On the buzzword approach to policy formation

Introduction

This paper draws attention to a phenomenon thatought to worry many more people a lot more thanapparently it does. It also attempts to explain thisphenomenon. The explanation offered is highly con-tentious and unlikely to convince most readers. Thatis not my purpose. (I do attempt to provide a moredetailed explanation in Loughlin 2001b.) For mypresent purposes, I will be satisfied if I can:1 establish the existence of the phenomenon;2 show why it represents a serious obstacle tomeaningful dialogue about the problems of thehealth service (and other public services), and;3 raise debate – about how those of us who reallywant to have a serious dialogue should explain the

situation and also about what, if anything, we can doabout it.

David Hunter (2001) has recently argued thatpolicy-makers adopt blatantly inconsistent attitudeswith regard to, on the one hand, the standards of evi-dence that should govern clinical decision-makingand, on the other hand, those that should govern theprocess of policy formation. Very demanding stand-ards of evidence should be ‘routine’ in the case ofclinical decisions because it is important to ‘show thepublic that the NHS will not tolerate less than bestpractice’ (Halligan & Donaldson 2001, p. 1413).However, there does not appear to be a similarurgency to demonstrate that high standards of evi-dence inform decisions of policy, even in the case ofpolicies designed to ‘transform’ the nature of the

Journal of Evaluation in Clinical Practice, 8, 2, 229–242

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CorrespondenceDr Michael LoughlinManchester Metropolitan University,

Alsager CampusHassall RoadAlsagerStoke-on-Trent, ST7 2HLUKE-mail: [email protected]

Keywords: buzzwords, clinicalgovernance, communication,management rhetoric, manipulation,policy formation

Accepted for publication:2 January 2002

AbstractThis article draws attention to an absurd feature of contemporary politicallife that significantly affects health service policy and calls for an urgentexplanation. Policies are formed by a process that privileges rhetoric overreality, producing policies that are ‘operationalized’ first and only ‘concep-tualized’ at a later date. Two influential articles on clinical governance illus-trate this phenomenon perfectly. Lack of clarity about its true meaning andnature is a key feature of clinical governance. The lack of clarity allowspolicy-makers to shift responsibility for the problems of the health serviceonto the workforce, who are required to interpret the deliberately vagueand platitudinous statements of management in order to implement thepolicy. But management, through the creation of monitoring agencies,reserves the right to determine whether the policy has been correctly inter-preted, thus retaining power without responsibility. Government and seniormanagement have abandoned the communicative function of language,eschewing reasoned debate (as characterized by the use of evidence andstructured argument), instead employing language exclusively for the purposes of control and manipulation. Those of us still concerned that thefuture of our essential services should be determined by open and reason-able debate need to discuss urgently how to explain and respond to thisappalling situation.

E D I T O R ’ S C H O I C E

On the buzzword approach to policy formation

Michael Loughlin PhDSenior Lecturer in Philosophy, Manchester Metropolitan University, Stoke-on-Trent, UK

M. Loughlin

service for the foreseeable future (Donaldson 1999).In such cases, it seems, there is no need to show ‘thepublic’ any evidence whatsoever before initiatingchanges that ‘will have profound implications forevery hospital and primary care service as well asindividual doctors and other health professionals’(Donaldson 1999, p. 9). The heartfelt conviction ofsenior figures in NHS management should be morethan enough to convince professionals and the publicof the wisdom of the changes.

Thus, Liam Donaldson (1999) suggests that a suf-ficiently eloquent evocation of the ‘culture of excel-lence’, which, he assures us, the policy of clinicalgovernance will usher in, should dispel any residualdoubts in the minds of critics. Indeed, he implies,those who remain sceptical in the light of such assur-ances display the moral flaw of cynicism, and are in need of further inspirational rhetoric to ‘melt’ their ‘cynical hearts’. Whether the repetition of suchrhetoric serves primarily to melt the heart or damagethe brain is a point I will take up later in this paper.For the moment, it is worth considering what Donaldson would say to a clinician who refused tosupply evidence for controversial decisions to scepti-cal colleagues, patients and managers, and justifiedthis refusal with reference to the moral imperative to drive out cynicism from the health service. ThatDonaldson would not welcome such an approach isat once obvious and sufficient to confirm Hunter’spoint about double standards.

This anomaly has been noted by a number ofauthors (Black 2001; Goodman 2002; Thomas 2002).Pointing it out almost seems banal. Generally, we takeit as read that major policy decisions will be based noton evidence but upon the consideration of non-rational and extrinsic political factors. It would be‘politically naive’ to think otherwise. Rarely do wereflect on how outrageous this is. On the one hand,no level of sanctimony is excessive when managersand politicians pronounce upon the need for highstandards in professional practice. On the otherhand, anyone who thinks that the people who makesuch pronunciations should be judged by similarstandards is somehow being foolish. Yet, as policy-makers never tire of pointing out, their decisionshave implications that are ‘profound’ and ‘wide-ranging’ and affect the lives of many more peoplethan any ordinary practitioner could.

But the situation is more serious, and far morebizarre, even than this. Over a number of years now,the public sector in the UK has been subjected to aseries of ‘quality reforms’, clinical governance beingthe most recent major development in this process to affect the health service (Charlton 2000, 2001;Loughlin 2001a, 2001b). It would be a sufficient causefor concern if workers in the sector, and members of the public most affected by the reforms, under-stood the substance of the policies being proposed,but lacked knowledge about what evidence (if any)existed to suggest that they are good policies. In fact,no such common understanding exists. Typically,public sector workers are asked to put into practicepolicies whose substantial nature has never beenexplained. What is more, advocates of the policies, ingovernment and senior management, readily admitthat they do not even know what their policy state-ments mean.

