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New Technology, Work and Employment 17:2ISSN 0268-1072

Impact of MIS/IT uponmiddle managers: someevidence from the NHS

Graeme Currie and Stephen Procter

The paper meets a need for more context specific empiricalresearch in this area. Subject to medical group power, the threecases studied suggest that MIS/IT enhances the role of middlemanagers since it is they who are best placed to ‘synthesise’information from MIS/IT for executive management.

Introduction

Our research analyses the impact of MIS/IT upon middle managers in a specificorganisational context, that of the NHS with the intention of addressing an empiricalresearch gap about the impact of MIS/IT upon the role of middle managers in specificorganisational contexts (Dopson and Stewart, 1990, 1993; Pinsonneault and Kraemer,1997). Addressing the empirical research gap, it is hoped, will provide evidence toset against competing views—one that suggests the role of middle managers will bereduced, the other that suggests it will be re-shaped or even enhanced—so that amore sensitive or nuanced understanding is reached of how MIS/IT impacts uponthe role of middle managers.

Specifically we examine the impact of three MIS/IT interventions upon middlemanagers in three hospital trusts as perceived mainly by middle managers. Theserepresent three different types of MIS/IT intervention. First we examine the impactof two operational systems that emphasise clinical information at a ward level—Patient Administration System (PAS) and Results Reporting System (RRS). Secondwe examine the impact of an integrated organisation wide intervention thatencompasses both managerial and clinical information—Hospital Information Sup-port System (HISS). Third we examine the impact of an organisation wide manage-ment information and control system that combines management accounting andhuman resource management information—PRISM.

❒ Dr. Graeme Currie is a Senior Lecturer in Organisational Behaviour in the Business School at theUniversity of Nottingham and Dr. Stephen Procter is a Reader in Organisational Analysis in theManagement School at the University of St. Andrews.

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102 New Technology, Work and Employment

There are a number of questions to be specifically addressed with respect to ourresearch agenda:

1. To what extent is MIS/IT likely to reduce, re-shape or enhance the role ofmiddle managers?

2. Connected to this, how does the introduction of MIS/IT change the relationshipof middle managers with executive management and those whom they manage?

3. Is MIS/IT merely a facilitator of these changes for middle managers rather thanthe direct cause?

4. How do aspects of organisational context influence the interaction of the intro-duction of MIS/IT and the role of middle managers?

Does MIS/IT reduce, re-shape or enhance the role of middle managers?

One view of the impact of MIS/IT upon middle managers is that its implementationis associated with a reduction in their role (Drucker, 1988; Hicks, 1971; Hoos, 1960;Leavitt and Whisler, 1958; Simon, 1960; Wheatley, 1992). These accounts focus atten-tion on MIS/IT as a substitute for middle managers because the activity of middlemanagers is one that is informational and structured decision-making. It is arguedfrom this viewpoint that middle management decisions can be made at least as wellby computers since the majority of decisions made by middle managers are repetitiveand require ‘little of the flexibilities that constitute man’s principal comparativeadvantage over machine’ (Simon, 1960). Middle management serve only as ‘% relays,human boosters for the faint, unfocused signals that pass for communication in thetraditional, pre-information organisations’ (Drucker, 1988 cited in Dopson and Ste-wart, 1993: 11). Zuboff (1988), for example, sees middle managers as carriers of infor-mation up and down the organisation and suggests that MIS/IT, which makes infor-mation more widely available, is likely to attack the authority of middle managerswho previously dominated access to, interpretation of and communication of infor-mation. In this context MIS/IT will allow information to flow directly to executivemanagement rather than through middle managers. As a result the power of middlemanagers is eroded relative to executive management (Foster and Flynn, 1984; Hicks,1971; Neumann, 1978; Sewell and Alhaji, 1989). At the same time information willflow directly to first line managers and subordinates and the power of middle man-agers is eroded relative to these groups (Gottlieb, 1990; Polozynski, 1983; Weiss,1988). The result of this is that the number of middle managers will decline in theface of the introduction of MIS/IT (Brynjolfsson et al., 1988; Byrne, 1988; Drucker,1988; Hoos, 1960; Syedain, 1991). This assumes that MIS/IT decisions are made byexecutive management since, even where the role of middle managers is merelyinformational and structured they may be able to resist MIS/IT supplanting theirrole where they are able to control the choice and usage of MIS/IT (Pinnsonneaultand Kraemer, 1993, 1997; Kraemer and Dutton, 1979; Kraemer et al., 1989). It shouldalso be noted that for executive management to supplant middle managers withMIS/IT may require an environmental trigger, competitive or cost pressure(Pinsonneault and Kraemer, 1993, 1997).

An alternative view of the impact of MIS/IT upon middle managers is that itsimplementation has been associated with a re-shaping or enhancement of the role ofmiddle managers, rather than a reduction (Buchanan and McCalman, 1988; Kanter,1982; Klatzky, 1970; Millman and Hardwick, 1987; Nonaka, 1988; Polakoff, 1987;Senker and Senker, 1992; Shaul, 1964; Spilsbury et al., 1993; Weiss, 1988). Generallythese researchers believe that MIS/IT decreases the need for a small portion of mana-gerial activity only in which middle managers engage rather than the need for theirjobs as a whole. From this viewpoint, MIS/IT does not have a comparative advantageover middle managers because the activity of middle managers is interpersonal andunstructured decision-making. Further MIS/IT allows middle managers to take upmore important interpersonal and unstructured decisional roles to replace their com-munication activities, which have been supplanted by MIS/IT (Pinsonneault and

Impact of MIS/IT on managers 103 Blackwell Publishers Ltd. 2002.

