Shana Vijayan Thesis.Pdf
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Performance Anxiety: The nature of performance management in the NHS under New Labour Shana Vijayan Thesis submitted for the degree of Doctor of Philosophy Department of Science and Technology Studies University College London 0 Declaration I, Shana Vijayan, confirm that the work presented in this thesis is my own. Where information has been derived from other sources, I confirm that this has been indicated in the thesis. 1 Abstract This thesis explores both the proliferation and prominence of ‘performance’ in the NHS, focusing on the New Labour years from 1997-2010. The research’s main objective was to understand how performance policy impacts the work-place experience: to understand the nature of work undertaken by performance managers, the tools used and the effect of these techniques. The secondary objective was to understand the goals of performance management. The introduction and rise of performance saw a change in expert authority. A new set of professionals had arrived in the NHS: regulators, auditors and performance managers. This thesis looks at the performance managers’ body of expertise, drawing upon several forms of qualitative research. The primary research tool used was institutional ethnography, which included focused interviews, a case study and experiences and notes gathered during a period based as a participant in NHS organisations. Documentary analysis carried out in the first phase of this thesis revealed that the principal rhetoric employed by politicians concerned the function of performance management in reducing risk and harm to patients. However, further research based on interviews and ethnography suggests that performance was experienced as a process of rationalisation and stigma, with risk rarely mentioned in the same way as in policy documents. In particular, various aspects of rationalisation, including measuring, quantifying and tabularisation, were deployed, these processes being a means for state surveillance. Performance, it will be argued, was part of the bureaucratic machine by which efficiency and effectiveness were judged in areas where the state previously had little knowledge or information. The research draws heavily on approaches in Science and Technology Studies to consider ‘performance’ and audit as a form of socio-technological intervention as well the Sociology of Health to inform issues of organisational and work-based stigma. 2 Acknowledgements “Our doubts are traitors, And make us lose the good we oft might win By fearing to attempt.” "Measure for Measure", Act 1 Scene 4 My brother humorously refers to my thesis as my memoirs and to an extent he is right. It has taken up a substantial part of my life, at moments consumed me and at times almost defeated me. Yet, now I have reached the end, it seems appropriate to thank the following people. Firstly, the girls I met in Kenya whose enthusiasm for education reminded me that learning is an attitude to life and encouraged me to return to university. The three wise men, my supervisors, Brian Balmer, Graham Scambler and Charles Thorpe, have been central to this process; they see my potential and give me confidence in my abilities. Anne Coulson, a woman with a way with words, who edited this work and enabled me to find my voice to speak with conviction during my viva. Fellow students in the STS department helped sustain my enjoyment of my subject when it was on the wane. “Team Shana”- my support squad, friends who unflaggingly believe in me and cheer me on from the sidelines. My parents, who put up with me, pushed me to be better and ensured the completion of this research project. Finally, this thesis would look very different without the input of NHS staff who gave up their time to talk to me. To all of them a heartfelt thank-you. London, August 31, 2013 3 Contents Declaration 1 Abstract 2 Acknowledgements 3 Preface 9 Abbreviations 11 Diagrams and Tables An overview of NHS structure as proposed in 2001 35 Models of accountability 43 Ideal type contradictions: managerial / professional 44 Competence and caring in relation to building trust 73 Forms of trust relations 75 Working relationships for Heads of Performance 97 Translation of strategy into action 124 Chapters 1 Introduction 12-20 2 The History of NHS Performance Management 21-53 2.1 Formation of the NHS 21 2.2 The NHS under the Conservatives; the formative performance years 24 2.3 The NHS under New Labour; performance becomes modernisation 30 2.4 Reform of the NHS 38 2.5 The role of trust: the medical profession and the NHS 39 2.6 Autonomy within the medical profession 40 2.7 The New Public Management 42 2.8 Management as a new type of work 45 2.9 Notions of Governance 46 2.10 Performance management: a tool for increased accountability? 