autonomy and modernisation: the management of change in an english primary care trust

Health and Social Care in the Community

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© 2004 Blackwell Publishing Ltd

Abstract

Recent New Labour policy for the ‘modernisation’ of Government places a good deal of emphasis on decentralisation. This emphasis is particularly marked in relation to the organisation of primary care. However, like hospitals and other National Health Service institutions, primary care trusts (PCTs) are subject to a substantial raft of centrally established performance targets and indicators, including those which contribute to the public award of between zero and three performance ‘stars’. This raises questions about the extent to which employees can exercise autonomy in the context of rigid top-down directives. This paper presents findings from a study using participant observation and interviews to examine the impact of a training course aimed ostensibly at increasing employee autonomy in an English PCT. The suggestion is that attempts to make employees more autonomous can be seen as a strategy for increasing central control based upon the internalisation by the employees of centrally promulgated values. The attraction of such strategies is that they may be potentially more effective and less costly than alternative strategies of direct control. However, the study suggests that the outcome of attempts by such methods as programmes to increase employee autonomy may be very different from those intended.

Keywords:

autonomy, change management, empowerment, modernisation

Accepted for publication

26 January 2004

Blackwell Publishing, Ltd.

Autonomy and modernisation: the management of change in an English primary

care trust

Ruth McDonald

BA MSc PhD

and Stephen Harrison

BSc MPhil PhD

Department of Applied Social Science, University of Manchester, Manchester, UK

Correspondence

Ruth McDonald Department of Applied Social Science University of Manchester Williamson Building Oxford Road Manchester M13 9PL UK E-mail: [email protected]

Introduction

Organisational change has been one of the few con-stants for those working in the National Health Service(NHS) in recent years. Recent New Labour policy forthe ‘modernisation’ of Government places a good dealof emphasis on decentralisation, as the following quoteillustrates:

Giving front-line staff and patients the opportunity to thinkand work differently to solve old problems in new ways is theonly way to deliver the improvements set out in the NHS Plan.The changes […] will provide a structure that supports thedevolution of power to front-line staff. (Department of Health2001)

This emphasis is particularly marked in relation to theorganisation of primary care. Primary care trusts (PCTs)

have acquired many functions formerly exercised athigher hierarchical levels, including the commissioningof secondary and tertiary care for local populations.Primary care trusts will control 75% of NHS healthcareresources by 2004 and have been officially described asputting front-line staff ‘in the driving seat’ (Depart-ment of Health 1997). Such decentralisation representsa departure for NHS managers. Being on the receivingend of change management initiatives can be seen inthe context of recent decades of successive Governmentreforms of the NHS, which have been aimed at strength-ening the power of the centre to make it more efficientand more responsive to the needs of its customers (Klein2000). At the same time, however, strong elements of thisearlier approach remain. Like hospitals and other NHSinstitutions, PCTs are subject to a substantial raft ofcentrally established performance targets and indicators,

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including those promulgated in the NHS Plan (Depart-ment of Health 2000) and those which contribute to thepublic award of between zero and three performance‘stars’ (Commission for Health Improvement 2003).One way of reconciling these apparently contradictorytrends is through the notion of ‘earned autonomy’,under which institutions that perform ‘well’ are granteda less-onerous regulatory regime (Hood

et al

. 2000, Depart-ment of Health 2002a). This logic has been employedas part of the concept of NHS ‘foundation’ trusts, underwhich the best-performing hospitals are able to seekfreedom from direct governmental control (Departmentof Health 2002b).

A different response to the above centralisationcritique is to focus on more micro-level managerialautonomy and Peters & Waterman’s (1985, pp. 318–325)concept of ‘simultaneous loose–tight properties’. In sum-mary, this entails the rigorous adoption of overarchingvalues with substantial autonomy for operationalmanagers in deciding how to enact these values. This is,of course, still a control strategy (Hickson & McMillan1981, Barker 1999), based upon the internalisation ofvalues, and therefore, it is potentially more effectiveand less costly than alternative strategies of directcontrol (Sewell & Wilkinson 1992). Peters & Waterman(1985, p. 74) were fully aware of this, providing a rangeof prescriptions for how to change employee values andstrategies for gaining commitment to organisationalgoals. The above authors characterised employeesessentially as social dopes: ‘the fact … that we

think

wehave a

bit

more discretion (even when we don’t) leadsto

much

greater commitment’ (Peters & Waterman 1985,p. 81). As Knights & Willmott (2002, p. 63) put it:

What is termed ‘self-determination’ or ‘self-mastery’ in discus-sions of autonomy is real or substantive in its effects; and theseeffects are plausibly attributed to autonomy as a regulativeidea insofar as the ideal of autonomy promotes and legitimisesparticular kinds of action and agency that are described as‘autonomous’.

