesson, 2003). Such fragmentation inevitably acts as a conduit for
clashing discourses and multiple identity positions. My personal narrative of a self
identity referred to earlier as someone who delivers and is in control becomes
increasingly difficult and painful to maintain. Increasing effort is required for identity
work. My many other identity positions relating to my professional background, my

gender, my roles at home and university also merge, confuse and influence my
managerial work identities.
The current multiphrenic condition, the release from an authentic self, the
awakening to the possibilities can be both threatening and intoxicating (Gergen, 2000).
We can interpret this to enable us to have incredible freedom or we can feel tremendous
vulnerability. The importance to my self-image of being competent can mean Im
particularly vulnerable to undertaking personal identity formation for organisational
purposes (Grey, 1994; Knights and Willmott, 1999; Leonard, 2003). I am seduced by the
management texts and presentations that tell me how to be an effective leader and how
to manage my time. My ambition and wish to be competent could result in me
ultimately feeling exploited, perceived as a commodity rather than a human being. The
public sector in particular has been noted to promote certain work identities that are
heavily influenced by managerial and entrepreneurial discourses (Leonard, 2003).
However, I am increasingly seeing the possibilities of multiphrenia and
experiencing a sense of liberation. Ive always, whilst being seduced,
correspondingly held a deep suspicion of management gurus and their glib
assurance of having all the answers. My exposure to postmodern and poststructuralist
texts, the dissolution of there being any one single right answer, holds a promise of
alternative ways of being in the world of work.
If identity is a production then I can produce on a number of levels: I can
superficially perform certain identities for strategic manipulation and social gain,
though this is a game I would feel somewhat uncomfortable with. Or I can self
consciously play at constructing and reconstructing myself(ves) with humour, irony
and parody. I am currently experimenting with this; playing at being the assertive
leader in my black power suit, warning people to watch out when I wear red! Playing
the rebel with my circulation of humourous electronic mailings, which often poke fun
at heavy, bland and colourless corporate discourse and even more recently sharing my
Matrix analogy of the pods always with a smile and a twinkle in my eye. I can see
the unsettling effect this has on others not quite sure how to respond and have to
confess to enjoying myself.
However, whilst amusing and a form of temporary resistance against becoming a
corporate bore or allowing myself(ves) to burn out in my exhausting constant strive to
achieve, deliver and improve, I feel there must be something more. Gergen (2000)
suggests that we need to move beyond these individual strategies to a state of more
connectedness, a way of being that recognises the social relatedness of our selves and
our interdependence. Whilst agreeing we need a counterbalance to the increasing
individualization of the human condition my question is how?
Reflection and opening
I purposely have named this final section of my paper as an opening rather than a
conclusion. I started this autoethnographic piece by expressing my many fears: of
sharing my vulnerability, of experimenting with alternative poetic expression, of
outing my insecurity and of being permanently labeled in your eyes. Despite this
stream of anxieties I have found creating this text enjoyable and strangely liberating.
This paper has emerged and evolved as I have written it: I purposely resisted the
normal process of structuring essays and ordering thought and instead, in true
postmodern fashion, let the chaotic clash of my many influences scatter across the

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page. My many Is intermingle not always smoothly, as I move from I the emotive
one, sharing my story to I the academic, bringing in authoritative theoretical texts.
What I have found is that autoethnography is a methodology that has lived up to its
earlier promise. This feels ethically sound: I should like to develop on from this study,
to explore others experience and sense making of identity work. Do they share any of
my pain, struggles and insecurities? How could I research others stories of their
vulnerable selves without outing and exposing myself first?
My choice of poetry to express my (hidden) self is a very personal choice, perhaps
relating to an earlier performing career, and resulting association of art with personal
expression. Poetry used to represent aspects of lives:
. . . reveals the process of self-construction, the reflexive basis of self-knowledge, the
inconsistencies and contradictions of a life spoken as a meaningful whole (Richardson, 1997,
p. 143).

I think there is a further attraction that poetry offers me: I think poetry is my form of
embodiment. Within my poem there is the allusion to my loss of self. This may be my
narrative of self or alternatively my embodied self. Lennie (2000) describes the case of
a manager who is disembodied, exhausted and consistently taking work home. He only
realises his predicament and the toll it takes, when others point it out to him: he is not
in touch with what the long hours are doing to him (Lennie, 2000, p. 136). Within the
Escape and Return components of my poem are strong underpinnings of physicality: I
talk of heat, touch and sensuality and then of a physical jolt, pressure, a
thudding heart and tightening chest. I progress to describing the need to pull on
my armour (to hide my vulnerable body?). Thought for a poet is an experience, all
senses are involved, whereas in philosophy thought is abstract, in poetry it is concrete:
Words in poetry invite us to feel into or become rather than think about and
judge (Leavis, 1963, p. 212 in Lennie, 2000).
However, this is not a medium attractive to everyone and Ill need to and will enjoy
identifying other methods, metaphors, plays, stories and films; there are a profusion of
possibilities. Humans have always produced stories of themselves, whether by art,
sculpture, drama, or the sung and spoken word (Haywood Rolling, 2004).
There are many concepts I have briefly touched upon in this paper that hold
promise for future exploration: the concept of performativity and the impact earlier
biographical experience has on future identity work, particularly work relating to the
self-narrative. I want to further understand how we use narrative, in life and research
to create meaning and constitute ourselves; the challenges of such textual
representation and the various ways we adapt, resist and survive the challenge of
the multiphrenic world.
What are the consequences my story produces? What kind of person does it shape
me into? What possibilities does it open? I am coming to the conclusion, or rather
possibility, that writing is my form of resistance and survival; that I out not only
myself but certain managerial discourse and practice too.
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www.emeraldinsight.com/researchregister

The current issue and full text archive of this journal is available at
www.emeraldinsight.com/1477-7266.htm

A hermeneutic science: health


economics and Habermas

Health
economics and
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 Habermass 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
the product of health care, at the very least it involves environmental, economic and
social factors. It is also arguable that health is an intermediate good of no intrinsic
value in itself save its not insignificant contribution to fulfilment in life (Edwards, 2001,
635-4).

Journal of Health Organization and


Management
Vol. 19 No. 3, 2005
pp. 219-235
q Emerald Group Publishing Limited
1477-7266
DOI 10.1108/14777260510608952

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In this paper we explore what economics in general and health economics in


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 Harburys 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
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
it was located in this tradition.
Orthodox and dissident views in economics and health economics
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
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.
A narrowing orthodoxy in economics
The discipline of economics emerged alongside the pure and applied sciences and the
humanities and social sciences within the constructs of post Enlightenment modernity.
The Enlightenment was characterised by a new way of thinking that involved
breaking down complex structures into component parts in order to scrutinise,
understand and then utilize them. It involved a search for laws, for the predictable and
the universal. It was an approach that was about accumulating and then applying
knowledge in the world. The guiding metaphor of this new approach to the intellectual
project was a mechanical one the machine, with its component parts harnessed into
efficient working order.
But new forms of thinking do not replace other forms, rather they overlay existing
understandings and approaches and exist alongside counter approaches. The
mechanical metaphor might have been dominant in early modern thinking but it was
not ubiquitous. In economics it sat close to a concern with serving the commonweal
and upholding the moral. In the emerging discipline of economics Adam Smith,

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David Ricardo and Karl Marx were all concerned with how the human lot could be
bettered through the application of rational scientific analysis. But this was located, at
least in Smith and Marx, alongside a concern with ethics. Further, in Marx scientific
analysis and a vision as to what a better society would consist of were fused together.
In its early form then economics was philosophical, political and moral as well as
instrumental and technical (Edwards, 2001, pp. 636-7). Indeed, Adam Smith in his
lifetime was as well known for his Theory of Moral Sentiments as he was for his
seminal economic treatise The Wealth of Nations. He argued that people were inclined
to seek the approval of others and, in so doing, this exercised a restraint on purely
selfish and opportunistic behaviour. It may be that the enlightened pursuit of
self-interest is the driving force of a successful economy but, for Adam Smith, this is
exercised within the context of a shared view of what constitutes reasonable conduct.
There is then, within early economic thought, an assertion of the relevance of the
community and its impact on the regulation of purely self-serving behaviour.
As well as Adam Smith in The Wealth of Nations drawing no sharp distinction
between economic and social themes, an integrative approach continued well into the
nineteenth century, particularly in Germany where it became known as the Historical
School of Institutional Economics. In England however, the abstract deductive analysis
of economists such as Ricardo gained ascendancy. These two perspectives the
historical and social method based in Germany and the abstractive deductive method
based in England clashed at the end of the nineteenth century in what in Germany was
known as the Methodenstreit or the battle of the methods. The outcome was a
devastating victory for the abstract-deductive economists and, in the next century,
mathematics became the standard language of economics.
The reason for the success of this one approach can be linked with the rise of
physics to a position of prominence during the nineteenth century. The prestige
physics enjoyed among the sciences had a major effect upon the development of
theoretical structures in many disciplines. In taking classical mechanics, together with
Newtonian calculus as their exemplar, nineteenth-century economists attempted to
generate theories with the characteristics that had made physical theories so
impressive in the realms of prediction and control. Moreover, in line with the natural
science approach, economic theories began to deal primarily with quantities not
qualities, and economic analysis was directed towards the elucidation of laws
governing exchange, using arithmetic formalisms to pursue the underlying mechanics.
There is now a strong critique of an economics that is in thrall to formal
mathematical modelling and an economics that is reductionist and as imaginatively
impoverished as the dismal science described above. This critique rests on a split
between the micro picture such an approach generates and the sense that economics
ought to be engaged with practical everyday dilemmas and with big picture problems.
Much of this is to do with the very ontology of the subject with the way economists
view the world (Lawson, 2003) and with the need to locate analysis in the specifics of
historical circumstance (Hodgson, 2001). It is also concerned with a way economists
understand the focus of study, the economy, in ways that are prescribed and
proscribed by the formal model, rather than through approaches that reflect the
complexity characteristics of economic systems, systems that are fuelled by the actions
of reflective, reactive and interrelated people.

One consequence of this concentration on orthodox economics is that its


practitioners talk in a language that only other economists share (a common malaise in
many disciplines). Economists can elegantly model a theoretical rational actors optimum
consumption profile but find it harder to address the causes of economic inequality or the
problems of the stock market. Writing in the early 1980s, Nobel Prize winning economist
Wassily Loeontief assessed his discipline and found that it was not advancing towards
an understanding of the structure and operation of the real economic system:
Professional economic journals are filled with mathematical formulas leading the reader from
sets of more or less plausible but entirely arbitrary assumptions to precisely stated but
irrelevant theoretical conclusions (quoted in Lawson, 1997).

