The entrepreneur: a new breed of health service leader?

The Authors

Rosemary Exton, UK Work Organisation Network/NUHT NHS, Nottingham, UK

Acknowledgements

The author acknowledges the support of UKWON in undertaking the research which informs this article.

Abstract

Purpose – This paper aims to critically examine the notion of entrepreneurship in the UK National Health Service (NHS), promoted by government ministers and senior civil servants as part of the rhetoric of the modernisation agenda.

Design/methodology/approach – The paper explores literature on entrepreneurship in the private and public sector and qualitative case study evidence on the emergence (and non-emergence) of “entrepreneurs” who led the improving working lives (IWL) initiative in the UK National Health Service and discusses the issues involved.

Findings – The rhetoric serves an essentially ideological function, obscuring the real difficulty of securing effective and sustainable change, in organisations with deeply engrained power structures and as complex and intransient as the NHS in particular and health services more generally.

Practical implications – A “new breed of entrepreneurial leaders” may eventually appear but they face the challenge of surviving in the hierarchical NHS culture and in a climate of turbulent change created by the volatility of government policy.

Originality/value – The paper shows that efforts to pursue entrepreneurship in the UK NHS have to overcome obstacles involving the interplay of power, gender and language.

Article Type:

Research paper

Keyword(s):

Entrepreneurialism; Health services; Leaders; United Kingdom.

Journal:

Journal of Health Organization and Management

Volume:

Number:

Year:

2008

pp:

208-222

Copyright ©

Emerald Group Publishing Limited

ISSN:

1477-7266

Introduction

This paper critically examines the notion of entrepreneurship in the UK NHS, promoted by government ministers and senior civil servants as part of the rhetoric of the modernisation agenda. After more than a decade of government attempts to promote fundamental change in the NHS, ministers and civil servants have turned to the idea of “entrepreneurial leaders”, seeking to bring “vision, leadership and passion” to the NHS:

We know that entrepreneurial leaders think differently, outside the usual box as it were. This new breed of leader will be able to generate new and alternative solutions that extend the boundaries of healthcare … (entrepreneurial leaders must) challenge factors that are growth-limiting and refuse to accept the status quo – and that can mean, taking people out of their comfort zone (Crisp, 2005).

However the paper will argue that such rhetoric serves an essentially ideological function, obscuring the real difficulty of securing effective and sustainable change in organisations as complex as health services. Moreover it ignores the reality of those underlying structures of power and control which can constrain the potential for entrepreneurial behaviour, and impose real costs on those seeking to operate beyond prescribed norms.

This paper explores the literature on entrepreneurship, drawing on Ogbor's ideology-critique of the discourse on entrepreneurship and the reality of entrepreneurs. It compares literature on entrepreneurship in the public sector with qualitative case study evidence on the emergence (and non-emergence) of “entrepreneurs” who led the Improving Working Lives (IWL) initiative in the National Health Service (DoH, 2000c). The paper concludes that efforts to pursue entrepreneurship in the UK NHS have to overcome obstacles involving the interplay of power, gender and language. This is a conclusion that can be generalised to include health services in other developed countries. A “new breed of entrepreneurial leaders” may eventually appear but they face the challenge of surviving in the hierarchical health service culture and climate of turbulent change created by the volatility of government policy.

Defining entrepreneurship

There has been much debate surrounding the search for a definition of “the entrepreneur”. Early researchers Cantillon (1755) and Say (1803) regarded entrepreneurs as risk takers and driven by profit (Barreto, 1989; cited by Saddler, 2000). For Schumpeter the entrepreneur innovates but never invents (Schumpeter, 1934, p. 74; cited by Saddler, 2000). Likewise, Drucker regarded entrepreneurship as perceptiveness to change exploiting it as an opportunity (Drucker, 1985, p. 25; cited by Saddler, 2000).

