The role of middle managers in the NHS: the possibilities for enhanced influence in strategic change

This thesis concerns the role of middle managers in strategic change in the NHS. It addresses a research gap identified by Dopson and Stewart (1990) who called for more empirical studies of the role of middle managers in specific contexts and highlighted the public sector as being of particular interest. It reports qualitative research carried out across 5 successive case studies in the NHS. The contextual backdrop to the study is one of competing tensions around the role of the middle manager, both generally in organisations and specifically in NHS trusts. On the one hand, it is argued that the role of the middle manager is one of diminishing importance. On the other, it is argued that the role of middle managers is one that should be enhanced. Both sets of commentaries tend towards the speculative and lack an empirical foundation. In the NHS such tensions are reflected in government policy. An enhanced middle manager role is encouraged through the development of a general management ethos. Simultaneously there have been attacks upon middle managers from the Minister for Health in the past Conservative Government and the present Labour Government. Theoretically, a typology of involvement of middle managers upon strategic change developed by Floyd and Wooldridge (1992, 1994, 1997) is brought to bear as a conceptual lens with which to view the role of middle managers in strategic change in the NHS. Using this typology the role of middle managers is found mainly to be with the implementation of strategic change, rather than other roles, such as 'synthesising information', 'facilitating adaptability' or 'championing alternatives', although there are some illustrations of a role for middle managers beyond implementation of strategy. Despite their main role remaining within the implementation of deliberate strategy, the case studies illustrate that there is a possibility for an enhanced middle manager role in strategic change within this. However, Floyd and Wooldridge's typology does not sufficiently distinguish between the differing influence that middle managers may enjoy within the implementation of deliberate strategy. Therefore, one suggestion is that further constructs for the influence of middle managers upon strategic change be developed. It is also noted that middle managers operate under significant constraints that impact upon the possibility of taking up an enhanced role, within the implementation of deliberate strategy and in roles outside this. Principal amongst these constraints is the presence of significant medical group power and the influence of central government intervention. Therefore, middle managers' influence may be limited, on the one hand, to that which converges with the strategy set out by executive management that in turn has been driven by government prescription. On the other, it is likely to be limited mainly to that of the administrative domain rather than the medical domain or where influence is exerted upon the medical domain to changes with which the medical group is agreeable. The empirical findings also illustrate that any enhanced role for middle managers, within the constraints of government policy and medical group power, may require the presence of certain conditions. Firstly, where strategic change allows for emergence as well as deliberateness, then middle manager may exert more influence upon strategic change. Secondly, they may exert more influence upon strategic change, where it is not solely conceived in top-down rational planning terms, but where is combined with a political element of strategic change. As a result the formulation and implementation of strategic change are likely to be intertwined rather than separate and sequential. This may allow for more involvement of middle managers in the strategic change process. Finally, in order that middle managers can take up the potential for an enhanced role under these conditions, there may need to be some investment in organisation and management development and organisational structures that facilitate boundary-spanning opportunities for middle managers. NB. This ethesis has been created by scanning the typescript original and may contain inaccuracies. In case of difficulty, please refer to the original text.