Kraemer, 1993, 1997). Millman and Hardwick (1987) for example suggested that theintroduction of office automation without exception allowed middle managers morefreedom in how they performed their jobs and greater responsibility for the results.MIS/IT may allow middle managers to exert more authority over decision-makingthat traditionally remained the domain of executive management because it increasestheir confidence in making decisions and removes uncertainty from their decisions(Buchanan and McCalman, 1988). New technology, such as MIS/IT, may also beutilised by middle managers to increase their control over subordinates (Buchananand Boddy, 1983). The result of this is that the role of middle managers will beenhanced and that, indirectly, their numbers increase, although even in this situationits impact may be determined by the influence middle managers exert over the choiceand usage of MIS/IT (Pinsonneault and Kraemer, 1993, 1997).

While many studies take a technological perspective and consider MIS/IT as afundamental factor affecting organisations (Pinsonneault and Kraemer, 1993), otherstudies highlight that the introduction of MIS/IT takes place within a context ofwider changes that impact upon the role of middle managers. From this viewpointMIS/IT is merely a facilitator of de-layering of middle managers or an enhancementof their role rather than the cause. It is factors other than MIS/IT that cause areduction in their role and decreases in middle manager numbers or an enhancementof their role and increases in their numbers (Dopson and Stewart, 1993; Pinsonneaultand Kraemer, 1993, 1997).

We have indicated to some extent more political aspects of the debate about theimpact of MIS/IT upon middle managers. Who controls the decision about choiceand usage of MIS/IT may influence its impact upon middle managers. For exampleexecutive management may utilise MIS/IT to wrest control of information frommiddle managers. Even under a more positive scenario for middle managers whereMIS/IT enhances the role of middle managers, should executive management controlchoice and usage of MIS/IT then they may attempt to make the performance ofmiddle managers more visible. We have particularly highlighted that whether middlemanagers make informational and structured decision-making or interpersonal andunstructured decision-making is an important influence upon its impact. If middlemanagers are primarily seen to take informational and structured decisions then theirrole and numbers will be reduced. In contrast if the potential of middle managersto take interpersonal and unstructured decisions is recognised by executive manage-ment then, political considerations aside, their role and numbers may increase. Thisis a more general debate about the importance of middle managers to effective organ-isational performance rather than a specific one about the impact of MIS/IT uponmiddle managers.

Those commentators who view middle managers as mainly taking informationaland structured decisions argue that, in these roles, middle managers typically resistchange or ‘subtract value’ from organisations. Middle managers, from this viewpointare, ‘a source of uncertainty for top managers because they control information, andthey can withhold, bias, or alter the information they transmit upward’ (Pinsonneaultand Kraemer, 1993: 281). As a result executive management advocate their de-layer-ing (Peters, 1987, 1992; Peters and Waterman, 1982; Wheatley, 1992).

Others argue that an organisation’s advantage will increasingly depend upon thedegree to which it allows middle managers to enjoy an enhanced role through mak-ing interpersonal and unstructured decisions. This involves a greater input frommiddle managers into the strategy and policy arena (Dopson and Stewart, 1990; Froh-man and Johnson, 1993; Kanter, 1982, 1983; Smith, 1997). Information flows throughMIS/IT will allow middle managers to exert more influence over executive manage-ment decisions and contribute more meaningfully to strategy (Floyd and Wooldridge,1992, 1994, 1997, 2000; Nonaka, 1988; Nonaka and Tacheuchi, 1995). Further, MIS/ITby its very existence overwhelms organisations with information that requires furtherprocessing by middle managers so that it becomes endowed with relevance and pur-pose (Pinsonneault and Kraemer, 1993). Middle managers therefore contribute tostrategy by ‘synthesising information’ for executive management (Floyd and Woold-

104 New Technology, Work and Employment Blackwell Publishers Ltd. 2002.

ridge, 1992, 1994, 1997, 2000). Indirectly this may require an increase in the numberof middle managers. However, even in this situation executive management mayexert more control over middle managers because information available from com-puters means that the performance of middle managers is more visible (Dopson andStewart, 1993).

In summary, academic studies about the impact of MIS/IT upon middle managersappear to provide contradictory commentaries. This may be resolved through con-sideration of MIS/IT as a facilitator, rather than the cause of a reduction or enhance-ment of the number and role of middle managers. In particular the impact of MIS/ITupon middle managers appears determined by the relationship between executivemanagement and middle management following its introduction—that is, whetherdecision-making remains the privilege of executive managers or whether middlemanagers are involved in more strategic decision-making. This is influenced by therole middle managers play in organisations and the degree to which these roles arestructured, standardised, and routine. It also depends upon who makes MIS/ITdecisions—that is, the extent to which MIS/IT decisions are the province of executivemanagement or middle management and the presence of environmental, competitiveor cost pressures upon the organisation (Pinsonneault and Kraemer, 1993). The viewtaken by executive management about the importance of middle managers in con-tributing towards effective organisational performance and, who controls decisionsabout choice and usage of MIS/IT, combined with environmental, competitive andcost pressures, will influence whether there is a reduction in the numbers and roleof middle managers or an increase in their numbers and a re-shaping or enhancementof their role

The role of middle managers in the NHS and policy context

The debate about the impact of MIS/IT upon middle managers and the contingentfactors that determine this take a particular twist in the context of the NHS in the faceof changing government policy. The political significance of the NHS to successivegovernments has led them to intervene directly in the management and organisationof the service. The relationship of government policy and the role of middle managerscan be considered at two levels with respect to our research agenda. First, there isthe question of policy generally towards the organisation of health care services andits impact upon middle managers. Second, there is the question of government policytowards MIS/IT and its impact upon middle managers. It may be that governmentpolicy in the realm of MIS/IT is marginal to the reduction or enhancement in therole and number of middle managers. Government policy towards the organisationof health care services generally may be the main determinant of the impact MIS/IThas upon middle managers. To consider this debate we need to examine each of thepolicy areas in turn.