There are shortcomings in the approach of economics at the level of description,


prediction and explanation. Ormerod (1994) takes just the year 1993 and lists the failure
of forecasters to predict the Japanese recession, the strength of the US recovery, the depth
of collapse of the German economy and the turmoil in the Exchange Rate Mechanism in
Europe. More generally he argues that orthodox economics can not explain the business
cycle or the phenomenon of consumer markets. Consumer markets are shaped by the
opinions and actions of others, for example low budget films that become great
successes, or toys of choice at Christmas. The predictive and explanatory capacities of
orthodox economics crash on the rocks of demand for whatever that years must have
gift turns out to be (Ormerod, 1998). Lewis (1990) argues that economics as an intellectual
discipline plays almost no part in understanding the world financial markets. Like
Keynes, Lewis sees an appropriate set of skills for markets as better coming from a
familiarity with the casino rather than the academy.
If any intellectual area or research programme suffers shortcomings at the levels of
description, prediction and explanation then its defining paradigms should be
vulnerable to challenge. Has there been such a challenge in economics? Do the
criticisms, introduced above, herald the possibility of some sort of paradigm shift in
modernist economics? In practice any such paradigm shift would see a reversion, in part
at least, to an earlier approach. This would see a reversing a technical and reductionist
ontology and a move to an approach that engaged with meaning and values.
The circumstances that prefigure, and then define, a paradigm shift in any area of
activity have been have been examined by Kuhn and by Lakatos (Kuhn, 1970; Lakatos,
1978) (see Table I).
Edwards (2001) examines how far there has been a Kuhnian revolution in
economics. She argues that the theory of scientific programmes identified by Lakatos is
more appropriate for economics. Blaug (1976), also, has argued that a Lakatosian
position is more appropriate for economics where there has never been a Kuhnian
paradigm change:
The discipline is still based on the interconnected neoclassical theories of constrained choice,
consumer sovereignty, consistency of tastes, perfect knowledge, perfect certainty and perfect
mobility of factors and that it has been so since the eighteenth century.

As we have described above, the shift from political economy to mathematical economics
constituted a paradigm shift. We will go on to present a review of the challenges to the
currently prevailing paradigm that have arisen in the last quarter century. It is not clear
how far these challenges presage a further paradigm shift. If they do then this might
identify the history of economics as more reflecting a Kuhnian model.

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Table I.
Paradigm shifts as
identified by Kuhn (1970)
and by Lakatos (1978)

Kuhn

Lakatos

Paradigm stability There is a cessation of critical debate.


Theories and axioms are
unquestioned and are applied to many
problems, these problems are defined
by the paradigm, and anomalies are
explained from within the paradigm.
If you dont accept the basic
assumptions you are ostracised

There is an organic unity of


interconnected theories and research
programmes. The core of this is
hardly questioned. It has a positive
heuristic about how it will unfold and
should be defended. There is also a
protective belt of auxiliary theories
and axioms that can be altered

Crises

Anomalies initiate crisis when outside


demands for information, explanation
and forecasts cannot be met

One programme is replaced by


another when the new one has more
empirical content and can explain and
predict better. Sometimes anomalies
can be modified in such a way that the
programme is more empirically
supported (a progressive programme).
Sometimes in trying to explain
anomalies a programme becomes less
supported (degenerative programme)

Result

The paradigm is challenged from


within

A new programme is established

Voices outside the prevailing paradigm


In an earlier paper we have argued that there is a need for economics to engage with a
wide-ranging challenge to the truth claims and general laws that have shaped both the
topic and characteristic mode of thinking of the discipline (Mannion and Small, 1999).
Specifically we argued for the need to think more contingently within a postmodern
framework where truths and knowledge are viewed as multiple, malleable and
dynamic. We also described and commented upon approaches to health economics that
challenged the prevailing paradigm. These radical voices encompass a range of
epistemological assumptions and methodological approaches (see Table II).
Shipman has summarised contributions from other critical voices that operate on
ground that is closer to the dominant paradigm than those voices captured in Table II:
Evolutionists emphasise the path-dependent nature of technological and industrial change.
Institutionalists deny the reducibility of all social structures to individual decision making
and voting. Austrian theorists point out how markets can coordinate choice by
interdependent individuals with scattered and limited information, which inverts the
textbook depiction of fully informed and independent individuals. And post-Keynesians
want to return aggregate demand to explanations of economies short-run cycles and
reinstate income distribution to accounts of their long term growth (Shipman, 2003, p. 22; see
also Williamson, 1985; Kirzner, 1973).

There have also been alternative metaphors offered. Ormerod (1998) argues that a more
appropriate metaphor for the economy is that of a living organism (not the machine
model of conventional economics). The behaviour of the whole economic system cannot
be understood by simply adding the component parts. He goes on todescribe Butterfly
Economics where the connection between the size of an event and the magnitude of its
effects is not routine or mechanical. In using the motif of the butterfly he is placing

Further
reading

Noordhaven, 1995; McClosky,


1985; Brown, 1994

Hall et al., 1995

Focus on provision rather than


consumption

Granovetter, 1992

See market participants as social


actors who are guided by shared
experiences and observations of
others

Mooney, 1998

Focus on community
outcomes

Include shared goods,


e.g. health care through
public health measures

Consider sociability and social


approval; the impact of social
relations; the social construction
of economic institutions

Consider costs other than those


just traded in markets; include
altruism and co-operation

See conventional economics as a


text, as a language of persuasion
as metaphor and rhetoric

Proposes

Approach Dialogical research, reflexivity


and deconstruction

A concern with the citizen in


their community

The pursuit of economic and


non-economic goals

Communitarian economics

Women ignored or devalued

New economic sociology

The language of economics: the


consequences of economic
rhetoric: the way knowledge is
constructed, communicated and
understood: the language of
economics as discourse

Feminist

Focus

Postmodernist

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Table II.
Examples of voices
outside the prevailing
paradigm

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economics alongside considerations of complexity and chaos theory, something we


return too below.
The discipline and practice of health economics
Whilst the overall development and critical debates within economics encompass
health economics the sub-discipline has particular dynamics of its own. We now turn to
these.
Mainstream health economics (although the subject is becoming increasingly
heterogeneous in terms of both its methodology and application) is predicated on the
core normative and behavioural assumptions of neo-classical welfare economics. In
brief these are assumptions about:
.
Utility maximisation. The assumption that individuals choose rationally and that
provided with a set of competing options they will rank the options and choose
among them according to defined notions of consistency.
.
Consumer sovereignty. The assumption that welfare is idiosyncratic (i.e. a private
phenomenon). It is the individual (and not a third party) who is best placed to
judge his or her own welfare and the choices of activities that promote it.
.
Consequentialism. The proposition that choices and actions can only be judged in
term of their consequent effects. Action is viewed as instrumental and the
emphasis is upon outcomes rather than processes.
.
Welfarism. The maxim that the goodness of an action is to be judged solely on
the basis of the utility level of individuals undertaking that action.
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
an intermediate good with no intrinsic value. Its value is in its contribution towards the
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
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
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 peoples 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 Enthovens 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 Culyers 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

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abstract propositions? If practitioners of health economics are extemporising in such a


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
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).

Culture and complexity


So far our focus has been primarily on the intellectual discipline of economics. We now
shift to a concern with its topic area, the economy. In particular we will look at two
aspects, culture and complexity.
We have introduced above the criticisms of universalist assumptions as they apply
to complex systems. We wish to argue that economic action is contingent and learned
and is shaped by the dynamic interplay of the constraining and liberating effects of
culture bearing milieus and by the influence individuals have, each on the other
(Mannion et al., 2004). Economic choices do not occur outside the context of culture
(Mayhew, 1994). That culture is located in the institutions of economic process,
corporate cultures and habits of use (Kreps, 1990), and in individual preferences.
Further, the institutional and individual interact (Bowles, 1998).
Neo-classical economics, as we have introduced above, assumes that: all human
behaviour can be viewed as involving participants who maximise their utility from a
stable set of preferences (Becker, 1976, p. 14). For its proponents the narrowness of this
approach is justified on two grounds. First that it is the predictive power of the model
that counts and not the realism of its behaviour assumptions (Machlup, 1981). Second,
that it is a universalist approach and that it reflects the overriding importance of
exogenously determined preferences (Katzner, 2002). Thus, the neoclassical economist
has little to say about the formation of wants and preferences (these are viewed as the
province of sociologists and psychologists). For them the aim of the economist is to
trace the consequences of any given set of exogenously determined preferences. If
culture matters, however, preference patterns for the same individual may differ across
settings and therefore individual preferences will be endogenously determined. An
economics based on the assumption of endogenously changing preferences would
admit the possibility that preferences (choices) can be moulded and manipulated, for
example through advertising and socialisation practices. This manipulation might be
for good (e.g. health promotion) or ill (e.g. subliminal messaging targeted at children to
purchase junk food). The implications of these assumptions raises the spectre of
consumer choice based on commodity fetishism as identified by Marx, and casts doubt

on the hypothetical ideal of consumer sovereignty propounded in economic textbooks.


For our purposes however, conceptualising consumer choice as a social construct
allows us to see a basis for postulating an economics of transformative action.
Returning to the neo-classical approach we have argued above that its predictive
power is questionable in many key areas. Further, reliance on a model that
misunderstands the cultural context of preference formation is essentially unreliable
and is likely to be increasingly so as understandings of complex systems develop.
Complexity theory has developed as existing metaphors for understanding
interactions and change have become strained. Specifically the metaphors associated
with society (or an individual) as a machine are not sustained when no part of the
system is constant, independent or predictable. As Plsek and Greenhalgh (2001) have
suggested, what is needed is a science of complex adaptive systems (CAS) and
alongside this a set of new metaphors.
A complex adaptive system is defined as a collection of individual agents with
freedom to act in ways that are not totally predictable, where actions are
interconnected so that one agents actions change the context for others. It is a
description that would fit most systems. Certainly an economy, the health service, the
financial markets, an organisation or a family have these characteristics. Plsek and
Greenhalgh identify a number of characteristics of CAS:
.
They have fuzzy boundaries, membership can change and agents can be
simultaneously in several systems. Both agents and systems are adaptive over
time and co-evolve with other systems such that actions in one cannot be
understood without reference to others.
.
They have an inherent non-linearity such that small differences, particularly in
initial conditions, can lead to huge differences in outcome (see Ormerods
butterfly metaphor described above).
.
They are inherently unpredictable although there may be observable patterns
that can allow a person to function. For example meetings have the
characteristics of cas but there are patterns that we recognise that allow us to
function and understand what is going on (most of the time).
The CAS characteristically has: Positive and negative feedback loops in the system
which are acting recursively (repetitively and feeding back on themselves) (Kernick,
2002, p. 309). The observer cannot stand outside the system and events in the system
relate to each other and exist over time. Here the focus of effort is to facilitate
relationships through time rather than seeking an endless series of goals each of
which disappear on attainment (Kernick, 2002, p. 307).
Stacey (1996) locates complexity as one system descriptor alongside a continuum of
others. High rationality is on one side and chaos on the other (see Benhabib, 1992 on
chaos and complexity). The variables that determine where a system is placed are the
degree of certainty in respect of cause and effect and the level of agreement in that
system. Low agreement and low certainty moves one towards chaos. The opposite
describes rationality. If we consider applying complexity theory to health and to
economics we must engage with a range of novel methodological and practical
implications (see Table III).
Plsek and Greenhalgh argue that, Ultimately, the only way to know exactly what a
complex system will do is to observe it: it is not a question of better understanding of the

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Table III.
Examples of applying a
complex systems
approach to health and
health care

Clinical care

An evidenced-based system has to reconcile imprecise, equivocal or


conflicting evidence. Plans have to be drawn up with colleagues who
may have different perceptions, priorities and value systems

Public health

Epidemics involve fuzzy boundaries, there is an interplay of genetic


predisposition, environmental influences (sometimes outside the
health-care system) and lifestyle choices

Individual preference/public
and user involvement

The unique experience of context, choice and priorities of individual


patients operates alongside a set of public preferences and
professional/political priorities

Clinical governance

The introduction of clinical governance involves a complex adaptive


system characterised by uncertainty, by encounters with established
ways of working and by the encouragement of emergent practices and
norms (Sweeney and Mannion, 2002)