Whereas earlier literature on the traits or characteristics that distinguish entrepreneurs identified the significance of class, gender and ethnicity, more recent research focuses on the profiling of individual entrepreneurs (Roberts, 1992; Shaver and Scott, 1991) or seeks to characterise them by personality psychological, characteristics and behavioural patterns (Jennings, 1994; Kuratko et al., 2005; Bird, 1988). Different strands of research focus on corporate entrepreneurship (Pinchot, 1985; Knight, 1986; Slevin and Covin, 1990; Jennings, 1994); on entrepreneurship as the basis for economic development (Say, 1815; Schumpeter, 1934) and on small (Carland et al., 1984) and large businesses (Burgelmann, 1985).

By attributing to the entrepreneur the role of a “heroic” change initiator in the economy, Schumpeter stresses the importance of personal traits and motivation. He suggests that entrepreneurs are the:

Rare breed of individuals motivated intrinsically to utilize the benefits of technological, demographic, and social changes to create upheavals in the current state of equilibrium and to usher new products and services or new ways of working (Schumpeter, 1934; cited by Saddler, 2000, p. 26).

Contemporary discourse on entrepreneurship follows the gendered pattern of celebrating masculine concepts of control, rationality and dominance as the “heroic” entrepreneur (Calvert and Ramsey, 1992; Collins and Moore, 1964, p. 6), creating organisations and adopted management practices meeting male needs and reinforcing male values (Ogbor, 2000, p. 622). Moreover, the term “invisible entrepreneurs” describes the limited attention given to female business owners (Baker et al., 1997; cited by Ogbor, 2000, p. 621). Males are therefore seen as the archetype of entrepreneurs whereas females are restricted to what Bowen and Hisrich (1986) termed as “entrepreneurial ghettos” (Ogbor, 2000, p. 621).

Entrepreneurship in the public sector

The term entrepreneurship has increasingly appeared in the public sector literature over the past decade as western governments attempt to realign their public sectors with the changing global environment (Reith, 1996). New public management (Borins, 2000, p. 498; Hood, 1995; cited by Rowe et al., 2004, p. 16), with its emphasis on regulated internal markets and performance management, challenges traditional mindsets and places innovation and entrepreneurship at a premium (Forster et al., 1996; cited by Saddler, 2000, p. 26). Sceptics argue that the emphasis political leaders place on entrepreneurship in the public sector is an attempt to divert attention from government performance (Borins, 2000; Terry, 1993; Luke and Verreynne, 2006, p. 4).

Only recently has research focused on the differences and the development of entrepreneurship in the public sector. Issues and problems facing public organisations are of such scope and complexity that, it is argued, public sector entrepreneurs are needed to mould creative, flexible organisations to respond to our rapidly changing world (Cohen, 1988; cited by Roberts, 1992, p. 55). Entrepreneurial behaviour needs to be adjusted to fit a public sector environment in which wealth creation is not the principal objective (Ramamurti, 1986; Boyett, 1996; cited by Saddler, 2000, p. 28). Moreover, Forster et al. (1996) like Boyett (1996) recognised that other factors besides the profit motive encourage commitment to public entrepreneurialism, and concluded that unlike the private sector, it does not rely on particular individual attributes but on an institutional and collective desire to change, adapt, innovate and entertain risk (Saddler, 2000, p. 28). Likewise Leadbeater argues that public sector entrepreneurship is essentially about collaborative leadership and working across boundaries to meet increasingly complex client needs in a diverse society (Leadbeater and Cross, 1999, p. 18).

As government seeks economic growth through a new spirit of entrepreneurship, the public sector and particularly the NHS is caught up in an ambitious modernisation process and creation of an internal market with an expectation of entrepreneurial behaviour (Richardson and Cullen, 2000, p. 354). As Offe (1984, p. 14) argues, policy production in a capitalist state is driven by contradiction. On the one hand its role is to protect the status quo while appearing to remain neutral between different interests. On the other hand it needs entrepreneurial behaviour to overcome the limits of traditional modes of policy production even though this ultimately challenges the status quo, role of management and hierarchy (Roberts, 1992, p. 66).

Whereas political influence is not a barrier to private sector entrepreneurship, Saddler found that politics in public sector bodies was an important constraint on the pursuit of entrepreneurship. This is supported by Wanna et al. (1996) and Ostry's (1986) observations that public sector management has to be sensitive to political considerations.(Saddler, 2000, p. 38).

