Health Services Management Research 15, 165172

# Health Services Management Centre 2002

Meeting patient expectations:

healthcare professionals and service
re-engineering
Angus Laing
Open University, Business School, Milton Keynes, UK

A central theme underpinning the reform of healthcare systems in western economies since
the 1980s has been the emphasis on reorienting service provision around the patient.
Healthcare organizations have been forced to re-appraise the design of the service delivery
process, specically the service encounter, to take account of these changing patient
expectations. This reorientation of healthcare services around the patient has fundamental
implications for healthcare professionals, specically challenging the dominance of service
professionals in the design and delivery of health services. Utilizing a qualitative
methodological framework, this paper explores the responses of healthcare professionals to
service redesign initiatives implemented in acute NHS hospitals in Scotland and considers
the implications of such professional responses for the development of patient-focused
service delivery. Within this, it specically examines evolving professional perspectives on
the place of a service user focus in a publicly funded healthcare system, professional
attitudes towards private sector managerial practices, and the dynamics of changing
professional behaviour.

Introduction
The requirement for fundamental restructuring
and reorientation of public sector services has
been a constant refrain among policy makers in
post-industrial economies over the past two
decades (Lynn, 1998). Motivated by political
and economic pressures to enhance the efciency and effectiveness of public sector service
provision, such reorientation was aimed at
addressing what was seen as the essentially

Angus Laing, Open University Business School, Walton

Hall, Milton Keynes, MK7 6AA, UK.
E-mail: a.w.laing@abdn.ac.uk

introverted and unresponsive nature of public

sector service provision (Collins et al., 1994). At
the core of this reorientation has been a change
in the relationship between service providers
and users. From the service user being a passive,
subordinate partner in the delivery of public
sector services, the successive governments
have promoted the service user as an active
and equal partner in the design and delivery of
such services (Keaney, 1999; Walsh, 1994). This
policy level commitment to the redesign of
services has cascaded through the public
sector, forming a key element of government
policy relating to areas such as health and
education. The placing of the public sector
service user at the core of the service delivery
process has forced public sector organizations to
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fundamentally reappraise the prevailing organization and management of service delivery.

Inevitably such policy initiatives have had
major implications for public sector professionals in that the implementation of such
policies falls to front-line professional staff.
Specically they have challenged the established dominance of public sector professionals
in the design and delivery of services (Gray and
Jenkins, 1995). Inevitably such challenges have
engendered signicant resistance from frontline professionals. Although such resistance to
change may be attributable to narrow professional self interest (Dawson, 1994; Pettigrew
et al., 1992) it may also be attributable to more
fundamental questions regarding the appropriateness of such user-focused reorientation of the
delivery of public sector services (Brown, 1992;
Graham, 1994). This reects a deep-seated
unease with the potential consequences of
such consumerization of public sector services
given prevailing resource constraints and informational asymmetries between service users
and professionals (Hugman, 1994; Michael,
1997). Operationally, this concern has found
expression in antipathy towards the language
of consumerism and the associated management practices, most notably service re-engineering, among public sector professionals
(Clarke and Yarrow, 1997; Laing and Galbraith,
1995).
Focusing on the experience of the National
Health Service in Scotland (NHSiS), this paper
examines the reaction of healthcare professionals towards those policy initiatives aimed
at achieving a fundamental redesign of health
service provision. Specically it examines the
reaction of healthcare professionals to service
redesign initiatives implemented in acute hospitals in Scotland and considers the implications
of such professional responses for the development of patient-focused service delivery. Within
this, it specically examines evolving professional perspectives on the place of a service
user focus in a publicly funded healthcare
system, professional attitudes towards private
sector managerial practices, and the dynamics
of changing professional behaviour.

