It is striking when listening to health care managers describing their work how they move frequently between metaphors of caring and those associated with a business-oriented approach. They talk of caring, of sharing, of the values of service, of being 'pink and fluffy'. In contrast, they clearly appreciate the pressures on them to respond to business expectations, to be efficient, to argue finances, to 'blacken their hearts' in the way they manage others.
This separation of health care work into a caring component and a business orientation has always existed but has become a critical issue in Europe in the last 15 years. Over this period, various global and demographic changes have destabilised European economies with a knock-on effect on the funding of welfare systems in general and a political willingness to introduce into many health care systems new variations on the central control versus competitive market models.
However, a change in rhetoric does not necessarily lead to new values and hoped-for results. As Lowe (1993) pointed out, policy should be judged by its actual impact. This sentiment was echoed by Baldock (1993:24), who argued that the delivery of welfare relied on relationships between organisational forms and outcomes and that the organisation was 'the mechanism by which political commitments and intentions are turned into welfare outcomes'. It is the organisational process of translating strategy into action that is the focus of this chapter.
The aim of this chapter is to examine the effects of a contractual and managerialist approach to health care on middle managers' perceptions of power. Three contrasting groups of middle managers were interviewed: National Health Service (NHS) nurse managers, NHS finance managers with an accounting background and nurse managers from private hospitals. It was thought that the first two groups would illustrate how the introduction of general management and managed markets into the NHS had affected the