Examining leadership through critical feminist readings

PURPOSE: This paper seeks to explore a critique of the limitations of mainstream leadership research and publications and offers a critical management analysis through drawing on a feminist reading of leadership in organizations. DESIGN/METHODOLOGY/APPROACH: There has recently been witnessed a growing interest in the promotion of effective leadership within both organizational studies literature and organisational policy as the route to ensuring employee commitment and enhanced organisational performance and the achievement of ever demanding goals and targets. This turn to leadership is represented in both an upsurge of research studies and a proliferation in the promotion of leadership as the organisational panacea. An analysis of the literature on leadership was undertaken, giving due consideration to mainstream and more critical accounts in relation to illustrations drawn from the UK National Health Service (NHS). FINDINGS: This paper explores mainstream literature on leadership and finds it wanting, in terms of its failure to deliver a common understanding of the concept, in its generally uncritical accounts, and its inability to expose the androcentric nature of the core assumptions within hegemonic discourses of leadership. Drawing on critical feminist readings in relation to the UK NHS, a more critical account of leadership is presented. PRACTICAL IMPLICATIONS: Greater awareness is required for the adoption of culturally sensitive and locally-based approaches that take account of individuals' experiences, identities and power relations and that allows for the presence of a range of masculine and feminine workplace behaviours. ORIGINALITY/VALUE: This paper provides an overview of the dominant themes within the literature on leadership as they relate to the UK NHS, and presents a feminist critique of the more subtle ways in which notions of leadership in organisations fail to consider their potential for bias.     

Policy and organizational implications of gender imbalance in the NHS

PURPOSE: The purpose of the paper is to examine the policy and organizational implications of gender imbalance in management, which research suggests exists in the NHS. DESIGN/METHODOLOGY/APPROACH: The research in this paper involved a qualitative approach with an analysis of elite interviews conducted with a non-random sample of officials involved in health policy and interviews with a random sample of senior managers in NHS Scotland. The research formed part of a larger study, which explored the enablers and inhibitors to female career progression in various Scottish sectors. FINDINGS: The paper finds that gender imbalance in management exists in the NHS. This is manifested in a masculine organizational context, leadership and policy decision-making process, which have implications for female career advancement opportunities and subsequently access to macro policy decisions. RESEARCH LIMITATIONS/IMPLICATIONS: The paper involved a sample (30 percent) of senior managers and examined policy processes in NHS Scotland. To improve the external validity of the findings further research should be conducted in NHS organizations in England and Wales. PRACTICAL IMPLICATIONS: The findings in the paper suggest that gender imbalance in management and a masculine organizational context and leadership style within the NHS create a less than conducive environment for female employees. This has practical implications in terms of levels of part-time employment, career progression and attrition rates. ORIGINALITY/VALUE: The paper adds to the debate of gender and organizational studies by examining the health sector, which has high levels of female employment but low levels of female representation at senior management levels. The paper therefore adds to an often-neglected area of study, women in leadership and senior managerial positions. The paper is original in its approach by examining the micro and meso organizational dimensions which impact on women's ability to influence macro health policy.     

The changing role of health‐oriented international organizations and nongovernmental organizations

Apart from governments, there are many other actors active in the health policy arena, including a wide array of international organizations (IOs), public‐private partnerships and non‐governmental organizations (NGOs) that state as their main mission to improve the health of (low‐income) populations of low‐income countries. Despite the steady rise in numbers and prominence of NGOs, however, there is lack of empirical knowledge about their functioning in the international policy arena, and most studies focus on the larger organizations. This has also caused a somewhat narrow focus of theoretical studies. Some scholars applied the ‘principal‐agent’ theory to study the origins of IOs, for example, other focus on changing power relations. Most of those studies implicitly assume that IOs, public‐private partnerships and large NGOs act as unified and rational actors, ignoring internal fragmentation and external pressure to change directions. We assert that the classic analytical instruments for understanding the shaping and outcome of public policy: ideas, interests and institutions apply well to the study of IOs. As we will show, changing ideas about the proper role of state and non‐state actors, changing positions and activities of major stakeholders in the (international) health policy arena, and shifts in political institutions that channel the voice of diverging interests resulted in (and reflected) the changing positions of the health‐oriented organizations‐and also affect their future outlook. Copyright © 2015 John Wiley & Sons, Ltd.     