Despite this, contemporary research has done little to address public sector entrepreneurship, assuming that private sector models of entrepreneurship can be applied uniformly (Mintzberg, 1996; Saddler, 2000, p. 26). The public sector however operates within a different environment where risk is indirect (Roberts, 1992, p. 57). Public bodies have different accountabilities and objectives, and work within more formal governance structures to ensure the appropriate use of resources (Leadbeater and Cross, 1999, p. 16). As a result of these organisational constraints Leadbeater argues that:

There is still too little entrepreneurship within the public sector, too much of what is attempted is blocked or fails, and too little of what is excellent gets taken up by those in the mediocre middle (Leadbeater and Cross, 1999, p. 19).

Entrepreneurship in the public sector has to overcome peculiar obstacles including robust accountability and control mechanisms (Jennings, 1994; Slevin and Covin, 1990; cited by Saddler, 2000, p. 36), excess and ambiguity of goals which paralyse management, high visibility and limited managerial autonomy, skewed reward systems, short-termism and restrictive personnel policies, all of which reduce a leaders' ability to motivate subordinates (Ramamurti, 1986; cited by Morris and Jones, 1999, p. 79).

Borins argued that obstacles to innovation within the public sector arose from attitudes, “turf fights”, resistance to change, inadequate resources, legislative or regulatory constraints. Moreover the requirement of organisations to work within bureaucratic structures was the most significant obstacle to innovation, and the least frequently overcome obstacle was a lack of resources. (Borins, 2000, p. 504). However, Saddler's study suggests hierarchical, mechanistic structures are part of the fabric of the public sector and that if entrepreneurship is to emerge within the public sector it will do so despite the “red tape” and accountability (Saddler, 2000, p. 37).

Yet contrary to observations that ambiguous organisational goals paralyse management and constrain innovative behaviour (Cornwall and Perlman, 1990), inconsistent objectives and ambiguous goals appear to be important factors in stimulating public sector entrepreneurship by facilitating flexibility and opportunities which may otherwise not have emerged (Ramamurti, 1986; Saddler, 2000). Conversely performance objectives developed from “bottom up” participation between top management and staff, fostered entrepreneurial thinking (Jennings and Lumpkin, 1989). Similarly Borins found public sector innovation arose from comprehensive planning and holistic integration of organisation wide initiatives, initiated by middle managers and front line staff (Borrins, 1998b; cited by Saddler, 2000, p. 38).

Kuratko et al. (1990) found three factors, management support, organisational structure and rewards, to be the most important antecedents of middle-level managers' entrepreneurial behaviour (Kuratko et al., 1990, p. 703). However Roberts associated entrepreneurial behaviour with a power base that is contingent on resources and hierarchical position and which in turn influences strategies, tactics and modes of operation (Roberts, 1992, p. 64).

Ideology, facts and theories of entrepreneurship

The literature on public sector entrepreneurship continues to mirror traditional discourse reinforcing ideological constructs based on heroes with innate attributes, dominant organisational practices, and gender and ethnic presumptions, presupposing that only a select few have the vision and skill necessary to provide substantive leadership in public sector organisations (Morris and Jones, 1999, p. 72).

Ogbor is critical that although research in entrepreneurship has been critiqued from a gender perspective (Baker et al., 1997; Ogbor, 2000, p. 609), the silencing of the feminine perspective in entrepreneurship (Bowen and Hisrich, 1986; Ogbor, 2000, p. 609) and of multi-ethnic/minority entrepreneurship (Butler, 1991; cited by Ogbor, 2000, p. 624) continues. Moreover few attempts have been made to examine the mechanisms through which this dominant ideology is perpetuated or its effects on our understanding of entrepreneurship.

By adopting a critical perspective on the discourse on entrepreneurship, this paper examines the ideological basis upon which the dominant perspective of entrepreneurship is perpetuated, produced and reproduced. It is in the significant silences in text and discourse, and what is left out, that the “presence of ideology can be most positively felt” (Eagleton, 1976, p. 34; cited by Ogbor, 2000, p. 607). The traditional discourse on entrepreneurship characterised by ideological constructs based on heroes with innate attributes sustains the ideology of the dominant white male and:

Eliminates inconsistencies and non-idealistic forms of knowledge that could contribute to our understanding of the experiences of entrepreneurs (Ogbor, 2000, p. 607).

Moreover, exposing the use of dominant, essentially masculine language of text and discourse that creates the ideology, reinforces the existing power structure of the dominant groups in society. This becomes a model of knowledge production, serving as an “instrument of power” which privileges the dominance of the western male mentality in western entrepreneurial discourse (Ogbor, 2000, p. 608). As Foucault has shown, “power is exercised by virtue of things being known and people being seen” (Foucault, 1980, p. 154). The concept of power-knowledge therefore has an important implication in the idea that the discourse on entrepreneurship and its knowledge has served as a mechanism for the exercise of power (Ogbor, 2000, p. 608).

Ogbor criticises research in entrepreneurship for translating ideology into measurable abstractions giving rise to a conviction that the characteristics and traits of entrepreneurs such as motivations, backgrounds, values and other psychological constructs can be quantified to determine causal relationships between heroes and non heroes, while disguising researchers' ideological orientations (Ogbor, 2000, p. 623). Schumpeter also argues that positivistic quantitative methodology is inadequate in understanding the entrepreneurial phenomenon, and maintains that qualitative analysis would provide the necessary collaboration between facts and theory to advance the study of entrepreneurship (Schumpeter, 1947, p. 6; cited by Ogbor, 2000, p. 623).

The need for alternative perspectives in entrepreneurial research is discussed by Jennings et al. (2005). They cite examples of contemporary research that use textual analysis to examine the portrayal of popular perceptions in news reports, influencing the phenomenon of entrepreneurship (Nicholson and Anderson, 2005). Moreover the use of language and “official” discourse is found to entrap entrepreneurs into a defined role. On the one hand entrepreneurs are individuals with free will of their own destiny, but yet government demands that free will is exercised in a manner that benefits the economy (Perren and Jennings, 2005). Downing shows how narratives develop, mature and become interpreted as integral to the prevailing regulation in which entrepreneurs enact their perceived identity (Downing, 2005). Goss discusses the power of emotion and the portrayal of entrepreneurial behaviour as social action, defining free will as the power to only act within constraints. This infers that entrepreneurs may not have freedom to undertake entrepreneurial action, as determined by their position in the organisation, but do have the freedom to choose how to act entrepreneurially (Goss, 2005).

The ideology versus the reality of entrepreneurship in the NHS

This review of literature has revealed how particular ideologies, institutions, and belief systems have produced and shaped the pattern of entrepreneurship, now mirrored in the public sector. It has also identified a vacuum in critical literature on entrepreneurship in the public sector capable of confronting government rhetoric about a “new breed of entrepreneurial leader” in the NHS.

As exemplified by Sir Nigel Crisp, the championing of entrepreneurship by government assumes that NHS organisations are receptive to entrepreneurial behaviour. A critical view of the feasibility of entrepreneurship in the public sector therefore suggests the need to expose the ideological mechanisms through which the dominant perspective is produced and reproduced (Ogbor, 2000), allowing individual stories and experiences to emerge, identifying the contested nature of entrepreneurship in health services.

Chris Dabbs (NHS Networks social enterprise co-ordinator) argues that the NHS has always had people with entrepreneurial spirit, and has struggled to know what to do with them. As social enterprise is now forming a key part of policy from foundation trusts to primary care, Dabbs argues that:

How the entrepreneurs in the NHS's own ranks are recognised and encouraged by senior managers will almost certainly set the tone for the coming transformation (Dabbs, 2007).

The second part of this paper examines empirical evidence of “entrepreneurial behaviour” in the NHS. Using qualitative case study analysis on the emergence (and non-emergence) of entrepreneurs who led the Improving Working Lives (IWL) initiative in the National Health Service (DoH, 2000c), this paper identifies factors facilitating and obstructing entrepreneurship. Conclusions are drawn contrasting “entrepreneurs” with “champions”, revealing the repressive effect of hierarchy on entrepreneurship, and the necessity of choice to embed a culture of entrepreneurship or reverting back to mere compliance with performance targets.