In the NHS context, this suggests that local managersmight be allowed to decide for themselves the best meansby which to pursue national performance targets andvalues whose core they have internalised. From thispoint of view, the ‘modernisation’ agenda may be seenas a hybrid of top-down edicts and targets, with the detailsof service design and organisation filled in by localmanagers and professionals, who have adopted the broadnational philosophy. Of course, local decisions abouteither what to do or how to do it also imply the necessityof resolving local differences of opinion about these matters;logically, actors cannot all be entirely autonomous.

Whilst there is a large volume of theoretical litera-ture dealing with change management, a recent review

of the literature found that, in the context of changemanagement in health settings, ‘empirically basedpublications are relatively rare’ (Iles & Sutherland 2001,for a further review of the literature, see also Learmonth2003). All of this suggests three empirical questions,which this paper addresses in the context of a specificPCT in the English NHS. First, are managers really socialdopes? Do they really internalise nationally promulgatedtargets and values, and do they perceive themselves ashaving autonomously chosen to do so? Secondly, andindependently of the answer to the first question, howmuch autonomy do they perceive themselves as havingin relation to decisions about how to go about localimplementation of priorities and targets? Thirdly, howare local tensions which might arise from prescriptionsof increased autonomy resolved? The present authors’case study site, although only a single PCT, representssomething of a critical locus for these questions since itchose to provide training for its managers in ‘personaland professional effectiveness’, much of which washeld to depend on encouraging them to ‘self-actualise’.What follows is divided into five main sections. Thefirst provides contextual information about the casestudy site, the ‘Investing in Excellence’ (IIE) course thatthe PCT offered and the authors’ data collection methods.The next three sections discuss findings from the research,structured around the three questions suggested above.The concluding remarks provide an assessment of thefindings in relation to these questions.

Context and method

The pseudonymous Downtown PCT was created in April2001, formed from some existing primary care groupsand one community health services trust. The latter’srole was the provision of community services (e.g.community nursing, podiatry, and speech and languagetherapy), while the former were involved in the com-missioning of health services for the local population. Inaddition, staff from the health authority were incorpo-rated into the PCT. The community trust staff formedthe vast majority of the new PCT employees, and werelocated either in clinics within the local community or inWalsingham House (pseudonym), 1.5 miles (2 km) fromthe PCT headquarters which housed the PCT chairman,executive directors and some support staff (e.g. financeand human resources). This geographical separation ofthe senior managers from the rest of the staff exacer-bated the unhappiness felt by many members of theformer community trust when its chief executive wasnot appointed as the lead officer of the PCT. Staff atWalsingham House spoke in pejorative terms of ‘thePalace’ and its inhabitants and the chief executivepointed to this ‘them and us’ state of affairs in a staff

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briefing. The staff briefings were subsequently movedto a neutral venue (away from ‘the Palace’) in order toencourage attendance from former community truststaff. The creation of the PCT had involved not merelyassimilation of existing organisations, but reorganisa-tion of ways of working which involved the creation ofnew roles and the disappearance of old ones. Displacedstaff were labelled ‘at risk’. The use of this label wasintended to promote some sense of security since thesestaff would be given priority in applying for new posts,but it is not clear that this actually felt reassuring. Inter-nal reorganisation was a constant during the research,initially justified on the basis that the PCT was a neworganisation. Further processes of reorganisation includedthe introduction of locality teams aimed ostensibly atdevolving power to localities. In addition, as part of themodernisation/service redesign agenda that involvedbuilding new community and hospital facilities, therewas an ongoing process of redefining roles and pro-cesses for patient care.

