Managerialism and active citizenship in Britain's reformed health service: power and community in an era of decentralisation

PII: S0277-9536(98)00150-6

Soc. Sci. Med. Vol. 47, No. 4, pp. 507±517, 1998 # 1998 Elsevier Science Ltd. All rights reserved Printed in Great Britain 0277-9536/98 $19.00 + 0.00

MANAGERIALISM AND ACTIVE CITIZENSHIP IN BRITAIN'S REFORMED HEALTH SERVICE: POWER AND COMMUNITY IN AN ERA OF DECENTRALISATION TIMOTHY MILEWA*, JUSTIN VALENTINE and MICHAEL CALNAN Centre for Health Services Studies, University of Kent at Canterbury, George Allen Wing, Canterbury, Kent, CT2 7NF, U.K. AbstractÐThe creation of a large managerial stratum within the British National Health Service in recent years has been one of the most striking characteristics of reforms intended to develop a more ecient and ``business-like'' service. An accompanying political rhetoric of decentralisation has cast local managerial autonomy as a means to gauge and respond more easily to the needs and preferences expressed by local communities. This article therefore reviews the growth of the new managerial stratum with particular regard to its emerging relationship with the local populations in whose name the organisational reforms have been wrought. The dominant political interpretation of this relationship Ð that the organisational reforms constitute a movement from leaden ``bureaucratic'' administration to more locally accountable and responsive managerial regimes Ð is then tested with regard to an indepth study of two health authorities responsible for very di€erent local populations. Results show that the role of local populations in in¯uencing decisions and determining priorities is considerably less than inferred by the sustained political rhetoric in favour of the ``local voices''. Consideration of possible trends in the state and economy suggests however that this disjuncture may not be explicable solely in terms of the new managerial stratum maximising its in¯uence or of central government retaining a high degree of control. # 1998 Elsevier Science Ltd. All rights reserved Key wordsÐmanagerialism, managers, community participation, participation, local citizenship, local voices

INTRODUCTION

exposition. This article therefore focuses upon the nature of the relationship between local institutions of health care planning and local populations in the country associated by some with the most rapid health care reforms within a west European context Ð the United Kingdom (Ham, 1997). More speci®cally, the creation and rapid growth of a distinct managerial stratum within the British National Health Service (NHS) in recent years has been one of the most striking characteristics of reforms conducted in the name of a more ecient, responsive and ``business-like'' service (Butler, 1992). A political rhetoric in favour of local managerial autonomy has thus been premised not only on organisational eciency but also upon a perceived ¯exibility and attentiveness in relation to the needs and preferences expressed by local populations. This article therefore reviews the growth of the new managerial stratum in the British health service with particular regard to its emerging relationship with the communities in whose name the organisational reforms have often been justi®ed. The dominant political interpretation of this relationship Ð that the organisational reforms constitute a movement from a remote ``bureaucratic'' administration to more locally accountable and responsive managerial regimes Ð is then tested and discussed with regard to an in-depth study of two

Health care reforms in countries as diverse as Israel, Germany, Sweden, Brazil and the United Kingdom have typically been examined with regard to issues such as structural reorganisation, funding and the behaviour of particular interest groups (Consumers International, 1996; Huber, 1997; Theo®latou and Maarse, 1998). In this latter respect, the largest interest group of all, the citizens who fund and use health care systems run or regulated by the state, is also receiving considerable attention (Saltman, 1994; Fallberg, 1996; Tugend and Harris, 1997). The issue of citizens' empowerment in health care systems is being examined, for example, by the World Health Organisation's (WHO) network on the rights and responsibilities of citizens and patients and, similarly, has been the focus of the Council of Europe's international study group ``on the development of structures for patient/citizen participation in the decision-making process a€ecting health care'' (Council of Europe, 1997; WHO Regional Oce for Europe, 1997). Terms such as empowerment and participation are, however, possessed of an innate malleability that can only be given substance through empirical *Author for correspondence. 507

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health authorities responsible for very di€erent local populations. THE GROWTH OF MANAGERIALISM AND ``CONSUMERIST'' FORMS OF ACCOUNTABILITY

