It was also clear that there could be a strong self-referential bias that acted as a constraint on the direct import of management knowledge and ideas into practice:
The other phrase that is used a lot here is ‘Don’t reinvent the wheel’, so if another NHS trust has done something, well let’s just do that. Let’s copy what they’ve done. Let’s use their papers and their process, rather than ‘Is that the best way?’.
Research elsewhere has demonstrated that importing established best practices across health-care organisations is by no means a straightforward exercise, as those practices still need to be properly embedded in the local context and, in the process, contend with existing interest groups and their practices.30However, what is nicely crystallised in the above quote from Christian is the privileging of home-grown management systems and practices that may owe some debt to a wider, more diffuse management knowledge base, but which are shaped and driven more by local practical conditions and constraints. The following quote nicely captures the emphasis on cure rather than prevention this could reinforce:
I’m trying to bring in the ideas of concepts of service improvement, because the other thing here I would say is people identify that there’s a problem and they jump straight to solutions . . . It’s the natural thing to do. What I’m trying to get them to do is saying well, hang on a minute, why have we got the problem? They don’t answer that, they put sticking plasters on things all the time. Another plaster, another plaster, and the problem is never resolved properly because you never understand why we’ve got a problem in the first place
Melissa, general, Acute
The institutional requirements on trusts to meet expected standards of care and to do this according to
expected performance standards [as defined by Care and Quality Commission (CQC), Monitor, etc.] was
principal among these conditions and constraints. This emphasis on monitoring of levels of care and performance had clear consequences not only for the balance and focus of managerial effort, but also for the primacy attached to locally situated management knowledge that was embedded in systems and processes (as opposed to more abstract management ideas and practices). For example:
We already have integrated psychological services, we already have a really, really high standard of quality. We’ve implemented a thing called CAPA, which is a Choice and Partnership Approach, to manage our demand and capacity and, within that, comes the need for very clear pathways, review, constant review, flexibility of services, listening to what users want . . . We’re perceived, within the directorate, as being quite structured, quite robust and a lot of those principles fit with the IAT [interauthority transfer] principles, particularly CAPA, the separation of an assessment and a treatment process and making sure it’s evidence based, and meaningful, and collaborative.
Gabrielle, general, Care
It was clear that external institutional pressures, to the extent that they required more recording and reporting of information about performance in relation to targets, predisposed the trusts to apply and/or develop management systems and procedures that were geared towards standardisation and formalisation of process. As such, they could reinforce a more bureaucratic tendency in managerial work:
We still have to evidence that the quality of care that you are providing is at a level that the PCT don’t want to de-commission this service. So without saying unless you do it we’re not going to have money for your team any more, therefore you are going to be out of a job . . . [the] messages that we try to get across to them, actually this is about protecting the organisation by providing this information. It’s just the nature of the world . . . you all have to be able to evidence what you’re doing.
Carl, functional, Care
This did not necessarily mean that the organisations were seen as acting overall lessflexibly. At the care
trust, for example, a clear distinction was drawn between the imperatives of what Mintzberg111might
define as the machine bureaucracy operating within the organisation’s administrative core111and the
greater degree offlexibility and responsiveness found at the executive level.
KNOWLEDGE
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However, it did mean that pressures towards standardisation could work against attempts to develop distinct management practice targeted at the needs of particular parts of the organisation:
The organisation needs you to be able to tick their boxes, so being able to understand their must-dos and their must-haves and their givens, the data stuff – if you can pay attention to that and translate your activity into that in a comprehensible way that, that can carry you a long way.
Laura, general, Care
It also meant that one of the continuing challenges facing all of the trusts we looked at was the tension that existed between corporate attempts to standardise and rationalise processes and practices and the more localised, situated and embodied practices that managers continued to try to adopt within their own parts of the organisation.