Government policy toward the organisation of health care servicesIn the NHS, from the mid-1980s to the mid-1990s, the situation can be described asone whereby middle managers were in the ascendancy. The Griffiths Report (DHSS,1983),1 which represented the keystone document of the NHS reforms under theprevious Conservative government, appeared to strengthen the hand of middlemanagement in the NHS and this continued following subsequent internal marketreforms (Harrison et al., 1992; Pollitt et al., 1991; Stewart and Walsh, 1992).

However, from the mid-1990s onwards, there have been attempts to marginaliseand attack middle managers in the NHS. For example, in the latter period of theprevious Conservative administration middle managers were attacked by politiciansand policy-makers as ‘men in grey suits’ (Hancock, 1994; Health Service Journal, 1994a,b). Such attacks upon middle managers and the process of de-layering in the NHS

1 The Griffiths Report promoted general management in the NHS to replace a previous consensusmanagement ethos in which the decisions of professionals were merely administered.


are similar to the more widespread organisational trends (Cameron et al., 1991; Cas-cio, 1993; Dopson et al., 1992; Palmer, 1995). The Labour Government who announceda target of £100 million cuts in management costs in 1997–98 has continued thistheme. As a result, over time manager bashing has become an occupational hazardin the NHS for many years to the point where even the managers themselves believethat the NHS has too many managers (Pettinger, 1998).

Given the attacks upon middle managers by policy-makers in government it mightbe expected that the introduction of MIS/IT be used to reduce their role and furtherdecrease their numbers. However, as stated in the introductory paragraph, suchassertions about the future role of middle managers based upon their interactionwith MIS/IT lack an empirical basis (Dopson and Stewart, 1990; 1993). As a resultit is difficult to reach any conclusion about the interaction of MIS/IT and middlemanagers in the NHS without gathering some in-depth case study evidence aboutthis phenomenon. As Pinsonneault and Kraemer (1993, 1997) suggest, dependentupon organisational context, MIS/IT could be used to reduce or enhance the role ofmiddle managers in organisations. Further, as discussed in the next section, the linkbetween government policy towards the role middle managers and its policy intentwith respect to MIS/IT is not clear.

Finally, besides the impact of government policy, the role of middle managerscannot be divorced from their relationship with the dominant professional group inthe NHS—that of doctors. MIS/IT may offer the potential for middle managers tocontrol doctors. Limited literature, however, about the impact of MIS/IT upon theboundaries between decision-making domains of management and doctors suggestsany gains by middle managers at the expense of doctors unlikely (Bloomfield et al.,1997; Brown, 1994, 1995, 1998; Currie and Brown, 1997; Dent, 1991). We should alsonote that generally the medical group are adept at minimising the impact of attemptsby management to exert more control over their work (Ackroyd, 1996; Dopson, 1996;Ferlie et al., 1996; Harrison et al., 1992).

Government policy toward MIS/ITThe impact of MIS/IT upon middle managers was not only mediated by governmentpolicy towards the role of middle managers but also more specifically by governmentpolicy in the MIS/IT area. The expectation might be the two are linked. However,changes in NHS policy that impacted upon the role of middle managers, such as thedevelopment of general management and the internal market and then the sub-sequent calls for managerial efficiency gains, were not necessarily complemented byappropriate government MIS/IT policy (Bloomfield et al., 1997; Keen and Muris, 1995;Thomas et al., 1994). As a result it is not clear how MIS/IT is intended to impactupon middle managers from a government policy-maker viewpoint. An importantquestion specific to the NHS is the relationship between broader organisationalchange and MIS/IT change. Discussion above suggests that it is policy aimed atdriving organisational change broadly rather than policy aimed specifically towardsMIS/IT that influence the role of the middle manager. To consider this further weneed to examine the government’s MIS/IT policy in more detail.

Despite the importance of information to the NHS, prior to the implementation ofthe system of general management recommended by the Griffiths Report (DHSS,1983) while financial resources were devoted to computing resources, there was littleattempt to identify in detail how computer resources might benefit the NHS (Dent,1991). Thereafter, first through the Management Budgeting initiative and laterthrough the Resource Management Initiative (DHSS, 1986), nationally organised pro-jects were pursued in several hospitals to develop the concept of an integrated cor-porate system providing financial, patient activity and human resource data.

As part of the Resource Management Initiative (from 1986 onwards) an informationsystem known as the ‘case-mix management’ system was developed. In brief casemix management systems generated cost-per-case information for every patienttreated by attaching standard costs to each clinical procedure, drug, diagnostic test,bed-day, and so on, associated with their stay in hospital and aggregating them. This


could then enable doctors, for example, to be the object of a ‘case-mix’ analysis inwhich patients treated by a doctor could be analysed with a view to improve effectiveand efficient use of resources and measurable improvements in patient care(DHSS, 1986).