Health policy: developing a user focus

Turning specically to the NHSiS, the successive reforms occurring from the late 1980s
onward require to be viewed in the context
166

of the broader commitment to a fundamental

reorientation of public sector services. The
objective of making the NHSiS more responsive
to service users can consequently be seen as a
constant theme underpinning the reforms of the
health service introduced over the past two
decades. This promotion of a user focus or,
albeit within different organizational frameworks, is evident from the proposals contained
within both the 1989 and 1997 white papers, i.e.
Working for Patients and Designed to Care:
`We aim to extend patient choice. . . . All proposals
in this white paper put the needs of patients rst.
. . . The patients` needs will always be paramount.
(DoH, 1989)
`Our starting point is that every aspect of the
planning and delivery of services should be
designed from the perspective of patients.
(SOHD, 1997)

Such stated commitment to the development

of user-focused service provision is supported
by both the substantial proposals contained
within these white papers and subsequent
policy implementation initiatives. Together
these documents provide a clear insight into
policy makers determination to achieve a
fundamental reorientation of healthcare service
delivery.
In promoting such a user orientation, there
has been a consistent focus on the management
of the service delivery process rather than on
service, that is clinical, outcomes. In particular
there has been an emphasis on the importance
of what may be described as tangibles, responsiveness and assurance (Parasuraman et al.,
1991) as both indicators of service quality and
as measures by which users evaluate service
provision. Perhaps nowhere is this more
comprehensively illustrated than in Working
for Patients:
`At present the service provided on admission to
hospital is sometimes too impersonal and inexible.
This is not what either the Government or those
working in the Health Service want to see. . . .
It wants a service which considers patients
as people. It believes that each hospital should offer:

Appointments systems which give people individual appointment times that they can rely on.
Waits of two to three hours in outpatient clinics are
unacceptable.

Meeting patient expectations

Quiet and pleasant waiting and other public areas
with proper facilities for parents with children and
for counselling worried parents and relatives.
Clear information leaets about the facilities
available and what patients need to know when
they come into hospital.
Clearer, easier and more sensitive procedures for
making suggestions for improvements and, if
necessary, complaints.
(DoH, 1989, p. 6)

This emphasis on the processual aspects of

the delivery of healthcare services, that is what
Gabbott and Hogg (1994) termed the `care
dimension of the delivery of health services,
has subsequently remained the dominant
focus in Designed to Care. This is reected in
the ongoing emphasis on the importance of the
management of the `patient pathway or
`patient journey, i.e. the users experience of
the service delivery process, to the attainment of
user-oriented service provision. In this regard
health policy may be viewed as drawing heavily on the re-engineering agenda characteristic
of the public sector from the mid-1990s (Jones
and Thwaites, 2000).
`We believe that our modern NHS must care as
well as it cures. We will improve the patients
journey from GP surgery to outpatient clinic,
from hospital to home. (SEHD, 1999a, p. 8)
`Modernizing the NHS is about reorganizing the
entire healthcare system. Making the patient journey as good as it can be. People talk to me about
their experience through the system . . . Cancellations, changes to appointment, disruption to
family life. (SEHD, 2000)

The ultimate objective of such reorientation of

the service delivery process is that both health
service organizations and professionals.
`. . . would (a) put the individual at the centre of its
policies and practices; (b) recognize and support
diversity by striving to meet the widest possible
range of needs; (c) seek to achieve the best
``match between provision and the needs of the
individual (SEHD, 1999b, para. 2.7)

Although clinical standards, i.e. service

outcomes, were addressed in Designed to Care,
reecting growing public disquiet with the
medical profession as a result of increasing
evidence of professional malpractice, the dominant focus has remained on the processual
aspects of service delivery. Such a focus argu-

ably reects the perception, based on evidence

from commercial service sectors, that users
evaluation of complex professional services is
largely framed in terms of the process attributes
of service delivery (Taylor and Cronin, 1994).
Central to such process redesign has been
the improvement of communication between
health service professionals and service users.
Long perceived to be the Achilles heel of
the NHS, the focus has been on ensuring that
service professionals provide users with the
information they require both to facilitate the
service delivery process and to contribute to
clinical decisions about service provision
(Entwhistle et al., 1997).
`. . . clear and sensitive explanations of what is
happening on practical matters such as where
to go and who to see, and on clinical matters, such
as the nature of illness and its proposed treatment. (DoH, 1989, p7)
`Being informed means having access to the right
amount of information at the right time, information which may be supplemented by discussion
with a healthcare professional. It is important to
emphasise that all healthcare professionals can
contribute to this process. (SEHD, 1999c, para. 95)

