An exploration of medical director identity and performativity in the UK National Health System

This abstract is submitted to address the third area of interest in this stream. The paper will enhance our understanding of identity related conflicts (e.g. Alvesson and Willmott, 2002) particularly in relation to professionals, such as doctors, who become managers. It contributes to an increased understanding of the function of talk in the construction of complex professional identities such as that of ‘medical director’. It provides a detailed understanding of how medical directors discursively construct ‘management in general’, and how they construct their own managerial identity(s) in comparison. In doing this it shows how the participants in this study discursively construct medicine’s dominating position in the medical management struggle in the NHS. This is so in spite of the context in which medical directors are exhorted to manage and reduce the divide between medicine and management. This paper, based on doctoral research, explores how medical directors discursively construct their identity in the challenging context of the National Health Service (NHS). The role of NHS medical manager was created as a hybrid bringing together the conflicting roles of doctor and manager to help overcome medical resistance to management. The medical director, as the most senior doctor-manager, is a board appointment with responsibility for medical affairs. While this is presented as a high status position allowing doctors to take responsibility for managing their institutions, the different demands and identifications could cause conflict between the role of doctor and manager within medical director identity construction. It will explore the utility of Social Identity Theory (SIT) (Tajfel & Turner, 1986) and Judith Butler’s (1999) theory of performativity in understanding the identity experience of medical directors. In utilising these two approaches to understanding identity from different ontological frameworks identities are explored as both enduring and fleeting. In taking a performative perspective with an emphasis on Foucauldian notions of discourse and power, this paper broadens our understanding of professionals and managers from that which focuses on differences in their respective orientations to one which draws attention to the implications of the complex webs of discourse and power on their identity. It is argued that both social identity theory and performative identity have theoretical value in understanding medical director identity. The former explains the attractiveness and robust nature of the ‘medical identity’, and the latter is a useful approach to understanding the experience of ‘medical director’ as opposed to ‘medical doctor’ identity. SIT sees identity as a central and unifying concept and it emphasises the social aspect of identity construction through the idea of the group. A performative identity, in contrast, is one which is enacted though language in conversations and interactions and is therefore unstable and temporary rather than stable or self-evident. Viewed from the perspective of Judith Butler (1999) identity is understood as a performative achievement. She defines performativity as the feature of discourse which has the power to produce what it names (Salih, 2002) and her focus is on the power of the discourse to produce and regulate identity. Therefore in interactional terms identity in SIT is focused on group identification while in performativity it is focused on individual interactions. Both SIT and peformativity acknowledge the importance of culture and context but look at these constructs in different ways. The complex interplay of power and resistance is strongly implicated in an understanding of the identity construction of medical directors. While the hybrid medical manager may be theoretically seen as a new form of engagement (Cohen, et al., 2002) between the two powerful discourses of medicine and management, the identity remains a site in which the struggle between medicine and management is localised. The tensions and contradictions that ensue are managed and exposed in the performance of medical director identity. Through the use of clinical credibility as a tactic of resistance, medical directors retain their identity as doctors and thereby their affiliation with the group identity of medicine. Managerial identity on the other hand is enacted as an instance of performative identity rather than as anything more substantial or stable. The achievement is that medicine simultaneously retains its hegemonic position in the medical management hierarchy and resists the implications of managerialism. The paper will reveal that the medical director role is ambiguous, that medical identity is robust and that medical management is difficult compared to clinical work. Managerial identity in general is constructed negatively from the perspective of doctors. In authoring their own managerial identity medical directors emphasise the positive intellectual challenges of the role but struggle with relationships with their medical colleagues, particularly those in difficulty. The importance of maintaining clinical credibility is both embraced and contested as a resource which bolsters and maintains medical identity and so distinguishes medical directors from the taint associated with the pejorative managerial identity. Medical directors identify themselves as a bridge between management policies and medical professionalism. However, analysis of this discourse demonstrated the ways in which it might maintain separation and preserve medical uniqueness. In conclusion, while the identity of doctor is best understood through SIT as powerful, desirable and stable, the identity of medical director is seen to be a less stable performative achievement. The hegemonic struggle is localised in the identity of the medical director where the dominant discourse of medicine retains its ascendant status in the very role designed to reduce the divide between medicine and management. The paper raise doubts about the success of New Public Managment (NPM) and managerialism as an identity project (Du Gay, 1996) in socialising doctors into management and in drawing doctors in to management positions. The results imply that doctors are appropriating aspects of managerialism not as an occasion to engage in management but as an opportunity to preserve the position of doctors. These findings add to our understanding of the management of healthcare and for engaging doctors in the process of change in the NHS