The government subsequently introduced an internal market for health care inwhich the purchasers (health authorities and fundholding GPs) and providers(hospital, community and mental health trusts) were separated. At this point govern-ment policy towards the organisations of health care delivery and its specific MIS/ITpolicy appeared to be incongruent. With the introduction of the internal market thegovernment became intent on introducing a health care system comprising of com-peting and autonomous hospitals. The success of the internal market relied upongood information and was dependent upon implementing and using IT (Keen, 1994)and there was a particular need for a reasonably reliable way of ‘pricing’ the workcarried out (Dent, 1991), which case-mix management systems did not meet. Thedominant issue on the agenda of health care purchasers and providers in the wakeof the introduction of the internal market became contract monitoring rather thancase mix. This meant case mix management systems were substantially modified oreffectively shelved (Bloomfield et al., 1997).

Following the implementation of the internal market in the NHS (DoH, 1989, 1990),another attempt was made to realise an integrated information system for hospitals.The Department of Health supported the development of Hospital Information Sup-port Systems (HISS), as part of an Information Management and Technology (IM&T) Strategy in 1992. HISS was conceived as an integrated MIS/IT environment ableto meet the real-time operational and information needs of both health-care pro-fessionals and their professional managers. It was to provide the ability to bringtogether data from different areas, such as patient registration, theatres, cardiologyand wards and to send that amalgam of data, indexed by patients name, to whereverit could contribute to patient care. At the same time it would provide managementwith information to control the costs of patient care. However, again aspirations foran information system, which combined both clinical and managerial informationand allowed greater managerial control over how health service resources aredeployed and committed, have gone largely unrealised. One of the main reasons forthis is the power exerted by various medical professions to make clinical decisions(Audit Commission, 1995; Brown, 1995; Currie and Brown, 1997; Keen, 1994; NationalAudit Office, 1996).

This brings us to the current policy backdrop in relation to MIS/IT in the NHS.As a result of the Audit Commission Report (1995) and other reports critical of the‘big bang’ approach to the implementation of MIS/IT that HISS initially represented,hospital trusts have been given more discretion in pursuing their own local strategiesalthough these are expected to complement the national strategy. The overall aim ofthe IM&T Strategy is to have an electronic patient record and all trusts and NHSbodies connected through the NHSnet. The expectation is that the aspirations of pol-icy-makers in introducing HISS initially in a top-down way will be realised but in amore incremental, emergent way as individual trusts build their IM&T capabilitiestaking into account local circumstances. The result is that hospitals, instead of pur-chasing top-down information system solutions, have opted instead to strengthenoperational systems such as ward-ordering and results report systems, replacing orupgrading PAS systems, and then using relatively cheap and flexible software pack-ages for data-analysis and report writing (Bloomfield et al., 1997).

In summary, an historical overview of the development of MIS/IT in the NHSreveals a number of issues that are pertinent to our research study. The main issueis that of the balance between a top-down approach to the introduction of IT to theNHS and local discretion. Until recently the former tendency has prevailed. This isa tendency likely to result in the exclusion of middle managers from the developmentand implementation of MIS/IT. However, hospitals have stopped letting their infor-mation systems agenda be imposed upon them by government policy and insteadare making computing decisions at the local level, albeit framed by national policy


(Bloomfield et al., 1997; Keen and Muris, 1995; Thomas et al., 1994). Further, the indi-cation is that hospitals are emphasising operational clinical activities on the wards,rather than emphasising management information and control systems at organis-ational level (Bloomfield et al., 1997). This may allow middle managers to enhancetheir role if such computing decisions are decentralised within the health care organ-isation itself. There is a caveat to this argument however. As illustrated with HISS,the medical group exerts considerable influence over clinical decisions. An enhance-ment of the role of the middle manager in the realm of clinical decision-makingutilising MIS/IT may therefore be considerably constrained.

Case and methodology

The case studies

Case studies were selected to illustrate the interaction of middle managers with bothclinical and managerial information systems and both ward-based and organisationwide systems with the expectation that the degree of centralisation of decision-mak-ing would vary. For example, with ward-based clinical systems the expectation wasthat computing decisions would be decentralised while the opposite might be thecase with organisation-wide integrated systems concerned with management infor-mation and control. Three case studies were undertaken. These were:

Case Study 1—Eastshire Hospital (October 1997 to March 1998) The impact of aPatient Administration System (PAS) and Results Reports System (RRS) upon therole of middle managers.

Case Study 2—Parkside Hospital (May 1998 to September 1998) The impact of a Hos-pital Information Support System (HISS) upon the role of middle managers.

Case Study 3—Edwards Hospital (March 1999 to September 1999) The impact of anMIS/IT system—PRISM—that combined management accounting and humanresource information upon the role of middle managers.

The first case study at Eastshire focused upon the Patient Administration System(PAS) and the Results Reporting System (RRS). Although both were part of the devel-opment of an overall HISS, they were fairly narrow interventions with an emphasisupon clinical information. PAS keeps of a record of the patient from GP referralthrough to discharge—patients personal details, generating appointments for clinicwhen required, keeping waiting lists, recording details of attendance and clinicalinterventions for each patient. RRS offered a facility for the electronic transfer oforders and reporting of results, between the wards and hospital support services,such as haematology. The objective was that clinicians could receive test results trans-mitted electronically to work stations in the wards. Over a short period of time thesystem was to be further developed to incorporate the electronic ordering of tests.

Our second case study at Parkside focused upon HISS. This was based upon anAmerican system, which was modified to meet local requirements. It consisted ofa number of ‘modules’—master patient index, patient administration, contracting,radiology, case-mix management, patient care enquiry, care planning, pharmacy,billing, nurse management, theatres, order communication and results reporting.That it was based upon an American system meant that central to it was the conceptof billing. It therefore fitted with the new contracting climate established by theinternal market.