Downtown PCT encouraged its managers to parti-cipate in an IIE programme aimed at ‘helping participantsbecome more effective in their personal and profes-sional lives’. As the personal resource manual for the IIEcourse explains in its ‘key concepts’ section:

Locus of control: the place where control is perceived to be.This is internal for independent, self-directed, accountablepeople. It is external to dependent, other-directed people whohave given up accountability for themselves to others, orworse, to circumstances. (Pacific Institute 1998, p. 2)

The principles underpinning the course are derivedfrom a range of psychological and other theories abouthuman behaviour and motivation, and are intended tohelp individuals to become ‘self-actualising’. Althoughthis conception of the individual as exerting themselveson the outside world emphasises the importance of humanagency, it pays very little attention to the constraints ofthe structures in which individuals work on theirfreedom to act:

Self-actualizing people are, without a single exception, involvedin a cause outside of themselves … They are working at some-thing fate has called them to somehow, and which they love,so that the joy/work dichotomy in them disappears. (Maslow,cited in Tice 2004)

All PCT employees were asked via a message in theirpayslip to nominate those people whom they con-sidered to be ‘influencers’ within the organisation.The nominees were invited to participate in the IIEprogramme. Influencers were split into groups andbrought together within these groups for 5 days overthe course of approximately 12 months. An externalfacilitator ran the events, and during this time, partici-

pants watched IIE videos and engaged in discussion,and group and individual exercises. In addition, theyworked through audio materials and workbooksprovided as part of the IIE course during their sparetime at home. They were also invited to attend an in-fluencers’ lunch at which they were briefed, givenlunch and the chance to mingle with the chief executive,chairman and other senior officers of the PCT. (Furtherdetails of the course content can be found at <http://www.pacificinstitute.com.au/invest.htm>.)

The data presented here are part of a 2-year partici-pant observation study conducted between 2001 and2003 examining decision-making within the PCT, dur-ing which time one of the researchers was based withinthe PCT. A variety of methods were used during the con-duct of the case study, including formal interviewingtechniques, participant observation and documentaryevidence. Thirty semi-structured interviews wereconducted with employees who had participated in theIIE programme. These employees held posts at or belowdeputy director level. They were from a variety offunctions including the management of clinical ser-vices (e.g. nursing and podiatry), the provision of services(e.g. health visiting), training, public health and servicedevelopment.

A framework approach to the analysis of data wasused (Ritchie & Spencer 1994). This involves establish-ing a thematic framework within which material canbe sifted and sorted drawing on

a priori

issues (thoseinformed by the three research questions and exploredin the interview schedule), emergent issues raised byinterviewees and analytical themes identified fromresponses. The tape-recordings of interviews were tran-scribed in full and coded, using the framework, intorelevant categories and sub-categories. In addition to theinterview transcripts, detailed notes from a field diaryrecording observations were coded, together with doc-umentary evidence from the PCT. Most of what followsis drawn from interview data, but observational materialhas been used to illustrate both the research context(see above) and instances where behaviour outside ofthe interview setting diverges from that presentedduring taped interviews.

Results

On being autonomous

In general, attitudes towards the IIE course fell in to threecategories. The majority of people (21 out of 30) praisedthe course and a small number expressed ambivalence(five out of 30) or were openly critical (four out of 30) ofit. Most enthusiasts (16 out of 21) saw themselves aschanged and becoming more confident or content in



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their work as part of the process. Those who were criticalpointed to tensions between the rhetoric of autonomyand the reality of what they saw as a top-down controllingenvironment. Amongst those who were wholeheartedlyin favour of the programme, there were inconsistenciesin the accounts presented. For example, most respond-ents described how they enjoyed a great deal of autonomyin respect of their workload and objectives. However,many also complained that, although they saw attend-ance at IIE sessions as extremely important, they hadnot been able to attend all sessions because of pressureto work on ‘must dos’. This suggests that respondentsare subject to pressures beyond their control and aregrudgingly forced to accept the priorities that othersimpose upon them. Certainly, some respondents expressedresentment at having to miss sessions of what they sawas time for their own development because of unreason-able demands made from ‘on high’:

My own director only went on one of the courses. She neversaid anything, but when she was also missing sessions, I didn’tfeel strong enough to go … I think a few people felt like that. Isuppose we should have been stronger, but we weren’t. (R16)

