Lost in translation: a multi-level case study of the metamorphosis of meanings and action in public sector organizational innovation

This paper explores the early implementation of an organizational innovation in the UK National Health Service (NHS) – Treatment Centres (TCs) – designed to dramatically reduce waiting lists for elective care. The paper draws on case studies of 8 TCs (each at varying stages of their development) and aims to explore how meanings about TCs are created and evolve, and how these meanings impact upon the development of the organizational innovation. Research on organizational meanings needs to take greater account of the fact that modern organizations like the NHS are complex multi-level phenomena, comprising layers of interlacing networks. To understand the pace, direction and impact of organizational innovation and change we need to study the interconnections between meanings across different organizational levels. The data presented in this paper show how the apparently simple, relatively unformed, concept of a TC framed by central government is translated and transmuted by subsequent layers in the health service administration, and by players in local health economies, and, ultimately, in the TCs themselves, picking up new rationales, meanings and significance as it goes along. The developmental histories of TCs reveal a range of significant re-workings of macro policy with the result that there is considerable diversity and variation between local TC schemes. The picture is of important disconnections between meanings, that in many ways mirror Weick's (1976) 'loosely coupled systems'. The emergent meanings and the direction of micro-level development of TCs appear more strongly determined by interactions within the local TC environment, notably between what we identify as groups of 'idealists', 'pragmatists', 'opportunists' and 'sceptics' than by the framing (Goffman 1974) provided by macro and meso organizational levels. While this illustrates the limitations of top down and policy-driven attempts at change, and highlights the crucial importance of the front-line local 'micro-systems' (Donaldson and Mohr 2000) in the overall scheme of implementing organizational innovations, the space or headroom provided by frames at the macro and meso levels can enable local change, albeit at variable speed and with uncertain outcomes.