The Objectives of NHS Trusts
This thesis explores the motivation and goals of NHS Trusts which were set up under statutory instrument from 15t April 1991 by Margaret Thatcher's Conservative Government and which continue to have a role under the Labour Government elected in 1997. The research question asks 'What are the objectives of Trusts? What is the extent of the constraints under which they operate?' The central piece of empirical work uses a questionnaire survey to explore individuals' objectives, yielding 1,577 responses. A second exercise uses cost and volume data to review the performance of 100 Trusts. A third strand uses a case study to consider the behaviour of Trusts within their external environment. Consultants, or 'doctors', and managers are identified as the main power coalition within Trusts. Empirical findings are consistent with the hypotheses that, firstly, doctors and managers have different sets of objectives and that, secondly, doctors are interested in production, in particular maintenance of service quality, while managers are interested in the 'bottom line', defined as financial break-even. Under financial conditions described as 'bad times' where the interests of doctors and managers conflict, evidence suggests that doctors tend to dominate the performance of Trusts. It follows that Trusts will pursue a service objective, defined mainly through quality, rather than a financial goal. This dynamic is reinforced by the environment which sends signals to actors about how they should behave and, through lack of market exit, weakens the financial motivation of Trusts. While such behaviour is coherent in terms of the dominant actors, it is at odds with the overall goals of the Trust organisation which are perceived by doctors and managers alike to be the single-minded pursuit of financial targets. The thesis finds that this driver is not owned or acted upon by either doctors or managers and that, in accordance with the balance of its internal motivation, the Trust's primary objective is to maintain service quality.