The third case study at Edwards Hospital—PRISM—was a system, which was con-cerned with managerial information requirements and combined managementaccounting and human resource information. The system consisted of a core ‘mod-ule’, which was designed to hold a record of individuals names, addresses, salary,job title and other personal details, such as qualifications, professional registration


numbers and renewal dates. To this was added optional ‘modules’ such as trainingand development, sickness and absence monitoring, health and safety, occupationalhealth information and nurse rostering. The intention of the system was that middlemanagers have responsibility to collect the information and access to the informationcollated. As with RRS at Eastshire it was also connected to the development of anoverarching HISS.

Middle managers

Given that many studies of middle managers have been criticised because they donot sufficiently delineate middle managers from other levels of manager above andbelow them (Dopson and Stewart, 1990; Pinsonneault and Kraemer, 1993, 1997;Turnbull, 1998) it is important to define who we are talking about when discussingthe ‘middle manager’. In the cases, middle managers were those, ‘within divisions,directly involved in planning and co-ordinating the production of services that arespecific to their own units’ (Smith, 1997: 23) or ‘who mediate, negotiate and interpretconnections between the organisation’s institutional (strategic) and technical(operational) levels’ (Floyd and Wooldridge, 1997: 466).

Middle managers in the NHS are a sub-set of the ‘general manager’ group referredto in the NHS policy documentation since this also includes executive managers andas general management has elaborated also include ward managers. For our pur-poses middle managers in the NHS are senior nurse or speciality managers in clinicalor operational directorates. We are not talking about ‘business managers’, whoseremit is rather narrowly focused upon contracting and as such can be considered tobe ‘off-line’. Ward managers are seen as equivalent to first line supervisors. It is alsoimportant to note that, while clinical directors, drawn from the medical group for-mally head up specialities, they are considered to be separate from middle managers.This is because of their reluctance to become involved in management (Buchanan etal., 1998; Ferlie et al., 1996; Harrison et al., 1992) and their considerable power anddiscretion over the development of service activity (Dopson, 1996; Harrison, 1988).An important characteristic of middle managers in the NHS that might differentiatethem from their counterparts in some other organisational contexts was that theytypically had clinical backgrounds themselves, often in nursing. This may enablethem to make an enhanced contribution to strategic change, given their specific oper-ational and clinical knowledge, beyond that which might be seen in organisationalcontexts other than the NHS.

Data-gathering techniques

Within all three case studies data was gathered via semi-structured interviewsaround one hour in length. An interview approach was adopted so that a set ofthemes, developed from the literature, could be covered. We recognise the problem-atic status of interview data (Dingwall, 1997) but settle for this as telling a plausiblestory (Melia, 1997) in a way that represents a time-efficient means of gathering data.All interviews were fully taped and transcribed.

In all three case studies, access was negotiated through the central IT Departmentin the trust. Four interviews were carried out with members of this department beforegoing on to interview 16 middle managers who were positioned outside this depart-ment. In most cases, those middle managers identified as interviewees were currentlyor had been members of a project group concerned with the development andimplementation of the IT system under consideration. In Eastshire this was the Infor-mation Management Group. In Parkside this was the HISS project group and inEdwards Hospital this was the PRISM Working Group. A further four interviewswere carried out with executive directors across the cases. In total, therefore, 64 inter-views were completed.

In addition to the data generated in this way, a wealth of documentation was


gathered from the trust and the central IT department. This included strategy docu-ments and minutes of project group meetings.

Findings and discussionA number of themes emerge in the findings that are linked to our research questionsset out in the introduction. First is the question of whether the informational role ofmiddle managers is supplanted by MIS/IT and if so, is their role therefore reducedor does it free them up them to take on an enhanced role. Second, the relationshipbetween (de)centralisation of decision-making generally and specifically about com-puting and the impact of MIS/IT upon middle managers is discussed. Third, theextent to which MIS/IT renders middle manager performance visible to executivemanagement is discussed with reference to its implications for the role of middlemanagers. Fourth, the relationship between middle managers and other stakeholderswhose activity they seek—doctors and sub-ordinates—to manage is discussed. Fifth,we assess whether MIS/IT is a cause or merely a facilitator of changes in the role ofmiddle managers.

The informational role of the middle manager

Assertions in the literature that the informational role of middle managers was likelyto be supplanted (Drucker, 1988; Foster and Flynn, 1984; Hicks, 1971; Neumann, 1978;Sewell and Alhaji, 1989; Zuboff, 1988) appeared wide of the mark. While one middlemanager, was worried about a redistribution of power that resulted from implemen-tation of MIS/IT:

I think it will open up more information to more people. I am slightly worried that it takes awaymy role of disseminating information [Edwards 13],

most middle managers felt that MIS/IT would enhance their informational role intwo ways. First, it freed them to engage in less routine decision-making and becomemore proactive. This was likely on the basis of having better information with whichto make decisions. There were numerous examples of middle managers being freedup to be more proactive in their jobs—for example, in managing bed occupancy:

Bed occupancy, for example, we used to spend an hour at the start of the day walking aroundwards to see what the situation was. Now I can get that information from HISS. I know whatthe bed situation is like in our area and other areas. If other areas are empty when we are fullI can divert patients there. I now have that information whereas I didn’t before [Parkside 7],

or in planning activity. For example, in Immunology:

I transfer all the raw statistical data that I get from our computer system and I break it downinto how many of each test we do each quarter and I also analyse workload needs you could dohundreds of tests which only take one minute and that might be less significant than if you aredoing 30 or 40 other tests that are time-consuming. So I use it for workload analysis [Eastshire 14].