It is hard to think of many areas in professionalpractice where it would be deemed intelligible, nevermind good practice, to ‘operationalize’ a policybefore ‘conceptualizing’ it. As I have argued in anumber of places, such ideas are, nevertheless, com-monplace in public sector management. It is by nomeans uncommon for the authors of articles explain-ing how the latest innovation in management think-ing has been ‘incorporated’ into their organization to describe lengthy, time-consuming and sometimesexpensive processes of re-organization, only to admitthat they do not know how to define the key termsused to describe the policy, and that no commonunderstanding of the meaning of these terms exists.(Numerous examples of this strange process are citedin Loughlin 1993a, 1993b, 1994, 1996, 2000, 2001a,2001b.) But if we do not know what the words usedto describe a policy mean, it follows that we do notreally know what the policy is. In which case, it is notat all clear how we can be sure that what we do to‘operationalize’ the policy is really working – by whatcriteria could we make an assessment of this?

Such considerations rarely seem to trouble theauthors, and do not prevent them from declaringtheir efforts an unqualified success. At some point inthe process, they might express the hope or convic-tion that some ‘shared meanings’ of the key termsused to describe the policy will ‘emerge’, perhaps inthe context of a specially convened workshop. One

230 © 2002 Blackwell Science, Journal of Evaluation in Clinical Practice, 8, 2, 229–242

of the more ironic features of this situation, whichmight actually be funny if its implications for our pro-fessional lives and the fabric of our social serviceswere not so tragic, is that this phenomenon is at leastin part the result of something authors in the field call the development of ‘scientific methods of management’ (Joss & Kogan 1995, p. 8; discussed inLoughlin 1996, pp. 93–94).

In what follows I will examine this peculiar andpervasive phenomenon in more detail, using tworecent articles by influential figures in the NHS toillustrate its key features. I will then consider brieflyits implications for the working environment in thepublic services, as well as offering an explanation forwhat is happening.

Key features of the buzzword approach

I recently described the ‘buzzword approach topolicy formation’ in the following terms:

Pick a word, either because it sounds good orbecause it (or something very like it) is alreadybeing employed extensively in industry, then tryto encourage its widespread use in the healthservice.At some point declare that it has becomea ‘key concept’ and perhaps even the ‘philo-sophical basis’ for health service activities . . . a‘cornerstone’ . . . or indeed a ‘major corner-stone’ of health care. (Loughlin 2001a, p. 12)

Contemporary ‘management science’ is foundedupon the rhetorical force of certain words (Loughlin2001a). Terms like ‘quality’, ‘excellence’, ‘efficiency’,‘equity’, ‘effectiveness’, ‘patient autonomy/patientempowerment’ (and a host of other buzzwords)abound in government and management literature,and are frequently cited as either the goals, methodsor anticipated outcomes of policies. (Or as we will see shortly, they can be all of these things at once.According to its most prominent advocates, qualityand excellence are the goals, outcomes and methodsof clinical governance.) These terms are selected not for their substantive meaning but because theyare seen to be ‘useful’ to policy-makers (Loughlin2001a). Indeed, they are useful because their sub-stantive meaning is so vague. The term ‘quality’retains its rhetorical force in any context: to say ofsomething that it has ‘quality’ is to say that it is a goodinstance of its kind. As management theorists note,

it makes little sense to be ‘opposed to quality’ (Curtis1993, p. 191). By continually associating their policieswith the word ‘quality’, policy-makers can create anenvironment in which it appears unreasonable tocriticize those policies. But by refusing to explain thesubstantive meaning of the term when using it in anygiven context, they are absolved of the requirementto make any testable claims. Effectively, it becomestrue by definition that the outcome of a policy mustbe a ‘quality’ outcome, whatever that outcome is(Loughlin 2001b, pp. 73–76).

Thus, a great deal of management literature is an exercise in claiming ‘ownership’ of persuasive terminology. If you can make every positive buzz-word your own, then you leave no terms in whichyour favoured approach to the organization of ser-vices can be persuasively criticized – whatever thatapproach might be (Loughlin 2000). The terms iden-tified as key buzzwords are useful in the construc-tion of tautologies (statements that are true in virtueof the meaning of the words used rather than their testable implications) and platitudes (near-tautologies: statements to which only someoneinsane or wilfully perverse could possibly object).These statements then become the ‘axioms’, ‘founda-tions’ or ‘cornerstones’ of your theory. This is how itis possible for authors to declare a term foundationalto their branch of management science, only to admit(sometimes in the very next sentence) that they have not yet thought what the term might mean(Loughlin 2001a).

At the risk of being taken for a logical positivist,it seems fair to point out that this is not what mostof us would think of as a ‘scientific’ approach. Whilethere may be no watertight definition of science thatcould adequately capture every instance of bona fidescientific enterprise, the idea that scientific theoriesmust at some point be testable against reality seemshard to deny (Sokal & Bricmont 1998, pp. 58–65).Certainly, those authors who go on at length aboutthe need for ‘evidence-based medicine’ are in noposition to deny this. So Scally & Donaldson (1998)and Halligan & Donaldson (2001) are caught out ina rather glaring inconsistency by on the one handdeclaring allegiance to ‘management science’, and on the other hand endorsing the very positivisticassumptions about science that characterize the evi-dence-based medicine movement.


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It seems to me peculiar, and rather unfortunate,that authors who make often insightful criticisms ofcurrent trends in management thinking (and I includein this group many who work in the area of ‘CriticalManagement Studies’) frequently espouse someversion or other of ‘postmodernism’. By rejecting theidea that scientific claims can meaningfully be testedagainst reality, postmodernism is one of the few philo-sophical doctrines that actually risks making sense ofcontemporary management theory! If we really couldconjure reality out of rhetoric, as some radical post-modernists seem to suggest (Bertens 1995; discussedin Loughlin 2001b, pp. 31–38), then this ‘managementscience’ would start to look like a going concern. It isour stubborn intuition that this cannot be done thatreinforces the sense that there is something suspectabout the claims of management theory (Loughlin2001b). Mantras may have psychological benefits forsome, but even if managers could found an entireorganizational ‘culture’ on the mantras of ‘excellence’and ‘continuous quality improvement’, getting allworkers in the service to recite these mantras at daily‘morning workshops’, this purely verbal ‘revolution’would not prove that services really were continu-ously improving. To establish that point, we needsound intellectual arguments about what is meant by‘quality’, and evidence that particular policies reallydo produce tangible benefits.