Development of the National Health Information Systems in Botswana: Pitfalls,prospects and lessons

Background: Studies evaluating development of health information systems in developing countries are limited. Most of the available studies are based on pilot projects or cross-sectional studies. We took a longitudinal approach to analysing the development of Botswana’s health information systems.Objectives: We aimed to: (i) trace the development of the national health information systems in Botswana (ii) identify pitfalls during development and prospects that could be maximized to strengthen the system; and (iii) draw lessons for Botswana and other countries working on establishing or improving their health information systems.Methods: This article is based on data collected through document analysis and key informant interviews with policy makers, senior managers and staff of the Ministry of Health and senior officers from various stakeholder organizations.Results: Lack of central coordination, weak leadership, weak policy and regulatory frameworks, and inadequate resources limited development of the national health information systems in Botswana. Lack of attention to issues of organizational structure is one of the major pitfalls.Conclusion: The ongoing reorganization of the Ministry of Health provides opportunity to reposition the health information system function. The current efforts including development of the health information management policy and plan could enhance the health information management system.     

Health democracy in Europe: Cancer patient organization participation in health policy

Background

Patient organization participation in health policy decision making is an understudied area of inquiry. A handful of qualitative studies have suggested that the growing number of patient organizations in Europe and their increasing involvement in policy issues do not result in high political effectiveness. However, existing research is largely country‐specific.

Objective

To examine the degree and impact of cancer patient organization (CPO) participation in health policy decision making in EU‐28 and to identify their correlates.

Methods

A total of 1266 members of CPOs participated in this study, recruited from a diversity of sources. CPO participation in health policy was assessed with the Health Democracy Index, a previously developed instrument measuring the degree and impact of patient organization participation in various realms of health policy. Additional questions collected information about participants' and the CPO's characteristics. Data were gleaned in the form of an online self‐reported instrument.

Results

The highest degree of CPO participation was observed with respect to hospital boards, reforms in health policy and ethics committees for clinical trials. On the contrary, the lowest was discerned with regard to panels in other important health‐related organizations and in the Ministry of Health. The reverse pattern of results was observed concerning the Impact subscale. As regards the correlates of CPO participation, legislation bore the strongest association with the Degree subscale, while organizational factors emerged as the most important variables with regard to the Impact subscale.

Conclusions

Research findings indicate that a high degree of CPO participation does not necessarily ensure a high impact. Efforts to promote high and effective CPO participation should be geared towards the establishment of a health‐care law based on patient rights as well as to the formation of coalitions among CPOs and the provision of training to its members.     

The evolution of human rights in World Health Organization policy and the future of human rights through global health governance

The World Health Organization (WHO) was intended to serve at the forefront of efforts to realize human rights to advance global health, and yet this promise of a rights-based approach to health has long been threatened by political constraints in international relations, organizational resistance to legal discourses, and medical ambivalence toward human rights. Through legal research on international treaty obligations, historical research in the WHO organizational archives, and interview research with global health stakeholders, this research examines WHO's contributions to (and, in many cases, negligence of) the rights-based approach to health. Based upon such research, this article analyzes the evolving role of WHO in the development and implementation of human rights for global health, reviews the current state of human rights leadership in the WHO Secretariat, and looks to future institutions to reclaim the mantle of human rights as a normative framework for global health governance.     

