What are the implications in research?

In this study, we have sought to respond to a number of research questions related to how knowledge mobilisation is understood, performed and enacted in everyday working practice of NHS trust CEOs in England. We have asked in particular what are the material practices and organisational arrangements through which NHS trust CEOs make themselves knowledgeable, how different types of ‘evidence’ or information are brought to bear in their daily activities, and whether specific organisational arrangements support or hinder their processes of knowledge mobilisation (i.e. what is the practical influence of context on this process). In this chapter, we conclude by briefly foregrounding some of the study’s implications for practice, and some of the directions for future research that stem from the project.

Implications for practice

Our main aim in this study was to address the almost total lack of research evidence on what it means to mobilise knowledge when operating at the very top of English NHS organisations. We have done so by directly observing and reporting on the daily work of seven trust CEOs, with special attention to the practices whereby these executives made themselves knowledgeable for all practical purposes, as dictated by their specific job.

Accordingly, the first major practical contribution of the present research is that it provides much needed empirical data on the actual jobs of NHS trust CEOs, their mundane preoccupations, what they do most of the time and with what in mind. This information is important given that the only other comparable study dates back more than 30 years.104 Recounting in depth the activities of CEOs will allow policy-makers, trainers, consultants and others to design initiatives, tools and actions based on what NHS CEOs actually do and where they are now in terms of their practice (rather than what they think they should be doing). For example, authors of policy documents could take note that that most of the time CEOs will not read them directly and are likely to pass them to one of their immediate collaborators. This will allow them to redesign their documents accordingly. Many others could derive similar implications from most of our findings. Our study thus responds to the call made by, among others, Gabbay and Le May,7 who highlighted as problematic

the glaring disparity between the policy makers’ methods for trying to promote EBP and what social scientists, philosophers, psychologists – and just about anyone who studied such things – have long told us about the nature of knowledge and how it gets used in the real world.

In this sense, we believe that our research is especially timely in the aftermath of the Francis report,100 which calls on NHS managers to become more open to scrutiny and challenge. If an inaccurate idea of what it means to be ‘evidence-based’ is adopted as a consequence of this (i.e. one that equates EBP with one of the normative models we criticised above), CEOs and other managers may be driven towards a largely ceremonial adoption of EBP. This may result in a focus on creating audit trails of ‘evidence’ before making decisions, rather than improving the practices through which they make themselves knowledgeable; and may result in excluding, rather than giving more prominence to, ‘mundane’ types of evidence, such as patients’ experience. While this type of information could constitute a critical source of intelligence, the risk is that it is disregarded or not valued enough simply because it does not fit the traditional formal idea of what constitutes ‘evidence’.

A second important implication of our study derives from our finding on the uniqueness of the knowledge and information work carried out by NHS CEOs as part of the TMT. Our findings point to a specific set of capabilities, information sources, decision styles and strategies, and attitudes towards knowledge and evidence that may set apart the work of the CEO from that of other members of the executive team. Although analysing our data with a view to identifying and codifying these skills and behaviours goes beyond the remit of the current project, contacts have already been established with the appropriate institutions (including the NHS Leadership Academy and the Institute of Healthcare Management) to explore how this can be achieved collaboratively in the near future.

A third implication stems from our reframing of the issue of how to nurture and support the knowledgeability of CEOs in developmental, rather than instrumental, ways. Our findings suggest in fact that knowledge mobilisation, understood as a series of practices and tools that support, foster or hamper the continually evolving knowledgeability of a CEO, is a personal and organisational capability that can and needs to be learned and refined as one’s perceived context and tasks change over time. Accordingly, our research suggests that we need to abandon the simplistic instrumental view that asks ‘what knowledge products are more suited to CEOs?’ or ‘what technology should we give to CEOs to make them better decision-makers?’ Instead, the issue of how to nurture and support the knowledgeability of CEOs may need to be addressed in terms of how such a capability could be taught, developed and improved through a reflective and continual monitoring of one’s personal infrastructure of knowledgeability.

