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NHS reform on the quiet

The most profound National Health Service reforms may come from low-cost initiatives that operate ‘in the shadows’ because they escape resistance from vested interests, says study at Cambridge Judge Business School, University of Cambridge.

A doctor with a Stethoscope around his neck looking at a patients file.

The most profound reforms of the National Health Service (NHS) may come from initiatives that operate “in the shadows” with little financial resources because they attract less attention from vested interests, according to a study by Cambridge Judge Business School researchers.

Reform projects that operate away from scrutiny can develop “resourcing space” that allows for rapid change with little negotiations and minimal coordination cost, found the study published in the prestigious Academy of Management Journal.


“We found that reform initiatives which attract little attention can achieve bigger results because they are relatively shielded from too much interference,” said co-author Michael Barrett, Professor of Information Systems and Innovation Studies at Cambridge Judge Business School.

“The study shows that change can come despite – and perhaps even because of – a lack of resources,” Barrett said. “Usually, organisational change entails a shift in resource control, and this prompts resistance by people who feel this can undermine their resource-derived authority.”

The researchers focused on a large agency (one of 150 in England) that administers local hospital contracts following new UK rules in 2010 designed to make the NHS less bureaucratic and more clinically attuned to patient needs (the agency studied is not named, in order to preserve anonymity).

The study, based on a four-year period, is based on 700 hours of direct observation, 66 interviews and more than 20 GB of archival data.

The study found that while the agency’s mental health contract management saw a “radical transformation” into a clinically-led “showpiece” of reform, management of hospital and community care contracts saw far less change – even though mental health contracts had “not been regarded as a strategic priority” and experienced a loss of potential funding.

The researchers identified a few key themes to explain this discrepancy in outcomes:

  • a “large number of highly interested individuals” connected to hospital and community care contract management made it difficult to reach decisions in those areas, while mental health contract management was “conspicuous due to the absence of participation and monitoring”
  • in contrast to mental health contract management, hospital contract management “was directly associated with a high level of potential gains and losses of valued resources”
  • GPs in the hospital region objected at times to any arrangement “that appeared to favour one hospital over another,” stymying decisions and reform.

While hospital and community care contracting involved many people inside and outside the agency, mental health contracting was quickly streamlined – with historically separate meetings merged in order to align quality of clinical services with performance outcomes.

“The general lack of interest from most (agency) managers and local GP representatives allowed making and implementing decisions, and thus effectively using available (albeit limited) resources, without lengthy negotiations,” the study found. “In contrast to other service areas, disagreements or tensions among and between GPs representatives and (agency) managers were rare” in mental health contracting.

The study – entitled “The emergence of change in unexpected places: resourcing across organisational practices in strategic change” – is co-authored by Dr Rene Wiedner of Warwick Business School, Professor Michael Barrett of University of Cambridge Judge Business School, and Professor Eivor Oborn, a Research Fellow at Cambridge Judge Business School and Professor at Warwick Business School.

The authors say they hope the paper shifts thinking in terms of what is considered “valuable” when it comes to strategic change initiatives: “We argue for shifting our thinking away from a consideration of the role of resources in shaping strategic change towards examining the role of strategic change initiatives in shaping resources.”