The early National Health Service in Britain Ð although concocted largely from a patchwork of existing public, voluntary and private services in 1948 and subject to considerable professional in¯uence Ð is often characterised as an example of a centralised, hierarchical bureaucracy. Indeed the Secretary of State for Health has from the service's inception remained functionally and legally responsible for the provision of ``a comprehensive health service designed to secure improvement in the health of the people'' (HMSO, 1977). Substantive discussion of local ``democratic'' accountability has thus tended to centre not upon formal electoral mechanisms but on di€erent strategies of consultation or participation (Gurney, 1994; Bowie et al., 1995; Mort et al., 1998). This part of the discussion therefore focuses upon the symbiotic organisational and ``ideological'' phenomena that have arisen in the absence of local democratic control. These are the growth of a distinct managerial stratum and ethos within the health service and a corresponding political emphasis upon an accountability based largely on the depiction of local populations as entities engaged in a form of public sector ``consumerism''. This form of accountability might however be more accurately described as re¯ecting an ethos of ``active citizenship''. Such a term serves to distinguish this form of accountability from what would be a contextually inaccurate conception of ``pure'' consumer sovereignty and, secondly, from the ideologically charged idea of ``passive'' citizenship that some on the political right associate with the unquestioning receipt of publicly funded health and social care (Green, 1992). In more substantive terms, the British health service in the post-war period was traditionally associated with the notion of hierarchical planning. By the mid-1970s this hierarchy encompassed the political executive and the Secretary of State who were responsible for formulating policy goals; civil servants in central government institutions charged with creating detailed policies; regional health authorities who supposedly informed the planning process and oversaw the realisation of national plans and ®nally Ð within England and Wales Ð ninety area health authorities responsible for the direct provision of secondary health care. In keeping with the bureaucratic ethos of the health service the boards of area health authorities were not subject to popular election. They instead consisted of a ``small and capable membership'' based upon nomination by the regional health authorities, hospital doctors, relevant trade unions and elected local authorities who could nominate up to a third of the

board of each health authority. This would, argued the government, allow health authorities ``to take a wide, unbiased and constructive view of the priorities across the whole range of needs'' (HMSO, 1972, p. 2). Local citizens were, implicitly, merely recipients of technocratic and medical expertise delivered in accordance with central planning and clinical judgement (Milewa, 1997a). This role though was susceptible to gradual change as the political consensus around the welfare state and economy began to unravel in the 1970s. The National Health Service Reorganisation Act 1973, introduced by a Conservative government, signalled the beginning of a very gradual move away from the mere administration of local health services to their pro-active management. For the ®rst time, health authorities were allowed to carry forward a proportion of their revenue from one year to the next. They could also, within very strict limits, use revenue funds for capital projects and Ð to a very limited extent Ð generate revenue from capital expenditure. A third change involved the formalisation of ``consensus management'' in hospitals. Between 1974 and 1984 each hospital had a consensus management team composed of an administrator, a treasurer, one or more doctors and a nurse. Each team had formal operational responsibility for the running of hospitals and a collective identity in dealings with the Area Health Authorities. In a fourth respect though, the government was of the view that any new provision for the representation of local communities would be most e€ective if it was allowed ``to concentrate on its own special function'' (HMSO, 1973, 9(1)). In this last respect, the legislation of 1973 created a series of Community Health Councils (CHCs) to mirror each health authority. These councils, which are still in existence, are required ``to represent the interests of the public'' in the local health services. As with health authorities though, members are not directly elected but instead appointed on behalf of the Secretary of State for Health, local government and selected voluntary sector organisations. Although the councils pursue individual complaints they only have a right to be consulted when ``substantial developments or variations'' in local health services are proposed. The government did not however provide a statutory de®nition of a ``substantial variation'' in services short of their permanent closure. Indeed health authorities were not required to consult the new councils if planned changes were described as ``phased'' or temporary (Longley, 1990). The Conservative government elected in 1979 was however to display an apparent commitment to the further devolution of management and accountability to a local level. In terms of local management, the 1982 National Health Service Act abolished the 90 Area Health Authorities and replaced them with 192 District

Managerialism and active citizenship

Health Authorities. The number of members of each authority board nominated by elected local councils was however reduced from a third to one quarter. Signi®cantly, each District Health Authority would be able to determine its own management arrangements and the remit of speci®c managers. It was thus at this point that the transformation from administrators to managers began to crystallise. Indeed there was within the government an explicit and growing sentiment that the use of business management methods might improve the service's performance by making it more accountable for expenditure decisions and issues of eciency. Consequently, in February 1983, Roy Griths Ð the managing director of a large supermarket chain Ð was asked to produce a report on the management of the NHS. Griths' NHS Management Inquiry reported in the same year. Among a number of recommendations, the report advocated the creation of a general management function with regard to the planning, implementation and control of services (Hunter and Williamson, 1991). Upon this basis, over the next three years general managers were appointed at regional, district and clinical unit levels. The regional and district managers were given responsibility for organising the ``management structure of their respective authorities to suit their preferences and local circumstances'' (Barrett and McMahon, 1990, p. 258). Hospital doctors were also encouraged to plan and take responsibility for clearly delineated management budgets. Consequently in England alone the number of general and senior managers in the health service was to grow almost ®vefold from just over 4600 in 1989 to nearly 23 000 in 1994. Over the same period the number of directly employed medical and dental sta€ increased by just 12.7% while the number of nursing and midwifery sta€ actually fell by over 12% (Government Statistical Service, 1996, p. 79). Accordingly expenditure on the pay of general managers rose from £25 million in 1987 to £251 million in 1991 Ð a ten-fold increase compared to a growth of only 60% in the total pay bill for nurses and midwives (Jones, 1992, p. 2). This explosive growth in the number and cost of managers did not in itself have implications for the relationship between health authorities and local populations until 1989 when a parliamentary bill, Working for Patients, was presented in terms of making ``the Health Service more responsive to the needs of patients'' and enabling ``hospitals which best meet the needs and wishes of patients to get the money to do so'' (HMSO, 1989, pp. 4±5). Again though, when faced with a notional choice between popular legitimacy and professional management of the health service, the government chose the latter. The ensuing legislation, the National Health Service and Community Care Act 1990 removed the right of elected local government to

