Between Organizations and Institutions. Legitimacy and Medical Managers

Abstract

INTRODUCTIONThis article focuses on how the National Health Service, as a major public service organization, operating in a dynamic environment and utilizing complex processes of human interaction to deliver health care, creates and manages legitimacy. During the late 1990s the NHS embodied a particular series of changes which demanded novel responses from managers, clinicians and service users in relation to governance and professional standards. Most challenging of all are the attempts being launched to exert influence over the organization and management of clinical services, through clinical governance systems which create 'shared forums' for quality improvement (Scottish Office/Department of Health 1998). The emphasis here is to draw upon theoretical constructs of legitimacy and discourse as organizing schema for making sense of such change processes. The role of doctors who assume managerial duties will be examined as a prominent feature of the reform programme.The problem of sourcing, building and maintaining legitimacy in the NHS is viewed through the new medical managers' representations of their role in the devolved management structures of the NHS in the 1990s. The new medical managers are clinicians who take on a management position within NHS trust organizations. As argued elsewhere the NHS has been for the first fifty years of its life, essentially a federation of professional tribes, each with their own social practices and inclination to attach different subjective meanings to health care processes (Hunter 1994). The new medical managers are seen as occupying a position between the organization that is the NHS trust and the profession-based institutions. Their part in creating an integrated corporate form of legitimacy is of some importance for the NHS in the next century. The developments under examination may signal a radical departure from earlier organizational practices, which relied on finding accommodations between professional tribes, whose insistence on high levels of autonomy was normally tolerated. THE NHS AND LEGITIMACYThe NHS has traditionally relied on strong sources of societal legitimacy, derived from the extent to which its patients, employees and the public at large were persuaded of the integrity of familiar values and processes. In part, legitimacy was derived from the role played by professionals. Hogg (1999 p. 7) writes that 'doctors are expected to be experts, adhere to high ethical standards and not make mistakes'. However, the raw evidence contained in electoral surveys, also consistently demonstrates public support for the National Health Service as an organization. Nigel Lawson, a prominent politician of the right during the 1980s, described the NHS as the nearest thing the British had to a national religion (Timmins 1996, p. 453). In short, the NHS has seemed to deliver health care in the 'right way' and has, more than any other organization, fulfilled the principles of the postwar settlement struck by Labour in the late 1940s. It has been an organization, which has bee...

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