Case study evidence on the emergence (or non-emergence) of “entrepreneurs” in the NHS

This research is based on the author's experience as Lead for the Improving Working Lives (IWL) initiative, with responsibility for 11 National Health Service (NHS) organisations achieving Practice Plus Standard towards “becoming a world class ‘model employer’” (DoH, 2000a, b).

Ten IWL “organisation leads”, with senior managerial responsibility for the implementation and co-ordination of the initiative for their respective organisations, were interviewed following IWL accreditation, about their experiences throughout the IWL process. A second interview was undertaken a year to eighteen months later with the same interviewees, capturing reflections on their role and the varying successes and sustainability of workplace improvement and innovation in their organisation, since achieving IWL accreditation of practice plus standard. The following section outlines an account of the study and discussion of the findings to date.

Exploring the proposition that regulatory mechanisms on their own can only secure compliance with audit requirement, rather than creating the conditions for sustainable change and improvement; this research seeks to identify the factors which, at individual NHS organisation level, lead to successful change and sustained improvement in a context driven by regulation.

The pilot study used some of the elements of a grounded theory approach (applying coding to stories based on truth) (Strauss, 1987; Harding, 2006) and Free Association Narrative Analysis (presenting patterns of behaviour through psychosocial interpretation) (Hollway and Jefferson, 2000, p. 69), to generate emerging theories through a comparative analysis of qualitative reflections from interviews with IWL leads. This hybrid qualitative methodology ensured rigorous analyses; using the whole text from semi-structured interviews it demonstrated both credibility of interpretations and clarity of links made from data, exposing structural support issues, behavioural and psychosocial factors. Two interdependent overarching themes emerged as findings from the pilot study that identified Chief Executive and Board support as drivers and entrepreneurial behaviour as key factors contributing to sustainability of change (Exton, 2006).

Subsequent analysis for the full research study using thematic sampling through comparative coding of interview data (Harding, 2006, p. 25; Hayes, 2000), from the remaining case studies further explores these themes. Firstly the extent to which the Chief Executive and Board support or failure to support the IWL initiative, affects the performance, capacity and entrepreneurial behaviour of the IWL lead within each organisation, and consequently the sustainability of change and improvements. The second theme identifies the emergence of different levels of entrepreneurial behaviour between the organisational IWL leads.

The following section explores the emergence or non-emergence of entrepreneurial behaviour and the varying levels of support they received as they led this change initiative, using initial data analysis from interviews with three of the IWL leads.

Case study A

The conflict of compliance of organisational objectives to improve the working lives of staff with the capacity of the organisation to deliver due to a lack of strategic commitment, presented dilemmas to the role of the IWL lead for organisation A. Equally, it identified the potential power of the role of the IWL lead as entrepreneur, to embed IWL principles and over come obstacles to sustainable change. Despite being isolated from strategic management and with no human resource input or support, factors that were both a motivator and a constraint, she displayed an ability to work “outside the box”:

They (management) didn't do anything, to be very honest. Basically I was told about March time that the director was the lead for IWL and I was just doing the work, and to me that just says it all … just there in name but didn't do anything and neither did the deputy.

Over a period of 12 months she co-opted board support through a non executive director and successfully drove the initiative, identifying both issues and areas of good practice through staff focus groups. She enlisted the support of a colleague, but other than that there was no strategic leadership or support:

If we weren't there as drivers it (IWL) wouldn't have happened.

She overcame obstacles of poor top down communication, hierarchical management styles and non engagement of staff by introducing innovative posters, saturating areas with flyers and introducing inter departmental dialogue seminars. Unchallenged by the major staff side engagement issues and the “barrier” of middle management (Exton, 2003), whose interests were not always convergent with the organisation's corporate objectives creating conflicting power relations, she introduced all party round table discussion groups. Through the IWL initiative she initiated the dissemination of policy information (that the organisation had a duty to provide), ensuring channels were open to encourage a free flow of information. Informing staff about the HR policies, for example flexible working, she had identified that despite the policies now being available “the staff did not know about them” or their entitlement to use them:

What we have done as an organisation is we have got those polices on the web so staff can access them (pause) and they (managers) have gone mental because staff have now got access to them and therefore they have got to be seen to be doing it (long pause) and that's wrong (pause) two area managers saying how come staff have got hold of this policy (IWL lead interviewee A).