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nominate any members to health authority boards and reduced the size of these bodies from 16±18 members to just 11 members, at least ®ve of whom would usually be ``professional'' executive managers. These executives and the non-executive appointees would be expected to ``discharge their responsibilities in a business-like way'' (HMSO, 1989, p. 65). The responsibilities would, in the reformed health service, centre upon planning and commissioning health care for local communities from public, private and not-for-pro®t ``providers''. It was this role for health authorities Ð the planning and commissioning of services rather than their provision Ð around which one of the most sustained political emphases upon managerial responsiveness to local views arose. In 1992 the NHS Executive produced a document, ``Local Voices'', which described a variety of mechanisms by which health authority managers could engage local people in a dialogue about health care priorities and planning issues. Suggestions included the use of surveys, focus groups, opinion polls and community panels (NHS Management Executive, 1992). This intervention received further momentum when, in 1993, the Health Secretary publicly insisted that health authorities and NHS providers ``must actively seek to encourage public participation in ... establishing priorities and in making decisions based upon them'' (Mihill, 1993, p. 2). Similarly, two years later another Health Secretary instructed all health authorities to provide him with written details of what they were doing in terms of engaging and ``listening'' to local populations. Subsequently, the annual planning document for the NHS as a whole, Priorities and Planning Guidance for 1996±1997, makes it clear that health authorities should concentrate upon ``giving greater voice and in¯uence to users of NHS services and their carers in their own care, the development and de®nition of standards set for NHS services locally and the development of NHS policy both locally and nationally'' (National Health Service Executive, 1995). In a similar vein the new Labour government, elected in 1997, committed itself to broadening the composition of health authority and trust boards in favour of greater local ``community'' representation and to transforming Community Health Councils into ``Local Health Advocates''. The membership of the latter will, the government argues, ``re¯ect the interests of the community'' and scrutinise health authority plans to ``ensure that processes are in place to enable patients'' views to be heard' (Labour Party, 1996, p. 294). From bureaucrats to public servants? The growth of a new managerial stratum in the British service has thus been accompanied not only by a recurrent emphasis upon decentralisation, operational ¯exibility and a more entrepreneurial

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ethos (Learmonth, 1997). There has also been an apparent sustained political concern to ensure that health authorities respond more eciently to the needs of their ``clients'' Ð local populations. Any attempt to assess historically the reality of this new emphasis upon a pro-active role for local populations is however limited by the organisational turbulence associated with successive reforms of the health service. Most obviously the relatively recent division between health care providers and those charged with planning services precludes any longterm historical comparisons. The investigation under consideration thus draws on the ®eldwork in order to compare the reality of the symbiosis between managerial culture and active citizenship with the political rhetoric. The emphasis is thus more upon the contemporary nature of the relationship between the unelected local state and local populations than the traditional focus on measuring the extent of ``real'' participation or involvement (Richardson, 1983; Beresford and Croft, 1990). METHOD

The ®rst phase of the investigation was based on an interview and documentary survey of twelve health authorities in the NHS Executive South Thames area in southern England, encompassing a population of almost 6.7 million people. This survey was designed to elicit descriptive data on how health authorities had formally engaged with their local communities with regard to particular service areas. Data was classi®ed according to a schema modi®ed from that employed by the NHS Executive in its review of ``Local Voices'' initiatives (Donaldson, 1995). The detailed descriptive results of this mapping exercise have already been considered elsewhere (Milewa et al., 1997). In order however to investigate some of the issues raised in the initial phase of the research in more depth two health authorities were selected to act as case studies. The documentation and interview data from the regional survey suggested at least four criteria for the selection of health authorities to act as casestudies Ð perceived levels of activity with regard to engaging local populations around issues of commissioning and prioritising health care; the socioeconomic pro®le of local populations and, thirdly, an urban-rural division in terms of geographical location. In a fourth, less formal, respect some consideration was also given to the political composition of local elected councils. Drawing on issues identi®ed in the ®rst phase of the investigation, themes and prompts were designed for semi-structured and non-standard interviews in relation to three broad issues apposite to health authority relations with local populations. These encompassed relevant organisational initiatives and programmes, organisational structures and intra-organisational attitudes. Particular issues that