Note: see Plsek and Greenhalgh (2001)

agents, or better models, or of more analysis. Orthodox approaches to management


consider system parts in isolation, specify changes in detail, tackle resistance to change
and believe that reducing variation will lead to better performance. Alternatively, taking
account of the insights afforded by complexity science requires a new mode of thinking
and different kinds of design and control strategies than those allowed by conventional
economic approaches. The latter allows only two types of control mechanism, either a
market or a hierarchy. In CAS the quality of the relationships between the component
parts, the connectivity of a system, is more important than the individual elements.
Minimum specification may yield more creativity than pre-specified detailed plans.
If complex systems are a better way to conceptualise health and a better way to
structure the sorts of questions health economics seeks to answer, are we restricted to the
quietism implied by Plsek and Greenhalgh above? That is, do we best understand by
observing and best intervene as minimally as possible? Where is the scope for an agenda
about change, about engaging the moral and the political concerns evident in the
economics of Adam Smith, Keynes and Marx? We will now continue to consider if an
approach structured around critical theory can be both non-mechanistic and emancipatory.
Critical theory and health economics
We have introduced above Habermass summary of the transformation of the social
sciences in the 1970s. He characterised this as exhibiting a move from objectification
and an engagement with applications other than the manipulation of self and others. In
this section we will look at Habermass approach to knowledge and rationality. We will
then consider his understanding of political economy and the nature of crises in late
capitalism. In looking at both these areas of concern we will consider the relevance of
his formulations for health economics.
Knowledge, rationality and science
In these years of transformation that Habermas describes, critics of positivism used
ethnomethodology and hermeneutics as a route to challenge positivisms claims to
objectivity. New kinds of knowledge were prioritised: local knowledge, discourse,
ritual, understandings of forms of interaction (Best, 1994). At the same time a series of

works had critiqued modernity, arguing that it was exhausted (Mills, 1959; Berger et al.,
1973; Bell, 1976). There was, in some, a pessimism that we had shifted into a totally
administered society (Adorno and Horkheimer, 1972). But for Habermas and others
there was still the possibility of an emancipatory dimension in modernity. The
Enlightenment project of freedom through progress and progress achieved by reason
need not be abandoned if reason and progress were redefined.
For Habermas reason divides into two, instrumental and communicative. The
former is concerned with what governs the choice between means and given ends. It is
this that is more generally assumed to constitute rationality. But this sort of rationality
is not sufficient to explain our cultural evolution. It is not even sufficient to explain our
economic or administrative systems, these are too complex to be so narrowly
understood. What must be added is communicative rationality, the activity of
reflecting upon our background assumptions about the world and bringing our basic
norms to the fore, to be questioned and negotiated (Braaten, 1991, p. 12).
Habermas argues that we can look to three sorts of science (see Scambler, 2001):
(1) The natural or empirical-analytic which are governed by a technical interest in
the prediction and control of objectified processes. The facts relevant to the
empirical sciences are first constituted through an a priori interest in the
behavioural system of instrumental action (Habermas, 1986, p. 109).
(2) Historical-hermeneutic sciences governed by a practical interest in
intersubjective understanding.
(3) Critical-dialectic sciences directed at emancipation from the domination of
ideologically frozen relations of dependence that can, in principle, be
transformed (Habermas, 1986, p. 310).
We can see in Habermass 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.
Political economy in late capitalism
We have looked briefly at Habermass re-conceptualisation of reason and we will now
turn to his thoughts on the second pillar of the Enlightenment project that needs to be
re-examined, progress. Here he offers as a context for considering progress a
distinction between the system and the life-world. The system is constituted by the
external world of nature and systemic environments including government and
economy. The life-world encompasses both the processes of consensus formation that
we experience in our interactions with others and the world of inner subjectivity, of
desires and needs (Rundell, 1991, p. 136).

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For Habermas the nature of the contemporary political economy is problematic


because of the danger of its becoming increasingly hyper-rationalized in focussing on
immediate returns. Participants encounter each other as legal entities and as parties to
contracts rather than thinking and acting subjects (Crook et al., 1992, p. 28). This
move, that sees the system increasingly dominating the life world, is akin to Webers
rationalization and Marxs commodification (Scambler, 2001).
Within the system and the life-world there are a number of areas of focus. These produce
different things; the economy money; the state power: the public sphere influence
and the private sphere produces commitment. Products are traded between subsystems but
their relative strength can vary. There is, in effect, a complicated relationship that crosses
system and life-world. It is a relationship that can be highlighted if we look at the role of the
state in late capitalism.
Habermas (1976) uses the example of taxation to illustrate the varying functions of
the state. The state is concerned to manage the economy in such a way as to avoid or
minimise disturbances in growth. One instrument it uses is taxation. But, both in how
taxes are raised and how they are utilised, taxation is also designed to foster a sense of
legitimation for the existence and activities of the state by providing a series of state
programmes, for example health and social welfare facilities. We have then taxation
policy impacting on both system and life world. If the state is not effective at
minimising disturbances in growth then this results in a deficit in administrative
rationality. If it cannot continue to meet the programme aims it has committed itself
to, if there is a reduction in taxation income in a period of recession, then this can result
in a deficit in legitimation (Sitton, 1996, p. 154).
Habermass formulation of political economy identifies complexity via the impact
different systems can have each on the other. It is this interaction, not a structural
deliniation of role or power, that shapes the experience of living in the world. There are
tendencies to objectify via a narrow rationalization and commodification. Such an
approach encroaches on the life-world and Habermass intention is to warn of the
mistake of elevating narrow and isolated instrumental concerns. The inter-related
nature of the emancipatory project and its need to engage both system and life-world is
summarised in his identification that, Liberation from hunger and misery does not
necessarily converge with liberation from servitude and degredation (Habermas, 1986,
p. 169).
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


complexity theory adds a crucial dimension to understanding modernity and that
communication and culture are essential ingredients in seeking to understand
economic behaviour.
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
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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www.emeraldinsight.com/1477-7266.htm

Examining leadership through


critical feminist readings
Jackie Ford
Nuffield Institute, University of Leeds, Leeds, UK

236
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

Journal of Health Organization and


Management
Vol. 19 No. 3, 2005
pp. 236-251
q Emerald Group Publishing Limited
1477-7266
DOI 10.1108/14777260510608961

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
governments focus on the modernisation of our services calls for better management
and better leadership across the public sector services and has resulted in the
establishment of numerous units dedicated to develop leadership initiatives. As part of
this process, the Council for Excellence in Management and Leadership was founded in
April 2000 with the remit of developing a strategy to ensure that the UK has the
managers and leaders of the future to match the best in the world (Council for
Excellence, 2002, p. 1).

This turn to leadership in the UK National Health Service (NHS) has been reflected
in the creation, in 2001, of a Leadership Centre within the Department of Healths
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
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

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237

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of the different perspectives of the researchers and the aspect of the phenomenon of
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
following section explores the dominant discourses of leadership and proffers a
discussion of the limitations to these accounts.
Dominant discourses of leadership
Dominant approaches to the study of leadership within the mainstream body of
literature adopt a positivist perspective, which espouses that the truth is out there and
through objective data collection and analysis the one true definition of leadership will
be realised (Easterby-Smith et al., 1991). Such approaches tend to assume that the
study of organisations can be undertaken in a similar way to studies within the natural
sciences, and would see leadership as existing as a social reality which can be studied
in a similar way to the natural world (Boje et al., 2001). Thus positivist researchers
undertake research in order to collect facts, to search for the truth and to explain and
predict the organisational world.
Based on an analysis of mainstream leadership literature, the range of studies
appears to be governed by at least six clear approaches. (Bass, 1990; Bryman, 1992;
Chemers and Ayman, 1993; Fulop and Linstead, 1999; Northouse, 2001; Wright, 1996;
Yukl, 1994). The discourses that dominate the mainstream literature can be identified
as leadership traits; leadership behaviours; leadership situations; transformational and
charismatic leadership; guru theory discourses of leadership; and more recently, notion
of post-heroic leadership.
One of the earliest, and perhaps most basic approaches to the study of leadership
focussed on the notion of traits, on the assumption that there were certain innate
personal attributes of leaders that they were born with and that these could not be
learned by those who did not possess these genetic qualities. This approach has been
responsible for the body of literature referred to as the great man approaches,
characterised by such heroic historical figures as Churchill, Gandhi and Wellington.
The trait studies, particularly prevalent in the 1930s and 1940s, sought to discover a
universal set of traits that could be identified as those constituting effective leadership.
However, despite extensive research studies, no compelling evidence could be found of
traits that held universal success in all leadership situations and contexts (Yukl, 1994;
Fulop and Linstead, 1999; Grint, 1997, 2000).
The inability of researchers to define a universally applicable set of traits led to
researchers paying closer attention to how leaders act, rather than what they are, in
some innate sense. Thus much of the research evidence switched attention to a focus on
styles of leadership, ranging from early studies seeking answers to questions such as
whether autocratic or democratic styles lead to the most effective leadership outcomes
(on which scientific management theories for the former and human relations theories
for the latter predominate). Later studies became more concerned with leadership style
and motivation theories (such as McGregors theories that built on Maslows work),
and led to further studies considering task accomplishment and concern for
subordinates studies, such as those reflected in the Ohio State and Michigan studies

(Northouse, 2001). Participative leadership is also firmly rooted within the tradition of
behavioural research, and is primarily concerned with power sharing and
empowerment of followers. Yet again, this approach has fallen to criticism owing to
its failure to consider the situation or context within which the leader is functioning.
This led to both researchers and practitioners refocusing their efforts away from the
behavioural approaches and towards situational or contingency approaches, which
stress the significance of contextual factors such as the nature of the environment, the
nature of the work performed and the characteristics of followers. This research is
frequently classified into two sub-categories. One line of research thinking treats
managerial behaviour as a dependent variable, and researchers seek to discover ways
in which this behaviour is influenced by aspects of the situation, such as type of
organisation or managerial position.
The other sub-category of situational research seeks to pinpoint aspects of the
situation that moderate the relationship of leader behaviours to leadership
effectiveness. The assumption here is that for a given situation, there will be one
best style of leadership. Thus, it differs from the universal approach that suggests that
there is one optimal pattern of behaviour irrespective of the situation.
Whilst this approach has been suggested as having intuitive appeal, in that it may
be considered as somewhat self-evident that different situations lend themselves to
different styles of leadership behaviour, there is a danger that assumptions about
power and organisational politics are not given due consideration. Furthermore, the
choice of variables considered as part of the contingency factors has little consistency
between one study and another, and indeed the variables themselves are frequently
poorly justified in the research (Fulop et al., 1999). Finally, other factors or dimensions,
such as organisational context, size, structure etc are not taken sufficiently into
account. It also, perhaps somewhat implicitly, assumes the importance of the style of
the leader in organisational contexts.
This emphasis on the style of leader led to a research focus that emphasised a turn
to transformational leadership approaches. Most theories of transformational or
charismatic leadership advocated by writers such as Burns and Bass identify the types
of behaviour used by the leader and the traits that facilitate the leaders effectiveness.
In contrast to other approaches in leadership research, the perceptions and attributions
of followers are deemed to be significant in understanding leadership effectiveness.
Thus, the effectiveness of a leader is explained in terms of his or her influence on the
way followers view themselves and interpret events.
Criticisms of this approach have focussed on issues such as the excessive, almost
evangelical role accorded to the transformational leader, who virtually unaided has the
vision to guide the organisation through turbulent changes and crises.
Transformational theorists have also promulgated or at least given further credence
to the view that leadership and management are separate activities, which indirectly
reaffirms the trait theory of leadership. Thus to earn the office of the transformational
leader is to be equivalent to the great man model depicted by earlier trait theorists
(Fulop et al., 1999; Tourish and Pinnington, 2002).
At a similar time to the emergence of transformational approaches, guru theories
of leadership really came to the fore in the 1980s and proliferated in the 1990s. Since
that time, they have become a dominant concept within management writing.
Huczynski (1993) contends that the term guru when applied to managers, is used to

