PurposeThe use of the balanced scorecard has been subject to increasing scrutiny and criticism in academic literature. The purpose of this paper is to explore the limitations of, and implications for, the Performance Assessment Framework (PAF) as a balanced scorecard approach in the NHS. Although Kaplan and Norton suggested that the balanced scorecard can be adapted for strategic performance management purposes in the public sector, this study aims to argue that such claims fail to give sufficient weight to the political context in which a public sector organization operates.Design/methodology/approachSemi‐structured interviews were employed to investigate the perceptions about the PAF of local managers and whether and how they incorporated central government's performance targets into their local operations within two health authorities. Furthermore, in order to examine these two health authorities' performance measurement practices, documents relating to their internal performance reports and local delivery plans were analysed.FindingsEmpirical findings drawn from local health authorities indicate that the use of the PAF was primarily for legitimacy seeking purposes rather than for rational performance improvement. For central government, the PAF was used to make the performance of the NHS visible to the public so that the public would receive the signal that central government has attempted to deliver government mandates. For local health authority managers, in order to seek legitimacy from central government, imposed performance indicators were incorporated into their local performance measurement practice. However, the use of the PAF was symbolic and ceremonial and had little impact on improving performance valued by local managers in NHS.Originality/valueThis study agrees with institutional theorists' argument that the use of performance measurement systems should take into account politics and power faced by an organization. In the NHS, performance measurement might be used by local NHS organizations primarily as a ceremonial means of demonstrating their symbolic commitment for legitimacy seeking purposes.
This study examines the impact of political interests of the Blair Government on the development of the NHS star rating system. It argues that the use of performance measurements (PMs) is not detached from its political context but influenced by institutional interests including in particular those of the Government. The analysis indicates that the formulation of the specifics of PM, and of performance information within the NHS star rating system, was skewed to reflect the political objectives of the Blair Government. PMs are not merely neutral instruments, but, suffused with institutional interests, serve as a coercive mechanism to impose pressures upon the NHS as well as seeking to create a public perception of performance improvement. This study concludes that PMs in the public sector are influenced by the need to serve the political interests of the Government.
This study draws upon institutional theory to examine the extent to which the political interests of New Labour influenced the application of NHS performance measurements devised for accountability purposes between 1997 and 2007. This study adopts an interpretative perspective and emphasises the ‘ethos’ of New Labour's policy initiatives to convey its beliefs and moral superiority to the electorate. It argues that the performance measurements constituted by political interests served as a source of power deployed by New Labour to strengthen its credibility as being an accountable person. Where political interests were in play, multi‐dimensional performance measurements did not necessarily promote a balanced pursuit of performance improvements but led to various distortions and dysfunctional behaviour which hindered the stated aims of the NHS reforms and undermined the ethos of New Labour.
This study examines National Institute for Health and Care Excellence's (NICE) application of cost effectiveness analysis (CEA) for normalizing patients' access to newly licensed health technologies. Drawing upon evidence from the appraisal of four drugs developed for a rare form of cancer, this study demonstrates that the discourse of CEA provided a medium whereby contradicting ideologies of fairness were contested and resistance was provoked. Far from being docile, the patients whom the NICE technology appraisal sought to administer were actively challenging the legitimacy of the calculation of CEA. The patients' recalcitrance not only undermined the normalizing force but also compelled NICE to revise its application of CEA to suit their own interests. This study concludes that the discursive characteristic of calculating technologies not only constituted but was also constituted by conflicting interests and power struggles.
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