I am happy to think of the management science I have been discussing as a ‘postmodern science’,so long as this means that it is a bogus science,whose present popularity can be explained in certainways. (In particular, the current climate of anti-intellectualism and the fashionable rejection of mate-rialist explanations of social phenomena – see laterin this paper.) Suffice it to say that it is more usual inscientific practice for intellectual and empirical workto precede the invention of terminology. Phenomenaare discovered and concepts developed, and a lan-guage is formulated to accommodate these discover-ies and developments (Loughlin 2001b). I can thinkof no credible branch of science where the inventionof terminology actually precedes intellectual work,such that terms and phrases are coined, and thenwork begins to ‘give’ them some meaning (Liddle1992; discussed in Loughlin 2001b, pp. 103–104). Cer-tainly, it is hard to imagine any other applied sciencewhere terms so invented were employed in the solu-

tion of practical problems, even before the work to‘give’ them some coherent meaning was completed!Who would feel secure crossing a bridge built by a‘postmodern engineer’ who proceeded in thismanner, or being operated on by a ‘postmodernsurgeon’ who espoused such methods? Is it plausible,then, to claim that the health service is in securehands, when its structure is constantly being tam-pered with by a management whose methods are sostereotypically postmodern – whose preoccupation iswith making reality conform to their rhetoric, ratherthan with making their rhetoric reflect reality?

The key features of the buzzword approach cannow be summarized:1 Articulate some foundational principles – theseshould be either tautologous or platitudinous, tocreate the sense that opposition to whatever it is youare saying is absurd, that all disagreement is unrea-sonable. Produce as many documents as you candescribing these foundational principles as your‘vision’ for the future of the service. Offer ‘explana-tions’ of the principles in terms that are no less vagueand platitudinous than the principles themselves.Publish papers and organize workshops and confer-ences where you ‘challenge’ others to work out whatyour vision ‘means to them’. (This is an extremelyuseful strategy since it shifts the responsibility toexplain what you mean to those who are trying tounderstand you, making it their job to make sense ofyour claims.) Perhaps get them to develop ‘missions’that are, in some loosely defined way, ‘linked’ to your‘vision’. Intimate that the vision expresses some pro-found insight into matters of fundamental impor-tance, but never say precisely what that insight is.2 Give the impression of a complex theoreticalstructure by repetition of incomprehensible jargon –the more unnatural and counter-intuitive it sounds,the greater the sense that this is a bona fide scientifictheory. Find ways to imply relationships between thedifferent components of the ‘theory’ but never stateexplicitly what these relationships are supposed tobe. Diagrams are extremely useful in achieving thiseffect: the more components they have, the more thereader will feel something complicated is being said,and the less she will be bothered employing her crit-ical faculties in trying to work out what, exactly, it isthat you are saying – and whether you have providedany evidence at all in its defence.


3 Embed within the complex jargon certain nuggetsof the just plain obvious – pieces of sheer commonsense that only an idiot would even consider ques-tioning, allegedly to ‘illustrate’ what you say with‘real-life examples’.Then the reader,having ploughedher way through all the verbiage, will encountersomething she can connect with and experience amoment of clarity. This will bolster the sense that thetheory really has substantial implications after all.This is a particularly useful device because it servesto insinuate that your ‘approach’ or ‘perspective’somehow explains, justifies or ‘validates’ the commonsense point being articulated in your ‘illustration’. (Infact, the point should be obvious anyway, such that itsvalidity has nothing to do with the ‘insights’ yourapproach provides. Thus, the theory borrows credi-bility from the obvious point it purports to explain.)

Illustrations: how to say nothing at length

Two recent papers promoting clinical governance,co-authored by the Chief Medical Officer and theDirector of Clinical Governance for the NHS (Halligan & Donaldson 2001; Halligan et al. 2001)provide excellent illustrations of how the buzzwordapproach works. The first of these opens by associat-ing the policy to be promoted with a number of buzz-words including ‘excellent leadership’, ‘learningculture’, ‘partnerships with patients’, ‘staff . . . valuedand supported’ (Halligan & Donaldson 2001,p.1413).The authors assert that these terms denote the ‘fun-damental components of quality care’, adding, ‘theseelements have perhaps previously been regarded astoo intangible to take seriously or attempt toimprove’ (Halligan & Donaldson 2001, p. 1413).

This strongly implies that their paper is going toprovide a ‘tangible’ or substantive account of theterms listed: that they are going to explain clearlywhat they mean by ‘quality care’ and ‘excellence’ inleadership, and demonstrate systematically howthese things can be improved. Presumably, clinicalgovernance is meant to be the mechanism via whichall of these things will be improved, although whatthe authors actually say is that it ‘provides the oppor-tunity’ to ‘learn and develop’ these things (Halligan& Donaldson 2001, p. 1413) and they never providean account of these terms that is any more ‘technical’or ‘tangible’ than the intuitive understanding we

bring with us to their paper. Thus, the policy is‘explained’ as a mechanism to bring about a numberof desirable outcomes, but the precise meaning ofthese outcomes, and the methods by which they areto be achieved, remains unexplained, and theauthors’ claim to have provided us with an ‘opportu-nity’ to ‘learn’ something that we did not knowalready is unsubstantiated.