REGIONAL VARIATION IN THE PRODUCTIVITY OF THE ENGLISH NATIONAL HEALTH SERVICE

Variation in the provision of health care has long been a policy concern. We adapt the framework for productivity measurement used in the National Accounts, making it applicable for sub‐national comparisons using cross‐sectional data. We assess the productivity of the National Health Service (NHS) across regions of England, termed Strategic Health Authorities (SHAs). Productivity is calculated by comparing the total amount of healthcare output to total inputs for each region, standardised to the national average. Healthcare output comprises 6500 different categories, capturing the number and type of NHS patients treated and the quality of care received. Healthcare inputs include NHS and agency staff, supplies, equipment and capital. We find that productivity varies from 5% above to 6% below the national average. Productivity is highest in South West SHA and lowest in East Midlands, South Central and Yorkshire and The Humber SHAs. We estimate that if all regions were as productive as the most productive region in England, the NHS could treat the same number of patients with £3.2bn fewer resources each year. The methods developed lend themselves to investigate variations in productivity in other types of healthcare organisations and health systems. Copyright © 2012 John Wiley & Sons, Ltd.     

Western organizational change capacity theory and its application to public health organizations in China: A multiple case analysis

As health reform becomes a crucial task for both Chinese and United States government, public health organizations are required to adopt changes based on reform policy. Organizational Change Capacity theory is a Western theory that indicates the capacities that organizations should possess when pursuing successful organizational change. This study seeks to understand the applicability of this theory to Chinese public health organizations by contrasting organizations that have achieved success or remained challenged in implementing organizational change to optimize health reform. The research questions are: Is the Organizational Change Capacity theory applicable in Chinese public health organizations? How should it be modified to best fit Chinese public health organizations? Seventy‐two participants from 12 public health organizations in Beijing and Xi'an were recruited for interviews and follow‐up questionnaires that asked for experiences during their organizational changes. During the analysis, a new Chinese Organizational Change Capacity theory with nine main themes emerged. This new framework provides a guideline for Chinese public health organizations to evaluate their change capacity, and offers a theoretical foundation for researchers to design interventions that increase these organizations' capacity in achieving successful change.     

我国部分地区妇幼健康分级服务政策实践分析

目的:了解我国部分地区妇幼健康分级服务政策的实践进展与存在问题.方法:采用主题框架法,从领导治理、服务提供、筹资支付、人力资源、药品供应、信息共享六个方面梳理分析江苏省常州市、上海市、四川省成都市、河北省石家庄市的妇幼健康分级服务政策和改革措施.结果:调研地区选择不同的妇幼健康服务内容开展分级服务,以行政规制的方式明确...     

Two at the top: relations between Chairs and Chief Executives in the NHS.

The relationship between the Chair and Chief Executives of Health Authorities (and Boards) and NHS Trusts denote the managerial and political character of the NHS, creating an organizational apex with 'two at the top'. This article considers the nature of relationships between Chairs and Chief Executives in a variety of different NHS organizations according to two theoretical perspectives: role theory and negotiated order. Empirical evidence addresses the views of the roles of Chairs and Chief Executives, the content of their roles and the local and national factors which influence them (including critical incidents). Conclusions are drawn about the conceptualization of this crucial relationship in the NHS and also on the association between the Chair-Chief Executive relationship and organizational effectiveness.     

Promoting quality: the health-care organization from a management perspective.

BACKGROUND: Although agreement about the need for quality improvement in health care is almost universal, the means of achieving effective improvement in overall care is not well understood. Avedis Donabedian developed the structure-process-outcome framework in which to think about quality-improvement efforts. ISSUE: There is now a robust evidence-base in the quality-improvement literature on process and outcomes, but structure has received considerably less attention. The health-care field would benefit from expanding the current interpretation of structure to include broader perspectives on organizational attributes as primary determinants of process change and quality improvement. SOLUTIONS: We highlight and discuss the following key elements of organizational attributes from a management perspective: (i) executive management, including senior leadership and board responsibilities (ii) culture, (iii) organizational design, (iv) incentive structures and (v) information management and technology. We discuss the relevant contributions from the business and medical literature for each element, and provide this framework as a roadmap for future research in an effort to develop the optimal definition of 'structure' for transforming quality-improvement initiatives.     

