ABSTRACT
INTRODUCTION Since the mid-1970s the British National Health Service has gone through a series of structural transformations in which the desire to implant a ‘managerial’ discourse and practice within a service that had previously been ‘administered’ has played a strategic role. The attempt to introduce a managerial discourse and practice has taken very different ideological forms and produced varying programmes of structural reform. While the 1970s were dominated by the ethos of corporate rationalization and bureaucratic centralization, the 1980s have been shaped by the rhetoric of ‘market decentralization’ and organizational autonomy (Harrison et al. 1990, Small 1989). The era of corporate rationalization was based on an ideology of bureaucratic centralization and control which left ‘professional power’—particularly the power and authority of the doctors-relatively untouched. The political drive to design and administer a health service which was more efficient and effective in structuralrather than operational-terms left medical power largely unscathed. However, the major shifts in ideological and political context experienced in the British National Health Service in the 1980s necessarily entailed a more substantial assault on the professional privileges and collaborative networks that had directed and legitimated the provision of health care practice from the inception of the NHS in 1948. A service which had previously been centrally administered and locally selfmanaged was now deemed to be in need of management, and all the paraphernalia of external controls and monitoring which this radical transformation in organizational and ideological rationales entailed (Clark and Starkey 1988).