were addressed included the genesis and rationale of particular initiatives; the deployment of relevant organisational resources; the managerial and functional ownership of resources and the degree to which preferences and priorities identi®ed by local people were or were not fed into decision making procedures. Pilot interviews were conducted with four informants and a further 41 individuals from the two health authority districts were selected for interview. Informants were identi®ed through consultation with chief executives and other health authority personnel, directly by the investigators and through a review of relevant health authority documentation. Their backgrounds ranged from chief executive level to junior management grades. All of the formal interviews were tape-recorded and transcribed but notes were also taken of less formal conversations. The analysis and validation of the qualitative data encompassed two stages. In the ®rst phase, one investigator applied a paper-based coding to each transcript, largely in accordance with the original thematic emphases in the non-standard and semi-structured instruments. Concurrently, but independently, another of the investigators applied comparable categories to the data via the ATLAS qualitative software package. In a second stage, the interpretations were considered and reconciled upon the basis of a re-examination of the data and triangulation discussions with an ``independent'' third investigator not involved in the initial codings. Overall, although the software package was more amenable to revision and thematic precision, both interpretations of the data Ð encompassing such themes as the organisational ownership of participatory initiatives and the use made of local public views that had been elicited Ð were comparable in terms of their focus and emphases. The case study health authorities The criteria for the selection of health authorities to act as case studies, discussed above, resulted in the identi®cation of two areas for more focused research Ð the pseudonymous districts of Redville and Bluetown. In terms of the ®rst criterion, ``levels of activity'' with regard to engaging local populations, Redville Health Authority appeared to be one of the more active of the twelve health authorities over a period of eighteen months. The authority's initiatives encompassed eight of ten possible methods of engagement in relation to seven of a possible eight service areas (Table 1). Conversely, although Bluetown Health Authority reported activity in seven of the eight service areas, respondents and documentation only referred to three principle methods of engagement Ð regular and ad hoc contact with formal and informal voluntary groups, liaison with health forums and, thirdly, distribution of a magazine produced by the health authority to all local households (Table 2).

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511

Table 1. Redville Health Authority: summary of formal non-statutory engagements with the local community by method and service area over eighteen months Service portfolio

Public meetings Voluntary group liaison Focus groups Themed forums Rapid appraisal Community initiatives Patient satisfaction surveys One-to-one interviews Public opinion surveys Combined/other methods

1

Acute

1 1

Primary care

1

2

In relation to the socio-economic pro®le of the two areas the age structure of the populations in the two health authorities was not radically di€erent and comparison of standardised mortality ratios revealed no obvious and fundamental contrasts. The ``class'' pro®le of the two areas, however, diverged considerably in some respects. The de®nition of class is of course open to considerable debate but one of the more enduring classi®cations used in ocial censuses within the United Kingdom is that based upon the occupational background of self-nominated economically active heads of household. Most notably, in Bluetown, the proportion of economically active heads of household classi®ed as ``professionals'' was 11.9% compared to a corresponding ®gure of just 5.1% in Redville, 8.2% in the NHS Executive South Thames area and 6.8% in England and Wales as a whole (Table 3). Indeed, Bluetown's own annual public health report describes the area as ``one of the most a‚uent districts in the country''. Accordingly, although the proportion of economically active household heads with ``managerial and technical'' occupations was over 45% in Bluetown, the percentage for Redville was less than 29%. Concurrently, the proportion of economically active heads of household in ``unskilled'' occupations was just 2.3% in Bluetown

Mental health

Special needs Community care

1 1 3 1

1 2

2

1 1

Health Public promotion awareness of planning issues

1

1

1

but over twice that ®gure in Redville. The corresponding ®gure for the South Thames area was 3.9% and that for England and Wales reached 4.4%. With regard to the geographical criterion both health authorities were situated in southern England. Redville however encompassed a largely urban and suburban area on the south eastern periphery of outer London with direct and rapid access to the centre of the city via private and public transport. Conversely Bluetown had a location and identity distinct from the capital. Bluetown's mixture of rural and suburban geography, encompassing some of the most a‚uent suburbs in the country gave it the reputation of a base from which commuters travelled from very comfortable homes to well-paid jobs in London. This was re¯ected in comparisons that arose on the fourth criterion Ð ``political culture''. Local elected councils in the Bluetown Health Authority area were usually dominated by the right-of centre Conservative party or Britain's third largest party, the centrist Liberal Democrats. Redville Health Authority encompassed two boroughs. One borough had traditionally been a Labour strong-hold and the other was ruled by a Labour and Liberal Democrat coalition at the time of the research.