A couple of occasions when something very major came up atwork, I had to drop everything and do this … It meant that Icouldn’t go on two of my days. I was furious that this impor-tant part of my personal development had to be put on holdbecause this big piece of work trumped it. (R20)

Additionally, recognition that autonomous individ-uals act in certain ways (the exercise of responsibleautonomy) may lead employees to choose to prioritisecertain aspects of workloads over others. Since theserelate to Department of Health edicts, this choice maybe seen less as an exercise of free will than an obligationto choose the ‘appropriate’ course of action:

Two people didn’t come because of the LDP [Local DeliveryPlan]. (R4)

Although being too busy may have provided a con-venient excuse for those who were critical of the courseto absent themselves from IIE sessions, as Jack, whomissed sessions because of other pressures admits,‘maybe my heart wasn’t in it’ (R19). The sense of auto-nomy as a regulative idea was conveyed in the behaviourof ‘empowered’ managers who welcomed the chiefexecutive’s suggestion for an increase in flexible work-ing. However, whilst they wanted to be able to spendsome time working from home, they awaited permis-sion for this from members of the senior managementteam rather than deciding to reorganise their own worktimetable. In a culture where working long hours andbeing ever present was seen as the behaviour of adedicated manager, respondents did not appear to besufficiently autonomous to buck the trend and rearrange

their working practices without first being givenpermission to do so.

Other managers who saw themselves as autonomousdescribed the boundaries of this autonomy in a way thatmight imply to an observer that there were majorlimitations on the exercise of autonomy, but these individ-uals did not seek to question whether these boundariesshould exist. Indeed, they often failed to connect theseboundaries with limitations on autonomous behaviourand merely accepted their existence. For example, shortlyafter claiming, ‘I do completely what I want to do to behonest,’ one manager went on to elaborate that:

There’s only certain sets of things you can do. We have a verystructured, er, I suppose it’s an appraisal system. We’ve got 10competencies we have to meet, so all the time, you’re trying toget work that fits your competencies and fits the needs of theorganisation. (R11)

Others complained that senior managers were notfully committed to the process of empowering staff andwere guilty of reverting to top-down modes of thinkingin the face of more pressing organisational objectives,creating tensions and mixed messages in the system:

You can see people, the formalin dries, their wings start grow-ing … We’ve got some great front-line workers and local peo-ple, and then we’ve got this wind tunnel that blows rightthrough the middle … If these [front-line workers] have gotpermission at a locality development engagement level to dosomething they have to be given the autonomy and the controlto do it. They can’t be pulled at the eleventh hour and told,‘Oh, why have you dropped your 3 years’ old caseload study?’‘Cause I’m carrying three empty case loads and I’m trying towork in a different way, and you want me to do a public healthagenda.’ They have to be given the autonomy to make thosedecisions and [be] supported by the key level strategic people,don’t they? (R2)

Despite the enthusiasm for the IIE course, two-thirdsof all respondents were openly critical of PCT seniormanagement practices. This suggests that the process ofshaping values is not so simple as Peters & Waterman(1985) have implied. However, this voicing of criticismin confidential interviews was, for the most part, notextended to unguarded or open condemnation outsideof those settings. Much of this criticism related to theprocess of change being undertaken as part of the ‘mod-ernisation’ process.

Being autonomous in a changing environment

For respondents who had previously been employed bythe former community trust, the way in which changewas being managed was a source of criticism and stress.The sweeping away of the old organisation and its replace-ment by the PCT left many staff feeling undervalued


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and unable to reconcile the discourse of autonomy withtheir own experiences of working in the PCT:

The impression that is given at the moment is that any oldcommunity trust staff are not really worth anything and thejobs that they did weren’t, and in all this mad rush to changeeverything, it seems as though any good work that has beendone in the past is just being ignored … There are an awful lotof good things in the old organisation including … [my] service.(R26)

I always had autonomy over budgets. Now my name’s beentaken off so I have to go and ask [names two managers] to signit … I had about an £8 million budget with [names old job] …and so I find that difficult. I have a lot of autonomy, but …people are very unsure what I do … because the directorate’schanging, I don’t actually fit in. I don’t know where I fit … I feela bit bereft … I feel very isolated. (R21)