Overcoming role dependency on management support and resources, she harnessed new innovative resources, mobilising people to champion innovation and improvement across the organisation; she chose key leads who she could work with, and by-passed obstructive management in order to engage with staff of all levels:

Middle management forums (pause) … we needed them so much (pause) and if we couldn't get to the managers we did a questionnaire (IWL lead interviewee A).

I think IWL sits with HR, to be perfectly honest and I think they are the right people to move this forward because they should be there for the interest of the staff, but it hasn't even hit that door (IWL lead interviewee A).

The IWL lead received no acknowledgement for successfully leading the organisation to practice plus standard despite the validation team noting the improvements and changes over the past year that had been reflected in staff feedback. Due to the volatility of the changing NHS agenda she was removed from post immediately on the organisation achieving IWL Accreditation; work on the initiative was ended just when changes were being acknowledged within the organisation, at which point all activity stopped:

They've taken me out, (of IWL) (pause) the focus is again Agenda for Change and the focus again now is this Reconfiguration (long pause) which is bad because I think slowly we were starting to bridge that gap and I don't know whether its going to continue (IWL lead interviewee A).

A second interview with the same interviewee a year later found:

There is no follow on so basically it's (IWL) shelved, It's in a box on a shelf and that is such a shame, for that amount of work (IWL lead interviewee A).

Case study B

Organisation B's approach was characterised by compliance with IWL regulation with board commitment. Initially IWL and the lead's role was well supported by the CEO and a director but otherwise unsupported internally:

Most of the level of support was no doubt from my Director and Chief Executive … there was a void between me and staff, managers just didn't play the part (IWL lead interviewee B).

At first I felt as though we had quite a strong network in terms of how the improving working lives core group sat, if you like there was, OK the number dwindled towards the end of the process but, you know, right at the early stages there was quite a lot of sort of key managers sitting round the table not so many staff side, but they were present, and that was really, really useful in terms of what our action plan was going to be, but yeah I definitely did feel that beyond those meetings it was me and (the Director) (IWL lead interviewee B).

Appointed from within human resources (HR), the IWL Lead worked as a “champion” within management parameters, towed the corporate line and was compliant in leading agreed changes to meet the criteria for the initiative as a “tick box” exercise. Despite acknowledging the support she had from her Director she continued to have difficulty engaging management:

I did feel very much supported by him, there were also times where I felt as though he didn't put enough sort of pressure on some of the mangers within the organisation (IWL lead interviewee B).

Initially the lead displayed a general reluctance to access IWL regional support or networking opportunities with other organisations. Using only traditional management hierarchical structures to communicate IWL information to staff, she also struggled to engage staff, managers, staff side or Board members, and was unable to utilise their full potential as active partners. Ineffective middle management support throughout the IWL process resulted in minimal staff engagement and little evidence of trade union partnership. However issues raised at focus groups by staff identified areas of concern requiring senior managerial input, and had made some of the managers:

A little bit more believing in the purpose of it (IWL) (IWL lead interviewee B).

Throughout the programme IWL remained championed within the HR domain; accreditation was marginally achieved but with little evidence of wider organisational learning, innovation or change:

And at the end of the day you had somebody in HR that did in the end, you know, pull it all together, I mean we managed and we got through it (IWL lead interviewee B).

A second interview with the same interviewee a year later found that:

Following Accreditation IWL came to a screeching halt … following reconfiguration, in the new organisation there is no talk of either IWL or how we continue that work to happen (IWL lead interviewee B).

Case study C

From the outset of the IWL process there was clear organisational commitment by the Board and senior management, staff and trade union stewards to work in partnership, with evidence of a supportive culture and willingness to embed change throughout the organisation. The IWL lead, selected by senior management, was enthusiastic and a skilled communicator with all staff grades, enlisting board engagement at all stages of the initiative. She developed innovative ways of overcoming the challenges of engaging staff and managers across a widely distributed geographical area and organisational divisions and was keen to share experiences and knowledge with other organisations through active participation in the IWL regional network:

I was able to function like that was because I had support from the HR Director, CEO and senior managers, I mean I was doing all the work on the ground, but they were projecting it for me and saying this is what must happen … I had that knowledge of the organisation and the credibility with the work-force … . what they gave was the autonomy (IWL lead interviewee C).