Second, it was necessary for information within MIS/IT to be interpreted for execu-tive management. Middle managers with their knowledge of clinical and operationalmatters, were best placed to do this. A significant contextual difference revealedbetween middle managers in the NHS and those in organisations generally is that,typically in the NHS, middle managers have a clinical background. This gives themknowledge necessary to wield influence in operational areas because executive man-agement either do not have clinical expertise or are unaware of operational require-ments because they are situated at the corporate centre:

Although you’ve got the data [from HISS] you still need to interpret it in the light of your knowl-edge as a professional [Parkside 3].

Therefore MIS/IT is unlikely to displace their informational role. Rather, it couldbe argued that the information role assumes greater importance and that in this role


middle managers exert more influence, rather than less, upon non-routine decision-making. Middle managers imbue information with meaning—that is they interpretinformation for executive management through, for example, management reports—and this allows them greater influence upon non-routine decision-making:

So suddenly we actually had information to support suppositions we were making. Suddenly itgave you power rather than information [Parkside 2].

I take the information that has been downloaded by the Information Department from HISS toMicrosoft Access and I manipulate that information further to suit my requirements. I have tobe able to present it in a form that executive management and the medical staff understand[Parkside 2].

Such influence, based upon knowledge of operational and clinical context,extended to computing decisions. As one IT manager admitted, ‘I don’t really knowwhat goes on the wards’, and he stressed that middle managers, ‘are crucial in help-ing me understand what’s required’ [Eastshire 17].

(De-)centralisation of decision-making

In all three cases the approach to the development and implementation of MIS/ITwas one that was decentralised and Pinsonneault and Kraemers’ (1993, 1997) argu-ment, that where decision-making is decentralised, MIS/IT may enlarge and enrichthe job of the middle manager appeared to hold. This was part of a philosophydescribed by one executive as one in which, ‘clinical and managerial decision-makingcan be made at the lowest point nearest to the patient’ [Parkside 9—Director of Nurs-ing] so that with respect to computing decisions, ‘the case of IT need is made by thedepartments themselves. It’s not IT people who are seen as responsible for it andimposing it upon others’ [Eastshire 1—IT Manager]. This was most apparent at East-shire but was also a feature of the other cases. One middle manager described theextent of their involvement in computing decision-making:

We weren’t happy with our existing system and it was coming up for replacement anyway sinceit was quite old. So we initiated a tender process, carried out option evaluation and selected asystem which met most closely the criteria we defined [Parkside 7].

When decentralisation was extended to computing decisions it allowed middlemanagers to facilitate the development, implementation and utilisation of MIS/IT.While they lacked the technical skills to design the software itself in most cases theyconceptualised information flows and needs that informed technical design:

Initially we looked at the paper chase we used. We did a flow chart to say blood’s taken here,which the porters take and then they phone the ward and the paper report goes through the postetc. Then we tried to envisage how the RRS would change that flow chart and show benefitsfrom setting it up [Eastshire 20].

Middle managers would then interact with software suppliers during technicaldesign. This enabled information requirements, such as different patient categories,defined by middle managers, to be included in the software.

I’m in the middle between the software consultant and those who deliver healthcare. The softwarepeople who write the programs I make sure they do it in a way that the healthcare workers wantthem to. For example it’s important that different types of patients are recognised in clinicalareas, based upon the intensity of care required, rather than merely aggregating patient numbers[Eastshire 4].

This extended in some cases to bringing software suppliers together. For example,at Eastshire, ‘the RRS and PAS suppliers talked through me. I was like a piggy inthe middle’ [Eastshire 18]. Despite significant involvement in the development ofMIS/IT some middle managers felt the end product to still be insufficiently contex-tualised to their area and further developed software to meet the needs of theiroperational areas:


Things like PAS are fine for sending out appointments but we wanted to do a lot more besides.You’re probably aware that radiology have their own x-ray databases and we wanted somethinglike that in medical physics. We couldn’t buy what we wanted off the shelf so we developed,over the period of a year, our own database [Eastshire 19].

The involvement of middle managers in the development and implementation ofMIS/IT helped ensure that, in the main, MIS/IT enhanced their role rather than beingused to de-layer middle managers and diminish their role. Computing decisionsunsurprisingly may be a product of self-interest and whether one group’s role isenhanced or reduced may be a product of the extent to which they have influenceover the computing decision (Pinnsonneault and Kraemer, 1993, 1997; Kraemer andDutton, 1979; Kraemer et al., 1989).

MIS/IT and performance visibility

While the role of middle managers appeared to be enhanced by MIS/IT and thiswas viewed positively by middle managers, they exhibited concern that MIS/ITrendered their performance more visible to executive management. In one example,a middle manager in Theatres found herself put under pressure by the NursingDirector to add more patients to the list for operations one week:

She’s [Director of Nursing] now got immediate access to the theatre lists now. She used to getthem before but HISS just makes it easier for her and quicker for her. My lists for the week getquestioned. It was so much easier before HISS [Parkside 4].

This opportunity to control middle managers was commented upon by execu-tive management:

Service Managers will put their activity onto HISS and we can extract it off this and compile areport. There is an activity target to meet and I can see how active the department is comparedto expenditure [Eastshire 6—Director of Finance].

Such surveillance of the performance of middle managers was linked to a needfor individual trusts to meet performance indicators set out by central government:

With this [MIS/IT] I can produce a report saying 95 per cent of patients are seen within tenminutes, all that Patient’s Charter stuff we have to do. You are obliged to do it but this makesit easier [Eastshire 15].

