Organizational Transformation and Top‐Down Change: The Case of the NHS

This paper analyses the effects of government-sponsored attempts to change the way that the NHS, one of the largest employers in Europe, is managed. The theoretical issues raised relate to the concept of transformational change and attempts at public-sector restructuring, which set the context for the presentation of data. The empirical research, carried out over three years, examines the changes since the most recent reforms (the NHS and Community Care Act 1990). The research considers the extent of organizational change which can be seen as the outcome of these reforms in relation to: a multiple and inter-related change agenda; the creation of new forms of organization; the creation of new roles; the reconfiguration of power relations; and the creation of a new culture, ideology and organizational meaning. These are presented as the key variables which could indicate whether transformational, rather than incremental, change has occurred. The focus of this analysis is at local board level. This article concludes that earlier analyses of the limited success of administrative reform are no longer the case. Our analysis of the key variables suggests that what is occurring at least at local board level goes beyond incremental change and may represent the beginnings of an ‘organizational transformation’. This contains unintended as well as intended elements as an unanticipated ‘hybrid’ form of management may be emerging.