For many staff, the lessons learned from the IIE coursehad helped them to cope during a period of changeand uncertainty. Some managers, such as one whoconfessed to being ‘an old cynic’ prior to the course,described a transformation which had taken place:

Over a period of weeks, she [the external facilitator] saw myacceptance of the course and how much I’m getting out of it,which is true … I think I’m a lot calmer than I was. My agenda’squite wide, and we’ve had loads of capacity issues that beforewould have been a real pressure and would have really got medown, and I think, perhaps it’s just looking at things from adifferent perspective, which the course allows you to do inmany ways. (R5)

Others described how the IIE course had taught themto recognise the limits to their autonomy. This meantthat, rather than wasting energy on tasks which werebeyond their sphere of influence, they were able toconcentrate on things which they could influence:

For some things, the time’s not right and you just have to gowith what you can do. It’s about sometimes acknowledgingit’s not the right time and it’s not personal it’s not you. You areonly in control of yourself. (R24)

This emphasis on recognising one’s own limitationsand sphere of influence can be seen as a means of trans-forming what might previously have been conceived asa source of frustration and a threat to individual auto-nomy into a benevolent aid, which helps the individualto appreciate the futility of engaging in areas wherethey have no control. Although securing complianceand turning one’s back to the rest of the organisationdoes not necessarily equate to enthusiastic support forthe PCT agenda or identification with its aims, it mightnegate or reduce the potential for the expression ofresentment and resistance. That the consequences ofincreased autonomy are an acceptance of one’s owninability to influence or challenge seems paradoxical.

Whilst the notion of autonomy as a regulative idea thatpromotes certain types of behaviour is helpful in under-standing this paradox, the comments of intervieweesand the message contained in the IIE materials raisequestions about who decides where the locus of controllies for particular sets of events and whether that under-standing is shared by all participants in the process.

Some employees who reported exercising a highdegree of autonomy were unhappy with this state ofaffairs, seeing it as an indication that the organisationdid not ‘give a damn’ about what it was that they weredoing, and as if to underline this, very few respondentsreported receiving any feedback on individual perform-ance. Autonomy appeared problematic in the context ofa changing environment where managers felt ill-equippedto carry out the ‘modernising’ of services for which nohistorical precedent existed and for which they hadlittle support:

I can see some of the stress that clinicians are going through.I’ve gone back into managerial situations and said, ‘Look –you’re gonna have to do something about this. Your recruitmentand retention figures are gonna be low … You’re not supportingthem. They’re frightened of being in clinical situations on theirown … They’re on their own they’re independent, they’reautonomous. “Oh, my God, this has never happened to mebefore what do I do now?” There are some young clinicianswho have real problems with that and we’re not helping them…’ (R30)

Whilst strategy documents and pronouncementsfrom the chief executive communicated the vision, thelack of detail in relation to the vision meant that somemiddle managers viewed their autonomous status asa millstone. Empowering staff appeared to mean hand-ing over responsibility to them for delivering the visionwithin limited resources, and numerous and conflictingstakeholder expectations.

The PCT had several service development leads withresponsibility for the opening of a new community healthand social care centre according to a strict constructionand design timetable. However, since the design,planning, building and financing of such centres was atotally new area for the PCT, there were no precedentson how this was to be achieved and no project plan.Nevertheless, without any training or guidance, theseleads were engaged in issues such as how the task ofdeciding which services would be located in the build-ing, how the chief executive’s commitment that manymore people could work from home was to be factoredinto the requirements for office space in the building,who was to fund the space that would be a communityresource for local groups as promised by the chiefexecutive, and how the town-centre sites would cope withstaff parking requirements. Satisfying the competingexpectations of PCT senior managers, the local authority,



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the community, the voluntary sector and other partnerorganisations within a fixed budget placed thesemanagers under great stress. During the course of theinterview, one lead admitted that autonomy was ‘a two-edged sword’, particularly in his new role where hefaced deadlines which were ‘ridiculous in the extreme’,and was responsible for everything from the services tobe located in the building, car parking and the numberof plug sockets required:

I don’t like getting involved in the building design becauseI’m not, by nature, an architect-type, numbers-type, area-per-square-metre-type person, and my thought process does notmatch that of the builders … We’re classed as a team, but we’renot a team. I prefer working as part of a team where we’ve gotobjectives, where we’ve got a plan, we’ve got a project outline,we’ve got something written down where everybody’s work-ing to the same goals. Well, we are working to the same goals,but what is not the same is how we go about it. I feel like I’mworking like a lone ranger within a team, which is difficult.(R10)

The inconsistencies and tensions between the sup-posed benefits flowing from being autonomous whilst,at the same time, working within the context of time-scalesand objectives imposed from above open up space forcriticism or resistance. The above respondent’s viewscan be said to reflect the exchanges observed betweenthe four development leads, none of whom appeared tobe basking in their new-found autonomy. However, thehigh public profile of the project, and the fact that theyhad to sell it to others in the PCT and beyond, coupledwith their status as previously ‘at risk’ employees, meantthat criticism was reserved for private exchanges. Allappeared reluctant to engage in more public displaysof resistance. For example, when asked to describe thedirectorate in three words at an away day, one develop-ment lead who had not participated in the IIE pro-gramme and was most vocal in his criticisms answered,‘Aldous Huxley’s

Brave New World

,’ but did not elabo-rate. Other members were critical outside of this settingwhen the director was absent, but chose words suchas ‘exciting’, ‘developing’ and ‘challenging’ at the away-day exercise.

Being autonomous where goals conflict

Interviewees tended to talk in terms of their own, ratherthan broader organisational, objectives. This emphasis onindividual goals is hardly surprising given the assump-tion in the IIE course that individuals are a seethingmass of unfulfilled goals. The autonomous individual isconstantly striving to achieve goals which are not imposedfrom above, but freely chosen as representing the indi-vidual’s true aspirations. When different PCT employeeshave goals which conflict with those of other PCT

employees, this can create tensions, particularly wheneach of these members of staff is being encouraged tomake positive affirmations on a daily basis about theachievement of their individual goals. Respondentsexpressed surprise and dismay at the failure of someother IIE participants to comply with their wishes:

In some ways, it [the IIE] added to my frustrations. My man-ager’s on this course. Is she not listening to this? I’m coming toher and being slapped down. (R27)

The emphasis in the IIE course on positive affirma-tions, not giving in to negative thoughts or self-doubt,and Maslow’s depiction of self-actualisers as having an‘older sibling’ attitude to others less fortunate (Maslow,cited in Tice 2004) all underlined the ability of the indi-vidual to determine the correct course of action and notbe diverted from it. This may explain why managerswere surprised when they encountered resistance fromothers. For example, one interviewee complained that‘the blockers’ were people who had been through theIIE course and ‘ought to know better’ (R10), and severalsuggested that certain members of staff should be senton the IIE course to teach them the error of their ways.However, in an organisation with multiple and conflict-ing goals, this behaviour, which was construed as resist-ance by one manager, may have represented the pursuitof organisational goals to another.

The subordination of individual or directorate goalsin the interests of achieving short-term targets imposedby Government and prioritised by senior managementwas also a source of stress for employees. For example,a senior member of the public health team was dis-mayed by the fact that others chose to prioritise waitinglists rather than tackling health inequalities. Althoughboth were the subjects of organisational targets, thetime-scale for achieving waiting list targets was moreshort-term:

Who are our allies? We don’t think we’ve got any, not peoplewho, when their back’s against the walls on access, will say,‘No we’re gonna put the money here.’ (R11)

Furthermore, the imposition of many short-termtargets from Central Government meant that the PCTwas unable to prioritise competing goals, with the resultthat some managers perceived their department’s statusas marginal and undervalued. A senior member of theTeaching and Learning team was disappointed by theway in which the PCT ‘top level’ had failed to appreci-ate its importance as a core function underpinning thePCT’s work, ascribing to it a discrete and peripheralstatus:

It should be underpinning and infiltrating everything in thePCT, but somehow, they see it as this tiny little bead that’ssitting on its own. (R12)


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Nevertheless, training or research initiatives, whichmay involve granting study leave or secondments, andserving long-term organisational goals may conflictwith short-term targets. Similarly, a senior member ofthe modernisation directorate felt frustrated that otherdepartments did not afford appropriate recognition tothe importance of her directorate:

We

are

the PCT, and for a long time, it’s felt like primary carewas just that bit bolted on to the side. (R5)

With so many targets relating to hospital performance,the PCT board is unlikely to be able devote as muchtime as it would like to the development of primary care.

Discussion and concluding remarks

The promotion of a discourse of autonomy can be seenas an attempt to introduce an efficient and indirect meansof controlling employees through organisational culture,with the IIE programme contributing to that process.However, the present research suggests that, whilstmany of those who have been through the programmeare happy to embrace this process and accept the specialstatus that they believe the label confers on them, not allemployees are easily convinced by such labels (Knights& McCabe 2000). Respondents certainly appeared to befocused on achieving national targets in relation to whatthey saw as their sphere of influence or area of respon-sibility. However, as two respondents pointed out,it is difficult to take issue with the aim of reducinginequalities and improving access to healthcare, andit is implausible to assume that the Downtown publichealth team have merely internalised values and targetswhich have been foisted upon them. Thus, to summa-rise an answer to the first question posed in this paper,the present case study suggests that the characterisationof employees as social dopes (Peters & Waterman 1985)is crude and inaccurate. The present authors’ findingsare consonant with earlier NHS studies of attempts tointroduce organisational change through top-downdecrees of ‘empowerment’. For example, Leverment

et al

.’s (1998) study of organizational change in a hospi-tal trust found that empowerment processes ‘as a resultof unilateral management initiative [were] regarded asan attempt at direct control by management’ (p. 137).Similarly, Joss & Kogan (1995) found little evidence ofstaff empowerment in their evaluation of Total QualityManagement in the NHS, and in one of the few studiesto examine the impact of organisational changeinitiatives on middle managers in the NHS, Currie (1997)concluded that the process ‘would have been more pro-fitably replaced by a programme which recognized wherethe managers were starting from rather than where theother stakeholders wanted them to go’ (p. 311).

Turning to the second and third questions, mostrespondents perceived themselves as having a degreeof autonomy in relation to the achievement of targets.However, this was seen by some as less of a blessingthan a curse in the context of inadequate resources, andlimited knowledge about the cause-and-effect relation-ships between PCT actions and health outcomes. Addi-tionally, commands from Central Government meantthat the PCT was unable to prioritise competing goals,with the result that some respondents perceived theirdepartment’s status as marginal and undervalued.

With regard to the third question that the presentauthors raised in their introduction, one means by whichtensions arising from the prescriptions of increasedautonomy were resolved was by autonomous individuals‘freely’ choosing to accept that certain activities werebeyond their sphere of influence. However, the frustra-tions expressed by many respondents suggest that noteverybody chose this course of action. Furthermore,workload pressures reduced the ability of employees toparticipate in events which they saw as important fortheir personal development. Such pressures are likelyto reduce the impact of programmes such as the IIE interms of their culture-shaping intents, and may leaveemployees feeling resentful or lacking in autonomy.The result may be to mitigate the transformationaland reconstitutive effects of a discourse of autonomy(exercised responsibly, as promoted by the IIE course)aimed at increasing commitment and contribution tothe PCT.

Much ‘management of change’ literature depictschange as something being driven by managers withhealth services employees being on the receiving end ofthe process (e.g. see Potter

et al

. 1994, Buchanan 1997).This assumes that managers are part of a unified whole,intent on controlling the productive capacity of theworkforce, but such a view ignores both the essentiallyequivocal role of managers in the labour process (Watson1994, Wilmott 1997) and the fact that, far from being incontrol of their environments, middle managers havebeen on the receiving end of major organisational changein the NHS in recent years (Procter

et al

. 1999). Events atDowntown PCT suggest that there are tensions betweenthe promotion of a discourse of autonomy and the needto control employees in order to achieve centrally deter-mined objectives within short time frames. Althoughthe data suggest that participation in the IIE programmehas reduced the potential for resistance in some quarters,it has also increased it elsewhere by creating expect-ations which are not fulfilled, or leaving staff feelingundervalued and demoralised. Thus, whilst the intentof initiatives ostensibly to increase autonomy might bethe creation of new forms of subordination, the resultmay be rather different (Alvesson & Willmott 2002).



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Acknowledgements

This work was undertaken whilst the lead author wasin receipt of a Department of Health National PrimaryCare R&D Award.

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