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An Examination of the Negotiated Order of Nhs Commissioning: a Case Study of a Clinical Commissioning Group “Decisions in the Absence of Objectivity”

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An Examination of the Negotiated Order of Nhs Commissioning: a Case Study of a Clinical Commissioning Group “Decisions in the Absence of Objectivity” AN EXAMINATION OF THE NEGOTIATED ORDER OF NHS COMMISSIONING: A CASE STUDY OF A CLINICAL COMMISSIONING GROUP “DECISIONS IN THE ABSENCE OF OBJECTIVITY” SIMON N. COX A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS OF NOTTINGHAM TRENT UNIVERSITY FOR THE DEGREE OF DOCTOR OF PHILOSOPHY JULY 2018 1 AN EXAMINATION OF THE NEGOTIATED ORDER OF NHS COMMISSIONING: A CASE STUDY OF A CLINICAL COMMISSIONING GROUP “DECISIONS IN THE ABSENCE OF OBJECTIVITY” “Reason is, and ought only to be, the slave of the passions and can never pretend to any other office than to serve and obey them.” David Hume (1978) “In crashing obviousness lies objectivity.” Daniel Dennett (1992, p.80)1 This work is the intellectual property of the author. You may copy up to 5% of this work for private study, or personal, non-commercial research. Any re-use of the information contained within this document should be fully referenced, quoting the author, title, university, degree level and pagination. Queries or requests for any other use, or if a more substantial copy is required, should be directed in the owner(s) of the Intellectual Property Rights. 2 Abstract Decision-making is a significant part of the business of board level activity in NHS organizations, including the recently created Clinical Commissioning Groups (CCGs). This research explores the behaviour of decision-makers within a CCG as part of a detailed case study focussing on a major strategic decision and looking at the various influences present. The aim being not merely to describe the decision and its outcomes, but to investigate the social interactions of those charged with making the decision and how the influences shape the eventual outcome. The analysis used the concept of the negotiated order, analysing the texts produced in a series of decision-making meetings and qualitative interviews with the decision- making participants. Data was analysed through critical discourse analysis within a case study research methodology. Thus, the textual data and generated narratives provided the evidence for how the social relationships and interactions emerged in the case study. The decision-making process demonstrated the negotiated order being created through the power relations of the participants with formed coalitions using and re-shaping cognitive frames. The interpretation of the research findings produced a social power model for organizational decision-making, shaped by the use and exchange of frames within the discourse. This is considered an original contribution to knowledge and supports the further development of the concept of the negotiated order and the use of cognitive frames within organizations. There are a number of implications for management practice that may improve decision-making and help further explorations into upper-echelon behaviour. The research is one of the first to explore the clinically led NHS CCGs and is and a rare example of detailed scrutiny into NHS decision- making. Furthermore, the research has a relatively unique position of the researcher as a participant observer already established as a senior position within the organization being studied. This provides a significant contribution to the body of knowledge and research practice of ethnography. 3 Table of Contents Abstract ....................................................................................................................... 3 Table of Contents ........................................................................................................ 4 Chapter 1 - Introduction ............................................................................................. 10 In the beginning ..................................................................................................... 10 Research questions and objectives ....................................................................... 11 Background, motivation, and practitioner context .................................................. 12 Strategic context and organizational strategy ........................................................ 16 Case study decision-making subject ...................................................................... 17 The decision-makers and the decision-making bodies .......................................... 19 Original contribution to knowledge ......................................................................... 22 Tolstoy, the battlefield, and me .............................................................................. 23 Structure of the document ...................................................................................... 25 Chapter 2 - Literature Review .................................................................................... 27 2.1 Introduction .......................................................................................................... 27 2.2 What is strategy? ................................................................................................. 29 Not just any old plan .............................................................................................. 29 Introduction ............................................................................................................ 29 Definitions and origins ............................................................................................ 30 Strategy as a management concept ...................................................................... 31 Approaches to strategy .......................................................................................... 37 Strategy in a real-world public sector context ........................................................ 39 Concluding discussion on strategy ........................................................................ 42 2.3 What is a decision? What is a strategic decision? ............................................... 44 Sociology and strategy ........................................................................................... 44 Introduction ............................................................................................................ 44 Definition ................................................................................................................ 45 Strategic decision-making process and structure .................................................. 46 Decision-making models ........................................................................................ 48 Prospect Theory ..................................................................................................... 52 System 1 thinking as Fast and Frugal Heuristics ................................................... 54 Decision-making behaviours: heuristics and biases; and habits and backgrounds ............................................................................................................................... 56 4 Strategic decision-making tools ............................................................................. 58 Concluding remarks on strategic decision-making ................................................ 59 2.4 Negotiated order and group decision-making ...................................................... 61 No such thing as… ................................................................................................. 61 Introduction ............................................................................................................ 61 Group behaviours in decision-making .................................................................... 62 The organization: as a coalition ............................................................................. 64 Negotiated order and negotiated environment ....................................................... 67 NHS Boards ........................................................................................................... 70 NHS Boards as negotiated orders ......................................................................... 75 Agency and Stewardship Theories ........................................................................ 75 Tools of negotiation: exploring the role of power ................................................... 77 Concluding remarks on group decision-making ..................................................... 82 2.5 What is commissioning and healthcare commissioning? .................................... 85 Still barking up the tree .......................................................................................... 85 Introduction ............................................................................................................ 85 Comparative commissioning .................................................................................. 88 Policy approaches to healthcare commissioning ................................................... 88 Concluding remarks on commissioning ................................................................. 91 2.6 Frames and influences in the decision-making environment – Developing the conceptual framework ............................................................................................... 93 The moralization gap ............................................................................................. 93 Introduction ............................................................................................................ 93 Framing .................................................................................................................
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