Table 2. Bluetown Health Authority: summary of formal non-statutory engagements with the local community by method and service area over eighteen months

Public meetings Voluntary group liaison Focus groups Themed forums Rapid appraisal Community initiatives Patient satisfaction surveys One-to-one interviews Public opinion surveys Combined/other methods

Service portfolio

Acute

Primary care

Mental health

1

1

1

2

2

1

1

Special needs Community care

2

Health Public promotion awareness of planning issues

1

1

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Table 3. Occupational classi®cation of economically active heads of household (as a percentage of all households with an economically active head): 10% sample Classi®cation based on occupation of household head

Redville Health Authority (%)

Bluetown Health Authority (%)

NHS Executive South Thames (%)

England and Wales (%)

5.1 28.6 16.9 28.3 11.8 4.7 4.5 17.1

11.9 45.3 13.1 18.7 7.0 2.3 1.3 18.6

8.2 36.0 14.2 23.9 10.5 3.9 3.3 17.9

6.8 30.6 12.0 28.4 13.5 4.4 4.3 17.3

(I) Professional occupations (II) Managerial and technical (III) (N) Skilled occupations Ð non-manual (III) (M) Skilled occupations Ð manual (IV) Partly skilled occupations (V) Unskilled occupations Other Households with a retired head of household as a percentage of all households (Source: Public Health Common Data Set, 1995).

MANAGERIALISM AND THE LIMITS TO ACTIVE CITIZENSHIP

As noted, the ®eldwork data was considered in relation to three themes Ð organisational initiatives and programmes with regard to engaging local populations, associated organisational structures and relevant intra-organisational attitudes.

but non-prescriptive emphasis on engaging ``carers''. More speci®c initiatives included the health authority's regular liaison with two ``Local Voices'' groups established by CHCs to o€er ``ordinary'' local people the opportunity to raise and pursue general and speci®c issues relevant to local health services.

Organisational initiatives and programmes

Organisational structures

Clearly, no two health authorities are the same in terms of the extent and substance of engagements with their local populations. As Barnes and Wistow (1992) intimate, health authorities vary in their tendencies to rely upon intermediaries or proxies such as general practitioners or formal, established, conduits such as Community Health Councils rather than develop innovative methods of engagement. Indeed, simply with regard to the relationship between health authorities and Community Health Councils Buckland et al. (1994) identify at least four types of interaction that range from active partnership to confrontation. It was therefore necessary to gauge the extent and tenor of forms of engagement developed by the two health authorities in the study. In this respect Redville Health Authority appeared to be far more active than its counterpart in Bluetown both in terms of the number of such engagements and the breadth of constituencies that were addressed. Redville's engagements included (i) formal and semi-formal meetings with bodies such as Community Health Councils and local authorities Ð all of whom received draft commissioning intentions for comment; (ii) research on the health promotion needs of homosexual men and on facilities for interpretation in primary care consultations; (iii) established forums that involved users, such as joint panels with social services departments on learning disability and elderly services; and (iv) committees and panels around community care planning (including a voluntary sector liaison committee). Conversely, Bluetown health authority deliberately adopted a more focused approach. In the preceding year, several informants observed, the authority as a whole was committed to responding to the views of service ``users'' Ð in the following year there was a similar

Both health authorities regularly liaised with forums comprised mainly of family doctors Ð the ``Umbrella Group'' in Redville and the ``General Practitioner Forum'' in Bluetown. Redville had identi®ed seven localities based on clusters of general practices. As a result the authority had adopted a system of matrix working whereby relevant sta€ from di€erent backgrounds formed four ``locality teams''. Three of the teams were concerned with two localities each and a fourth team with the remaining cluster of general practices. Although an experiment with ``total'' health care commissioning at the general practice level was being conducted in one locality the exact direction of planning and commissioning at a locality level remained uncertain. The locality structures were however seen as an important basis for still closer liaison and co-operation with general practitioners in the area of needs assessment and thus in the determination of health care priorities. Indeed, in addition to the Umbrella Group seven ``lead'' general practitioners from the localities met formally with Directors of the health authority in a ``Partnership'' group. Bluetown was also committed to locality working with general practitioners. Ten ``Locality Groups'', composed largely of general practitioners, re¯ected a variety of degrees of involvement in planning and commissioning services although several forums already had responsibility for the commissioning of selected specialties. In terms of re¯ecting local public views and preferences, the health authority was encouraging the groups to examine ``how they tell the public that they are changing services that they commission at the moment'' (interview BH10). Accordingly some of the Locality Groups had adopted patient participation groups while others made use of newsletters Ð the precise role of the