… it's (IWL) a high priority, our work-force is a high priority and Improving their Working Lives; I think there is a recognition that err they are our … (pause) and again I suppose being therapies and what have you, we don't have machines and things to invest in. We only have one resource, and that's our people (IWL lead interviewee C).

An enthusiastic, motivational leader, yet not a senior manager, this IWL Lead used her broad knowledge of the organisation to engage with managers, staff and staff side to take on responsibilities and tasks within the IWL programme. They were encouraged to “champion” IWL within their respective departments, extending the initiative outside of HR domain and to identify areas of good practice and ongoing implementation of the principles of improving the quality of working lives throughout the organisation:

I think as much as anything it made us aware of some of the things we do well, because on a day to day basis, you focus on the things that you need to do better, don't you? And I think it really hit home when we saw that Self-Assessment particularly, just how much we were doing, and how much we did well that we hadn't previously given ourselves or anybody else a lot of credit for, because you just take it for granted don't you (IWL lead interviewee C).

Continual feedback to the staff, sharing of good practice and organisational learning became key aims for the IWL lead:

I think they (the staff) expected it to be a tick box exercise that was all done you know, in a huddle and we say we were doing things that we weren't, and that we would get credit for that; but I think you know, the validation team had a high profile, they met with people across the trust, and they could see that what they said was taken on board, and those recommendations that came out of the validation were really important because they really, you know, embraced what they were trying to say and I think, you know, it really gave it the credibility (IWL lead interviewee C).

At Validation there were demonstrable improvements in the quality of working lives of staff and services delivered throughout the organisation, with evidence that principles of IWL were becoming embedded within mainstream practice. Towards the final stages of the IWL initiative plans were being made for the organisation to continue ongoing self-assessment, review of strategic management roles, continued staff engagement through focus groups and embedding new ideas and ways of working, towards enabling the sustainability of change:

The improving working lives award was actually something for them (the staff) really rather than something for the organisation (IWL lead interviewee C).

In a report to the Board and organisation the IWL lead concluded:

The (IWL) journey has been something of an adventure, during which we have been presented with challenges, obstacles and setbacks. However, we have always tried to face these positively, and the impact of these has been balanced by successes, achievements and triumphs. The process has become increasingly more inclusive, has generated a “contagious” team spirit and promoted excellent working relationships. We recognise that Practice Plus Accreditation does not signify the end of the journey, rather that most people are now on board and we are ready to move forward together (IWL lead interviewee C).

A second interview with the same interviewee, a year later found:

There is a general commitment to it … the organisational development team has been resourced with IWL in mind really, and now there is a budget for that team. We'll carry on as we are because we've got our own sort of mechanisms for ensuring that we continue to monitor ourselves in terms of Improving working lives, it's part of our organisational strategy now, and not just to maintain the standard but to improve on it (IWL lead interviewee C).

Conclusions drawn from the case study data

Conclusions drawn to date from this study identify three main factors.

Firstly there is a clear distinction made between entrepreneurs and champions working within the NHS. As shown in case study B champions can be appointed to lead agreed changes within a given set of parameters, involved in both the design and implementation phases to monitor and administrate. However mere compliance with regulatory measures (“ticking boxes”) is often achieved by diverting resources to achieve a specific measurable outcome in ways which do not necessarily lead to sustained change or improvement. Entrepreneurs faced with inconsistent objectives and ambiguous goals, as in case study A, reject compliance and challenge the status quo. They use the need to achieve performance targets as a lever that enables them to design and lead fundamental changes in organisational practice and behaviour. Entrepreneurs forge creative and unpredictable solutions, often in the spaces between formal organisational structures and protocols; performance targets are achieved as a by-product of new ways of working. Case study C, as Roberts also argues, describes the necessity of entrepreneur involvement in all stages of innovation, creation, design and implementation (Roberts, 1992, p. 61), therefore directly addressing the goals and objectives which specific performance measures are intended to represent, but do so in a way which reaches the core of the problem.