The authors then cite the paper (co-authored byone of them) that ‘set out the vision of clinical gov-ernance’ in the following definition:

A framework through which NHS organizationsare accountable for continually improving thequality of their services and safeguarding highstandards of care by creating an environment inwhich excellence in clinical care will flourish.(Scally & Donaldson 1998; cited in Halligan &Donaldson 2001, p. 1413)

Because the terms used in this definition are buzz-words, selected for their rhetorical properties ratherthan their substantive meaning, the authors feelunder no obligation to spell out the criteria thatexplain and justify their employment. The grammati-cal structure of the sentence suggests that it consistsof three phrases, punctuated by the words ‘and’ and‘by’. However, as Goodman (2001) notes, the normalconventions of grammar are frequently abused inmanagement writing, to imply the existence ofsemantic distinctions and logical relationships wherein fact none exist. He cites an example from the samepaper which provides this ‘definition’ (Goodman2001, p. 90). Goodman notes that the authors use theterm ‘although’ to suggest a logical contrast betweentwo phrases when in fact they are simply re-iteratingthe same, vacuous point.

In this case, the first two phrases appear to set outgoals or intended outcomes of the policy. The phrase‘a framework . . . their services’ does little more thansuggest that clinical governance will (in some unspec-ified way) make NHS organizations very good. Thisis surely the implication of making them ‘accountablefor continually improving the quality of their ser-vices’. One might expect the second phrase to intro-duce some new semantic content but it, too, doeslittle more than assert that clinical governance willmake NHS organizations very good. For suppose weinquire as to the concrete meaning of ‘improving thequality of . . . services’. Any account that did not



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include the idea of ‘high standards of care’ would beinadequate. So this idea does not really add anythingto what has been asserted already.

The use of ‘by’ suggests that the next phrase willstate the method for achieving the already statedgoals or outcomes (like: ‘you start the car by turningthe key’). But if we want to know what sort of envi-ronment is being envisaged by the authors then wewill find no blueprint in their paper. All we knowabout the type of environment envisaged is that, insuch an environment, ‘excellence’ (a superlativemeaning ‘very good’) will flourish. In other words, thedefinition tells us that clinical governance will makethe NHS very good, and it will make it very good, andit will achieve this by making the NHS very good.The connectives ‘and’ and ‘by’, which punctuate thebarrage of terminology, serve simply to break up thestream of buzzwords, in the process insinuatingsemantic distinctions and contrasts to produce theillusion of meaning.

The paper by Halligan & Donaldson (2001)promises to ‘take the story forward’. ‘Two years on,’they ask, how has the policy ‘developed’? (p. 1413).They begin by charting briefly the history of variousquality initiatives in the NHS, presenting clinical gov-ernance as the culmination of a number of ‘disparate’and ‘fragmented’ approaches. They give no argumentto support their clear assumption that clinical gover-nance will preserve whatever was supposed to begood about these earlier initiatives, while dispensingwith whatever was wrong with them. Instead, theyintroduce ‘another driver for change’ in the form of‘a series of high profile failures’ in recent NHShistory.

The references cite a number of scandals, includ-ing the tragic incidents involving paediatric cardiacsurgery at the Bristol Royal Infirmary and theHarold Shipman affair. Immediately following thispoint, the authors introduce a section in which clini-cal governance is called a ‘central element’ of a‘framework that supports the delivery of quality’(Halligan & Donaldson 2001, p. 1414; note that it waspreviously the framework itself, not an elementwithin that framework. The role that its key ‘techni-cal terms’ play within the explanation of the policy –including, here, the role of the term denoting thepolicy itself – changes apparently arbitrarily.) Herewe have a series of claims, set out as if logically

related, but with no clear relationship between themthat the authors care to explain or defend. All theysay about the ‘high profile failures’ is that they ‘estab-lish a sense of urgency’. But that does not show thatany specific response to such failures is likely to bethe right one. It does not even tell us how to go aboutlooking for the right response, since it does not helpto establish criteria that could enable us clearly todistinguish good from bad responses.

Do the authors mean to imply that clinical gover-nance will prevent such incidents occurring in future?If so, how? Since they have not explained the sub-stance of the policy in any very exact terms, they canhardly explain how exactly it will bring about anyparticular substantial effect. It is hard to see how a ‘culture’ of ‘no blame’ (one of the ‘fundamentalcomponents’ mentioned in the opening paragraph)would be at all appropriate, let alone effective, whendealing with someone like Harold Shipman. But ifthey do not mean to claim that failings such as thesewill be addressed by clinical governance, then whymention them at all in a paper with the explicit goalof explaining the meaning and implications of thepolicy?

That it cannot be the goal of clinical governance to ‘weed out’ instances of bad practice is establishedby the paper whose ‘story’ this article aims to ‘takeforward’. Scally & Donaldson (1998) cite as a keyinfluence on their thinking about ‘continuous qualityimprovement’ a paper by Donald Berwick (1989).The whole point of Berwick’s paper was to contrastthe ‘Theory of Bad Apples’ to the ‘Theory of Continuous Improvement’ and to reject the formerin favour of the latter. The former focuses on ‘theexceptional few’ at the ‘end of the spectrum’, whilethe latter is designed to ‘help the average ones’ withthe goal of ‘raising the quality curve’ of the wholeservice (Berwick 1989, p. 53). Berwick stresses thatthe ‘scientific’ approach to management he wishes topromote is aimed at the average worker, not theextreme cases of gross incompetence and malprac-tice. So whatever clinical governance does aim toaccomplish, one thing it does not aim to do is provideany specific insights into the general problems ofhuman incompetence and human wickedness.Incidents of doctors who negligently or murderouslykill their patients have nothing to do with the ratio-nale and methodology of clinical governance, if we


are to take seriously the claims its most prominentdefenders make about the supposed ‘theoreticalbasis’ for the policy.

What, then, does this policy, framework or compo-nent of a framework do? The authors list a numberof ‘national structures and mechanisms’ aimed atimproving standards, promoting ‘best practice’ andreducing ‘poor performance’ (Halligan & Donaldson2001, p. 1414). What they do not provide is any clearaccount of how they know that the effect of settingup these mechanisms will be to ‘improve quality’.Instead, we have more argument by word associa-tion: there will be more ‘patient advocacy’, ‘consent’and ‘participation’ and these are bound to be goodthings.The use of one buzzword (‘quality’) is justifiedwith appeal to a number of others, but at no point isthe rhetorical circle broken with reference to anytestable claims. One demonstrable effect of the struc-tures listed is a massive increase in the amount ofpeople employed to monitor the behaviour of others.And one substantial assumption that the authorsquite clearly do make is that an increase in such mon-itoring automatically leads to an increase in ‘quality’.What they of course do not do is explain and defendthe conception of ‘quality’ that could make sense ofsuch an assumption.

