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Opportunity 2000 in the National Health Service: a missed opportunity for women.

Opportunity 2000 is a nationwide, Government and business-supported voluntary campaign aimed at increasing the quantity and quality of women's participation in the workforce by the year 2000. In the NHS, Opportunity 2000 initially took the form of eight goals to be achieved in England by the end of 1994 as milestones towards the year 2000. These goals concentrate on improving the quality, and not the quantity, of women's work as the NHS is the largest employer of women in Western Europe.

This article shows that the NHS is failing to meet at least some of its Opportunity 2000 goals and, overall, the position is patchy. The reasons for failure partly relate to the context, including the autonomy of trusts in an NHS restructured on quasi-market lines, and partly to the failure of NHS managers to implement Opportunity 2000. Partly, however, the NHS Opportunity 2000's lack of success stems from inherent flaws: for example its business case rationale is less than convincing to many health professionals who attach a high value to ethical considerations. Also, partly, reasons for failure relate to factors common to other equality programmes, whether or not they come under the Opportunity 2000 banner, such as a value system which sees the male career pattern as the norm. Accordingly, the article concludes that movement towards equality for women in the NHS is only likely to be made if there is a different approach to goal setting.

Context

Women comprise 79 per cent out of a total NHS staff of just over one million. There is a marked concentration of women in four occupations: nursing and midwifery (90 per cent female), professions allied to medicine (88 per cent), administrative and clerical (84 per cent) and ancillary staff (74 per cent). Nursing and midwifery, with some 500,000 employees, is the largest occupational group in the NHS. Women, however, are not well represented in all NHS occupational groups. They form a small proportion of doctors (26 per cent), ambulance staff (21 per cent), works staff (7 per cent) and maintenance staff (5 per cent). Moreover women are in a minority in senior positions. For instance, only 17 per cent of unit general managers and 15 per cent of consultants were women in 1990-91. In other words there is occupational segregation by gender to a significant extent.

Many NHS female employees work part-time: 76 per cent of female ancillary staff, 41 per cent of female nurses, 42 per cent of female administrative and clerical workers. According to the Equal Opportunities Commission, part-time workers are concentrated in the lower paid occupations and the lower graded posts in the occupational hierarchy (Equal Opportunities Commission, 1991).

There have been a number of research studies in the last few years highlighting the differences in promotion rates for men and women in the NHS. For instance a Department of Health Working Party on women doctors and their careers (Department of Health, 1901a) found that women progress more quickly than men up to senior house officer level but this trend is reversed at registrar level and beyond. Davies and Rosser (1986) found that men are promoted to nursing officer much faster than women; 8.4 years as opposed to 17.9. The Institute of Manpower Studies (IMS) found that, although only 10 per cent of nurses are male, they fill 40 per cent of senior nurse posts (Hutt, 1985).

Studies also indicate the problems women find in combining NHS work and parenthood, even in midwifery (somewhat ironically, given its child-centredness) (Corby, 1991a). The IMS found that, whereas 90 per cent of male chief nursing officers (CNOs) have children, only 14 per cent of women CNOs do (Hutt, 1985).

Goss and Brown(1991) produced a report for the NHS Management Executive in 1991 identifying a number of barriers to women's progress including the limited availability of part-time and flexible working at senior levels, the limited availability of appropriate child-care provision, the convention in many senior jobs that long hours are required, the culture which tends to use male career patterns as the norm and the widespread use of patronage and head hunting for senior posts. The report recommended a strategy, including raising the profile of equal opportunities in the NHS, embedding equal opportunities into management practice and monitoring and evaluation (Goss and Brown, 1991).

In the same year, the Equal Opportunities Commission produced a report into women's employment in the NHS based on a survey of health authorities in England and Wales and health boards in Scotland. It found that, although equal opportunities policies were common, equal opportunity practices were not being implemented effectively. For instance, most health authorities did not plan or evaluate progress, while almost a quarter included potentially unlawful discriminatory questions on their job application forms. It recommended a national corporate plan with equality targets and the establishment of an NHS equal opportunities unit (Equal Opportunities Commission, 1991).

Against this background, the Health Secretary, Virginia Bottomley, in a speech in June 1991 said the NHS must "become a byword for good 'women-friendly' employment practices" and promised monitoring, good practice documents and conferences (Department of Health, 1991b). Then the Department of Health, on behalf of the NHS in England, signed up to Opportunity 2000.

Opportunity 2000 is a business-led, voluntary campaign to increase the quality and quantity of women's participation in the workforce by the year 2000. It does not push the moral case for equal opportunities for women, as it believes the business case is strong enough (Incomes Data Services, 1993). These include industry's concerns (despite the recession) over demographic changes, the trend away from low skilled towards professional and related occupations and the need to attract the best people irrespective of gender.

The campaign was launched by the Prime Minister, John Major, and some saw it as a cynical attempt to gain women's support prior to the 1992 general election. Be that as it may, Opportunity 2000 fits in with important strands in Conservative party thinking, including a predilection for voluntary measures rather than legislation, an emphasis on business needs rather than the social or ethical dimension and a concern with the top, i.e. increasing the number of women managers, rather than the bottom, i.e. eradicating women's low pay rates.

Formed in October 1991, it had 275 member organizations three years later. On joining, an organization commits itself to carrying out a staff audit, setting goals and monitoring progress with the goals based on the organization's starting-point and circumstances. The goals do not have to be numerical targets and, in fact, only a minority set numerical targets (Opportunity 2000, 1994).

The NHS established a women's unit as part of the NHS Management Executive (NHSME), now called the NHS Executive, which in turn set eight Opportunity 2000 goals, of which four are numerical. The goals were to be achieved by 1994 as a milestone towards the year 2000 (NHS Management Executive, undated). At the same time as the NHS was setting goals on equality for women, it was, however, being reorganized and this reorganization may have an adverse impact on the framework and/or climate for NHS equality. As a result of the NHS and Community Care Act 1990, there is a split between the purchasers and providers of health care, and the purchaser (e.g. the health authority) can choose the provider with which it wishes to enter into a quasi-contractual relationship to buy services. Provider units, i.e. hospitals, ambulance services, and community health units, can acquire self-governing trust status and in fact by April 1994 over 96 per cent had done so. A trust, subject to employment law constraints, has autonomy on personnel matters, but this autonomy at best does not sit easily with a comprehensive, NHS-wide equal opportunities programme strategically directed at the top.

Thus, the NHS women's unit can only cajole, support and provide funding for innovative projects. It cannot order and control, although each trust is required to produce monitoring statistics and an action programme for the NHSME's women's unit each June. For instance the women's unit, on seeing a job advertisement by a Mersey trust, wrote to the trust to say that the job should have been advertised as suitable for job sharing. The trust noted the comments but its subsequent advertisement for the same kind of job made no reference to job sharing.

This increasing decentralization is exacerbated by two further matters. First, although trusts have to abide by national, so-called Whitley agreements for existing staff (unless staff choose to change to trust terms), the agreements themselves are becoming much looser. Thus, for instance, in the area of equal opportunities the General Whitley Council (GWC) has concluded so-called enabling agreements. The GWC, for instance, "commends" the establishment of an appropriate range of child-care facilities, "recommends" that managers should consider the possibility of job sharing and "believes" that retainer schemes should be drawn up. These enabling agreements cannot be imposed directly locally. They only set parameters for local negotiations.

Second, decentralization is reflected in and will be exacerbated by the demise of the regional health authorities (RHAs) in England. They have, in the main, played a proactive part in equality. For instance, they developed their own action plans for achieving the Opportunity 2000 goals and administered management training schemes and could thus encourage purchasers and providers to put forward applicants from under-represented groups. Their number and their functions, however, were reduced in April 1994, prior to their abolition in 1996 (Department of Health, undated).

Moreover, the quasi-contractual process and the need for efficiency in the quasi-market may pose problems for an equality programme which inevitably carries a cost. For instance, there are resource implications in starting a creche, producing and publicizing an action plan and administering a career break. Although the NHS makes "half a billion pounds' annual investment in training", essentially units bear only a small proportion of this cost as much training is carried out above unit level (Department of Health, undated). In other words there is little financial incentive for trusts to adopt measures to aid retention. As Willis (1991) says:

Equal opportunity issues may be lost under the pressure to succeed in contracting. Hard issues such as business planning may well take precedence...Another danger faces the levels of management where women have traditionally predominated, for example nursing officers...[These] levels could well be stripped out in order to achieve a flatter managerial organization in the form of clinical directorates, so cutting off another career route for many nurses without necessarily creating an alternative.

Research design

The aim of this article is to assess the progress the NHS in England is making on Opportunity 2000. To that end, information was collected in 1993/94, i.e. over two years after the setting of the initial goals, in two northern regions: North West and Yorkshire, and two southern regions: Oxford and Wessex. (The regions' names and boundaries are those which applied pre-April 1994.) The Thames regions were deliberately excluded because health care reorganization and hospital closures are taking place in London. If equality issues were not properly addressed there, this may not be typical of the NHS elsewhere. On the other hand, two regions chosen are close to London and are arguably more affected by the business case for equality, particularly the need to retain staff, as southern areas have had much higher labour turnover rates than northern areas (Corby, 1991a).

Progress on the first four numerical goals was assessed by reference to the statistics gathered regionally. Progress on the remaining goals, however, could only be accurately assessed by looking at what was happening at unit level. So questionnaires were sent out in November 1993 with repeats to non-respondents in January 1994. The questionnaires centred on nursing and midwives for two reasons: first, three goals specifically relate to them and, second, they comprise not only the largest occupational group in the NHS but also the largest occupational group for women.

The questionnaires were sent out to management, i.e. the Opportunity 2000 contact, normally the personnel manager. However, so that perceptions of action towards equality would not just be gleaned from one perspective, questionnaires were also sent to union representatives/stewards of the three main nursing and midwifery staff organizations in the four regions: the Royal College of Nursing (RCN), UNISON and the Royal College of Midwives (RCM), asking virtually the same questions.

A total of 93 questionnaires were sent out to management and 67 were returned, giving a response rate of 72 per cent. Questionnaires were sent out to 282 staff representatives and 101 were returned; a response rate of 36 per cent.

The higher response rate from management may be due to the fact that both the RCN and the RCM in many cases had not yet altered their structures to fit in with the new NHS structures and so the staff representatives could not easily complete the questionnaire. As to UNISON, the union had just been formed from an amalgamation of three unions and was in the throes of considerable re-organization.

The goals

Jewson and Mason (1986) classify equal opportunity agendas as either liberal or radical. The liberal conception, they say, stresses bias-free competition, the removal of collective barriers to individual talent and an emphasis on training. In contrast, the radical approach is concerned primarily with outcomes. Cockburn (1989) takes issue with this dichotomy and classifies equal opportunities agendas as of shorter or longer length. Both the Opportunity 2000 campaign, in general, and the NHS Opportunity 2000 goals, which mix liberal rationales with target setting, support her view that the dichotomy does not apply. Four of the eight NHS goals for 1994 are numerical, i.e. connected with outcomes, and one of the goals is concerned with training. In fact, the goals set for the NHS are longer rather than shorter to use Cockburn's preferred frame of reference. Yet they cannot be what Cockburn calls "a project of transformation", i.e. they are not that long, not least because (as we have seen) the goals were set by the NHSME, which has no power to transform trusts.

Bearing this in mind, let us now see how the respondents were measuring up to the goals as follows.

Goal 1: Increase the number of women in general management posts from 18 per cent in 1991 to 30 per cent in 1994

North West RHA defines "general management posts" as chief executive or unit general manager. Their figures indicate that women formed 12.3 per cent of general managers/chief executives in the North West in December 1991 but by June 1993 the position had slipped back to 8.6 per cent. The figures for Wessex, which uses the same definition, are somewhat better. The percentage of women rose in 18 months from 6.5 per cent to 15 per cent by July 1993.

However the Wessex RHA 1993 progress report points out that "the turnover in general manager posts is now extremely low. For this reason the statistical target...will not be met by 1994". The NorthWest RHA makes the same point. Only in the Oxford region, where the definition of general management posts was unclear, was the 30 per cent target achieved by 1993, a year early, while Yorkshire adopts the definition of senior manager and gives a 26 per cent figure for 1993.

Goal 2: increase the number of qualified women accountants in the NHS (revised in 1992 to include a 35 per cent target by 1994)

Some regions reported that they had achieved this goal by 1993. Thus Oxford had 38 per cent qualified women accountants and Wessex had 36 per cent. North West had 26 per cent in December 1992 - an increase of four percentage points in six months. Yorkshire RHA does not give figures. As substantial numbers of women are studying accountancy, progress is likely to continue.

Goal 3: increase the percentage of women consultants from 15.5 per cent in 1991 to 20 per cent by 1994, necessitating an annual increase of 10 per cent. Accelerate the rate of increase in the number of women consultants in surgical specialties from the current 9.7 per cent to 15 per cent per annum

The percentage of women consultants in the North West was 15 per cent in June 1993, as it was in Wessex. In the North West, women comprised 3.7 per cent of consultants in surgical specialties. Both regions point out that it will not be possible to achieve this goal by 1994 because turnover is low. In contrast, in the Oxford region women formed 19 per cent of consultants in 1993, though only 5 per cent in surgical specialties. It says "there has been no improvement in this difficult area", while Yorkshire RHA does not seem to have produced specific figures.

Goal 4: increase the representation of women as members of authorities and trusts from 29 per cent in 1991 to 35 per cent in 1994

All four regions report that this target had already been exceeded by 1993.

Goal 5: introduce a programme allowing women aspiring to management positions to go through a development centre with a view to establishing their own personal development needs

In the questionnaire, respondent managers were asked to give the number of full-time and part-time nurses/midwives in junior management positions (grade G and above) who had made use of a diagnostic process or a development centre for women into management. There were only 18 (27 per cent) who responded to this question and the aggregate number of nurses/midwives going through a development centre was 265.

Goal 6: introduce initiatives on recruitment and retention to ensure that the number of qualified nurses and midwives leaving the profession does not rise

(The quit rate nationally is estimated at 5.7 per cent per annum.) According to management respondents, in 50 per cent of the units there were written agreements on a retainer/career break scheme. In 70 per cent of units there was a written agreement on job sharing and in 82 per cent of units there was a written carer leave agreement. A total of 47 nurses/midwives were on career breaks out of 22,541 nurses/midwives covered by written agreements, i.e. 0.2 per cent. The equivalent figure for carer leave was 0.8 per cent.

Also information was collected on workplace nurseries from the NHS Women's Unit. This showed that 182 units in England (over 40 per cent) had creches in 1993. They all closed at around 6 p.m. and at weekends, although hospitals are open round the clock (NHS Management Executive, 1993).

Goal 7: ensure that following maternity leave or a career break all women, including those returning to nursing part-time or as a job share, are able to return at a grade commensurate with their leaving grade and to work of a similar status

Management respondents reported that half the units (34) had job sharers. These came to 354 in aggregate out of 34,038 covered by such an agreement, i.e. 1 per cent. (See also p. 31 below.)

Goal 8: monitor the time taken for nurses to reach management positions to ensure that men and women have equal access to these positions

No information was collected on this as it was felt that the short time that had elapsed could give an unfair picture.

Discussion

This research, therefore, suggests that the only goal that was surpassed was goal 4 - women as members of authorities and trusts. This may be because the Secretary of State appoints the non-executive chairman and up to three out of five non-executive directors of each trust (the RHA appoints the others.) Moreover this finding ties in with the NHS context. As we have shown above, the NHS women's unit has little power to direct trusts, which have a large degree of autonomy, except on the matter of board appointments.

The other goal, which many are meeting, was goal 2 - women accountants. Otherwise these findings suggest that the goals are often not being met and further analysis shows that there is no significant difference in responses according to region or according to whether the unit is acute or not.

This failure to achieve all the goals can be grouped in categories: the NHS context (discussed above) which provides infertile ground for an equality programme; the shortcomings of NHS managers in implementing Opportunity 2000; flaws inherent in Opportunity 2000 in the NHS; and factors applying to equality programmes generally.

Turning to the category relating to shortcomings in implementation, Opportunity 2000 in the NHS should be seen as a cultural change and equal opportunity messages need to be conveyed comprehensively and adequately, as Hammond and Holton (1991) point out. The NHS women's unit in 1991 asked authorities and trusts to "produce an action plan which shows how they will achieve these goals" (NHS Management Executive, undated). In many units this is not being done: 17 per cent of respondent managers said their unit did not have a local action plan. Where units had local action plans, questions were asked about how they were publicized: copy given to all staff, copy given to staff representatives, notice on notice-board, other. Essentially, management reported more methods of publicity than staff representatives where samples were either matched or unmatched. It is worth noting that the variation between management and staff representatives on whether a copy of the local action plan was given to the latter varied by 16.5 percentage points!

A UNISON representative commented "There has been no discussion/information about Opportunity 2000 via the employer". An RCM representative said that, before she received my questionnaire at the end of 1993, she had not known about Opportunity 2000 and thanked me for bringing it to her attention.

An RCN representative said: "I have seen posters on notice-boards in some parts of the hospital advertising Opportunity 2000 ... Altogether the grass roots staff have received little information, including us as stewards". Related to this, Opportunity 2000 is being given a low priority. For instance, when the newly appointed human resources director of the NHS, Ken Jarrold, gave an interview to Personnel Management in April 1994 outlining his plans, he did not mention Opportunity 2000 (McLachlan, 1994). It could be argued that Opportunity 2000 is the preserve of the women's unit but this leads to equal opportunities being marginalized and seen as separate from mainstream personnel matters.

The lack of priority given to Opportunity 2000, however, can also be seen from the responses to the questionnaires. Management respondents said 27 units (40 per cent) did not collect figures on the number of job sharers. An RCN representative said redundancies and changes in shift patterns were her priority. An RCM representative said: "We as a Joint Staff Negotiating and Consultative Committee have been so busy trying to get agreement on recognition, discipline procedures, etc., I have to confess that Opportunity 2000 has taken a lower place."

There is a notoriously low take-up rate of women-friendly employment measures in many organizations. For instance, less than 10 per cent of eligible women in 88 per cent of 182 Opportunity 2000 organizations used job share arrangements (Opportunity 2000, 1994). Even judged by that benchmark, however, this research, which shows 1 per cent take-up of job share arrangements, indicates a low rate for the NHS. Undoubtedly, women-friendly employment practices cause problems for NHS managers. A UNISON representative said that "staffing levels/constraints of the service" were often used by management as reasons for not implementing Opportunity 2000, while an RCM representative said that a community midwife was refused job sharing because of the cost implications - job sharing would necessitate an extra telephone and car user.

Nevertheless the numbers of nurses/midwives refused job sharing or part-time work in their old grade after maternity leave or a career break was very small. Even on the staff representatives' figures (which were higher than management's) 27 nurses/midwives were refused informally and six were refused formally but this comprised 0.1 per cent of nurses/midwives employed in units where there were written arrangements/agreements. The equivalent figure for carer leave was 22 refusals.

However, there is some evidence of what under the Northern Ireland Fair Employment Act they call the chill factor, i.e. people do not apply because they think they will not be successful.

An RCM representative said: "Girls who do request certain hours have been told that work comes first.... One girl has actually been told that she (the manager) chose not to have children".

The manager's approach may not be unusual. As cited above, the IMS found that 90 per cent of male chief nursing officers (CNOs) are married and have children, whereas 86 per cent of female chief nursing officers are either single or married without children (Hutt, 1985).

Another example of the chill factor was given by an RCN steward. She said: "There has only been one grievance taken about refusal of carer leave. It was a builder. Nurses have been put off by managers' attitudes ... and so take either holidays or sick-leave."

The study looked at the number of staff refused permission to go on the retainer/carer break scheme, to work part-time or job share, or refused permission for carer leave who then took out a grievance. The number is tiny. Five put in grievances on part-time work or job sharing out of 33, three out of 22 in respect of carer leave, and none in respect of a career break. This suggests that either the initial refusal was perceived as fair, so a grievance was not instituted, or the chill factor operates. Support for the latter view comes from a comment by a UNISON representative who said: "The nursing members are prone not to pursue any grievances, though this does not mean that nurses are not being refused".

Interestingly there is evidence that persistence pays. An RCM representative said: "Management haven't been encouraging and it's taken a lot of hard work on the part of prospective job sharers and the steward". Moreover in four out of the five cases where staff took out grievances in respect of a refusal of job sharing or part-time work, the grievance was upheld. This suggests that opposition is at the level of the immediate line manager.

So far we have looked at how Opportunity 2000 in the NHS is not being implemented. In essence, we have said that, if only the programme was properly communicated and implemented, then goals would be achieved and problems obviated. This article would argue, however, that this is not an adequate explanation. There are also problems inherent in the NHS's Opportunity 2000 itself. One flaw relates to the lack of specificity in the goals. For instance "general management posts" in goal 1 are not defined. As a result some RHAs (on the advice of the NHS women's unit) define them as "chief executive or unit general manager" but others do not. Similarly "qualified" accountants in goal 2 is not defined, although there are many accountancy qualifications (Baker, 1993). From responses to the questionnaire, it seemed many managers were unsure what the term "development centre", as used m goal 5, means.

Goal 6, which calls for the introduction of initiatives to ensure that the numbers of nurses and midwives leaving the profession do not rise, is open to considerable interpretation. Does this goal mean having arrangements in writing or implementing initiatives? Do managers not need to introduce initiatives if labour turnover is static? If nurses move from the NHS to the private sector, they are not lost to the profession, so does that mean initiatives are unnecessary (Buchan, 1992)?

In other words, the way the goals are formulated gives considerable leeway to those who supply statistics and both the NHS women's unit and local personnel managers have an interest in presenting matters in the most favourable light to demonstrate progress. As one personnel manager said: "We all know how to fill in NHSME forms to give the right impression."

In a similar vein a trust personnel director said that he had cited the same woman's career step each year for three years but the words he used could be taken to mean three separate women's career steps.

Another flaw in Opportunity 2000 stems from the fact that the NHS gives out mixed messages about nurses and midwives. As we have seen, three of Opportunity 2000's goals relate specifically to them. Yet the female nurse uniform, with its cap, dress and black tights/stockings, as opposed to the male nurse uniform of tunic and trousers, conveys a message of women nurses as sex objects and reinforces the female stereotype. However in Burrett v. West Birmingham Health Authority, the Employment Appeal Tribunal (EAT) found that the employer did not discriminate against a female nurse by requiring her to wear a cap as part of her uniform, although male nurses were not so required. Both male and female employees were required to wear uniforms and thus this did not amount to less favourable treatment. The EAT was not convinced by Ms Burrett's submission that a nurse's cap was demeaning. The editor of Industrial Relations Law Reports, however, has criticized this decision[1].

Finally, we deal with factors which limit the effects of many an equal opportunity programme, not just Opportunity 2000 in the NHS. Such programmes are often justified on the grounds that they make business sense but in the NHS, in particular, business case arguments may carry little resonance. After all, the NHS is posited on principles of social justice. Its purpose is to provide health care to all, regardless of ability to pay. Although the business case carries weight with ministers and may carry weight with unit chief executives, it does not necessarily convince health-care professionals, whose codes of conduct embody an ethical dimension.

Leaving aside, however, the particular characteristics of the NHS, the business case argument has its limitations, as Dickens (1994) points out. First, she says, the impact is uneven since the business case is dependent on the business cycle. Allied with that, the business interest may be perceived differently at different levels in the organization. Economic rationality in terms of cost benefit can point away from equal opportunities, as well as towards it. An illustration of Dickens's point is provided by an NHS personnel manager, who explained a lack of measures to improve the retention of female staff by saying: "As a trust we have virtually no turnover of qualified nurses".

Dickens also points out that business case arguments rarely deliver a thoroughgoing approach and may encourage action only in areas where it is clear that equal opportunities and business needs immediately coincide. The fact that none of the NHS's Opportunity 2000 goals specifically relates to ancillaries, a significant and female-dominated group at the bottom of the NHS hierarchy, supports her argument.

Opportunity 2000, both in the NHS and elsewhere, and equal opportunities programmes more generally, emphasize the aspect of women in management. In the NHS we have seen how the only goal achieved a year in advance of the target date relates to women non-executive directors. Other initiatives taken by the NHS women's unit include a publication entitled "Women managers in the NHS: a celebration of success" (Proctor and Jackson, 1992) and their link-up with Ashridge Management College to produce an NHS women's career development register.

Of course, equality programmes for women are aimed at breaking down occupational segregation by gender and moving women into traditionally male-dominated areas, such as maintenance and management. But do women managers make a difference to organizational policies and practices? Some are of the view that, if there are more women in management, more women will be involved in organizational policy and decision making with the result that organizations will reflect the needs and interests of women. However, radicals take the view, as Walby (1990) points out, that, even when women achieve very senior positions and a lot of power, their ability to effect change for and on behalf of women is limited, as discrimination is rooted in the social and structural. Others, such as Coyle (1993), argue that women who have gained power under the system may only want to change it marginally. Even feminists in senior positions are likely to be primarily concerned with the imperatives of running a cost-effective service. The refusal by the female Director of Midwifery Services to grant a community midwife a job share (mentioned above), because it would entail an extra telephone and car user, is consonant with Coyle's argument.

A third factor, common to all equal opportunities programmes for women, centres on the value system that sees women as the problem. The male career pattern is seen as the norm and organizational structures are based on the arrangements which suit men, not women. Equal opportunity programmes, (for instance part-time work or career breaks), are designed to organize the women round the work, rather than the other way round. They are interventions in existing androcentric practices. Yet as Cockburn (1991) points out, they are a mixed blessing for women. Women generally welcome measures to promote flexible work. They help them combine work and the family but confirm them as the domestic sex. Thus women enjoying such measures are seen, at best, as having dual demands on their time arising from their paid work and their work at home and, therefore, different from other (mainly male) employees and, at worst, as second-class employees.

Although this value system lies at the root of many an equal opportunity programme, its existence in the NHS in general and in nursing in particular, is remarkable. Nursing is predominantly a female profession (see percentages above). As Davies (1990) notes, historically it was built on the career path of a single woman who lived and devoted herself to the job. The transition, however, has been to the male career path and not to the path of the woman with domestic responsibilities, even though only 10 per cent of nurses are male. There is some resignation by managers, she says, that part-time work and episodic contributions are inevitable given that the profession contains so many married women but such work is rated less highly than full-time, uninterrupted work. Thus part-timers are concentrated in lower grades (Corby, 1991b) and are assumed by many managers to be less committed to work than full-timers, compared with whom they face additional barriers to career progression and have less access to training (Jackson and Barber, 1993). As Davies (1990) says: "Today's nursing it would seem reflects conventional career thinking and values conventional careers in a context where such careers have always been impossible for many of those involved."

