Power in the health service : The effects of reorganisation on professions and bureaucracies

The National Health Service (NHS) has been analysed predominantly in terms dictated by a systems/functional model of organisational behaviour. Decision-making processes which did not comply with this model were regarded as pathological or dysfunctional. This study takes a different stance and looks at District Health Authorities (DHAs) to see if the NHS can be better understood by accepting Lukes' conception of a "third dimension of power". The study is not focussed around conflicts of interest because the third dimension of power involves situations in which "real" interests may remain unknown. Power may prevent conflicts becoming apparent and interests becoming realised. Because, however, Lukes had suggested that interests may become realised during periods of change, the study focusses on the restructuring which began with reorganisation of the NHS in 1982. The parts played by medical professionals, administrative staff, nursing staff, and lay-members on DHAs are examined and demonstrate the extent to which their activities were influenced by one another and by their external political environment, notably the Conservative government. The mechanisms of power used during the period 1982-1985 when new management structures were established and then replaced by a further reorganisation of management are examined. This shows the extent to which these new management changes became accepted as legitimate and how the legitimation process began with the 1982 reorganisation. Lukes' third dimension of power is confirmed as too restrictive a conception and that power is more subtle than even he had proposed. Nor is it always repressive or manipulative.