The March to Accountable Care Organizations—How Will Rural Fare?

Purpose: This article describes a strategy for rural providers, communities, and policy makers to support or establish accountable care organizations (ACOs). Methods: ACOs represent a new health care delivery and provider payment system designed to improve clinical quality and control costs. The Patient Protection and Affordable Care Act (ACA) makes contracts with ACOs a permanent option under Medicare. This article explores ACA implications, using the literature to describe successful integrated health care organizations that will likely become the first ACOs. Previous research studying rural managed care organizations found rural success stories that can inform the ACO discussion. Findings: Preconditions for success as ACOs include enrolling a minimum number of patients to manage financial risk and implementing medical care policies and programs to improve quality. Rural managed care organizations succeeded because of care management experience, nonprofit status, and strong local leadership focused on improving the health of the population served. Conclusions: Rural provider participation in ACOs will require collaboration among rural providers and with larger, often urban, health care systems. Rural providers should strengthen their negotiation capacities by developing rural provider networks, understanding large health system motivations, and adopting best practices in clinical management. Rural communities should generate programs that motivate their populations to achieve and maintain optimum health status. Policy makers should develop rural‐relevant ACO‐performance measures and provide necessary technical assistance to rural providers and organizations.     

Potential challenges facing distributed leadership in health care: evidence from the UK National Health Service

The discourse of leaderism in health care has been a subject of much academic and practical debate. Recently, distributed leadership (DL) has been adopted as a key strand of policy in the UK National Health Service (NHS). However, there is some confusion over the meaning of DL and uncertainty over its application to clinical and non‐clinical staff. This article examines the potential for DL in the NHS by drawing on qualitative data from three co‐located health‐care organisations that embraced DL as part of their organisational strategy. Recent theorising positions DL as a hybrid model combining focused and dispersed leadership; however, our data raise important challenges for policymakers and senior managers who are implementing such a leadership policy. We show that there are three distinct forms of disconnect and that these pose a significant problem for DL. However, we argue that instead of these disconnects posing a significant problem for the discourse of leaderism, they enable a fantasy of leadership that draws on and supports the discourse.     

Reforms in the Portuguese health care sector: Challenges and proposals

Portugal has one of the most complete public systems worldwide. Since 1979, the Portuguese National Health Service (NHS) was developed based on the integration and complementarity between different levels of care (primary, secondary, continued, and palliative care). However, in 2009, the absence of economic growth and the increased foreign debt led the country to a severe economic slowdown, reducing the public funding and weakening the decentralized model of health care administration. During the austerity period, political attention has focused primarily on reducing health care costs and consolidating the efficiency and sustainability with no structural reform. After the postcrisis period (since 2016), the recovery of the public health system begun. Since then, some proposals have required a reform of the health sector's governance structure based on the promotion of access, quality, and efficiency. This study presents several key issues involved in the current postcrisis reform of the Portuguese NHS response structure to citizens' needs. The article also discusses the implications of this Portuguese experience based on current reforms with impact on the future of citizens' health.     

Undermining patient and public engagement and limiting its impact: The consequences of the Health and Social Care Act 2012 on collective patient and public involvement

Patient and public involvement has been at the heart of UK health policy for more than two decades. This commitment to putting patients at the heart of the British National Health Service (NHS) has become a central principle helping to ensure equity, patient safety and effectiveness in the health system. The recent Health and Social Care Act 2012 is the most significant reform of the NHS since its foundation in 1948. More radically, this legislation undermines the principle of patient and public involvement, public accountability and returns the power for prioritisation of health services to an unaccountable medical elite. This legislation marks a sea‐change in the approach to patient and public involvement in the UK and signals a shift in the commitment of the UK government to patient‐centred care.     