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denote an elite, albeit diverse category, who provide comment on management at the
same time as shaping and reshaping the forms and practices of management. He
identifies three category of guru, namely the academic, the consultant and the
hero-manager. He argues (Huczynski, 1993, p. 38) that the label guru encompasses a
rag-bag of prescriptions which include the importance of innovation, more teamwork,
more empowerment of the individual, more employee participation, fewer levels of
hierarchy and less bureaucratization.
Thus, guru theory involves elaborate claims of being able to transform an
organisation, its people and structures, to move it to a different (higher) level of
achievement and success through an almost supernatural transformation of the factors
that comprise the organisation. Guru ideas have had an enormous impact on the
leadership of organisations. Indeed, it has been argued that gurus have provided senior
executives with a sense of certainty and direction, by defining the managerial role in
terms of the executives responsibility for managing meaning for their employees, for
creating employees moral universe (Clark and Salaman, 1998, p. 153). Thus, the
gurus role and their appeal to organisational leaders, is the central, heroic status that
their writings and prescriptions celebrate: the focus is very much on the manager as
corporate leader, as organisational redeemer. The model is one of organisational hero,
endowing management with a high-status leadership role in transforming the
organisation. The connotations with biblical imagery and prophet-like behaviours are
not lost on critiques of this guru industry (see, for example, Clark and Salaman, 1998;
Collins, 2000; Jackson, 1999; Tourish and Pinnington, 2002).
More recent approaches have moved these heroic perspectives onto a different
dimension. So-called post-heroic leadership became popular in the literature during the
1990s as a consequence of three noted trends, notably: increasingly tumultuous
changes in the corporate environment; rising dissatisfaction with the image of
managers/leaders (noted especially in the UK in the public sector); and the recognition
of the need to manage diversity in the workplace. This model of leadership, advocated
by Bradford and Cohen; Heifetz and Laurie; and Kelley (cited in Fulop et al., 1999),
purports that instead of focusing on styles and contingencies of leadership and the
heroic qualities of leaders, writers argue that leadership is the work of many people in
an organisation. The focus thus shifts from leaders to followers, in terms of giving
voice to all people in an organisation, to harness the collective intelligence of the
workforce as part of a process of building new relationships within, across and outside
the organisation.
Despite the rhetoric of this post-heroic model of an inclusive and adaptive
leadership approach, research evidence would suggest that within our present-day
organisations, heroic behaviours, images and virtual cult followings seem still to be
very much in evidence (Fulop et al., 1999, p. 191). The post-heroic discourse appears
therefore more as an ideology than a reality, and this claim is further supported by
Fletchers more recent writings (Fletcher and Kaufer, 2003; Fletcher, 2004).
Furthermore, it is suggested that many leaders are suffering from narcissism, which
has been defined as the most common behavioural condition of the late twentieth
century (Downs, 1997; Fineman, 1993; Lasch, 1979). Thus, rather than leaders seeking
some form of subservient, follower-driven approach to their role in organisations, they
are more likely to be driven by a desire to remake their world in their own image.

A critique of positivist discourses of leadership


Many of the shortcomings of these approaches to leadership have been highlighted
above, but by way of illustration: a focus on leadership traits, contingency approaches
or transformational leadership requires consideration of the individual leader with
almost complete disregard to the context within which s/he is situated. Consideration
of situational, transformational and guru theory approaches present seemingly neutral
and unproblematic accounts that ignore issues associated with gender inequalities in
organisational life, and power differentials and organisational politics, which are
explored further below.
One danger of much of this mainstream research is that there is an attempt to create
generalisable findings from complex data. Ontologically and epistemologically,
positivist researchers are searching for a reality and for true findings that validate a
predetermined set of hypotheses. This approach to the study of leadership dominates
the literature, whereby each set of studies is seen to build on the findings of earlier
studies. Furthermore, many studies of leadership have focussed on quantitative
empirical research and whilst there is some evidence of a move towards
methodological diversity (Bryman, 2004) there is a dearth of qualitative studies,
whether of hypothesis driven or of an interpretive nature. The favoured approaches
adopted within the literature are laboratory-based experiments or questionnaires, to
the exclusion of contextually specific, qualitative studies. Butterfield and Grinnell
(1999) caution against this approach, suggesting that researchers should evaluate
critically the limitations of past research as they develop their own studies. Greater
attention needs therefore to be paid to scrutinising contextual variables within studies
of leadership, gender and managerial behaviour (Alvesson, 2002; Alvesson and
Sveningsson, 2003; Fletcher, 2004).
Another danger of this research is that, much of the literature on leadership, and
most leadership theories (whilst failing to state this explicitly) are domestic theories
disguised as universal theories (Adler, 1999). Most commonly, these leadership
theories describe US-based models and behaviours of leaders that seem to favour an
ideology of celebrating individualistic (perhaps even iconoclastic), strong, masculine
characters who can lead. The dominance of US perspectives has been further analysed
by other writers who note that the characteristics and behaviours uncovered by the
research reinforce Americans extreme individualism combined with their highly
participative managerial climate. These factors may render US management practices
(including leadership) unique; that is, differentiated from approaches in most areas of
the world (Adler, 1999, p. 242). More recent research undertaken in the UK suggests
that the distant heroic model of leadership so favoured in contemporary US writing,
does not fit the cultural contexts of the UK (Alimo-Metcalfe, 1998; Alimo-Metcalfe and
Alban-Metcalfe, 2001). Major criticisms of these dominant discourses are that
individual difference is denied, context ignored and little or no consideration is given to
the influence of diverse settings within which managers, leaders and subordinates
operate. Furthermore, there is a broad tendency both in leadership research and among
practitioners to focus exclusively on the top director/chief executive role, to portray the
manager (leader?) as a superior being, uni-directionally interacting with subordinates.
These studies fail to recognise that almost all managers are also subordinates and thus
have a hierarchy above themselves as well as below (Alvesson, 2002; Fournier and
Grey, 2000; Watson, 1994, 2001).

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As depicted earlier, there remains a dearth of critical management study within this
field of research and practice. Of the few studies published within the critical
management literature, the following appear to be significant contributions.
Critical discourses of leadership
Contemporary critical management research on organisation and management
provides opportunities to reconsider the dominant discourses of leadership as an aid to
our understanding of the research field. It enables us to challenge basic assumptions in
use in mainstream management research (Alvesson, 1996, 2002; Alvesson and
Sveningsson, 2003; Alvesson and Willmott, 1992; Knights and Wilmott, 1992).
Rather than the disinterested (objective?) pursuit of the truth, the researcher is
recast in an active role constructing the very reality s/he is attempting to investigate
(Chia, 1996, p. 42). As academics in our research, we make leaders and create leadership
as much as we study them. That is, we make visible something called leadership and
we develop subject positions into which those who are designated organisational
leaders will step. However, we cannot assume a straightforward translation of theory
into the constitution of subject positions or identities. We need to look at the social and
cultural context into which we assume theories are inserted. Accepting someone as
leader or recognising leadership characteristics is as much about what we call the
social and cultural context and also what we call the characteristics of those labelled
the followers. As Alvesson (2002) has noted, a cultural understanding of leadership
requires an understanding of local meaning. He argues that leadership can be defined
as about influencing the construction of reality the ideas, beliefs and interpretations
of what and how things can and should be done (Alvesson, 2002, p. 114). A social and
contextually specific (local) definition of leadership allows us to be receptive to the
meanings ascribed to leadership by the community employed within the organisation
under study. We must therefore explore how the academic theories are translated
within organisations and transformed into local understanding of leadership.
More critical approaches to the study of leadership pay attention to situations,
events, institutions, ideas, social practices and processes that may be seen as creating
additional repression or discursive disclosure, and some of these will be considered
within this section of the paper. There is a plea within some of these more critical
writings for a strong ingredient of management of meaning (Alvesson, 2002; Smircich
and Morgan, 1982), in which greater attention to the above factors is given. Burrell
(1992) suggests that the rise of management to corridors of power has allowed some
talk of managers as if they were heroic figures. He describes the semantic inflation that
has set in, whereby many senior executives refuse to call themselves managers, and
instead refer to themselves as directors. Indeed, I would argue that in many UK
public sector organisations (the major focus of my research studies), this semantic
inflation has displaced managers and management in favour of leaders and leadership.
A challenge to the very existence of leadership is pursued by writers including
Alvesson and Svenningsson (2003) and Gemmill and Oakley (1992), who suggest that
mainstream management writers approach the study of leadership from the
unquestioned presupposition that leaders are essential for the effective functioning
of an organisation. Locked within such a positivist epistemology, much of the
leadership research reflects functionalist roots in theorising on leaders and leadership,
and assumes that leadership is an indispensable component of all organisations. The

reification of leadership has created this assumed indispensability and the concomitant
dependence that it creates in followers. Through this process of reification, the concept
of leadership takes on an objective existence, which seems to make it beyond challenge.
Notwithstanding the slippery nature of the concept and the definitional problems
highlighted ealier, researchers and practitioners assume that because there is a word
leader (or leadership) there must be an independent objective reality it describes or
denotes. Gemmill and Oakley (1992, p. 114) argue that whilst mainstream writers
proclaim a positive subtext for leadership, they suggest it is a serious sign of social
pathology, that it is a special case of an iatrogenic social myth that induces massive
learned helplessness among members of a social system. This learned helplessness
can be seen in an inability of the followers or other members of an organisation to
imagine or perceive viable options, along with accompanying feelings of despair and a
resistance to initiating any form of action. Thus as social hopelessness and
helplessness deepen, the pursuit for a saviour (leader) or miraculous rescue (leadership)
also begins to accelerate.
This childlike dependency basis of the leader myth is supported in Smircich and
Morgans (1982) writing, in which leadership is perceived as a process whereby
followers give up their mindfulness to a leader or to leadership. As they state (Smircich
and Morgan, 1982, p. 257), leadership is realized in the process whereby one or more
individuals succeeds in attempting to frame and define the reality of others.
This forms the basis of a quest for a shift in focus away from the myth of leadership
that advocates alienation, deskilling and reification of organisational forms and
towards the dynamics of leadership as a social process. This approach encourages
individuals and organisational members to interrelate in ways that encompass new
forms of intellectual and emotional meaning, for the experimenting with new
paradigms and behaviours to discover more meaningful and constructive ways of
relating and working together.
Leadership is not about a leader decreeing what should occur and followers
responding in a mechanical way, but is a performative process in which the use of the
very word leader brings into being socially constructed positions whereby some
must aspire to a complex identity which others follow (Butler, 1993). To define and
describe leadership is to recognise its slippery nature, its meaning shaped by both the
individuals own experiences, personal background and reflexive thoughts and by
those of all the other people involved within the local context (Alvesson, 2002;
Campbell, 2000; Smircich and Morgan, 1982). Nevertheless, a recognition of the social
context and the socially constructed nature of leadership may still overlook a
fundamental dimension in the study of organisational life, notably that this
performative process of leadership is achieved through a range of exclusionary
practices that aim to offer a homogeneous definition of what a leader in an organisation
is expected to be. One such exclusionary practice is the failure to consider the
androcentric nature of organisational life and the lack of recognition of this concept in
many organizational studies.
A feminist critique of leadership
Feminist critics (Acker, 1990, 1998; Calas and Smircich, 1992; Martin, 1990, 1994) point
out how the existing body of organisation and management theory assumes implicitly
that managers and workers are male, with male stereotypic powers, attitudes and