In this sense, although our research falls short of developing a fully formed diagnostic tool (given its exploratory nature), it clearly signposts the main dimensions of a framework for reflecting on the personal knowledgeability infrastructure of NHS executives. Such dimensions, which derive from our model summarised in Figure 8 above, suggest that executives critically reflect on the following fundamental questions:

1. What kind of a manager/CEO do I wish to be, or need to be at the moment in my context?

2. What is the nature of my organisational and institutional context right now?

3. What is the nature of my work at present (e.g. pace, structures, people)?

4. What personal style do I tend to adopt (i.e. where does the CEO sit on the various continua concerning foci of work, e.g. internal/external, operational/strategic)?

5. Do I have the right infrastructure in place (both people and objects, e.g. trusted deputies, live IT performance system, informal ward visits) to allow me to be the kind of manager I wish or need to be? If not, what do I need to change?

The framework, which is graphically summarised in Figure 9, is premised on the notion that each choice of ‘what works’ is individual to the CEO working in situ, and involves certain advantages and drawbacks, which, if they are pragmatically known and continually reflected on and managed by the CEO, can facilitate crucial processes of capacity building over time. The framework also suggests that we should abandon the idea of a silver bullet or ‘one best way’ to address the issue of knowledge mobilisation and how to make managerial work more ‘evidence-based’. The suggestion instead is to embrace more individual-centred and context-sensitive approaches and solutions.

FIGURE 9

A signposting framework for reflecting on one’s knowledgeability infrastructure.

Finally, our study provides indications to recruiters regarding a number of desirable and necessary skills that future CEOs may need to have or develop in order to carry out their jobs. Again, contacts have been established between the research team and a number of NHS bodies so that the findings of the present study can be incorporated in the existing and future capability-building frameworks.

Implications for future research

Our study, being of an exploratory and interpretive nature, raises a number of opportunities for future research, both in terms of theory development and concept validation. More research will in fact be necessary to refine and further elaborate our novel findings.

First, while we have generated a number of new and we believe useful conceptual categories, given the in-depth sampling strategy focused on exploring the work of seven trust CEOs, very little can be said of the nature of information work of the larger population of NHS CEOs in England. Our study could thus be extended in search of statistical, rather than analytical, generalisability, as we have sought here.

Second, our study offers the opportunity to refine and validate the concepts and constructs that emerged from our inductive analysis. For example, the idea of a personal knowledgeability infrastructure will need further refinement and elaboration, in terms of both its component elements and its internal dynamics. One could also ask whether and to what extent it is possible to identify different ideal types of knowledgeable managers, so that a typology of managerial forms of knowledgeability can be constructed.

The model discussed in Figure 9 could also be used to generate a number of hypotheses for further empirical testing using a broader sample and quantitative research methods. Questions could include the following:

• Is there a statistical correlation between the type of personal infrastructure of knowledgeability, its elements, and the personality of the CEO (e.g. in terms of Myers–Briggs indicators)?

• Is there a statistical correlation between practices of knowledge mobilisation and other outcome measures, such as financial performance, regulatory compliance or dimensions captured by the NHS Staff Survey?

• Is there a systematic correlation between the types of organisation and the information work carried out by top managers (i.e. are the distinctions we outlined in this report supported by further evidence)?

The study could also be extended in longitudinal and comparative ways. For example, here we have hypothesised that CEOs will adapt their styles and practices of knowledge mobilisation in relation to career development and experience. Further research could elaborate on this point, providing precious information to selection panels and training bodies. Further research could also take a historical perspective and ask if the work of top NHS executives has significantly changed in the last several decades, including a significant shift in skills and attitude (and if it should have occurred). Again, this would provide valuable information to those tasked with selecting or developing top managers in the NHS. Finally, comparative questions can also be asked with regard to differences between executives in the NHS and other health-care systems (e.g. Canada, New Zealand, the USA and Europe), as well as the NHS and other sectors.

Finally, as discussed in Chapter 3, Limitations of the study, further work is necessary to examine the practices of knowledge mobilisation and information work at the level of the executive management team, and from the particular perspectives of the individual directors, rather than the CEO alone, as we have done here. Further research can thus shed light on the dynamics of knowledge circulation, sharing and exchange among this particular group of individuals, asking what sort of infrastructure they need, both individually and as a group, to support the knowledgeability of the top team. Such research, which could and should examine the processes whereby information and data are turned into actionable ‘evidence’, could also extend to existing and new supporting structures, such as the Academic Health Science Networks, in order to consider their role in practice.

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