A collaborative approach to embedding graduate primary care mental health workers in the UK National Health Service

The UK National Health Service (NHS) workforce has recently seen the arrival of the Graduate Mental Health Worker (GMHW) in primary care. We established a Quality Improvement Collaborative to assist in embedding this new workforce in one Strategic Health Authority Area of England. The intervention utilised 'collaborative' technology which involves bringing together groups of practitioners from different organizations to work in a structured way to improve the quality of their service. The process was evaluated by an action research project in which all stakeholders participated. Data collection was primarily qualitative. During the project, there was an increase in throughput of new patients seen by the GMHWs and increased workforce satisfaction with a sense that the collaborative aided the change process within the organizations. Involvement of managers and commissioners from the Primary Care Trusts where the GMHWs were employed appeared to be important in achieving change. This was not, however, sufficient to combat significant attrition of the first cohort of workers. The project identified several barriers to the successful implementation of a new workforce for mental health problems in primary care, including widespread variation in the level and quality of supervision and in payment and terms of service of workers. A collaborative approach can be used to support the development of new roles in health care; however, full engagement from management is particularly necessary for success in implementation. The problems faced by GMHWs reflect those faced by other new workers in healthcare settings, yet in some ways are even more disturbing given the lack of governance arrangements put in place to oversee these developments and the apparent use of relatively unsupported and inexperienced novices as agents of change in the NHS.     

我国乡村卫生一体化管理模式与比较

通过剖析乡村卫生一体化管理的内涵和政策目标,将其归纳出乡村卫生组织一体化和乡村卫生服务一体化两种模式;对两种模式的推进障碍因素和优劣进行了比较;提出新医改政策背景下推进乡村卫生服务一体化的建议是：分步分类推进、把连续的卫生服务作为一体化管理的落脚点、由国家层面建立乡村两级卫生服务规范“管理包”,以及县级卫生行政部门要积极发挥主动作用。     

Constructing notions of healthcare productivity: the call for a new professionalism?

Improving performance is an imperative for most healthcare systems in industrialised countries. This article considers one such system, the UK's National Health Service (NHS). Recent NHS reforms and strategies have advocated improved healthcare productivity as a fundamental objective of policy and professional work. This article explores the construction of productivity in contemporary NHS discourse, analysing it via the Foucauldian concept of governmentality. In this manner it is possible to investigate claims that the commodification of health work constitutes a threat to autonomy, and counter that with an alternative view from a perspective of neoliberal self‐governance. Contemporary policy documents pertaining to NHS productivity were analysed using discourse analysis to examine the way in which productivity was framed and how responsibility for inefficient resource use, and possible solutions, were constructed. Data reveals the notion of productivity as problematic, with professionals as key protagonists. A common narrative identifies traditional NHS command/control principles as having failed to engage professionals or having been actively obstructed by them. In contrast, new productivity narratives are framed as direct appeals to professionalism. These new narratives do not support deprofessionalisation, but rather reconstruct responsibilities, what might be called ‘new professionalism’, in which productivity is identified as an individualised professional duty.     

The paradox of non-evidence based,publicly funded complementary alternative medicine in the English National Health Service: An explanation

Despite the unproven effectiveness of many practices that are under the umbrella term ‘complementary alternative medicine’ (CAM), there is provision of CAM within the English National Health Service (NHS). Moreover, although the National Institute for Health and Care Excellence was established to promote scientifically validated medicine in the NHS, the paradox of publicly funded, non-evidence based CAM can be explained as linked with government policy of patient choice and specifically patient treatment choice. Patient choice is useful in the political and policy discourse as it is open to different interpretations and can be justified by policy-makers who rely on the traditional NHS values of equity and universality. Treatment choice finds expression in the policy of personalised healthcare linked with patient responsibilisation which finds resonance in the emphasis CAM places on self-care and self-management. More importantly, however, policy-makers also use patient choice and treatment choice as a policy initiative with the objective of encouraging destabilisation of the entrenched healthcare institutions and practices considered resistant to change. This political strategy of system reform has the unintended, paradoxical consequence of allowing for the emergence of non-evidence based, publicly funded CAM in the NHS. The political and policy discourse of patient choice thus trumps evidence based medicine, with patients that demand access to CAM becoming the unwitting beneficiaries.