Institutional theory is shown to offer potential for
understanding processes of change, as actors in specific
organisational settings deal with contradictions through
enactment of praxis, and how transformation of institutionally
– embedded practices does or does not occur.
Empirical analysis reveals how endeavours by actors to
overcome contradictions between more traditional understandings
of objectives of hospitals, and those engendered
as a result of new structures led to different outcomes
for different Trusts. Seo and Creed (2002) offer four
propositions for understanding how actors effect change,
highlighting four facets of institutional contradiction
which can result in actors mobilising for change to varying
degrees. In this study, considerable support was found
for their propositions. Perceived inefficiencies of institutionalised
practices in the running of the NHS, combined
with limited resources, constituted a contradiction that
provided an important initial impetus for change, and
was set in a broader political and economic context of
pressure to reform public services in general. Accountants
and managers, traditionally marginalised in the NHS by
existing rules, structures and practices which recognised
clinical dominance, are identified as important potential
change agents of previously institutionalised practices.
The evidence shows that change took place at differing
rates and with varying levels of co-operation in different
Trusts. Where examination of praxis revealed less evidence
of collaboration, adaptability to change was slower and
there were implications for the financial situation of these
Trusts.
In Trust A, where there was evidence of new shared
understandings and more positive professional collaboration,
some contradictions were resolved, and in some cases
improvements were made in terms of both financial and
quality aspects of performance. Even in this Trust, however,
concern was expressed about ongoing contradiction,
with the Finance Director critical of the business acumen
of clinicians: