Chapter 6Conclusions, implications of the study and directions for future 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.

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Implications for practice

The main aim of the philosophy implication in a research was to address the almost total lack of
research evidence on what it means to mobilize knowledge when operating at the very top in the
organizations. We have done so by directly observing and reporting on the daily work of seven trust
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:

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

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

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

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)?

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.

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.

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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 knowledge ability
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 knowledge
ability can be constructed.