What assumptions about good practice will informthose who control the ‘standard-setting mecha-nisms’? How will those charged to enforce the stand-ards interpret them in specific situations? How do weknow that they are any more likely to make soundjudgements than particular practitioners? (Goodman2000; Charlton 2000). Does the fact that differentindividuals would make different decisions abouthow to interpret the standards affect the status of the mechanisms as ‘rational’ and ‘objective’ tools for‘quality improvement’? (Loughlin 2000).

Under the heading ‘what might clinical governancelook like on the ground?’, we might expect to findanswers to these questions. This would give us aclearer idea of what clinical governance actuallymeans. Then we would at least have the basis for adecision about whether we agreed with it. Unfortu-nately, Halligan & Donaldson supply only a set ofgeneralizations and the observation that implemen-tation at the level of specific organizations will vary– a point made by an unhelpful use of the terms ‘criteria’ and ‘style’. The authors list several ‘criteria’,

including ‘effective leadership’, ‘being truly patient-centred’, ‘ordinary people doing extraordinarythings’ and ‘demonstrating success’, saying some-thing under each heading. For instance, under theheading ‘planning for quality’, they state that healthorganizations ‘need a plan to develop quality’ which‘should be based on an objective assessment’ of anumber of factors (Halligan & Donaldson 2001,p. 1414). Patients’ ‘needs and views’ should be con-sidered, as should ‘regulatory requirements’ and‘unmet training needs’. ‘Ownership of the plansneeds to be generated . . . right down the organiza-tion’ and ‘key underpinning strategies’ such as ‘edu-cation and training’ should ‘serve the purposes ofquality assurance and quality improvement’.

Obviously, these phrases are vague and for themost part platitudinous. (Who believes that plansbased on subjective assessments that ignore theneeds of patients are likely to be better than objec-tive assessments that take these needs into account?Or that it is better to leave training needs unmet?)So they do not, in fact, help to clarify what the phraseor ‘criterion’ ‘planning for quality’ means – oneunclear idea is explained with reference to a set ofother, equally unclear notions. As before, the rhetori-cal circle is unbroken. But in that case, it is not clearwhat it means to call ‘planning for quality’ a ‘crite-rion’. The whole point of a criterion is supposed tobe to provide the basis for distinguishing proper fromimproper applications of a term (Loughlin 2001b),and this is precisely what these ‘criteria’ cannot do.Questions about the concrete applications in any realorganizational context are relegated to matters of‘style’. So for any matter of substance, label it an issueof ‘style’ and say no more about it. Halligan & Donaldson call their ‘criteria’ ‘underpinning organi-zational attributes’, which, they say, will give rise to‘an organization with a strong positive culture ofteamwork’ and ‘better ways to deliver quality care’ –outcomes that they ‘sense’ ‘most’ health profession-als want (Halligan & Donaldson 2001, p. 1414).

Since only most, not all, want this, can we take itthe authors ‘sense’ that some professionals do notwant these things – that such professionals prefer towork in organizations with a weak negative cultureof non-cooperation, and are seeking inferior ways todeliver care? Such preferences would, of course,appear crazy or perverse. Again, the only meaning to



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the authors’ claims consists in the rhetorical force of the terms from which they have constructed their(platitudinous) foundational principles – herelabelled ‘underpinning attributes’. I have noted elsewhere that (claims on the part of Halligan &Donaldson to be saying something new, innovativeand ‘revolutionary’ aside) it is something of a tradi-tion for management specialists to say they have discovered sets of ‘basic’ or ‘underpinning’ organiza-tional ‘criteria’ or ‘attributes’, in order to create theimpression of a general system or scientific basis for their claims (Loughlin 2001b, pp. 77–80; it is, ofcourse, also traditional to claim one has developed arevolutionary and innovative new approach). But asgeneralizations such claims state only the blindinglyobvious, and on all the interesting questions – abouthow to apply the general principles or ‘criteria’ inreal cases – authors by tradition remain silent. Halli-gan & Donaldson’s paper is firmly within that tradi-tion of managerial writing. It privileges rhetoric oversubstance, attempting to create the appearance of anapproach grounded in an impressive theoreticalunderstanding of organizations and with significantpractical applications. At the same time it studiouslyavoids committing itself to any substantial claimsabout the reality it purports to affect. From its inspi-rational title (‘. . . turning vision into reality’) to itstriumphant conclusion (‘this revolution has begun’),it is a barrage of hollow terminology, packed withbuzzwords and quite impressively lacking in seman-tic content.

The other paper mentioned earlier (Halligan et al.2001) is in some respects an even better illustrationof the buzzword approach. This paper repeats largesections of the first one verbatim, or near-verbatim.It is characterized by similar rhetorical devises.Platitudes are heralded as great discoveries andimaginary opponents are invented to create the illu-sion of significant dialogue. See, for instance page130, where we learn that in the new NHS, quality isregarded as a ‘prevailing purpose rather than a desir-able accessory’.Are we to take it that the people whoworked in the old, pre-New Labour, pre-clinical gov-ernance NHS thought of quality as a ‘desirable acces-sory’? Since doing something with ‘quality’ really justmeans doing it well, this suggests that NHS staff inthe dark days before Blair thought that doing theirjobs well was not particularly important, that this was

not their ‘prevailing purpose’ at work. [Offensive?Well obviously, though perhaps no more so than theattempt to ‘validate’ NHS staff ‘as individuals’ in thecontext of a workshop (Halligan et al. 2001, p. 135).Only a senior manager would have the presumptionto validate another person ‘as an individual’ – letalone think that one could do this by running a work-shop with person-validation among its stated objec-tives.The question ‘what planet are they from?’ reallydoes arise and should, frankly, be asked openly moreoften.] In fact, no-one has ever seriously defendedthe view that quality is merely an ‘accessory’. Man-agers must be familiar with the idea of a ‘straw man’argument, yet so much contemporary managementwriting is a veritable production line devoted to theconstruction and demolition of (wilfully perverse)straw men.