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obligations. Organisational structures, cultures and everyday practices have all been
shown to constitute the ideal employee and especially the ideal manager as a
disembodied and rational figure, one which fits more closely to the cultural images of
masculinity rather than femininity. Femininity on the other hand, has tended to be
associated with embodiment, emotions and sexuality; as such it is constituted as
subordinate to male rationality and possibly out of place in rational organisations
(Fournier and Kelemen, 2001).
The type of behaviour deemed appropriate for managers in contemporary
organisations coincides with images of masculinity and centres on rationality,
measurement, objectivity, control and competitiveness. While men are portrayed as
fitting organisational behaviour, women are associated with the feminine
characteristics of caring, nurturing, and sharing that are allegedly more appropriate
for the domestic sphere and the reproduction of the home and the family. So, the
cultural construction of femininity around body and emotions, and of masculinity
around disembodiment and rationality, has made men the natural inhabitants of
organisational life, whilst positioning women as out of place in organisations
(Gerhardi, 1995). Furthermore, Gerhardi argues that the presence of women in
organisations calls for remedial work that seeks to address the ambiguity that their
position as female occupants in a male world creates. Remedial work refers to
individual and collective strategies that may be used by both women and men to
restore the (gender) order when such order has been disturbed by women stepping out
of their feminine position. Fournier and Kelemen (2001) identify many studies that
show the effort that women have to invest in presenting what Judy Marshall (cited in
Fournier and Kelemen) calls viable public images, images that make them acceptable
in the organisational world (see also Gerhardi, 1995; Brewis, 1999). For example,
women may make themselves acceptable in employment by being discrete and
invisible; by requesting permission to speak in meetings or other behaviours
demonstrating a lack of assertiveness, so as to repair the damage done by
infringement of the symbolic order of gender (Gerhardi, 1995, p. 141).
Alternatively, women may downplay their gender identity and try to blend in as one
of the boys, or as an honorary man (Collinson and Hearn, 1996), or a female man
(Marshall, 1995). Several studies have shown how women try to fit in by adopting
masculine styles, by being tough and aggressive or by adopting a cold professional
approach (Calas and Smircich, 1996; Collinson and Collinson, 1996; Fletcher, 2004;
Marshall, 1995).
In a similar way, leadership theories that have formed the dominant ways of seeing
and understanding leaders and leadership in organisations, suggest leaders have
become both sacred and institutionalised, divorced from their gendered value-laden
foundation, to the extent that we assume that they are beyond critique, deconstruction
and reformulation. Such theories, in the language of Berger and Luckmann (1995, cited
in Yancy, 2002) assume an ontological status through a process of reification. Their
masculine roots are then rendered incognito, and assumptions are made that these
theories of leadership are gender neutral (Oseen, 1997; Yancy, 2002).
Within the field of management and organisation generally, the feminist voice has
been slow to be heard, in no small part as a consequence of the domination by men and
by discourses that continue to privilege the trappings of masculinity (Calas and
Smircich, 1991; Hearn et al., 1989; Martin, 1990). Theories of leadership still require the

existence of heroes in order to make sense; notions of heroines do not tally (Oseen,
1997). As Fletcher (2004) observes, dominant traits associated with traditional models
of transformational (heroic) leadership are masculine and are socially ascribed to men
in our culture. These include such traits as individualism, control, assertiveness and
dominance.
Calas and Smircich (1991) present a Derridean-informed deconstruction of four
management texts celebrating leadership so as to demonstrate how theories of
leadership privilege masculinity. Their paper seeks to show the multiple meanings that
can be derived from the same text when read in a different way. Through this process,
they demonstrate that the term leadership is not simply ambiguous (as I have
suggested elsewhere in this paper) but can be read as necessarily masculine in origin
and effect. This gendered nature of organisational life generally, and of leadership in
particular, has been addressed by other critical writers in the field. Discourses on
leadership (as well as corporate strategy, culture and other features of organisational
life) are understood to involve core elements of masculinity that reinforce male
identities and thereby sustain asymmetrical gender relations in organisational life
(Alvesson and Wilmott, 1996; Collinson and Hearn, 1996; Hearn et al., 1989).
Implicit in many of these masculine-based models of leadership is the continual
search for what has been described as the holy grail of the idealised business model
of organisational life, so well depicted in early (classical) studies of management by
Taylor, Fayol and other writers and practitioners of a rational and logical approach to
managing in organisations. Kets de Vries (1994) refers to the endurance of the myth of
logic and rationality (the masculine) and by implication, the absence of emotionality or
irrationality (the feminine). This favouring of masculinity and the pervasive
associations between men, power and authority in organisations appears to have
been taken for granted. Thus the literature and the practice of management have
consistently failed to question its gendered nature. A crucial issue at the heart of
organisations is what Irigaray (1985) has depicted as phallogocentrism, which is used
to describe the strong Western tradition which relegates the feminine to the position of
matter, material or object against which the masculine defines itself. It is the masculine
voice that governs discourse and exchange, the worlds of communication and economy
(Burrell, 1992; Harding, 2003).
The rest of this paper calls this failure to account, by drawing on feminist writings
to support the imperative of seeking ways to reconstruct a new way of theorising
leadership in organisations, so as to find a voice for the feminine. In adopting a critical
approach informed by feminist theories, (Calas and Smircich, 1992, 1996; Irigaray,
1993; Martin, 1990, 1994; Oseen, 1997; Whitford, 1991), this allows for the consideration
of an alternative perspective, one that permits the presence of woman other than as
imitation men or excavated woman (Oseen, 1997), as well as recognising the presence
of men who do not conform to the masculine traits and behaviours as depicted by the
rational, objective, competitive model described earlier. It is evident from these studies
that (perceived) charismatic and masculine models of leadership are still featuring
heavily in our organisational analyses whereby the macho, individualistic, assertive
and dominant behaviours continue to take precedence over the more feminine qualities
such as empathy, capacity for listening, relational skills etc. The narcissistic leader
hiding behind this charismatic notion still reigns supreme with a focus on individual
and meritocratic notions of leadership and organisational success (Fletcher, 2004).

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Where the rhetoric of a more feminine set of approaches is suggested, such as within
post heroic discourse, these have yet to be translated into practice as can be witnessed
by the target-driven, financially-motivated performance measurements that continue
to dominate current assessment arrangements in UK healthcare organisations.
As Smircich and Morgan (1982, p. 258) have noted, leadership is realized in the
process whereby one or more individuals succeed in attempting to frame and define the
reality of others. The Leadership Qualities Framework is an attempt at offering a
holy grail solution to the definitional difficulties associated with leadership, and
becomes, for NHS managers and professional leaders, the assumed identity that they
need to adopt if there are to become successful leaders in the NHS. The leadership
formula offered by this framework provides a list of behaviours that need to be
practised, learned and finally acquired by managers in the UK NHS. Indeed the Code of
Conduct for NHS Managers (Department of Health, 2002b) defines the behaviours
expected of everyone involved in management in the NHS. Mangham and Pye (1991)
cited in Watson (2001, p. 221) characterise this mechanistic type of competency
approach as akin to an assembly process to management development so much
financial ability added to a bit of marketing and some strategic leadership together
with some interpersonal skills and a hint of . . .
These endeavours to define leadership can be seen as means of exerting control or
seeking to regulate individuals identity within the organisation, to seek conformity to
specific traits, competencies and behaviours. The NHS Code of Practice and the
Leadership Practices Framework provide managers with a means of self-regulation
and self-monitoring, in which managers are cultivated to become autonomous,
self-regulating, proactive individuals (du Gay, 1996, p. 60; see also Rose, 1998).
Managers very identities and senses of self are thus crafted by their experiences in
workplace settings. NHS organisations, through defining the leadership practices and
behaviours expected of NHS workers, provide a vocabulary and way of behaving that
constrains, influences and manipulates managers into how their very identity is
constructed. The powerful voices of the organisational leaders seek to persuade the rest
of the workforce to conform to organisational norms and behaviours (Alvesson and
Willmott, 2002; Knights and Willmott, 1992). In response, managers and other
professional within the NHS may (or may not) collaborate in this discursive production
of themselves by adopting the very behaviours and skills that are being promulgated.
Once having taken up a particular position as ones own, a person inevitably sees the
world from the vantage point of that position and in terms of the particular images,
metaphors, beliefs and concepts that this perspective offers. Management consultants
and indeed academics, trainers and educators seek to define and fix the concept of
leadership on the organisations behalf and thereby collude in the presentation of a core
identity for leaders within organisations. This view presumes a central, unitary
identity, a coherent view of the self against which it is possible to gauge whether an
individuals actions are true or false, genuine or spurious, good or bad. Furthermore, it
embeds an assumed homogeneity of approach to leadership, and serves to continue to
mask the masculine dominance of the model.
Thus specific inventories such as the Leadership Qualities Framework and the
associated 360 degree assessment tool may provide the portfolio of evidence that
supports the production of this identity, an identity that the individual can
manufacture or adopt to fit the profile created by the dominant discourse of

leadership in the NHS. Individuals thereby are categorised, and are required to adopt
this identity created through the leadership framework and into their workplace.
The continuing use of such psychometric and other personality profile inventories
as part of the diagnostic and developmental processes associated with the introduction
and maintenance of leadership in organisations, has the effect of defining the narrow
band or range of types of behaviours that people exhibit, as part of the
psycho-discourses of our time (Rose, 1998). These dominant discourses and
psychometric profiles become the learned profiles that people then attempt to
continue to absorb into their identities. Only a narrow range of identities are permitted
within which people are allowed to perform at work. Here we have not the iron cage of
bureaucracy but the iron cage of personality profiles.
Adopting a critical approach to leadership exposes this practice as accepting what
has become the dominant discourse within the field of leadership research notably in
the case of public sector organisations, the current discourses of the transformational
and post-heroic discourses as depicted earlier in this paper. A more critical approach
permits not only a social and contextually specific meaning to leadership, but also calls
for more locally based and culturally sensitive research into how the concept of
leadership is being enacted at local level, and how the (masculine) discourses that
dominate inform the (feminine) subordinated discourses and practices in the
organisation.
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

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experiences, identities, power relations and intersubjectivities; but also one that allows
for the presence of a range of masculine and feminine workplace behaviours.

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The current issue and full text archive of this journal is available at
www.emeraldinsight.com/1477-7266.htm

WORK IN PROGRESS

MMR public policy in crisis:


whose tragedy?

252

Laura Stroud
Nuffield Management and Leadership, Institute of Health Sciences and
Public Health Research, University of Leeds, Leeds, UK
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 ones 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

Journal of Health Organization and


Management
Vol. 19 No. 3, 2005
pp. 252-260
q Emerald Group Publishing Limited
1477-7266
DOI 10.1108/14777260510608970

Introduction
Since the publication of Andrew Wakefields 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
policies in the UK are dependent on collective action rather than individual
self-interest. Sides have been taken and media debate is polarised into good versus evil
good and evil being subjective positions that are interchangeable, depending on the
side one favours. The issue is also fraught with ethical issues, including consent.
However, little attention has been given to other philosophical viewpoints.