Secondly although these IWL leads do not fit the “white male heroic leader” ideology, these case studies explore the basis upon which the dominant perspective of hierarchy and power is perpetuated, as in case study A, defeating entrepreneurs by systematically closing the spaces in which they work: tying up resources, limiting available time, and the overly diligent enforcement of rules and customs. The excessive control by top management has been found to be a leading obstacle to entrepreneurship (Morris and Jones, 1999, p. 86). This may happen where strategic management feel threatened by innovation or change from below and as Leadbeater argues, “what is attempted is blocked or fails” (Leadbeater and Cross, 1999, p. 19). Moreover, as in all three case studies, the extent to which Chief Executive's and Board supported or failed to support the change initiative, affected the performance, capacity and entrepreneurial behaviour of the individuals leading the initiative. As management support, organisational structure and rewards have been found to be the most important antecedents of middle-level managers' entrepreneurial behaviour (Kuratko et al., 1990, p. 703), part of the Chief Executive's responsibility for ensuring the effective and sustainable implementation of change should be to create conditions conducive to the emergence of policy entrepreneurship.

Thirdly, part of the skill of the entrepreneur is to pass ownership of the change process and the new ways of working to the organisation as a whole, to embed it in day-to-day practice. Buchanan's model of “distributed leadership” is relevant here (Buchanan et al., 2006). The entrepreneur recognises that distributed leadership does not always happen naturally within most organisations, there is a need to create the conditions in which it can take place. This was recognised in both case studies A and C, and further distinguishes entrepreneurship from compliance. However without an early transition to distributed leadership, organisational innovation can become dangerously over dependent on the entrepreneur. As in case study A, if the entrepreneur moves away at a critical moment the process may simply revert to compliance.

This research is presented as work in progress and to date has discovered only what participant's views and experiences are and not the factors that the research question seeks to discover. However, by applying a critical perspective in comparing this initial data with the other case studies, identifying where the “hidden factors” preventing entrepreneurship may be the “norm” in an organisation, exposes what the hidden factors are, attempts to make these visible, and develops an explanation of why it does not happen in other NHS organisations, thereby providing “the necessary collaboration between facts and theory to advance the study of entrepreneurship” (Schumpeter, 1947, p. 6; cited by Ogbor, 2000, p. 623).

Conclusions

Literature suggests that accountability, operational and regulatory requirements as control mechanisms are the cornerstone of the public sector and are the main factors that make entrepreneurial activity such a difficult proposition. However, they may simultaneously enhance opportunities for entrepreneurship which can be fostered through support and facilitation for entrepreneurs, by incorporating staff in decision making, developing opportunities for novel processes within the structure and culture and making available appropriate resources (Saddler, 2000, p. 39).

However using critical analysis to apply Ogbor's argument of ideological mechanisms perpetuating the notion of entrepreneurship, this paper argues that government rhetoric portrays the NHS as prepared for and receptive to a new breed of entrepreneur to achieve the goals of its dynamic organisations. Moreover this ideology of entrepreneurship within the NHS may conceal elements of dysfunctional reforms, structured power and vested interests of the hierarchy both at national and organisational level.

Case study analysis examining the reality of experiences of leaders in the NHS, has found entrepreneurial behaviour effecting fundamental change, and contrasted these experiences to the champion leader maintaining the status quo. The findings to date suggest that without organisational support entrepreneur's can be defeated or constrained by the dominance of strategic or managerial hierarchy limiting the scope for entrepreneurs to create sustainable innovation and change in health services.

These findings will act as a platform for further empirical research, in understanding and unpacking the ideology of entrepreneurship and its potential and limitations within the NHS in particular, and health services more generally.

References

Baker, T., Aldrich, H.E., Liou, N. (1997), "The invisible entrepreneurs: the neglect of women business owners by mass media and scholarly journals in the USA", Entrepreneurship and Regional Development, Vol. 9 pp.221-38.