This article is substantially longer and containsmore sections than the Halligan & Donaldson paper.In particular, its sections entitled ‘Building organiza-tional capacity for clinical governance’ and ‘Thepillars of clinical governance’ (pp. 142–153) providesuch a wonderful illustration of features (2) and (3)of the buzzword approach (listed earlier) that theyare worthy of attention.

The dominant image of these sections is thediagram on page 142, which assists our ‘thinkingabout the implementation of clinical governance’ bydeveloping an ‘architectural metaphor – a Greektemple built on five foundation stones’ (Fig. 1). Thestones are identified as ‘components of the culture’that will ‘support’ organizational aspects of clinicalgovernance. There are seven pillars. These are sup-ported by the foundation stones and jointly supportthe roof of the temple. Each component of thediagram bears a label, corresponding to some obvi-ously good thing that any health care system shouldhave. What is more, the arrangement of the stonesand pillars suggests some sort of structural relation-ship between them – or else, if no such relationshipexists, how does this ‘metaphor’ assist our ‘thinking’about clinical governance? For instance, the pillarlabelled ‘communication effectiveness’ stands squareon top of the foundation stone labelled ‘communica-tion’ in the middle of the temple. The ‘clinical effec-tiveness’ pillar stands on top of the ‘systemsawareness’ stone while ‘risk management effective-ness’ straddles ‘systems awareness’ and ‘teamwork’.


The narrative that follows is structured underheadings taken from the labels on each componentof the diagram (with one exception – explored lateron). Unfortunately (if somewhat unsurprisingly), theaccounts of the different components of the ‘temple’are extremely vague, and offer little basis for anymeaningful distinction between the separate compo-nents. Certainly, no clear account of any systematic

relationship between the components emerges. Forexample, the ‘foundation stone’ of ‘ownership’ isexplained as being ‘about getting real participation of all those involved in a service’ (p. 145) and this is explained with reference to a ‘team’ that ‘valuesdiversity and encourages input from all its members’.By way of further clarification, the authors explainthat such a team will display ‘effective communica-



Figure 1 The Greek temple of clinical governance: an ‘architectural metaphor’ (from Halligan et al. 2001, p. 142).

Figure 2 The Roman ruins of clinical governance: a ‘deconstructionist metaphor’.

M. Loughlin

tion’ and work ‘together as a team’ (p. 146). So ‘own-ership’ is all about ‘effective communication’ (one of the pillars) and ‘teamwork’ (another foundationstone). Similarly, the accounts of the foundationstone ‘communication’ and the pillar ‘communicationeffectiveness’ are virtually identical. The former is(again, somewhat unsurprisingly) ‘not simply aboutpassing information’; it is also ‘about listening’(p. 145). The latter is about ‘sharing information,reaching a common understanding and listening aswell as talking’ (p. 147). So are these really two different ‘components’ of a theory (or ‘system’, or‘structure’, or ‘framework’) or just two very similarways of stating the same, rather obvious point?

These ‘explanations’ are punctuated with what Ipreviously referred to as ‘nuggets of the just plainobvious’, in the form of certain ‘case studies’ sup-posedly meant to ‘illustrate’ one of the foundationstones or pillars. Frequently, these examples couldillustrate a number of different ‘components’. Theexample of a paramedic (p. 143) – who makes whatseems (to me, as a non-specialist) a perfectly com-monsensical decision to treat an injured child, safelyand in the only way practically possible in the cir-cumstances, rather than carry that child for 15minutes in great distress – could be used to illustrate‘ownership’ or ‘risk management effectiveness’, butit is used to illustrate ‘systems awareness’. This isbecause management elected to adapt the guidelinesgiven to ambulance staff to accommodate suchcommon sense behaviour, rather than punishing themember of staff for doing what was quite obviouslythe right thing in the circumstances. The example ofputting porters on the e-mail system (p. 145) illus-trates ‘teamwork’, but it could just as easily illustrate‘communication’, ‘communication effectiveness’ oreven ‘resource effectiveness’. In each case, we canunderstand that the decisions made were sensibleones, quite independently of any insights provided bythe ‘structure’ the diagram supposedly represents.So the structure in no way ‘explains’ these decisions.Rather, by association it illicitly attempts to borrowcredibility from them.

It is worth noting that nothing at all is said aboutthe roof of the temple, labelled ‘professional–patientpartnership’. It seems that, when the rest of the struc-ture is ‘in place’, this component just follows logically.What is presented, as if it were the goal or end

product of clinical governance, might just as well beanother label for the whole process. What would bethe loss of semantic content if we substituted this foranother, equally positive-sounding phrase? What ifwe made ‘clinical effectiveness’ a foundational stoneand ‘systems awareness’ a pillar – how would thischange the overall meaning of the theory? (It wouldbe an interesting experiment to give a presentationto a group of enthusiasts for clinical governance,using all the right buzzwords but swapping theselabels on the diagram. Would anyone notice, and ifthey did, how could they complain that the ‘structure’had been ‘distorted’?)

Suppose instead I choose a slightly differentmetaphor. Not the Greek temple of clinical gover-nance, but the Roman ruin of clinical governance(Fig. 2). In my diagram we have not labelled pillarsand foundation stones but only a pile of 13 brokenblocks, in no specific order. (For added scholarlypiquance, I could add a grinning Vandal holding amallet, standing in the rubble.) Now suppose I labeleach block, using the same labels as the componentsof Halligan’s diagram. I label the Vandal’s mallet‘professional–patient partnership’. I then take aheading for each broken block, just as Halligan et al.do for each stone and pillar. (Just as they say nothingabout the roof, I say nothing about the mallet.) Iplace exactly the same text underneath each of theheadings as the text in their paper. What would bemissing from my diagram that was captured by theoriginal? Nothing at all, obviously – except for thetotally unjustified insinuation of a set of structuredrelationships that the ‘architectural metaphor’achieves.