The importance of such a shift in the culture

of information provision reects the impact of
the informational asymmetries characteristic of
complex professional services such as healthcare (John, 1996). Such improvement in communication and information provision is thus seen
to be critical to the effective reorientation of
service provision, i.e. in shifting the service
encounter from a professionally dominated
paternalistic model to a more egalitarian participative model (Toop, 1998).
Such commitment to the development of
user-oriented service provision inevitably has
fundamental implications for the way in which
healthcare services are designed and delivered.
As a result, the policy implementation initiatives following on from Designed to Care have
emphasized the need for sweeping changes to
the way in which services are organized and
managed. Such a process of redesign has significant implications for those professionals
involved in the service delivery process.
`The patient journey involves a huge range of
people, from cleaners to consultants. Its these
people together who are delivering health care.
And the quality of care will be determined by how
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effectively these people work together as a team.
Until now, patients have had to t into the system.
Thats not good enough. Now its crucially important that people get the care they need as quickly
and as effectively as possible. (SEHD, 2000)

This explicit acknowledgement of the need

for radical redesign, and the expressed determination to challenge established models of
service delivery and professional practice,
marks a clear continuation of the policy drive
towards the development of a user-oriented
health service initiated originally under the
aegis of Working for Patient. Ultimately,
however, the extent to which such a policy
direction is actually realized is dependent on
the compliance of service professionals to such
process re-engineering. It is the responses of
service professionals to such initiatives which
constitute the core of the paper.

Methodology: researching professional

attitudes
The paper is based on data gathered as part of a
broader research project examining the responses of NHSiS acute hospitals to the market
reforms of the late 1980s and early 1990s. The
research was based primarily on in-depth interviews with senior clinicians and strategic and
operational level managers across a sample of
acute NHS trusts in Scotland. Following an
initial mapping survey of Directors of Contracting of all acute NHS trusts in Scotland (N 31), a
stratied sample of nine acute hospitals was
identied and semi-structured interviews were
conducted with Medical Directors and Directors
of Contracting or Strategy. The selection of the
sample of hospitals for this rst phase of interviews was based on both the structural characteristics of the hospitals in terms of size, service
range and location; and evidence of evolving
responses to policy identied from the preceding
mapping survey. In order to secure greater depth
of data, a second round of interviews were
conducted with Clinical Directors and Directorate Business Managers from a convenience
sub-sample of three hospitals. This two-stage
approach ensured that the interview data,
together with the associated documentary material, was representative and provided a valid
picture of organizational and professional responses to policy pressures to restructure service
delivery develop a service user focus.
168

Professional attitudes: implementing a

user focus
The commitment of policy makers to achieving
a fundamental user-focused re-orientation of
healthcare delivery has placed enormous pressures on senior healthcare managers to deliver
radical change within their organizations. To
these managers such concepts of process reengineering appeared to provide:
`. . . a convenient set of seemingly different and
practical techniques that promised the radical
organizational and performance impacts that
these managers were charged with achieving.
(Willcocks et al., 1997, p. 620)

Central to these concepts was the idea of

consumer sovereignty and the need for
increased responsiveness to consumers on the
part of the producer (Hammer and Champy,
1993; Hammer and Stanton, 1995). Given the
prevailing political pressures on public sector
organizations to articulate a user orientation,
evidence suggests that private sector reengineering concepts were adopted widely and
uncritically within a variety of public sector
settings (Jones and Thwaites, 2000). Within the
NHS such concepts found expression in the
idea of patient-focused care.
`. . . patient-focused care brings elements of process
re-engineering and TQM together with multiskilling and team working to focus service
processes around the consumer. (Fischbacher
and Francis, 1998, p. 22)

The attraction of such concepts lay in that the

perceived problem with prevailing approaches
to the delivery of healthcare services was that no
one was responsible for the patient and had endto-end experience of the service process. This
critique was echoed in policy statements emphasizing the need to enhance the management of
the patient journey through the healthcare
system (SEHD, 1999a). Proponents of patientfocused care have specically argued that:
`. . . the number of processes and sea of faces underpin inefciency. . . . Although the evidence to date is
thin, a shift to patient focused care should at least
personalise the patients care as he or she interacts
with fewer staff. (Hurst, 1996, p. 68)

