POWER, MANAGEMENT AND COMPLEXITY IN THE NHS: A FOUCAULDIAN PERSPECTIVE JEAN ISABEL MATTHEWS A submission presented in partial fulfilment of the requirements of the University of Glamorgan for the Degree of Doctor of Philosophy February 2009 Power, Management and Complexity in the NHS: A Foucauldian Perspective Table of Contents Page No. Declaration..................................................................................................x Acknowledgements.....................................................................................xi Abstract.......................................................................................................xii Acronyms....................................................................................................xiii Glossary of terms ........................................................................................xiv Chapter One: An Introduction to the Thesis – Mission Impossible ............................................................................................... 1 Introducing the Thesis ............................................................................ 2 Physician Heal Thyself – The Agony and the Ecstasy .......................... 3 Prescriptions for Change – Modern Times ............................................ 5 Defining the Problem – What’s Up Doc! ............................................... 7 At Home in the NHS: An Alternative Reality – M.A.S.H .................... 8 Researcher Ambitions – Great Expectations .........................................10 The Structure of the Thesis – Murder on the Orient Express ..............11 Tales from the Silver Screen – The Last Picture Show ........................15 Chapter Summary ...................................................................................16 Chapter Two: Exploring the Discursive Landscape of Health Care – The Good, the Bad and the Ugly ..........................................17 Introducing the Hyperreality of the NHS - The Matrix .......................18 The Political Surface of Health Care Discourse – All the Presidents Men ...........................................................................................................21 The Evolution of British Health Care Policy – A Jewel in the Crown ................................................................................................22 The NHS in Wales – The Doctor and the Devils ...............................27 Political Statements of Health Care in Wales – Enter the Dragon ....28 A Quality Framework of Governance – Dead Ringers ......................33 Discourses Surfacing from a Managerial Field – How the West was Won ............................................................................................................36 ii Exploring Managerialism in the NHS – El Dorado .............................37 The ‘Opposition’ of Efficiency and Effectiveness – Keep on Running ...............................................................................39 Managerialism as a Rational Discourse – The Ladykillers ..................41 Managerialism as a Scientific Discourse – 9 to 5 ................................42 The Notion of Agent Commitment – The Three Musketeers ...............44 Discourses Surfacing in the Field Of Nursing – Carry on Matron ......47 An Historically Constituted Discourse – The Lady with the Lamp ...................................................................................................47 The Notion of Caring- Misery ..............................................................48 Exploring the Subordination of Nursing – The Stepford Wives ...........51 Nurses in Health Care Management – La Belle et La Bête ..................52 Discourses Surfacing in the Field of Medicine – Doctor in the House ........................................................................................................55 The Historical Emergence of a Medical Discourse – Hearts and Minds ..............................................................................................56 The Emergence of Specialist Knowledge – Look Who’s Talking .........57 Modernising Medicine – Dr. No ..........................................................58 The Perception of Doctor-Manager Conflict – Star Wars ...................61 Portraits of the Participating Context – Sliding Doors ........................62 The Trust’s Public Image – The Godfather .........................................63 The Partcipant’s Perspective – How Green was My Valley .................64 The Author’s Perspective – For Your Eyes Only .................................66 Conclusion to the Chapter ......................................................................68 Chapter Three: Moving Beyond Modernism – The Forbidden Kingdom ..............................................................................70 Introducing the Chapter .........................................................................71 Defining the Notion of Social Order – The Dirty Dozen ......................72 The Underpinning Ontology of Managerialism – Gremlins .................74 The Epistemic Constitution of Agency in Managerialism –Invasion of the Body Snatchers ..........................................................................76 Exploring the Ontology of Self in Managerialism – Pinocchio ............77 Midway on the Realist Continuum – Frankenstein ..............................79 iii Summary...............................................................................................81 Exploring an Alternative Paradigm of Social Order – Alice in Wonderland ...............................................................................................82 Restoring the Dynamic Ontology – Carousel .......................................83 Complexity, Self-organisation and the Importance of Noise – Butch Cassidy and the Sundance Kid ................................................85 The Concept of Compex Adaptive Systems Thinking – The Italian Job .........................................................................................................88 (Re)opening Systems to Co-evolution - 2001: A Space Odyssey ..........90 Human Systems as a Complex Adaptive System – Pirates of the Caribbean ........................................................................................91 Complexity in a Business Context – Mutiny of the Bounty ..................93 Did Gerry have the Right Idea in the NHS? – Die Another Day ..........96 Summary...............................................................................................97 Viewing Complexity through a Post-structural Lens – The French Connection .............................................................................................. 98 The Affinity of Compelxity and a Post-structural Discourse – A Beautiful Mind .................................................................................... 99 A Critique of Post-structural Critique – The Man Who Fell to Earth .101 Destroying the Notion of ‘I’ – Fight Club ..........................................102 Habitus as a Fractal Conceptualisation of Self – An American Werewolf in London ............................................................................104 The Relativity of Language – Lost in Translation ..............................105 Summary.............................................................................................107 The Discursive Constitution of a Complex Evolving System – Go .....108 Understanding the Nature of Discourse – Patriot Games ...................109 Revisiting the Epistemic Constitution of Self through Discourse – The Bourne Identity .........................................................................110 Understanding Discursive Practice as a Complex Adaptive System – Kaleidoscope ...................................................................................112 Discursive Practice Creating an Edge of Chaos Ontology – Sixth Sense ...................................................................................................113 Conclusion to the Chapter ......................................................................114 iv Chapter Four: Magical Expressions of Power – Monsters Inc. .........................................................................................................117 Introducing the Chapter .........................................................................118 Realist Conceptions of Power – Animal Farm ......................................120 Dichotomies of Power – The King and I ........................................120 Discursive Power: Ideological Notions of Control – My Fair Lady .................................................................................................123 Ideology in Organisational Management – La Dolce Vita ..............127 The Limitations of Ideology – Brave New World ...........................128 Summary.........................................................................................130 An Exploration of the Power Effects of Language – Look Who’s Talking Now ….........................................................................................130 Language as a Strategic Exercise of Power – The Mission .............131 The Power of the Speaker – The Great Dictator ............................134 Consolidating Truth as Text – The Greatest Story Ever Told ........136 The Language of Managerialism – Doctor in Distress ...................138 Summary.........................................................................................141