The advantages of the buzzword approach

Policy-makers are not fools. If they employ the buzz-word approach then it is overwhelmingly likely thatthey have a reason to do so. We cannot necessarilyinfer from the fact that they frequently talk nonsensethe conclusion that they are confused. For they mayperceive the continued existence of a nonsensicaldebate to be somehow in their interests.

Bruce Charlton (2001) has argued that if weassume the purpose of management discourse isreally to produce certain outcomes – ones that rep-resent substantial and demonstrable improvements


in health care and other public services – then we willinevitably be ‘looking for clinical governance in thewrong place’ (p. 73). The real purpose of clinical gov-ernance and other ‘management technologies’ is toserve the interests of certain groups: in particularthey serve to safeguard the jobs of senior managersand increase management control of the workforce.I agree, although I think a full account of the advan-tages of the buzzword approach will also make ref-erence to its ability to enable policy-makers to shift(or, in management-speak, ‘relocate’) responsibilityfor certain inevitable (and in the current socialcontext, probably insoluble) problems onto theworkforce.

I claimed earlier that the present popularity(indeed, dominance) of the buzzword approach inpolicy circles could at least in part be explained bythe current climate of anti-intellectualism and a fash-ionable rejection of materialist explanations of socialphenomena.

The anti-intellectualism of the current politicalenvironment is surely beyond doubt. One is consid-ered politically naive if one expects the explanationof government policies to make any sense. It is ap-parently regarded as impertinent or frivolous toquestion the intellectual foundations of currentlyfashionable policies, and pedantic to expect policy-makers to respond at all to such questions – or if theydo respond to answer the question asked, and fortheir answers to exhibit clarity and logical consis-tency. In the ‘real world’ (meaning the board roomswhere the powers that be, in government and seniormanagement, feel increasingly that they can do andsay whatever they like, without being expected tojustify themselves to anyone other than their finan-cial backers), such ideas lack ‘relevance’ – they are ‘not to our purpose’ (Wall 1994; discussed in Loughlin 2001b, pp. 149–150). In such a climate,debate is inevitably characterized by the exchange ofslogans, whose meaning and justification remainunexamined (Loughlin 2001b). It is in the interests ofthose in power to preserve this state of affairs, sincethey employ the spin doctors and control the flow ofpropaganda. The last thing they need is a populaceable to think critically, to unpick their slogans andreveal their emptiness.

Policy-makers have long since abandoned whatHabermas (1984) calls the ‘communicative function’

of language. They employ language not to communi-cate truths about the world or engage others in agenuine dialogue, but to control and manipulateworking populations and to ‘manage the perceptions’of the public at large – with the overall goal of ‘deliv-ering support’ for their policies (Spiers 1994; dis-cussed in Loughlin 2001b, pp. 87–91). The effect ofthis situation on professional life and the workingenvironment is as depressing as it is predictable. Ourcritical faculties are constantly under attack by therepetition of intellectually stultifying jargon. To goalong with this process, to recite the jargon on queue,is unlikely to warm (let alone ‘melt’) the heart of anyreasonably intelligent person, whatever Donaldsonmay claim. It is more likely to addle the brain, tocreate a sense of absurdity and frustration. To use apurely anecdotal argument, what is remarkableabout students from health service backgrounds whojoin my classes in conceptual analysis and criticalthinking is their palpable sense of relief when theyrealise that these terms, at least in the context of theclass discussion, actually mean something: that theyare not being asked to add the term ‘critical thinking’to their stock of buzzwords, but rather they really arebeing invited to think critically! We are so used to thegap between rhetoric and reality that the invitationto participate in honest and open dialogue comes asa surprise, and requires a moment of adjustment.Afterwards, it is as if something has been released.That such students should find the opportunity tothink so exciting and refreshing is at once pleasing(from the point of view of teaching) and shocking.For it suggests that in their working lives, the exer-cise of their critical faculties is stifled.

Indeed, to show evidence of genuinely independ-ent thought is dangerous in some contexts. To refuseto join the ‘celebration’ of ‘quality culture’ is to riskbeing seen as ‘negative’ and ‘cynical’ – one of theforces of conservatism standing in the way of themodernization project. Thus, the postmodernists areright to note the demise of reason in contemporarydebate, but wrong if they imply that we do not needreason. We need it all the more if we are to resist the tide of nonsense, to develop ways of understand-ing our present situation and to work out ways ofresponding to it that preserve our integrity in thecontext of what is increasingly a corrupting environ-ment (Loughlin 2001b). As I argue in more detail



M. Loughlin

elsewhere (Loughlin 2001b), conceptual analysis is anecessary form of intellectual and moral self-defence.

It is the common tendency to be satisfied withslogans, and not to expect any substantive point orunderlying explanation to be there in the back-ground, that makes it possible for policy-makers toignore the material causes of problems in their‘explanations’ of social phenomena. Thus, Halliganet al. (2001) lament the fact that ‘healthcare profes-sionals’ identify ‘lack of resources and lack offunding’ as the key problems for improving theservice (p. 148). They move swiftly from the claimthat ‘high quality health care requires far more thanmoney’ to the statement that ‘excellence will not costmoney, only effort’. The first claim is banal: clearlyinvesting more resources, without considering thebest way to use those resources, is not a ‘recipe forsuccess’. For example, spending a lot of time andmoney devising new ways to monitor the staff whoactually do the work, without ever justifying theclaim that more monitoring entails more quality, is atleast an unproven way to bring about any substantialbenefits, however much you invest in this process.