Government policy response to the MMR crisis has been to formulate policy from a
top-down perspective that is simply to re-iterate messages that the vaccine is safe
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
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.
Why use the Greek tragedy Antigone?
We need explanatory frameworks myth is one way of enabling us to take a fresh
look at problems that beset us. We use myth, and Greek myth in particular, in
everyday speech most of us will allude to the myths without much reflection but
nevertheless, they do resonate with us. Examples include: Herculean task; Trojan
horse; under the aegis; and many terms or words in fairly common usage originate
from the Greek e.g. she met her nemesis.
Using myths to theorise about current issues is powerful we know something of
the stories, they fascinate us, yet they also allow us to stand back and see things in a
new light, free of operational baggage they can both help de-contextualise
problems and also allow us to explore them from different angles. By using myth to
construct a model of a problem, we can challenge our understanding (Gabriel, 2004).
Czarniawska claims that myths and fairy tales are embedded in popular culture,
which in turn influences everyday activity including the way in which organisations
function. She claims that strong plots such as are found in myths, Greek dramas and
fairy tales are institutionalised, repeated through the centuries and well-rehearsed
with different audiences (Czarniawska, 2004). Gabriel similarly suggests that
pre-modern narratives (myths, legends, fables) can be used as a springboard for an
analysis of contemporary social and organisational realities (Gabriel, 2004). Such
statements led me to the pursuit of a recurring strong plot that could help me make
sense of the MMR-Wakefield story. One such strong plot is to be found in Sophocles
Greek tragedy Antigone (Sophocles, 1994).
The themes in the Antigone have been used by philosophers and critical theorists
such as Judith Butler to explore issues related to power, authority, and kinship (Butler,
2000). In her introduction to the play, Edith Hall notes that Antigone is overtly political,
and in modern times playwrights such as Jean Anouilh, Bertolt Brecht, and Tom
Paulin have used Antigone to . . . protest against everything from Nazism to

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eastern-bloc communism, South African apartheid, and British imperialism in Ireland


(Sophocles, 1994).
My intention in this short paper is to explore two themes that emerge from my
reading of Antigone with respect to the unfolding crisis of public confidence in the
MMR vaccine: firstly, the challenge to government in the form of a decrease in public
trust in government and government policies; and secondly, how such a challenge
assumes significance, and arising from that, the question of how we might we respond
to the challenge.
The story of Antigone
Antigone, Ismene, Polyneices and Eteocles are the children of Oedipus, King of Thebes
and his wife/mother Jocasta. Oedipus has killed his father and unknowingly married
his mother, thus fulfilling a prophecy by the Oracle at Delphi. When the truth is
revealed, Jocasta kills herself and Oedipus blinds himself. He exiles himself from
Thebes and claims a blood curse on his family. His sons, Polyneices and Eteocles
become the heirs of the kingship, with their uncle, Creon, as advisor. The sons agree to
share the kingship by ruling in consecutive years. However, after ruling for a year,
Eteocles refuses to hand over to his brother, Polyneices, who then raises an army of the
enemies of Thebes to storm the seven gates and depose his brother. The attack is
unsuccessful, and the brothers kill each other. Creon assumes the kingship and decrees
that Eteocles may be buried with full religious rites whereas Polyneices must lie
unburied. Anyone defying this decree will be executed.
Antigone defies the law of Creon and performs funeral rites for her brother, despite
the pleading of her sister Ismene. Antigone is caught, refuses to repent and is sentenced
to death. However, because she is his kin, Creon cannot have her executed (this is
contrary to his religious belief) so instead he arranges to have her walled up in a cave
so that she will die of starvation. This edict means that Creons hands will be clean of
Antigones blood, and his authority intact. However, Creons son, Haemon, who has
been planning to marry Antigone, is angry and challenges his fathers ruling, but to no
avail. Refusing to accept the inevitable, Haemon rushes to find Antigone, only to
discover that she has hanged herself in the cave where she was to be walled up. Creon,
seeking to make peace with Haemon, also goes to the cave, where he finds Haemon
mad with grief, In fury, Haemon tries to kill Creon but, being unsuccessful, kills himself
instead. Creons wife, Eurydice, hears of her sons death and kills herself.
The story of Antigone is (ironically) mainly told with respect to Creon, who, as King
(in this sense personifying the state the polis) has made a legitimate law, and has
justified that law that is, Polyneices has made war on Thebes and must be seen to be
punished, even in death. However, Antigone claims allegiance to a higher law than that
of Creon (and thus to that of the state) natural law, based on kinship and duty to
family. Furthermore, Creons identification of himself with the polis is brought into
question not only by Antigone in her defiance, but also by Haemon, Creons son, who
says that It is no state where one man rules. In this instance, the state is not a rational
source of authority and therefore must be challenged.
The MMR crisis
In 1998, a rather esoteric paper entitled Ileal lymphoid-nodular hyperplasia,
non-specific colitis, and pervasive developmental disorder in children was published

in The Lancet (Wakefield et al., 1998). The story of why this obscurely titled paper led
to a moral panic and a falling rate of MMR vaccination in children is of interest for
precisely that reason why are some issues (that seem to come from nowhere) taken
up whilst others are not?
So what is the story? The original paper explored a possible link between the
administration of the MMR vaccine and the development of a bowel disorder and
autism in children. After the publication of the original report, Wakefields team held a
press conference to announce the results, and were inevitably asked about the safety of
the MMR vaccine. The majority opinion of the authors was that the MMR vaccine
should continue to be given, but Dr Wakefield stated that until further research
resolved the issue there is a case for separating the three vaccines . . . (Horton, 2004).
Given that the three components of the MMR vaccine were not available separately in
the UK at that time, this immediately caused a problem for policy makers, who would
have been reluctant to advocate separate vaccinations because of the problems of
ensuring the high level of population coverage necessary to achieve herd immunity,
even if they had been convinced by Dr Wakefields findings.
It is not my intention to discuss the issues surrounding the provision of vaccines,
but as might be predicted when making controversial claims in the face of active
government public health policy, the weight of the establishment came down like the
proverbial ton of bricks on Andrew Wakefields head. Why? One answer is that
Wakefield defied the medical establishment in both making claims in advance of the
evidence, advocating a course of action for which the government was not prepared,
and also in publicising those (un-proven) claims outside the medical press. The media
like to have heroes and villains because such images sell, and Andrew Wakefield has
occupied both positions.
Journals such as The Lancet and BMJ (British Medical Journal ) often contain
newsworthy stories that journalists from the news media make accessible for mass
consumption. Certainly, this particular story has appeal healthy babies and small
children perhaps put at risk by something their parents consent to on their behalf.
Nevertheless, in the normal course of events, whilst we might expect to see some
headlines, we would also expect the story would soon begin to die a natural death as
newer stories commanded the headlines. The public might dismiss such a story as just
another example of doctors disagreeing, or if enough fuss were made about the work
itself, simply bad science. If there were errors in the study, the researchers would
wear metaphorical sackcloth for a while a blip in their careers perhaps, but nothing
too drastic. But this didnt happen here instead, a crisis of public confidence in the
MMR vaccine occurred that has been sustained.
So what makes this story different? After all, there have been other scares related to
vaccines, both in the UK and abroad, which have led to falling rates of vaccination
against other diseases (Greenwood, 2001; Vernon, 2003). Nor is this a new problem as
Greenwood points out in an article in the NHS Magazine (Greenwood, 2001), there have
always been suspicions about vaccines, going right back to Edward Jenner and the
discovery of a vaccine against smallpox in the early 1800s. But perhaps the challenge
to the institutions of state was already in place before the research was conducted.
In particular, the BSE (Bovine Spongiform Encephalopathy) crisis in the 1980s had
led to a loss of public confidence in science and government, leading at least one source
to claim that Much of the UK debate over the MMR vaccine is being fuelled by the

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effect of mad cow disease (BSE) on the nations psyche (Wilson, 2004). However,
Wilson goes further by arguing that this transposed mistrust was perhaps not
misplaced, citing evidence presented to the BSE Inquiry in the early 1990s (The BSE
Inquiry, 2000) about the potential safety of vaccines that incorporate bovine material.
During the BSE inquiry, different governmental agencies came into conflict about the
level of risk to human health, compared with the economic consequences of a
breakdown of confidence in British beef. So the apparently factual MMR story about
some bad science by Andrew Wakefield has some long roots and beginnings in the
failure of governmental policies to safeguard human health at the expense of economic
performance.
So did Andrew Wakefield simply stir up a hornets nest in an already controversial
vaccination programme? Some apparently clear flaws in his methodology and ethical
base certainly make his work consistently newsworthy, resulting in a Sunday Times
investigation that not only called into question the research of the Wakefield group but
also The Lancet and its editorial policies (Deer, 2004). In the midst of all this, some of the
co-authors of the study have distanced themselves from Andrew Wakefield perhaps
because he has sought to continue to publicise the work whilst Wakefield himself
claims that he has been unjustly vilified. Richard Horton, the editor of The Lancet, has
defended his decision to publish the original study, citing BSE as one reason why such
studies should be published, even at an early stage. Meanwhile, Andrew Wakefield has
seemed to court controversy, refusing to lie low or acknowledge fault in particular,
refusing to agree to a partial retraction of the original Lancet paper in a compromise
initiated by Horton and others, meant to help all save face.
Analysis and discussion
In Antigone, on the first day of a fragile new government, after a war instigated by one
brother against another, the new King chooses that one of the protagonists be punished
by remaining unburied. Antigone defies the law, not once but twice, until she is caught.
She then refuses to repent, thus challenging the King. She is an unmarried young
female, and according to Greek custom should acknowledge Creon not only as King but
also as head of her house. Antigones refusal to compromise ultimately results in her
death by her own hand.
Wakefield challenged public policy by suggesting that measles vaccine should be
given separately thus defying the edict of Chief Medical Officer and his
subsequent refusal to back down, even after a series of damaging reports into the
conduct of the original study, could also be held to have similarities with the character
of Antigone. However, this is not a line I wish to pursue. What is of more interest to me
is that the MMR crisis and Antigone have common themes in the failure of the state to
accommodate dissenting voices. Sophocles wrote Antigone at a time when Greek
society was moving from a more autocratic style of government to a more democratic
style. In the same way, Wakefields story seems to get caught up in a moment in which
public trust in science and government is waning and thus the message that I draw
from Antigone is that to hold firmly to a position that privileges one discourse the
public good whilst ignoring another the private sphere is to court disaster. In a
similar vein, Edith Hall argues in her introduction to Antigone that if the play has a
moral, it is that when political expediency cannot accommodate familial obligations, its
advocates are courting disaster (Sophocles, 1994).