Process re-engineering initiatives such as

patient-focused care can thus be seen as
comprising two discrete elements, rstly the

Meeting patient expectations

redesign of the overall service delivery process

and secondly the management of the service
encounter, the interaction between service
professionals and service users. As highlighted
in successive policy statements, the reform of
both these aspects is critical to achieving the realignment of healthcare delivery around the
service user.
Drawing on the data from the mapping
survey it is clear that the majority of hospitals
in Scotland (N 26) were actively engaged in a
variety of what loosely might be described as
re-engineering initiatives. These initiatives
encompassed activities ranging from the wholesale redesign of services to targeted customer
care training programmes. The unifying theme
underpinning all such reported initiatives was
the attempt to reorientate service provision
around the service user. The range and scope
of such initiatives is apparent from the following experiences reported by interviewed hospital managers:
`. . . the new breast clinic is looking at the service
from the patients perspective. The services that
have to be brought together to make that clinic
work have meant reorganization and not doing
things in the way that they have been done in the
past. . . . but for the patient it means they will have
the tests and the diagnosis by the end of the
day . . . that will reduce the traumatic period
when they dont know what the situation is.
(Business Manager Hospital B)
`I think from the patients point of view . . . you
start to realize that the patient has got a very long
unpleasant journey every time they come to an
outpatient clinic. Why cant we come out to them?
What is stopping us? Its an inconvenience to us
once a fortnight or whatever but it is a lot easier
for us to get there in our cars than it is for them
to struggle onto public transport. (Business
Manager Hospital H)
`. . . trying to get people to think beyond their own
department or own clinic because there is no use
saying to the patient ``your records are missing
because Joe Bloggs has got them in his car. The
patient doesnt want that, the patient wants the
notes there, so we have been trying to develop that
as well. (Senior Manager Hospital H)
`The hospital has been involved in a programme
of developing communication skills. Following a
Kings Fund audit we identied patient communication as an area which needed addressing
urgently. We employed a team of training consultants to develop a programme which they delivered to key front-line staff who would then unroll

it through their department. (Senior Manager

Hospital A)

It is readily apparent that such user-focused

re-engineering initiatives fundamentally impact
on the working practices of the professionals
involved in the delivery of these services.
Consequently the success or failure of these
initiatives is ultimately dependent on the ability
and willingness of front-line professionals to
change their established practices. Within the
highly politicized context of the NHSiS the
attitude of clinical professionals towards such
initiatives must be viewed as critical.
Focusing initially on those initiatives involving the redesign of the service delivery
process, it is evident from the mapping survey
that while in the majority of hospitals (N 17)
clinical professionals have supported such
initiatives, in a signicant minority of cases
(N 9) developments have been thwarted by
the opposition of clinical professionals. The
following experience is representative of the
reported basis for such opposition across the
hospitals forming part of the qualitative phase
of the research:
`. . . things like putting clinics in local centres of
population. Our consultant surgeons are not interested. They feel patients should come to them . . .
that is partly because there is not the backup
facilities at peripheral clinics so they feel that it
may not be efcient or effective . . . they are more
concerned at getting patients in, getting activity
levels up. (Senior Manager Hospital I)

Although there was an acknowledgement

among both managers and senior clinicians
that front-line clinical staff are under signicant
pressure in terms of expected levels of output
due to political pressure for reductions in waiting times, there was a perception that in certain
instances professionals deliberately utilized
workload pressure as an excuse to avoid changing their working patterns. In addition there
was a perception that many of these initiatives
are viewed by many clinicians as simply
another `top-down managerial imposition on
clinical staff, resulting in an almost automatic
rejection of such initiatives. This is frequently
coupled to an overt dislike of the language of
successive policy statements, and subsequent
managerial responses, with their constant
emphasis on the centrality of the service user.
The validity of this perception would appear
to be borne out by evidence from one hospital
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where a more participative redesign initiative

framed in less strident managerial terminology
resulted in widespread acceptance of a user
orientation by clinicians:
`It is fair to say we have been very happy with the
way the doctors have taken on the service
programme, . . . the areas of difculty have been
identied by patients and staff in the directorate
and the consultants are involved in coming up
with improvements. . . . They {clinicians} are actually getting involved. So long as it does involve
people and doesnt exclude people that is the key
really. (Business Manager Hospital E)

Such patterns of behaviour can be seen as

consistent with evidence from the experience
of other public sector organizations where
user-focused service re-engineering initiatives
have been undertaken (Willcocks et al., 1997).
Indeed a consistent theme within the critical
literature on re-engineering has been the extent
to which the failure of re-engineering initiatives
is directly attributable to the `political navete of
their proponents and the concomitant neglect of
what may be described as the soft dimensions of
organizational change (Knights and Willmott,
2000). Equally such experience corresponds
with evidence from broader studies of organizational change initiatives within the NHS highlighting the importance of participative
approaches to the management of the change
process (Pettigrew et al., 1992; Kitchener and
Whipp, 1995).
Turning to the management of the service
encounter, in particular the enhancement of
communication between professionals and
service users, there is evidence of a clear dichotomy in terms of the exposure to such initiatives.
The survey data indicates that although 91%
(N 29) of hospitals had developed what may
loosely be termed `customer care programmes,
the primary focus of attention was on reception
and ancillary staff and to a lesser on degree
nursing staff. Such staff were perceived by
managers and senior clinicians to be the critical
front-line contact point, that is the interface
between patients and the hospital. This emphasis corresponds with other service contexts
where the primary focus of customer care training is on the development of listening and
problem solving skills among `front-of-house
staff (Lovelock, 1996). While the behaviour of
front of house staff clearly has a signicant
bearing on patients evaluation of the service,
the interactions between such staff and
170

the patient are not necessarily the critical

interactions within the service encounter.
Rather it is the interaction between the clinical
professionals and the patient that is central to
the patients evaluation of the service encounter
(Turner and Pol, 1995). Yet of the hospitals
surveyed, only 16% (N 5) indicated that
they had developed customer care training
programmes for clinical professionals with the
following views being typical:
`Well we havent put any of our clinicians through
a customer care programme, I suspect if I
suggested it to some of my colleagues I might be
found hanging by certain parts of my anatomy.
There would be a perceived resistance, a perceived
discomfort about that sort of thing. (Medical
Director Hospital B)
`Most consultants would think that if I had said I
want you to go away for a couple of days and sit
and be told how to use your charm and skills, I
think they would say that that was a waste of
time, to cancel an operating session and have a
nice day. That is what it is perceived as. (Clinical
Director Hospital C)

The prevailing focus of customer care

programmes on ancillary and nursing staff
may in part be viewed as reecting the perceived resistance of clinical professionals
towards the concept of a consumer focus. This
hostility towards customer care initiatives is
underpinned by a complex set of factors. At
one level such initiatives can be perceived as
challenging their professional expertise and
judgement, altering the dynamic of the service
encounter (Toop, 1998). However, there is also
more substantive concern among clinicians that
these initiatives are a distraction from their core
clinical responsibilities for the delivery of treatment. Frequently this was framed in terms of
not having time for this `customer nonsense
and the desire to be left alone to do what
they perceive as their core clinical functions.
Although in part reecting the resource
constraints under which they operate, this also
highlights the tensions inherent in Gronroos
(1989) view of professionals as part-time
marketers embracing marketing activities
alongside their core technical function.
Equally, however, this focus on nonclinical
staff may also reect the ongoing wariness of
health service managers in challenging
clinicians behaviour, despite the prevailing
direction of health policy. These patterns of
self-limiting behaviour not only serve to

Meeting patient expectations

highlight the particular power dynamics

prevailing in healthcare organizations, but also
the impact of such dynamics on achieving
effective re-orientation of healthcare delivery
around the service user:
`. . . we have tended to concentrate on the non
professional staff, making the mistake of forgetting that professional staff should be concentrated
on as hard and shouldnt be allowed not to understand the {customer} focus. So thats where we
started because it is easier to deal with the non
professional staff. (Senior Manager Hospital F)
`The complaint that has come back through feedback from other staff groups is that no matter how
hard they try, if somebody in a white coat comes
along and is rude to the patient, it destroys it.
(Senior Manager Trust G)

These perceptions highlight the critical role of

professional staff, particularly clinical professionals, in the effective execution of a consumer
orientation in the NHSiS. Yet the evidence
would suggest that health care professionals
have frequently proved resistant to politically
derived re-engineering initiatives aimed at
reorientating service delivery processes around
the service user. At one level this apparent
professional hostility requires to be viewed as
a product of the process by which this type of
initiative has been introduced, specically the
tendency towards a `top-down imposition of
an externally derived agenda on front-line
professional staff. However, such professional
resistance must equally be viewed as reecting
the intersection of two key consequences of
moves towards a consumer orientation. Firstly,
concerns about the resource implications of
such user-focused re-engineering initiatives
within a resource constrained public health
care system, and secondly a perceived challenge
to professional expertise and autonomy arising
from the empowerment of service users.

Conclusion: from policy to practice

The commitment to placing the service user at
the core of the healthcare delivery process has
been a consistent policy theme across successive
governments. Although the philosophical and
organizational approaches to such reorientation
have varied, the objective of reorienting service
delivery has remained core to health care
policy. Yet while there has been consistent
policy commitment to such reorientation and

the concomitant redesign of services across

successive governments, it is evident that such
commitment is not necessarily shared by frontline healthcare professionals responsible for the
delivery of services. The absence of such
commitment raises fundamental questions over
the ability to translate policy into practice.
Evidence of professional reaction to reengineering initiatives aimed at reorientating
the health care delivery process suggests that
health care professionals in acute hospitals in
Scotland have not generally responded to
policy level exhortations for service redesign
with much enthusiasm. In part this must be
viewed as reecting the `top-down managerialist process of policy implementation
adopted in a signicant proportion of the hospitals studied. Reecting the language and ethos
of much of the re-engineering literature with its
emphasis on the importance of strong centralized leadership (Knights and Willmott, 2000)
rather than negotiated participation, such
approaches to implementation may be viewed
as resulting in professional alienation from the
change process. In this regard such initiatives
can be seen as mirroring the experience of other
of re-engineering programmes across the public
sector where the lack of progress can be directly
attributed to the failure to develop effective
professional ownership of the change process
at the operational level (Willcocks et al., 1997).
Equally, however, there may be more
substantial grounds for professional resistance
to the reorientation of service provision. Specically the reorientation of healthcare delivery
and the concomitant empowerment of service
users can be seen as fundamentally challenging
the expertise and autonomy of professionals in
the delivery of services. In particular, service reengineering has forced professionals to give
weight to processual aspects of service delivery
alongside conventional outcome considerations.
This has raised signicant concerns over
resource utilization among professionals, i.e.
whether individual consumer concerns should
be given any weight in service design within a
resource constrained public sector environment
where considerations of efciency and equity
are paramount. By the same token the reconguration of the service encounter and the
emphasis on user input may be viewed as a
distraction from the core objective of a public
healthcare system such as the NHSiS of enhancing the health status of the population.
Ultimately such professional reaction raises
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Health Services Management Research

fundamental questions over the role and

validity of private sector-derived management
concepts such as re-engineering within a public
sector setting.