We are by now used to being told that you cannotsolve problems by ‘throwing money at them’.However, the inference from this banal point to thesecond claim is a gross fallacy. From observing thatincreased resources are insufficient to solve the prob-lems of the service, Halligan et al. conclude that theyare unnecessary, that ‘excellence will not cost money’because ‘quality is free’. This is the logical equivalentof moving from the banal observation that youcannot live on fresh air, to the conclusion that you donot need a supply of air to live. Since the 1980s wehave witnessed a period of what might be describedas Radical anti-Marxism. From noting the falsity of a type of Marxist explanation so crude that it isunlikely anyone ever actually espoused it (forinstance, the idea that all one need do is ensurepeople have adequate resources and all social prob-lems will vanish), it seems now acceptable to claimthat material factors are somehow irrelevant to thesolution of social problems. From the ‘Theory of BadApples’ to Berwick’s more ‘sophisticated’ ‘Theory ofContinuous Improvement’, the explanations offeredover the last two decades for the problems of thepublic services have typically appealed to motiva-tional factors: what is needed is not ‘more resources’

but ‘more effort’. The ‘bad apples’ approach focusedprimarily on lazy, unproductive workers while themore ‘advanced’ theories view the motivation of the‘average worker’ as the problem to be addressed. Ineach case, the possibility of motivating the workforceby improving their working conditions via increasedresources is rejected, in favour of a focus on inspira-tional rhetoric and structured ‘learning experiences’.The staff are the key problem: they need to be ‘devel-oped’, and the best way to develop them is to requirethem to learn and repeat elements of an ever-expanding and consciousness-raising managementvocabulary. We do not solve problems by throwingmoney at them. We solve them by throwing termi-nology at them. Or rather, we throw terminology atthe workforce, then wait and see what they do.

The advantages of the buzzword approach topolicy-makers are clear. The problems that beset thehealth service are complex and difficult to solve. (Itmay, indeed, be impossible to solve all of the prob-lems created for publicly funded health care systemsby the social context of capitalism; see Seedhouse1993 and Loughlin 2001b.) In an electoral democracylike the UK, the government is nominally responsi-ble for solving these problems. Politicians (and thesenior managers they appoint to take charge of the public services) will be seen to be failing in theirduty of accountability if they do not address theseproblems.

As already noted, the buzzword approach enablespolicy-makers to shift responsibility for solving theproblems of the service onto the workforce. With thebuzzword approach, you do not need to develop arealistic account of the social world that identifies theobstacles in the way of progress for the service. (Thatroute might well lead to conclusions that would notplease groups you need to keep on side, so it is betternot to go there.) Instead, you can produce policiesthat are good by definition, and challenge the work-force to work out what those policies really mean inpractice: it becomes their responsibility to transformyour ‘vision’ into reality. You then appoint monitor-ing bodies to determine how well different elementswithin the service have performed this task.

If it turns out that they make a good job of it – ifthe end result of their productive activity in responseto your barrage of jargon is a positive one – you canclaim the credit for an excellent outcome. But if they


fail to translate your policies (which, remember, aregood by definition) into practical plans that producedemonstrable benefits, then it is they who are failing.Clearly, the working population still contains toomany counter-revolutionaries who are opposed toquality, miserable stick-in-the-muds who will not ‘geton board’, who would rather derail your initiativeswith their negative utterances. All the more need toweed out cynicism and to invest more in motivationalstrategies to create ownership, teamwork, organiza-tion-wide commitment and all the rest. The point is,there is someone else to blame, and you can ‘posi-tion’ yourself as the defender of quality while iden-tifying professionals as the real obstacles to progress.Play it right, and you can actually make politicalcapital out of the problems for the service, by assum-ing the role of defender of the public (against thereactionary workforce) and crusader for excellence.Hence the fashion for the powerful and overpaid (be they politicians or their appointed management‘watchdogs’) to launch strident attacks on under-resourced and usually underpaid public sectorworkers. The shameless expressions of contempt foruniversity teachers by the former head of the QualityAssurance Agency had a devastating effect onmorale in the sector. And were it not for the PR giftof the Taliban,Tony Blair would by now undoubtedlyhave felt the need to make several more speechesexposing intransigent public sector workers, and theirhostility to change, as the enemies of progress inhealth and education.

So for the policy-maker, this is the much sought-after ‘win–win’ scenario. In Marxian terms, it is aclassic piece of ‘exploitation’. Management science isthe science of exporting problems, but the skills ofthis sort of scientist have much more in common withthe skills of the illusionist than they do with those ofthe engineer.

Conclusion

Undoubtedly, defenders of current policies willeither ignore these arguments altogether or elsedismiss them by appeal to any number of labels attheir disposal: as ‘polemical’, ‘negative’, ‘unhelpful’,‘politically motivated’ or what have you. That suchlabels do not represent an argument is unlikely totrouble them, since such considerations have never

bothered them in the past. These arguments are notfor them. There is simply no point attempting toreason with people who have given up on the com-municative function of language. Instead, my argu-ments are addressed to those who are affected by thecurrent policies, and who have a sense of the absur-dity of the situation, even if they reject my explana-tion for it. But if they do reject my explanation, it istheir responsibility as rational beings to provide analternative account. For clearly there is somethingvery peculiar going on in the process of policy for-mation, and this strange phenomenon requires somecoherent explanation. When a society makes whatmust surely count among its most important deci-sions – about the future of its essential services – interms not of evidence, analysis and rational dialogue,but instead allows that future to be shaped by anunstructured exchange of vacuous terminology, it isthe obligation of theorists, practitioners and indeedall concerned citizens to give urgent attention to thequestions: what on Earth is going on? How do weexplain it? What can we do about it?

Obviously, these questions are related. The way weexplain the situation will affect how we think weshould respond to it, although it is extremely unlikelythat any view about how to respond will be capableof being read off an adequate theoretical account ofthe problem. Unfortunately, solving practical prob-lems is not a deductive science. For too long now wehave been trying to engage in a dialogue with forcesno more susceptible to argumentation than are wavesto the commands of kings. Halligan & Donaldson’s‘revolution’ may have begun, but the debate we needto have about how to save our public services has not.

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On the buzzword approach to policy formation

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