In Antigone, tragedy ensues from the failure of the state to accord a bereaved sister
the right to bury her brother with proper funeral rites. Her voice cannot be heard not
only because of the nature of her bereavement, but also because of whom she is. The
needs of government are privileged a government that must restore order after the
war waged by Antigones unburied brother. However, Antigone challenges that ruling
and who she is becomes important she is the daughter of a King and the bereaved
sister of another. Therefore, the challenge to government comes from within, but also
lays open the possibility of support from the citizens of Thebes. The Greeks would
have understood that Antigone was not standing alone however, her ultimate suicide
was perhaps because she did not have enough popular support for her position
(Markell, 2003).
One of the criticisms of Wakefields methodology is that the sample on which his
study was based was subject to selection bias, that is, parents who suspected that there
was a link between MMR and their childs subsequent diagnosis with autism and/or
bowel disease were over-represented in the study sample. These parents had already
established in their own minds the causal chain that had led to their childs disease and
in some cases were now seeking legal redress. However, even though the perceived link
between autism and MMR was dismissed on further investigation, see for example,
(Fombonne, 1998; Peltola et al., 1998; Taylor et al., 1999), the plight of these parents and
their children resonated with other parents, who chose to trust the anecdotal
experiences of their fellow citizens rather than the proclamations of government
scientists and officers.
In his essay on themes of tragic recognition in Antigone, Markell notes that it
matters indeed it is a matter of life and death that this play occurs against an
all-too-familiar background of profound social and political inequality, most obviously
between men and women, and observes that it is inequality of just this sort that the
contemporary discourse of recognition rightly takes as its concern (Markell, 2003).
The unequal struggle between Antigone and Creon, which ends in tragedy for both, is
mirrored in the contemporary struggle between parents concerned about the MMR
vaccine and the desire of the state to do the best thing for all of its citizens, a debate in
which some voices are more privileged than others. For example, Horton observes that
the Department of Health has put too little emphasis on understanding the concerns
and views of families with children who have autism and asks why such families are
ruled out as non-expert and therefore inferior protagonists by our politicians and
public health officials (Horton, 2004).
Public policy on vaccination in the UK depends on the population being willing to
be vaccinated. The real benefits are to a relatively small group within that population,
and there will be some who have consented that will be damaged as a result of the
vaccine. This is a risk calculation that is accepted by government. However, what the
MMR issue has done is to reveal that the state has been found wanting in not being
able to accommodate the dissenting voices and the legitimate needs of parents seeking
some sort of redress for what has happened to their children, whether or not as a result
of vaccination.
What responsibility does the state have to make all this transparent and explicit?
Current UK vaccination policy is based on a model of passive acceptance. People are
not in possession of all the information so consent is only partial, and there is no forum

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for seeking redress outside a court of law should harm occur, even assuming people
had the information to show that they could seek redress.
Thus, there is a problem with the states responsibility to its citizens if they are
damaged by public policy. The state is assuming the risks on behalf of its population
without gaining their informed consent. Hence there is an underlying fragility in the
status quo that is exposed when public confidence in science and government fall as a
result of events such as the BSE crisis. The state is imposing its wishes on the
population without taking into account the need to gain their consent by respecting the
laws of natural justice.
Furthermore, it is too simplistic to assume that all concerns about vaccination are
merely due to a misperception of risk, and that therefore providing more information
about the risks will overcome the controversy. Hobson-West argues that at least some
resistance functions as a critique which problematises the basic assumptions upon
which vaccination rests, assumptions about the relationship between the individual
and community, citizen and state, and health and disease (Hobson-West, 2003). These
are the themes that are addressed by Antigone, where the conflict between the needs of
the citizen and the needs of the state is exposed by the battle of wills between Antigone
and Creon. What is needed is a public space in which such debates can be played out so
as to reach a resolution and a consensus that is acceptable to society as a whole. Such a
debate necessarily involves a renegotiation of the balance between citizen and state to
achieve a Hegelian synthesis in which truth is the unity of the universal and the
subjective will, and the universal is present within the state, in its laws and in its
universal and rational properties (Hegel, 1975).
Richard Horton concludes his book on the MMR crisis by observing that although
Wakefield was guilty [. . .] of allowing his beliefs to drive a series of public statements
that cracked the foundation stone of one of Britains most important programmes for
protecting the health of its children, by so doing, his actions threw into sharp relief
more systemic failings of a medical and public health system that was and remains
poorly designed to meet the needs of todays more questioning, sceptical, and inquiring
public (Horton, 2004).
In the same way, Antigones defiance of Creon cracked the foundation stone of his
rule by questioning his authority and his right to impose his will for political reasons in
direct contravention to the unwritten laws of heaven.
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 Wakefields 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,


and the public right to know what has caused the damage whilst the bad
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:
. . . 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 Wakefields? 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 cant 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
(The) BSE Inquiry (2000), The Inquiry into BSE and variant CJD in the United Kingdom, Ministry
of Agriculture, Fisheries and Food, London.
Butler, J. (2000), Antigones Claim: Kinship between Life and Death, Columbia University Press,
New York, NY.
Czarniawska, B. (2004), Preface, in Gabriel, Y. (Ed.), Myths, Stories, and Organizations:
Premodern Narratives for Our Times, Oxford University Press, Oxford, pp. vii-viii.
Deer, B. (2004), Revealed: MMR research scandal, The Sunday Times, 22 February.
Fombonne, E. (1998), Inflammatory bowel disease and autism, The Lancet, Vol. 351, p. 955.
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.

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Markell, P. (2003), Tragic recognition action and identity in Antigone and Aristotle, Political
Theory, Vol. 31, pp. 6-38.
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
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.
Wilson, C. (2004), Intersecting discourses: MMR vaccine and BSE, Science as Culture, Vol. 13
No. 1, pp. 75-88.

The Emerald Research Register for this journal is available at


www.emeraldinsight.com/researchregister

The current issue and full text archive of this journal is available at
www.emeraldinsight.com/1477-7266.htm

The inception of the National


Health Service

The National
Health Service

A daily managerial accomplishment


Nancy Harding

261

Nuffield Institute for Health, University of Leeds, Leeds, UK


Abstract
Purpose It is commonplace to talk of the UKs 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 Mouffes
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 Mouffes 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 Mouffes 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 Britains 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 Mouffes (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
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 Mouffes (1985) theory to the NHS, using the
evidence in those papers, leads to the conclusion that there is no such thing as the

Journal of Health Organization and


Management
Vol. 19 No. 3, 2005
pp. 261-272
q Emerald Group Publishing Limited
1477-7266
DOI 10.1108/14777260510608989

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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.
Deconstructing the organisation
Organisation studies traditionally have been divided largely into studies of the micro
(the individuals who worked in organisations) and the macro (the organisations
themselves, and their interactions with the even larger system of their environments.
Here, the organisation is seen ontologically as something having its own existence,
separate and distinct from the people who work in it or have some other sort of
relationship, such as customer, with it. The organisation here can be clearly defined
and the organisation chart makes it visible (Harding, 2003, ch. 6). Within this
structuralist and deterministic model of working life, the focus was, as it continues to
be in much research into organisations, upon ways of making this machine more
efficient, more reliable, capable of turning out ever more outputs from skilfully
manipulated inputs, including workers.
There had been theories which had challenged this model of organisations before,
notably Silverman (1970), but poststructuralist theories turned it upside down. Cooper
and Burrell, in ground-breaking papers in the journal Organization Studies in 1988 and
1989 (Burrell,1988a,b; Cooper, 1989), were instrumental in introducing these theories to
organisation studies.
For Cooper and Burrell (1988) modernism, or at least that dominant form of
modernism they call systemic modernism or instrumental rationality, is an epoch
whose primary concern is with the rational and efficient organisation of large
institutions, where functional rationality is brought to the ordering of social relations.
There is an emphasis upon reducing complexity through mechanising social order, for
the world is seen as intrinsically logical and meaningful, and constituted by Reason.
Here performativity, or the capacity to produce goods effectively, is a principle of
realization and objectification which has precedence over thought itself (Cooper and
Burrell, 1988, p. 96). It is this focus upon performativity that dominates mainstream
management texts (Fournier and Grey, 2000).
Postmodernism, on the other hand, is beset not by Reason but by irreducible
indeterminacy. Meaning and understanding are not naturally intrinsic to the world
but have to be constructed, and the omniscient, rational subject of modernism is
denied. Organisations, rather than being seen as structures having their own, objective
existence, are interpreted as representations for subjects who/which attempt to
appropriate and master the system as a field of knowledge (Cooper and Burrell, 1988,
p. 105). Rather than modernisms normative-rational individual subject,
post-modernisms subject is understood as a material flow which produces itself.
Organizations thus are not structures but processes. Performativity in this
postmodernist perspective, can be read through Judith Butlers alternative definition,
arising from the theories of Foucault and of Althusser, as the reiterative and citational
practice by which discourse produces the effects that it names (Butler, 1993, p. 2). Here
the materiality of matter is achieved through the effect of power, thus granting
viability within the domain of cultural intelligibility. In this reading performativity
refers not to the efficient and profitable production of goods, i.e. to the organisation of

production, but to its reverse, in Cooper and Burrells much-cited phrase, that is, to the
production of organisation.
These two systems of thought, for Cooper and Burrell, are so radically different that
they may be fundamentally irreconcilable.
Later Cooper and Law (1995) argued that this thinking about organisations typifies
thinking in the social sciences in general, i.e. of two distinct but interdependent approaches.
These are distal and proximal. The first of these sees organisations as relatively stable
entities that have bounded parameters. They are seen to be real, and they can be directly
observed and purposefully modified. Proximal thought sees organisations as comprising
disparate and often uncoordinated acts and processes, open-ended in their nature, and
achieved through processes of becoming. In this perspective organisations are fluid. In
other words, there is no such thing as the organisation, only that thing which we call the
organisation and which we, its members, make up through our interactions. The focus
switches to the process of becoming. Organisations are thus processual. Robert Chia (1994)
took this perspective further, by arguing that to understand organisations we not only
have to explore how they become, we have to explore the becoming of the individuals who
make up the organisation.
Explorations of the performativity of language lead to a perspective on
organisations that critiques the ways by which language is used to carve out a
supposed reality of an organisation. In this perspective it is the imposition of
language upon a myriad of events that provides the thingness of organisation. There
is thus a radical organising in and organising out, with those things that are
omitted becoming the Other of the organisation. In other words, we know an
organisation by the things it is not. Chia calls this the incisional, ontological act of
cutting and partitioning off a version of reality from what has hitherto been
indistinguishable (quoted in Willmott, 1998, p. 227). For example, the way the
Department of Health has, in the last 20 years, taken to demanding statistics on all
manner of activities within the NHS could be seen as such a cutting and partitioning
off [of] a version of reality from what has hitherto been indistinguishable as these
statistics were previously unheard of the actions themselves may have existed but
they were not consciously thought of.
Such thoughts led Chia (1994; 2000) to echo Whiteheads lament that we have
mistaken our abstractions for concrete realities (Whitehead, 1929, quoted in Chia,
1994, p. 590), these abstractions including both organisations and individuals. Chia
(1994, p. 594) argues for an ontology of becoming when studying organisations, rather
than that ontology of being that still dominates research in the field. He argues that
organisations, thought about from a postmodern perspective, are processual,
heterogeneous and emergent configurations of relations (Chia, 1994). Categories such
as individuals and organisations thus cannot be seen as already given and existing
as precise beings having a seemingly concrete status. They are rather entities in the
process of becoming, or actions, interactions and local orchestrations of relationships
(Chia, 1994, p. 595). Chia argues that organisation should thus be seen not as a noun
but as a verb, and organisations and individuals both not as unified and discrete
entities but as social effects.
There is still however an element of dualism in such approaches, critiqued by
Knights (1997). A dualistic analysis, he shows (Knights, 1997, p. 10), involves either
treating the organisation as an objective reality independent of its members, or