References
Brown, P. Alternative delivery systems in the provision of social services. International Review of
Administrative Sciences 1992; 58: 20114
Clarke, D. and Yarrow, D. I nd the term consumer
offensive. International Journal of Health Care Quality
Assurance 1997; 10(7): 26776
Collins, C., Hunter, D. J. and Green, A. The market
and health sector reform. Journal of Management in
Medicine 1994; 8(2): 4255
Dawson, P. Organizational Change: A Processual
Perspective. London: Paul Chapman, 1994
Department of Health. Working for Patients. London:
HMSO, 1989
Entwhistle, V., Sheldon, T., Sowden, A. and Watt, I.
Evidence informed patient choice. International
Journal of Technology Assessment in Health Care
1997; 14(2): 21225
Fischbacher, M. and Francis, A. Managing the design
of health care services. In: H. Davies, M. Tavakoli,
M. Malek and A. Neilson (eds.) Managing Quality:
Strategic Issues in Health Care Management. Aldershot: Ashgate Publishing, 1998
Gabbott, M. and Hogg, G. Competing for patients:
understanding consumer evaluation of primary
care. Journal of Management in Medicine 1994; 8(1):
1218
Gabriel, Y. and Lang, T. The Unmanageable Consumer.
London: Sage, 1995
Graham, P. Marketing in the public sector: inappropriate or merely difcult? Journal of Marketing
Management 1994; 10: 36175
Gray, A. and Jenkins, B. From public administration
to public management: reassessing a revolution.
Public Administration 1995; 73: 7599
Gronroos, C. Dening marketing: a market-oriented
approach. European Journal of Marketing 1989; 23(1):
5260
Hammer, M. and Champy, J. Re-Engineering the
Corporation: Manifesto for Business Revolution.
London: Brearley, 1993
Hammer, M. and Stanton, S. The Re-engineering Revolution. New York: Harper-Collins, 1995
Hudson, B. and Hardy, B. Localisation and partnership
in the `new National Health Service: England and
Scotland compared. Public Administration 2000; 78:
27391
Hugman, R. Consuming health and welfare In: R. Keat,
N. Whiteley and N. Abercrombie(eds.) The Authority
of the Consumer. Lodon: Routledge, 1994
Hurst, K. The managerial and clinical implications of
patient focused care. Journal of Management in
Medicine 1996; 10(3): 5977
172

Jones, M. and Thwaites, R. Dedicated Followers of

fashion: BPR and the public sector. In: D. Knights
and H. Willmott (eds.) The Re-engineering Revolution: Critical Studies of Corporate Change. London:
Sage, 2000
Keaney, M. Are patients really consumers? International Journal of Social Economics 1999; 26(5):
695706
Knights, D. and Willmott, H. The re-engineering
revolution. In: D. Knights and H. Willmott (eds.)
The Re-engineering Revolution: Critical Studies of
Corporate Change. London: Sage, 2000
Kitchener, M. and Whipp, R. Quality in the marketing change process. In: I. Kirkpatrick and M. M.
Lucio (eds.) The Politics of Quality in the Public
Sector. London: Routledge, 1995: 190211
Laing, A. W. and Galbraith, A. Strategic marketing
in the NHS: Kwik-health NHS trust. Journal of
Management in Medicine 1995; 9(2): 614
Lovelock, C. H. and Weinberg, C. B. Public and NonProt Marketing, 2nd edn. San Fransisco: Scientic
Press, 1990
Lynn, L. E. A critical analysis of the new public
management. International Public Management
Journal 1998; 1(1): 10723
Michael, S. O. American higher education system:
consumerism versus professionalism. International Journal of Education Management 1997;
11(3): 3250
Parasuraman, A., Berry, L. and Zeithaml, V. Understanding consumer expectations of service. Sloan
Management Review 1991: Spring: 3948
Pettigrew, A., Ferlie, E. and McKee, L. Shaping Strategic Change. London: Sage, 1992
Scottish Executive Health Department. Making it
Work Together. Edinburgh: HMSO, 1999a
Scottish Executive Health Department. Implementing
Inclusiveness. Edinburgh: HMSO, 1999b
Scottish Executive Health Department. Towards a
Healthier Scotland. Edinburgh: HMSO, 1999c
Scottish Executive Health Department. NHS Way
Ahead. Edinburgh: HMSO, 2000
Scottish Ofce Home and Health Department.
Designed to Care. Edinburgh: HMSO, 1997
Taylor, S. A. and Cronin, J. J. Modeling patient
satisfaction and service quality. Journal of Health
Care Marketing 1994; 14(1): 3443
Toop, L. Primary care values. British Medical Journal
1998; 316: 18823
Turner, P. D. and Pol, L. G. Beyond patient satisfaction. Journal of Health Care Marketing 1995; 15(3):
4553
Walsh, K. Marketing and public sector management.
European Journal of Marketing 1994; 28(3): 6371
Willcocks, L. P., Currie, W. and Jackson, S. In pursuit
of the re-engineering agenda in public administration. Public Administration 1997; 75: 61749