47 2.11 The role of regulatory bodies vs. performance management as a regulatory instrument 49 4 3 Theoretical Background: Rationalisation, Risk, Audit & Stigma 54-90 3.1 Overview 54 3.2 Bureaucratic regimes and their effects 54 3.3 The rise of the Public sphere 65 3.4 Historical examples of the State as a social engineer 67 3.5 Understanding various approaches to risk 68 3.6 The work and function of risk 69 3.7 Professional life in the Risk Society 70 3.8 Trust within the Risk society 72 3.9 Accountability and Trust 73 3.10 Audit as form of accountability and a tool for risk management 75 3.11 Language as work 77 3.12 The language of illness; its role in healthcare 79 3.13 Conclusion 83 4 Methods 91-119 4.1 Introduction and overview to methods 91 4.2 Rationale for Chosen Method 93 4.3 My role as an institutional ethnographer 95 4.4 The use of in-depth focused interviews 99 4.5 Sampling and data collection 101 4.6 Coding and Interpretation 102 4.7 Using the 18 weeks policy as a case study 103 4.7.1 Introduction to 18 weeks initiative 103 4.7.2 Political background and detail to 18 weeks policy 103 4.7.3 Research Questions 110 4.7.4 Sources and Methods behind 18 weeks case study 111 4.8 Discourse Analysis on Department of Health 113 4.9 Summary of Ethical considerations 116 4.9.1 Gaining informed consent 117 4.10 Applying for and achieving ethics approval 118 5 Results - Risk: Solely State Rhetoric 120-160 5.1 Introduction of Performance to eliminate risk 120 5.2 Performance managers as risk minimisers 122 5 5.3 The Balanced Scorecard: strategy into action 123 5.4 Star ratings: encouraging success, marking out failure 126 5.5 Planning: forecasting the future 132 5.6 Do performance managers increase accountability? 135 5.7 Fundamental flaws: when disaster strikes it is neither new nor unexpected 139 5.8 Seeking assurance or requiring reassurance 141 5.9 Collaborative working: covering all bases 142 5.10 Lack of feedback and follow-up invalidates conducting lengthier reviews 144 5.11 Achievement of targets are dependent on organisational ownership 145 5.12 Ineffective measuring creates a false sense of security 149 5.13 The role of IT in reducing risk 151 5.14 Conclusion 158 6 Results - Rationalisation: Statecraft Work 161-206 6.1 Organisational Rationalisation 161 6.2 Measuring, quantifying and evidence 168 6.3 Arbitrary nature of targets and measures 177 6.4 Tabularisation; its purpose and proliferation 180 6.5 The rationalisation paradox 186 6.6 Transparency and Gaming 189 6.7 Rationalisation and increased bureaucracy 192 6.8 Economy, Efficiency and Effectiveness 195 6.9 State surveillance 199 6.10 Conclusion 204 7 Results - Stigma: Stigmatised Staff, Stigmatising State 207-254 7.1 Defining stigma 208 7.2 The discourse of Stigma and Organisational Change 209 7.3 Four aspects of stigma: time, conflict, communication & tribe/community 210 7.4 The discourse of Stigma and Policy Implementation 227 7.5 The political imperative to policy 236 7.6 The disenfranchisement of the consultative approach 241 7.7 The language of stigma 244 7.8 A dictionary of terms 247 7.9 Language applied: conversation decoded 248 7.10 Conclusion 252 6 8 Conclusion 255-268 8.1 How this research advances our understanding of NHS performance management 256 8.2 Performance management post-New Labour 259 8.2.1 Francis Inquiry 261 8.2.2 Francis Recommends 262 8.2.3 Keogh Review 263 8.2.4 Berwick Review 265 8.3 Future directions of this research 267 Appendices Appendix A: Roles of staff selected and interviewed 269 Appendix B: Participant Information Sheet 270 Appendix C: Consent Document 271 Appendix D: Balanced Scorecard for PCTs 272 Appendix E: 18 Weeks Executive Dashboard for NHS Commissioners 274 Appendix E: 18 Weeks Executive Dashboard for NHS Commissioners 275 Appendix E: 18 Weeks: Executive Dashboard for NHS Providers 276 Appendix E: 18 Weeks: Executive Dashboard for NHS Providers 277 Appendix F: Glossary of 18 weeks terms 278 References 281 7 “Reputation is an idle and most false imposition: oft got without merit, and lost without deserving” “Othello,” Act 2, Scene 3 8 Preface My interest in audit systems stems from working in NHS performance management between 2000 and 2010. I am interested in how the NHS is held to account and the means and methods of accountability. My career in the NHS began within Patient Information at a hospital Trust, where I worked on Chapter 10 of the newly published NHS Plan. I ensured patients had access to clear and accurate information on all aspects of their care. This is one of the key documents I look at in more detail as part of my research.