Managerialism and active citizenship

``local voices'' had yet to codi®ed in any way though. The health authorities were also similar in that they each dealt with two Community Health Councils (CHCs). All of the four CHC chief executives, who were also interviewed at length, were in regular formal and informal contact with the health authorities. They all raised a number of unprompted concerns about speci®c services and decisions. These included the contested ``rationalisation'' of ophthalmology services; the development of cottage hospitals; investment in private hospital facilities within ``unused'' hospital facilities and consultation on eligibility criteria for assisted conception services. None of these disputes and debates led, however, in the course of the investigation to the exercise by the CHCs of their ``power of appeal'' to the Secretary of State for Health. Similarly, none of the disagreements assumed such an importance that they gained the sustained attention of the national media. Intra-organisational attitudes The description of organisational structures and that of organisational initiatives gave little indication of the signi®cance attached by health authority managers to local public views in comparison to their own attitudes and other relevant factors. Intra-organisational attitudes with regard to individual service users or communities have however been accorded varying degrees of importance in related studies (Milewa, 1997b; Harrison and Mort, 1998). Taylor's (1995) study, for example, of attempts by selected English health authorities to more closely ``involve consumers'' in commissioning health care revealed some variation among managers with regard to understandings of the ``consumer''. In this respect, the informants in Bluetown and Redville echoed the absence of clear de®nitions of the community or client/consumer/citizen. Six themes did however tend to recur. First, in terms of rationalising a concern with the ``local voices'', nearly all informants made reference to the role of political exhortation and policy guidance at the level of national government in enforcing at least the appearance of interest in the issue. Indeed, discussing the emphasis upon engaging local populations, Redville's chief executive observed that: If we were honest the driver is government policy... It has been forced nationally upon us. And we would ignore it at our peril because it's rising up the political agenda at a rate of knots and we would be very unwise not to respond. (s11bRH4)

Despite this perceived pressure there was, secondly, an apparent general support among informants for engaging and responding to local populations. A commissioning manager for mental health services in Bluetown Health Authority typi®ed the incantation of similar but vague intentions in this respectÐ

513

I think everybody needs to take on more of an ambassadorial role to help users of services and the public to understand what the diculties are and... to inspire people... to take more interest. (BH8)

In a third respect though, as the discussions focused upon just what such sentiments meant in practice, there was little consensus on the precise purpose of engaging local populations. Informants placed a variety of emphases upon imparting information, asking the public to contribute thoughts on health care priorities or simply engaging in the mechanics of consultation with no speci®c commitment to respond to popular sentiment. This variation perhaps stemmed in part from the use of such broad terms as the ``public'' or the ``local community'' both by informants and interviewers/co-discussants. It was however clear, in a fourth regard, that informants de®nitely did not see local populations in the terms that local politicians might de®ne electoral constituencies. Despite the political exhortations that had cast health authorities as quasi-representative ``champions of the people'' the day-to-day operational emphasis was upon identifying and working with speci®c groups and interests around particular themes as necessary. Bluetown's Director of Commissioning for mental health services summarised what was typically cast as the ``pragmatic'' approach: It's about looking for anyone who's a stakeholder. Sometimes it's through the political network in terms of [elected local] councillors... Sometimes it's local Councils for Voluntary Service because they tap into a wider network. Sometimes it's residents associations because they are very concerned about an issue of resettlement. (s11aBH6)

Indeed, in a ®fth respect, this emphasis upon the local contacts and ¯exibility of individual health authority managers appeared more important to many informants than the elaborate structures for the involvement of general practitioners or for locality-based working that had been developed in both organisations. Most notably, an ``ethnic minorities development ocer'' complained at some length about the lack of responsiveness to local views in the locality structures developed by Redville Health Authority: I asked [the locality managers] ``What are you doing on user involvement? What mechanisms are you going to use? How are you going to develop it?''. And one locality said ``That's nothing to do with us''... They were aware of it but they had no intention of doing it because they felt they couldn't within existing resources and time constraints. (RH5)

These ®ve recurring themes, in rejecting a mechanistic perception of local participation in favour of a far more malleable and Ð from the perspective of health authority managers Ð selective approach to engaging local populations, point to the dominant perception of the role played by health authorities. This role encompassed the identi®cation of local needs, the sifting of di€erent views

