Between Organizations and Institutions. Legitimacy and Medical Managers
| Author | Gordon Marnoch,Nicola Dinnie,Lorna McKee |
| Date | 01 December 2000 |
| DOI | http://doi.org/10.1111/1467-9299.00240 |
| Published date | 01 December 2000 |
BETWEEN ORGANIZATIONS AND
INSTITUTIONS. LEGITIMACY AND MEDICAL
MANAGERS
GORDON MARNOCH, LORNA McKEE AND NICOLA DINNIE
INTRODUCTION
This 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, clin-
icians and service users in relation to governance and professional stan-
dards. 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 qual-
ity improvement (Scottish Office/Department of Health 1998). The empha-
sis 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 differ-
ent subjective meanings to health care processes (Hunter 1994). The new
medical managers are seen as occupying a position between the organiza-
tion 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
Gordon Marnoch, Lorna McKee and Nicola Dinnie are all in the Department of Management Studies
at the University of Aberdeen.
Public Administration Vol. 78 No. 4, 2000 (967–987)
Blackwell Publishers Ltd. 2000, 108 Cowley Road, Oxford OX4 1JF, UK and 350 Main Street,
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968 GORDON MARNOCH, LORNA McKEE AND NICOLA DINNIE
on finding accommodations between professional tribes, whose insistence
on high levels of autonomy was normally tolerated.
THE NHS AND LEGITIMACY
The 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 con-
tained in electoral surveys, also consistently demonstrates public support
for the National Health Service as an organization. Nigel Lawson, a promi-
nent politician of the right during the 1980s, described the NHS as the near-
est 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 post-
war settlement struck by Labour in the late 1940s. It has been an organiza-
tion, which has been capable of sourcing legitimacy from well-established
social and organizational processes.
However, organizational legitimacy is a relative rather than absolute
phenomenon, which requires mending and regeneration over time. It is
clear that new technologies, treatments, modes of delivery, care settings
and treatment philosophies are emerging fresh into the NHS at a rate which
can challenge the basic principles of the UK health care system and it’s
public legitimacy (Harrison, Dixon, New and Judge 1997). This is not a
problem unique to the NHS but is rather a worldwide phenomenon. Shor-
tell for instance believes US health care is in a state of ‘hyper-turbulence’,
with the institutional legitimacy of the American hospital being ‘shaken at
the core’ by changes in payment systems, delivery systems, use of tech-
nology, professional relations and societal expectations. (Shortell, Gillies
and Devers 1995). In the UK, health care planning ‘rationality’ is subject
to major change (Harrison and New 1998, pp. 67–70). Hospital planning
certainties established in 1960s, for example one district general hospital to
every 100,000 patients (Ham 1999, pp. 88–9), are breaking down, as exem-
plified by the readiness of professional bodies to discuss openly major
reconfiguration of hospital services. The Royal College of Physicians for
example, declared itself to be in favour of closing up to one-third of all
hospitals in England over the next ten years (The Observer 1999). This issue
of organizational legitimacy has been recognized elsewhere in the literature
on health care organization and management (Harrison, Barnes and Mort
1997, pp. 5–6). The managerialism of the 1980s and 1990s while tightening
up aspects of health service organization would appear to have failed to
deliver a new source of legitimacy in the form of performance account-
ability and service quality assurance. While the NHS may indeed be better
managed, this is not the perception held by the public or by many NHS
Blackwell Publishers Ltd. 2000
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