Well considering the national drive for nurse recruitment over the last 12–18 months, we’veneeded that information during that because we’ve needed to report to the government onwhether our recruitment has been successful [Edwards 19].

and an intensification of patient care processes driven by central government:

Government targets set increasingly difficult to achieve gains % Activity is always going on, thelength of stay is always dropping, so you’ve got a very quick turnaround and you never seemto have enough time or people to do it. Anything that can give you a little more time is of benefit(Eastshire 9].

Middle managers were not only concerned about the surveillance aspect of MIS/ITbut that executive management asked for more information because MIS/IT existed.In attending to executive management requests this took middle managers awayfrom managing clinical activity:

I feel like I’m flying a desk instead of being out there on the wards. You find yourself behindthe computer more and more % rather than IT supporting nursing care, we’re actually workingfor the IT system [Parkside 8].

It could be argued that middle managers were ceding their informational role toexecutive managers (Foster and Flynn, 1984; Hicks, 1971; Neumann, 1978; Sewelland Alhaji, 1989) because MIS/IT rendered information about performance directlyavailable to executive management. However this is to ignore the complex nature ofclinical data:


You get lots and lots of information and what you have to try and do is to sort out the usefulfrom the useless, what the right and wrong questions to ask are. You can get side-tracked wheninterrogating the data [Parkside 12].

As earlier discussed middle managers had clinical and operational knowledge,which in many cases executive management did not. Middle managers thereforeretained significant influence over interpretation of data from MIS/IT:

Data within MIS/IT can be very crude. There are often specific contextual reasons linked to thenature of the clinical activity that can be used to explain what executive managers see as negativeindicators of performance even if it means pulling the wool over their eyes sometimes[Edwards 8].

The relationship of middle managers with doctors and sub-ordinates

As well as commenting upon the role of MIS/IT in making their own performancemore visible to executive management, middle managers recognised that MIS/ITwas helpful to control the performance of their own staff. As Buchanan and Boddy(1983) note, MIS/IT may offer greater possibilities for middle managers to maintainsurveillance over subordinates. For example with PRISM in Edwards Hospitalmiddle managers emphasised its use for sickness and absence management. Therewas a necessity for monitoring sickness and absence because, ‘the Secretary of Stateannounced some targets for reducing absence in the public sector’. As a resultabsence was emphasised as a performance indicator at trust level:

You couldn’t work out the cost of absence with the old system. You knew some people were offsick but you didn’t know what their salaries were so they could be worth four-pence or threemillion pounds it allows me to show the bottom line to staff and convince them of the need toreduce it (Edwards 20].

PRISM could also be used to monitor staff training and ensure that, ‘they arekeeping up to date with the requirements for continuing development from theirprofessional bodies and to audit registration with professional bodies’ [Edwards 18].Also, when staff apply for internal posts or for re-grading, ‘we can quickly accessrelevant data such as appraisal and previous experience’ [Edwards 20].

MIS/IT even allowed them in some cases to move outside their own span of con-trol and to influence the activity of the most powerful group in a hospital, that ofthe medical group. For example, one middle manager claimed that he cut down onunnecessary x-rays ordered by medical staff:

RRS will allow us to manage demand and change clinical practice. We can get information to showwhich individual medics are ordering large numbers of x-rays and ask them why [Eastshire 10].

However attempts to control the medical group in the case of x-rays at EastshireHospital were aimed mainly at junior doctors, whose management was the responsi-bility of middle managers. It would be more difficult for a middle manager to chal-lenge the medical opinion of a consultant for example, who ordered an excessivenumber of x-rays. Doctors still dominated the decision-making process and thisapplied to computing and other management decisions:

We went into the medical ward first to implement RRS and PAS because two of the main sup-porters of MIS/IT within the medical group worked here. It was seen as very important to getthe doctors on-board [Eastshire 2].

Even in the case of RRS and PAS being introduced into a medical ward that washeaded up by supportive members of the medical group, ‘doctors were likely tocause the downfall of MIS/IT’ [Eastshire 3]. One of the problems was that nursescould not make the appropriate clinical decision that was a consequence of the resultreported through RRS. While middle managers reported that in some cases a seniornurse could make a good clinical decision, ‘the responsibility lies with the doctor toensure that there is an appropriate clinical intervention. We can’t dictate that nursesshould be empowered to take that decision. Changes like that are the responsibility


of the Royal Colleges’ [Eastshire 16]. At the same time doctors were unwilling toaccess the result directly from the screen. Instead they would expect the nurse toprint off the result and bring it to them in the same way that the written result wouldhave been brought to them before, albeit collected from the laboratories rather thanprinted from the computer screens. MIS/IT therefore was not utilised in the wayexpected to realise efficiency gains. One middle manager at Parkside expressed suc-cinctly how MIS/IT depended upon the co-operation of the doctors:

Whatever we want to happen through MIS/IT is dependent upon doctors. If they are resistantto the system it won’t go ahead in the first place If they accept but don’t use the system it gathersdust in the corner. If they use the system and input the relevant data and we then use it to tryto manage them then they’ll subvert the system at best and kick off at worst [Parkside 12].

In summary, any suggestion by middle managers that they could utilise MIS/ITto control of the doctors appeared aspirational. The data and literature suggest anextension of the domain of decision-making of the middle manager to includedecisions typically made by doctors to be unlikely. Instead doctors significantlyinfluence decisions made in the managerial as well as clinical domain (Bloomfield etal., 1997; Brown, 1994, 1995, 1998; Currie and Brown, 1997; Dent, 1991).