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and priorities and then the application of what was seen as professional judgement. Several informants emphasised at length the fact that it is health authorities and managers therein, rather than local people, who have a statutory responsibility for planning and commissioning health services. To the informants, such views did not constitute a paternalistic or authoritarian approach but instead represented a de facto organisational reality from which none of them could envisage a viable alternative. The chairperson of Redville Health Authority was thus clear that the organisation was not beholden to local public opinion but could instead take into account such views when it was deemed appropriate: I think the public would like to think they want to be involved. The bit they would like to involved with is making the positive decisions about things... They are very de®nitely much more anxious when they have to make decisions about what will not be done. Then, quite honestly, can you blame them for saying ``Well, that's what we have a health authority for!''? (RH10)

It was thus evident in both Redville and Bluetown that, at least for health authority managers, the role of local populations in in¯uencing decisions and determining priorities was considerably less than inferred by the sustained political rhetoric in favour of the ``local voices''. A reconsideration of the policy environment with regard to managerialism and active citizenship in the public sector health care within Britain does however suggest that it would be wrong to interpret this disjuncture simply in terms of the new managerial stratum defending or maximising its in¯uence. DISCUSSION

The results of the investigation in Bluetown and Redville have a relevance for the relationship between the ``new'' managerialism and local communities on at least two levels. Most obviously, one level centres on such relationships in the arena of individual health authority districts within the context of a ``quasi-market'' in the British health service. In a second respect though, the results of the study have a potential resonance within far broader conceptions of administrative and social change in the supposed ``post-bureaucratic'' era (Hoggett, 1991, p. 245). Initially, it is clear that there are some signi®cant parameters to radical change in local health service con®gurations simply as a result of managers proactively gauging and taking account of local public preferences and priorities. In one respect, the manner in which health authority managers should approach di€erent sections of the public is obviously subject to considerable professional discretion. Indeed, as the discussion of managerial attitudes in Bluetown and Redville indicates, such discretion appeared to exert considerably more in-

¯uence over the demarcation of and response to the ``local voices'' than organisational structures designed to enhance ``local responsiveness''. Moreover, the rhetoric surrounding the ``local voices'' in the shaping of health care provision has to be viewed in the context of the relatively new planning and commissioning function for the health authorities. Both Redville and Bluetown health authorities arose from mergers of smaller organisations and were still attempting to fully rationalise resources as basic as accommodation. Coupled with the historically limited emphasis placed upon the views of local communities in the planning and provision of health services, such diversions may go some way to explaining the striking dissonance between the political rhetoric and operational realities. In another, perhaps more fundamental, regard the assumption Ð implicit in early political rhetoric and documents such as Local Voices Ð that health authority managers simply decide which health services to plan and then commission is over-simpli®ed. It is increasingly clear that the planning and commissioning of health care is subject to a number of in¯uences against which local public preferences have to be weighed. Accordingly, comments from informants on the more obvious of these additional factors thus touched upon the geographical limits to the purchase of services and the need to maintain or develop relationships with local health care providers Ð sentiments presaged or echoed in other empirical investigations within Britain (Pickard et al., 1995; Baeza and Calnan, 1997). The data accrued in Bluetown and Redville thus indicates that the introduction of the ``internal market'' within the health service has so far only made issues surrounding the planning and prioritisation of services more explicit. The experience within the two health authority districts illustrates that this visibility and the development of a distinct managerial function have not, in themselves, led to a signi®cant increase in the in¯uence of local populations. From a second, much wider, perspective the results may give an interesting picture of how broader changes in the nature of modern state management relate to the admittedly opaque notions of ``community'' or ``citizenship''. The political arguments in favour of organisational reform have typically justi®ed and interpreted the organisational changes to the administration of the British health service as essential to the development of ``professional'' management practice. Paradoxically, despite this emphasis upon conscious political intervention, the results of the investigation may re¯ect elements of trends that are subject to broader understandings of post-bureaucratic or ``postFordist'' managerial characteristics within the public sector. Such understandings rest on the claim that structures in the economy, society and the state that