Summary and conclusions

This research has shown that the NHS has failed to meet at least some of its Opportunity 2000 goals. The reasons for this partly relate to the NHS context including the autonomy of trusts, the increasing flexibility in Whitley agreements and the quasi-market with its emphasis on cost saving. This, essentially, is incompatible with an equal opportunities programme strategically directed from the NHS centre. But the reasons also relate to the failure of NHS managers to implement the programme, to communicate it and to give it a high priority. Moreover there is evidence of a chill factor which discourages staff from applying for flexible work.

Partly, however, the NHS Opportunity 2000's lack of success stems from inherent flaws. Some of its goals are ill-defined. At best they are open to a variety of interpretations and at worst to manipulation by trust personnel managers. Also, while a number of goals relate to equal opportunities for nurses, Opportunity 2000 fails to tackle the sex stereotypical uniform of the female nurse.

In addition, the programme's justification on business grounds is a limitation. The NHS is based on ideas of social justice in which many may see a clash between ethical and business values and the business case itself is contingent on the business cycle. Moreover, almost invariably, equal opportunity programmes for women are managerialist, They aim to increase the number of women in management, presumably relying on them to make changes which will be beneficial for other women employees and ignoring the institutional, structural and cultural impediments to equality. Lastly equal opportunities programmes for women, including those in the NHS, founder because the value system views the male career pattern as the norm and women as the problem. Measures to enable women to work part-time or take career breaks may be valued by them, but underline their domestic responsibilities.

These findings lead on to a general consideration of the usefulness of goal and target setting in achieving movement towards equality. Kandola and Fullerton (1994) say:

In our survey, targets were the least successful of initiatives undertaken by organizations. Targets are problematic not only in the way they are currently established (which often seems to be a combination of wishful thinking and maximum PR coverage) but also in the basic thinking and philosophy behind them.

In contrast, Welsh et al. (1994) say: "There is some evidence that organizations who have targets and timetables are more likely to be successful in improving ethnic minority representation than those who do not".

Moreover, in Northern Ireland under the Fair Employment Act, where goals and timetables are promoted by the Fair Employment Commission (FEC) (1994), there has been "a degree of progress".

Against that background, this research suggests that essentially Kandola and Fullerton's strictures can be levied against the NHS's Opportunity 2000 targets. As Welsh et al. (1994) say, however, there is a "whole raft of factors" determining success, while in Northern Ireland there is a strong statutory framework, which even enables the FEC to require an employer to set goals and timetables. Accordingly, the author concludes that the setting of goals and targets is a necessary, but not sufficient condition of success. They are more likely to be achieved where there is a supporting statutory framework, where the goals themselves are clearly defined; where managers at all levels are perceived by union representatives to be committed to them; where the rationale for the goals is consistent with the values of actors and where those setting goals and monitoring achievements have power at all levels of the organization.

Cockburn (1991) found that equality achievements in the public sector have been disappointing and she outlines the measures that need to be adopted if there are to be far-reaching changes. This more recent research on the NHS suggests her analysis remains valid.

Note

1. [1994] Industrial Relations Law Reports 7. The editor points to the House of Lords derision in R.v. Birmingham City Council ex parte Equal Opportunities Commission where it was held that, in order to establish "less favourable treatment", it is enough that members of one sex are denied "a choice which...is valued by them and which (even though others may take a different view) is a choice obviously valued, on reasonable grounds, by many others". The facts in the Burrett case show that the choice not to wear a cap was valued by Ms Burrett and others in the hospital.

References

Baker, E. (1993), "Opportunity 2000 in the NHS with particular reference to the North West region", MA dissertation, Salford University, unpublished.

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The author would like to thank John Kawalek, senior lecturer at the Manchester Metropolitan University, and students on the BSc (Hons) business information technology course for their analysis of the responses to the questionnaires and to the Editor for his helpful comments.

Susan Corby is Senior Lecturer in Industrial Relations at the Department of Management, Manchester Metropolitan University, Aytoun Street, Manchester M1 3GH, UK.
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Date:Mar 1, 1995
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