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focusing on the actions, interests, motives of individuals as if these existed separately


from the structure of relations represented by the organisation. Deconstruction theory,
he continues (Knights, 1997, p. 16) does not simply mean an overturning or reversal of
this hierarchy of dualistic categories or a reconciliation of the presence/absence
dichotomy, but their complete eradication. No single category, meaning, motivation or
aspect of selfhood can be sifted out from its shifting placement in matrices of power;
thus categories such as resistance/compliance can be seen as impositions of the
researcher, who divides the world into neat, dualistic categories that seek to provide
order. It is therefore necessary not to show how employee and managerial subjects
make this thing called the organisation, but to deconstruct both organisation and
organisational subject.
In previous work with Jackie Ford (Ford and Harding, 2004) I have used empirical
data to critique dualistic thinking about organisations in which agentive employees
made, or refused to make, the structure of the organisation. Rather, we suggested, there
is no such thing as separate and distinct employees/managers and the
organisation(s), but places and spaces inscribed upon, collapsed into, defined by
and constitutive of psyches and bodies. The concept organisation was something
that we, as researchers, along with senior managers and those in power, imposed upon
a multiplicity of spaces, places and ways of being. There is therefore no such thing as
an organisation and its members. What there are are bodies, psyches, places, spaces, all
of which through interactions, talk, deeds, words, thoughts, subjectivities, habits of
presuming that a label brings an entity into being, etc., etc., etc., allow us our beliefs in
the existence of both organisations and members. To paraphrase Foucault (1980) the
individual is at the same time both an effect of an organisation and the element of its
articulation. In this paper I wish to take forward such ideas by exploring how the
work of Laclau and Mouffe (1985) can add to our understanding of how managers
make organisations and at the same time make their managerial selves. The
organisation I am using to develop this explication is, of course, Britains NHS.
Does the NHS exist?
The National Health Service is, we are told, an organisation which employs more than
one million people, whose work is carried out in thousands of departments and
buildings, and who are divided along numerous lines of task, profession, rank, reward,
etc. Unsurprisingly, Parker (2004) points out, this is an organisation of maddening
complexity, with myriad structures, cultures and orders, and where a singular
ordering can be nothing but a dream. The word organisation, indeed, alongside
words such as structure and culture, are frames for ordering materials: the
materials that require ordering so as to became the National Health Service are of a
magnitude that betrays the human mind in its capacity for imagination.
Parkers evidence leads us to consider how these materials have been brought under
one frame, the NHS or the health service. Compare what has been placed under that
one rubric with the list from Borges famously quoted in the Preface to Foucaults Order
of Things (1966, p. xvi). A Chinese encyclopaedia notes that:
. . . animals are divided into: (a) belonging to the Emperor, (b) embalmed, (c) tame, (d) sucking
pigs, (e) sirens, (f) fabulous, (g) stray dogs, (h) included in the present classification, (i)
frenzied, (j) innumerable, (k) drawn with a very fine camelhair bursh, (l) et cetera, (m) having
just broken the water pitcher, (n) that from a very long way off look like flies.

Such a list would seem to have no connection whatsoever with the health service to
our eyes it is not indeed a list. But what if we ask of the NHS the question Foucault asks
just a few pages later (p. xxi):
When we establish a considered classification, when we say that a cat and a dog resemble
each other less than two greyhounds do, even if both are tame or embalmed, even if both are
frenzied, even if both have just broken the water pitcher, what is the ground on which we are
able to establish the validity of this classification with complete certainty?

There is no such ground, he argues in a neo-structuralist mood (Dreyfus and Rabinow,


1982), rather there are fundamental codes of a culture which allow the ordering of
things and disallow other possible orderings.
So, when a considered classification is established, one which states that, in Britain,
the NHS includes one million employees whose work is to be categorised in certain
ways, and that certain categories of staff will undertake certain types of task, what is
the ground which establishes the validity of that classification with, in Foucaults
words, complete certainty? There can be no such complete certainty, for many
grounds of categorisation are open to contestation. The history of the NHS shows
this. Whereas doctors working in hospitals work in the NHS, those working as
general practitioners work outside it, providing services to it. Community nursing
services were for two decades located in local authorities and then became part of the
NHS. Cleaning services were made external rather than integral to the NHS by
government diktat in the 1980s. In all of these examples we see processes of
categorisation that have changed or been challenged over time. Indeed, although the
validity of some classifications may appear beyond challenge, many remain always
tentative and fought over. The taxonomy of tasks and functions that is called the
National Health Service in the UK, and by similar names in numerous other countries,
is as open to contestation as the lists in the encyclopaedia recounted by Borges.
McLaughlin (2004) shows how tentative is concordance with any new policy, even one
such as evidence-based medicine that would appear to have the army and navy of
regulatory organisations behind it. Classifications such as these are inherently
political. Where once there was a claim to structural determinism such a claim is now
seen, in light of poststructuralist analyses, to be permeated with undecidables. In
Laclau and Mouffes (1985) poststructuralist Marxist terms, an act of political
institution, finds its source and motivation nowhere but in itself. Using Lacans
concept of point de capiton, or nodal point, they suggest that master-signifiers allow a
particular element to assume what appears to be a universal structuring function; but
the field so encompassed exists only because of that master-signifier. Laclau and
Mouffe explore political movements, notably those claiming to represent workers,
but their analysis applies equally to the highly politicised services known as health
services. Thus for us the master-signifier is the health service and in Britains case
the NHS. Importantly, the master-signifier is not performative it does not bring
into being that of which it speaks. Laclau and Mouffes definition of performative is
drawn from Althusser and is akin to that of Butler (1990) Performative, in this
definition, means that through being interpellated, or called by a label, something is
brought into being. So, the master-signifier of the health service allows the
presumption that there is this one organisation, called the NHS, but this organisation is
not brought into being through this label.

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This argument can be illustrated through exploring briefly the inception of Britains
national health service.
The NHS was established in 1948 with the aim of providing health services free at
the point of delivery to all citizens. It did not emerge pristine and brand new but was
formed out of a melding together of pre-existing institutions which had their roots in
localised initiatives of the nineteenth century. By 1918 such localised developments
had resulted in considerable variations between different parts of the country, with
little collaboration between agencies and a far from comprehensive service. The First
World War provided the impetus to attempts to consolidate existing services through
discretionary legislation which advised local authorities what they should do but did
not require them to follow the guidelines. The result was a continued fragmentation of
services, and marked differences in services offered between different parts of the
country. The 1948 Act which founded the NHS aimed to consolidate these numerous
organisations, but it could be said that in the 1970s there were, in effect, 146 local
health services as opposed to a single national health service (Ottewill and Wall, 1990,
p. 92). Each of these 146 health services could themselves be seen as master-signifiers
working at the local rather than national level. Such a situation, Parker (2004) shows,
not only continues to this day but the whole concept of such a thing as a coherent and
unified health organisation must be brought into question. In Laclau and Mouffes
terms, the NHS can thus be seen as a master-signifier that does not bring into being
that which it signifies but which provides a term within which a taxonomising process
can take place..
Importantly, and this is where health services differ from many other
organisations, given their place in the political spectrum and their importance in
sustaining governments in power, health services are master-signifiers of particular
consequence for politicians. I suggest therefore that they are, like the political
movements analysed by Laclau and Mouffe, politico-hegemonic articulations which
retroactively create the constituencies they claim to represent. The patient is, in this
reading, the constituency claimed by politicians; but the patient is a mythical character
rendered meaningful by each one of us becoming ill at some point in our lives and
needing the care of health staff. As Sontag (1977) notes:
Illness is the night-side of life, a more onerous citizenship. Everyone who is born holds dual
citizenship, in the kingdom of the well and in the kingdom of the sick. Although we all prefer
to use only the good passport, sooner or later each of us is obliged, at least for a spell, to
identify ourselves as citizens of that other place.

Most of us are lucky enough to be patients for only a very small part of our lives,
but that Other, our ill self, is always there, always waiting to appear. We know that
we are healthy because we are not ill: that is one of the most basic premises in the
sociology of health. It is that which perhaps makes health services so fundamentally
political whichever party can claim to best represent this I that I may become
may have my vote.
Thus, I suggest, this thing called the NHS or its equivalent is a master signifier
which achieves definition through the tasks included in its list of things done to and for
a constituency called the patient. It exists, literally, only in the papers written by
those, such as members of government, senior civil servants or the most senior
managers, not directly involved in the work of delivering services to patients.

Making the organisation: the work of managers


If the NHS does not exist as an organisation, how can we account for the work of
those people who work within it? To answer this question I will turn to the managers
who are charged with the task of achieving the management of this organisation that
exists only as a process of becoming. Firstly, it is necessary to identify this thing called
management. Following Laclau and Mouffe, I suggest that management is what
Laclau has more recently called an empty signifier. Empty signifiers relate to what is
absent but present: they arise out of the impossibility of ever realising a fully-achieved
social field, such as a society or an organisation. The idea of the fullness and closure of
an organisation remains an impossible ideal, something yearned for but never
achieved. Empty signifiers are necessary for the emergence and function of these
ideals. Laclau (in Howarth and Stavrakakis, 2000) uses the concept of disorder to
explain the empty signifier: in a state of radical disorder order is present as that which
is absent, i.e. it is an empty signifier as it signifies that which is not present. Various
political forces compete to present themselves as ideally placed to fill that lack, and
indeed empty signifiers are the condition for the articulation of political discourses. In
the twentieth century, management (n.b. not managers, or the people who occupy the
subject position of management) has become a synonym for order. Indeed management
emerged, in its founding myth, as the bringer of order. This was the promise of
F.W. Taylors highly influential Principles of Scientific Management, or at least the
promise we read retrospectively into his Principles. In situations where health services
are seen to be out of control or, rather, too much under the control of the medical
profession; where health services are seen to be failing to meet their major objectives of
curing patients and thus sustaining political parties in power, the fault is seen to lie in a
lack of order/management. Order/management is absent but its presence is yearned
for. Management thus becomes for political parties the empty signifier which will bring
about that desired health service.
But management it follows, as the bringer of order and the controller of chaos, is an
impossible ideal, for reality is always too complex, and people working in
organisations (which, as the above argument shows, have no separate existence)
always too recalcitrant, to allow for this mythical thing called good management.
Numerous experiments in organising and re-organising health services, and the search
for ever-more refined methods of achieving control, testify to this. Management may be
an empty signifier for politicians, but for managers, the people responsible for
achieving management; it is an identity that contributes to practices of the self. For
Laclau and Mouffe (1985, p. 105), identities are achieved through four basic categories:
(1) articulation, i.e. any practice establishing a relation among elements such that
their identity is modified as a result of the articulatory practice;
(2) discourse, i.e. the structured totality resulting from this articulatory practice;
(3) moments, or the differential positions which appear articulated within a
discourse; and
(4) elements, or those differences which are not discursively articulated because
they can float during periods of crisis.
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

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discourse. The acceptance of management as the way of organising health services


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
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 Mouffes 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 Mouffes
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
improving management. These include leadership (Ford, 2004) and evidence-based
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,
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. Lees (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. Lees (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

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dominance in order to achieve the aims of sexual health promotion. There is a major
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
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 Mouffes
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 Mouffes 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. Todays 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 possible, i.e. they can never be achieved. The manager experiences this lack, this
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.
Analysing the NHS using the lens of Laclau and Mouffes 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
managements 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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