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have shaped life are becoming far less rigid. At the economic level, the growth of a global market and international investment have eroded traditional structures of manufacturing industry. This in turn has begun to undermine traditional industrial politics and divisions of class based on labour. In another respect, technical developments mean that many ®rms no longer have to organise themselves hierarchically in one location. Centres of production, control systems, the acquisition of raw materials, marketing and after-sales service can be dispersed and relocated with relative ease. But it has also been suggested by some that these changes are evident in the administration and management of health and welfare services (Jessop, 1991). The declining ability of the state to plan or direct industrial investment, prevent the decline of manufacturing and avoid the e€ects of developments in the wider global economy have, it is argued, undermined the credibility of traditional ``top±down'' planning. The idea of highly centralised bureaucratic state administration is no longer seen as tenable. Welfare systems are thus becoming far more ¯exible and decentralised. ``Instead of running large salaried health and social care services, the state will buy-in services from a range of free-standing state, voluntary sector and private for-pro®t agencies'' (Taylor Gooby, 1993, p. 461). In the case of the health service this decentralisation and ¯exibility has taken the form of a locally based ``quasimarket'' overseen by reactive and pro-active managers rather than a bureaucratic, centrally administered hierarchy. From this perspective the advent of a more pro-active and entrepreneurial role for managers within the state is not simply the product of neo-liberal political ideology but the outcome of far broader economic and cultural change. Such a broad interpretation of economic ``cause'' and social-administrative ``e€ect'' does not however preclude the role of particular governments and institutions in mediating and shaping policy ``regimes'' in response to pressures for ¯exibility and decentralisation (Jessop, 1983, p. 100). The exact nature of reform thus varies considerably. The ``top±down'' structural changes imposed in the United Kingdom contrast with the more consensual, incremental, approach in The Netherlands and the decentralised ``bottom±up'' in¯uence exerted by county councils in Sweden. Accordingly, the distribution of institutional and interest group power and inertia represents an omnipresent in¯uence upon the degree to which the political language of reform Ð such as the rhetoric in the United Kingdom of ``business-like'' management and ``responsiveness'' to local communities Ð is actually re¯ected in substantive change (Ham, 1997). Indeed, the extent in this instance to which managers within the British health service could be cast as truly ``entrepreneurial'' or autonomous was seen in the study to be highly quali®ed. The political

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executive and central government departments retain their traditional control over macro budgetary allocations and policy as a whole. Thus, although the results in Bluetown and Redville illustrate the ``contingent discretion'' of health managers, the ideology and practice associated with a pro-active or ``re¯exive'' role on the part of state management may not re¯ect or be attuned to any corresponding ``new'' ¯exibility and collective assertion of identity on the part of local citizens. This would re¯ect a lack of synchronicity between the political-administrative institutions of debate and change and corresponding social constituencies. The form taken by the new managerialism may thus either be failing to evoke or is not engaging with an equally nascent ``life politics'' Ð a social phenomenon associated with the post-bureaucratic or ``late modern'' age by Giddens among others (Giddens, 1991). These ``life politics'' are seen to re¯ect agitation, negotiation and contestation by individuals and collectivities and have two de®ning characteristics. First, this form of politics is increasingly beyond the formal political and administrative channels that are supposedly associated with the epoch of bureaucratic top±down planning. In another, possibly more signi®cant, respect the new politics re¯ect the end of a largely passive role for citizens in the receipt of state services. Against the background of this theoretical conjecture the relationship between the new public sector management, the British polity and the ``re¯exive'' basis of active citizenship would appear to be illustrated very clearly in Bluetown and Redville. The autonomy and discretion exercised by the managers tended to operate within parameters inherent to the traditionally centralised nature of political control over the health service and other areas of welfare in Britain. The post-bureaucratic managerialism remained however inherently limited in terms of rede®ning the relationship between local institutions of the state and local populations. The mechanisms by which managers engage local communities may thus change but this does not signal a substantive change in the ideology and e€ective practice of the relationship therein. CONCLUSION

The 1989 white paper, Working for Patients, and guidance exempli®ed by the 1992 document, Local Voices, appeared to re¯ect a concern to foster greater dialogue and responsiveness to local populations on the part of managers. Although these developments were accompanied by an emphasis upon local managerial autonomy in the planning and commissioning of local health services such changes have however to be viewed in the context of a highly centralised state. The managerial ¯exibility introduced in the health service re¯ected a highly contingent devolution of power that, despite

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the introduction of a quasi-market structure, did not dis-aggregate the essentially hierarchical nature of control over the health service. The reforms therefore constituted an ``internal decentralisation'' rather than the thorough-going ``external decentralisation'' that would have led to the e€ective disavowal of operational control and thus to the development of quasi-independent community relations strategies within health authorities. The legislative and organisational changes thus appear to have raised the issue of local empowerment but not stipulated any new basic principles or rights to underpin the plethora of consultative or participatory mechanisms employed by health authority managers. Upon this basis the relationship between the new managerial stratum and local communities continued to be marked by an ethos based upon an essentially passive role for local populations in relation to the nature and priorities of public sector health care. Accordingly, the political concern to create a pro-active managerial role at the level of local populations and thereby facilitate greater dialogue with and participation by local communities has been marked by at least some element of theatre. This may have signi®cant consequences in terms of whose voices are truly heard as implicit and overt processes of prioritisation and rationing assume an increasing importance within a health service upon which most British citizens are dependent. AcknowledgementsÐThis article is based on the results of a project funded by the NHS Executive South Thames, Incorporating Public Views into the Health Service Purchasing Process (RD 125.00). Comments from two anonymous referees are gratefully acknowledged and we thank all of the interviewees for their time and help.

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