Two at the top: relations between Chairs and Chief Executives in the NHS

Towards a Performative Theory of Resistance: Senior Managers and Revolting Subject(ivitie)s

This article develops a performative theory of resistance. It uses Judith Butler’s and Karen Barad’s theories of performativity to explore how resistance (to organizational strategies and policies) and resistants (those who resist such strategies and policies) co-emerge, within and through complex intra-actions of entangled discourses, materialities, affect and space/time. The article uses empirical materials from a case study of the implementation of a talent management strategy. We analyse interviews with the senior managers charged with implementing the strategy, the influence of material, non-sentient actors, and the experiences of the researchers when carrying out the interviews. This leads to a theory that resistance and resistants emerge in moment-to-moment co-constitutive moves that may be invoked when identity or self is put in jeopardy. Resistance, we suggest, is the power (residing with resistants) to say ‘no’ to organizational requirements that would otherwise threaten to render the self abject.

Towards a framework for enhancing the performance of NHS boards: a synthesis of the evidence about board governance, board effectiveness and board development

Background

There is a need to reduce the variation in organisational performance across the NHS for which boards hold ultimate responsibility. By exploring how boards can add value, we hope that this research will benefit patients and improve service efficiency and effectiveness.

Objectives

We know that there are knowledge gaps in relation to the composition and characteristics of effective boards in the NHS, their impact and the range of tools and techniques available for developing effective boards. This realist synthesis study, therefore, aims to add to existing knowledge by (1) providing a theoretical contribution to board governance and relating it to the NHS context, (2) offering fresh insights into effective board composition, structures, processes and behaviours in the NHS, (3) furthering an understanding of how NHS boards can affect organisational performance and (4) summarising and analysing the range of board assessment tools and development interventions available for the NHS.

Method

The study adopted a realist approach to an evidence synthesis of a diffuse literature. In line with realist review principles, we tested, honed and refined the research questions and emerging findings with a joint expert advisory and stakeholder group of 23 people. A search was conducted across relevant library and external sources including ABI/INFORM® (ProQuest, Ann Arbor, MI, USA), SciVerse® ScienceDirect® (Elsevier, Amsterdam, the Netherlands), MEDLINE, EMBASE and the Social Science Research Network, from 1968 to 2011. A total of 618 general articles, 209 health-care-related articles, 252 textbooks and 54 reports were identified.

Results

Frameworks that have developed from theory and from practice were categorised into the three elements of composition (board structure), focus (what the board does) and dynamics (the behavioural dimension), and the potential conjunction between board theories and practices was explored. We found some important distinguishing characteristics in the public, non-profit and health-care sectors. In relation to the impact of boards on organisational performance, the importance of contingency factors was highlighted and there is positive empirical support for the role of physicians on the board. Other than self-reports, we could not find any significant studies on the impact of board development on board effectiveness.

Limitations

The study is dependent on the diverse nature of the sources of evidence and the relative infancy of the realist synthesis method. The literature is fragmented, equivocal and, at times, contradictory. We believe, nevertheless, that the study offers insights in terms of developing middle-range theories for effective health-care boards.

Conclusions

We found no simple theory about how boards should operate. The use of certain models for boards may be more appropriate than others, depending on what the priority is in terms of organisation outcome. We have identified some important distinguishing characteristics in the public and non-profit sectors. On the whole, evidence lends some further support for a theory about the dynamics of an effective board in relation to high challenge, high trust and high engagement, modified in the light of our developing understanding about the linkages between different contexts and desired outcomes. We identified five areas in which board development approaches should be more focused. We suggest three main areas for further research: the composition of NHS boards, the conditions under which health-care boards are able to exert a sustained focus on clinical quality and an evaluation of the impact of board development activities on organisational performance.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Plus ça change, plus c'est la même chose: senior NHS managers' narratives of restructuring

The UK National Health Service (NHS) is regularly restructured. Its smooth operation and organisational memory depends on the insights and capability of managers, especially those with experience of previous transitions. Narrative methods can illuminate complex change from the perspective of key actors. We used an adaptation of Wengraf's biographical narrative life interview method to explore how 20 senior NHS managers (chief executives, directors and assistant directors) had perceived and responded to major transitions since 1974. Data were analysed thematically using insights from phenomenology, neo-institutional theory and critical management studies. Findings were contextualised within a literature review of NHS policy and management 1974-2009. Managers described how experience in different NHS organisations helped build resilience and tacit knowledge, and how a strong commitment to the 'NHS brand' allowed them to weather a succession of policy changes and implement and embed such changes locally. By synthesising these personal and situated micro-narratives, we built a wider picture of macro-level institutional change in the NHS, in which the various visible restructurings in recent years appear to have masked a deeper continuity in terms of enduring values, norms and ways of working. We consider the implications of these findings for the future NHS.

New roles and responsibilities of NHS chief executives in relation to quality and clinical governance

The role of the chief executive in the NHS is to act as organisational head, with financial and managerial responsibility, and now responsibility has been extended to include clinical standards as part of the duty of quality and the introduction of clinical governance. These new responsibilities have implications for relations with staff inside the organisation and, in particular, with clinicians, as well as adding to the overall public accountability of chief executives. As well as increasing expectations of chief executives to meet performance objectives and other targets within the organisation, their role remains relatively new and sometimes contentious in the health service, forming part of the history of NHS management reform. The developing role of chief executives and the complex world in which they operate in the health service is discussed. It is suggested that support from colleagues at both the organisational and national levels is required to help them discharge their new responsibilities, together with a greater focus on the development of their role and skills.