MIS/IT: facilitator or cause of change in role of middle managers

From the viewpoint of the middle managers the implementation of MIS/IT was seenas peripheral to a wider set of forces connected to New Public Management (Ferlieet al., 1996). Even when middle managers were de-layered they did not attribute thecause of this as MIS/IT supplanting their informational role. Instead they linked de-layering to a general efficiency drive by central government and specifically policyadvice by successive Health Secretaries that management costs be cut. Assessing theevidence in the light of assertions that MIS/IT may be used to de-layer middle man-agers, those interviewed suggest that MIS/IT was, ‘only one element that has causeda flattening of structures and it’s not the main one by a long way. Cost pressureshave been the key driver’ [Parkside 9—Director of Nursing]. In all three cases thereappeared to be no connection between the number of middle managers and theintroduction of MIS/IT. As asserted in literature (Bloomfield et al., 1997; Keen andMuris, 1995; Thomas et al., 1995), specific IM&T government policy and theimplementation of MIS/IT at a local level appeared divorced from the implemen-tation of an efficiency drive, which was an important element of government policymore generally.

However, it appeared to be an important facilitator for middle managers role inmeeting the information requirements of the internal market and the assessment ofperformance. While concern was expressed by middle managers about more surveil-lance of their activity or that MIS/IT was the cause of increased informationrequested by executive managers from middle managers, most middle managersviewed MIS/IT in a positive light because, ‘it saves the legwork in having to produceperformance and contracting information requested by government’ [Parkside 3]. Itbecame a necessary ‘workhorse’ (Eastshire 14] for middle managers to carry outtheir role:

I need to have a way of getting money for ECRs [extra-contactual referrals]. A renal transplantmay come from some other region and it costs us £23,000, a nurse equivalent of resource. Theydon’t expect to be sending us work so we don’t have a contract with them. So we need to identifyour spending on that patient and notify them for payment. At the moment the necessary infor-mation may lie in 60 or 70 files and we need to pick it out [Edwards 11].

ConclusionOur study has contributed towards a need for more context specific empiricalresearch regarding the impact of MIS/IT upon middle managers noted by Dopson


and Stewart (1990, 1993). In all three cases any increase of reduction in the numberof middle managers appears not to be directly caused by MIS/IT. This is tied upwith government policy more generally. On the one hand government policy pro-motes middle management through a general management ethos that is embeddedin the Griffiths Report (DHSS, 1983) and the implementation of the internal market(DoH, 1989, 1990). On the other government policy seeks to de-layer middle man-agers in pursuit of efficiency gains.

This is not to mean that MIS/IT does not influence the number of middle man-agers. Our study does indirectly, by examining middle managers perception ofchanges in their relationship with other stakeholders—executive management, subor-dinates and doctors—allow us to make a judgement of the impact of MIS/IT upontheir role, which may then affect their numbers subsequently. In our study the per-ception of middle managers is that MIS/IT re-shapes or even enhances the role ofmiddle managers in the NHS. For example, it gave middle managers more controlover their staff. MIS/IT allowed middle managers to be more proactive and under-take planning activity, which spanned activity such as rostering, bed occupancy, sick-ness and absence and quality management. In addition MIS/IT was crucial to sup-port contracting and payments associated with the internal market, much of theresponsibility for which lay with middle managers. The case studies provided evi-dence that middle managers may play an important role linking executive manage-ment strategic intention with the ‘reality’ of operational/clinical activity. This wasparticularly so where middle managers interpreted data from MIS/IT so that it con-stituted useful and accessible information for executive management. Thus, MIS/ITappeared to increase the importance of the informational role of middle managerssince it was they who were best placed to ‘synthesise’ (Floyd and Wooldridge, 1992,1994, 1997, 2000) the necessary information for executive management.

Not only does policy context and medical group power render over-simplistic theliterature that tends to view change in the number and role of middle managers astechnologically determined. Our study also illustrates that the likelihood of MIS/ITre-shaping or enhancing the role of middle managers is dependent upon certain othercontingent factors, particularly whether decision-making generally and computingdecisions are decentralised (Pinsonneault and Kraemer, 1993). Where middle man-agers contribute to the development of MIS/IT they are likely to enjoy an enhancedrole following its introduction. National IM&T policy has changed from top-downimposition to one where computing decisions are increasingly made locally, albeitwithin a broad national IM&T policy. This has significantly increased the potentialfor middle managers to contribute to computing decision-making and therebyenhance their role following the introduction of MIS/IT. In all three cases middlemanagers were represented on project groups who were given responsibility forMIS/IT development.

It is suggested that our research be followed up in two ways. First, in order toincrease the robustness of these findings, further empirically-based research is sug-gested to provide more evidence for assertions made about the impact of MIS/ITupon the role of middle managers. This may vary with context. In the case of theNHS, on the one hand the role of middle managers may be enhanced due to theirspecific knowledge of the clinical aspects of the operations of health care delivery,which meant they had a significant role in interpreting data in MIS/IT. On the otherany enhancement of the role of middle managers in the NHS may be constraineddue the presence of a powerful professional group—doctors. This may or may notbe the case in other contexts. Second, given that earlier top-down attempts to developMIS/IT in the NHS were poorly received (Audit Commission, 1995; Currie andBrown, 1997; Keen, 1994: National Audit Office, 1996), further research may be usefulthat examines the necessary conditions under which middle managers can beinvolved in the development and implementation of MIS/IT so that it is effec-tively utilised.


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