The effect of new public management on intensive care unit staff
The NHS is largely dependent on two groups of professionals – medics and nurses. Recent government changes support the development of a central role for management. The impact of these changes on the roles and relationships of those working in the NHS must be understood in light of the structures already in place within it. Medical dominance in healthcare decision‐making, nursing power emanating from the strength of the medical‐nursing relationship and the hierarchies within and between the two professions all affect and are affected by recent management changes. In intensive care a key feature of the context, insularity, had already significantly modified these structures prior to recent reforms. This paper starts by discussing and contrasting the response of medics and nurses to these changes before highlighting the differences in the way these changes have impacted on staff in intensive care. Analysis is based on data from an observational study of the formation of a new directorate and interviews with senior nurses, medics and managers in intensive care.
The Contradictory Simultaneity of Care and Technocracy: Understanding Vertical and Horizontal Pressures on English Nurse Middle Managers in Intensive Care
Part of the Coalition Government's health policy has been to enact austerity measures and restructure local health economies causing efficiency drives, even in trusts which are surplus-making. This paper evaluates the impact of this reconfiguration strategy on the intensive care workplace in London. To achieve this aim, a characterisation of the intensive care workplace is developed based on the perceptions of 10 nurse middle managers. It is demonstrated that the Coalition Government's reconfiguration strategy has been translated into the transformation of the intensive care workplace towards workforce restructuring, optimised asset utilisation and the beginnings of deprofessionalisation. However, top-down structural pressures comprise only one form of pressure bearing down on middle management with bottom-up pressures arising from the workforce and horizontal pressures emanating from the contradictory simultaneity of care and technocracy in the ICU. While technocracy tends to depoliticise the workplace, care can lead to instances of resistance, especially where patient need is affected so that the effects of reconfiguration are not linear or uniform.
Conflicts and context in managing the closure of a large psychiatric hospital
The slow progress in providing community-based care for mentally ill people and thus closing large psychiatric institutions has been well researched and documented. The enquiries have typically sought to demonstrate the gap between national policy intent and reality and have highlighted the structural, financial and organisational barriers to achieving new forms of service provision.1 Equally, an import ant recent study has shown that there are marked intra-Britain differences in how the assumed unitary national policy is interpreted and implemented.2 There isgeneral agreement that the present 'statutory framework' inhibits radical service change and, furthermore, that centralised planning, joint-work ing, joint-planning mechanisms are flawed and underpinned by a poorly formulated financial and manpower strategy.1 Some management 'process' factors have also been isolated such as the presence/ absence of clear leadership and 'committed local champions of change'.1'3 The issue of'interprofes sional tensions' has been only briefly alluded to. with even less recognition of how the other powerful or ganisational groups interrelate. Certainly, there has been little ethnographic detail of how these tensions between dominant groups arc played out at a local levelor indeed impinge on local decision-making and progress. More typically, existing accounts of the closure of the large institutions have had a structura list bias, with more emphasis upon the impact of re gional and national policy and on the machinery of collaboration than on internal politics or the effects of local power relations.3 As a corrective to this tendency to ignore internal dynamics, this paper looks at the significance of one strand of inter-organisational relationships, the management-clinician interface, and will illustrate, using detailed case study material from one hospital closure, how these internal relationships influence and constrain action. The data upon which the paper rests have been gathered as part of a larger investi gation into the 'Management of Change in the NHS'* based at the Centre for Corporate Strategy and Change at the University of Warwick and directed by Professor Andrew Pcttigrew, who has published widely on the management of strategic change in a range