The conclusion is a very important part of your essay. Although it is sometimes treated as a roundup of all of the bits that didn’t fit into the paper earlier, it deserves better treatment than that! It's the last thing the reader will see, so it tends to stick in the reader's memory. It's also a great place to remind the reader exactly why your topic is important. A conclusion is more than just "the last paragraph"—it's a working part of the paper. This is the place to push your reader to think about the consequences of your topic for the wider world or for the reader's own life!
A good conclusion should do a few things:
- Restate your thesis
- Synthesize or summarize your major points
- Make the context of your argument clear
Restating Your Thesis
You've already spent time and energy crafting a solid thesis statement for your introduction, and if you've done your job right, your whole paper focuses on that thesis statement. That's why it's so important to address the thesis in your conclusion! Many writers choose to begin the conclusion by restating the thesis, but you can put your thesis into the conclusion anywhere—the first sentence of the paragraph, the last sentence, or in between. Here are a few tips for rephrasing your thesis:
- Remind the reader that you've proven this thesis over the course of your paper. For example, if you're arguing that your readers should get their pets from animal shelters rather than pet stores, you might say, "If you were considering that puppy in the pet-shop window, remember that your purchase will support 'puppy mills' instead of rescuing a needy dog, and consider selecting your new friend at your local animal shelter." This example gives the reader not only the thesis of the paper, but a reminder of the most powerful point in the argument!
- Revise the thesis statement so that it reflects the relationship you've developed with the reader during the paper. For example, if you've written a paper that targets parents of young children, you can find a way to phrase your thesis to capitalize on that—maybe by beginning your thesis statement with, "As a parent of a young child…"
- Don’t repeat your thesis word for word—make sure that your new statement is an independent, fresh sentence!
Summary or Synthesis
This section of the conclusion might come before the thesis statement or after it. Your conclusion should remind the reader of what your paper actually says! The best conclusion will include a synthesis, not just a summary—instead of a mere list of your major points, the best conclusion will draw those points together and relate them to one another so that your reader can apply the information given in the essay. Here are a couple of ways to do that:
- Give a list of the major arguments for your thesis (usually, these are the topic sentences of the parts of your essay).
- Explain how these parts are connected. For example, in the animal-shelter essay, you might point out that adopting a shelter dog helps more animals because your adoption fee supports the shelter, which makes your choice more socially responsible.
One of the most important functions of the conclusion is to provide context for your argument. Your reader may finish your essay without a problem and understand your argument without understanding why that argument is important. Your introduction might point out the reason your topic matters, but your conclusion should also tackle this questions. Here are some strategies for making your reader see why the topic is important:
- Tell the reader what you want him or her to do. Is your essay a call to action? If so, remind the reader of what he/she should do. If not, remember that asking the reader to think a certain way is an action in itself. (In the above examples, the essay asks the reader to adopt a shelter dog—a specific action.)
- Explain why this topic is timely or important. For example, the animal-shelter essay might end with a statistic about the number of pets in shelters waiting for adoption.
- Remind the readers of why the topic matters to them personally. For example, it doesn’t matter much if you believe in the mission of animal shelters, if you're not planning to get a dog; however, once you're looking for a dog, it is much more important. The conclusion of this essay might say, "Since you’re in the market for a dog, you have a major decision to make: where to get one." This will remind the reader that the argument is personally important!
In exploring how managers in health care encounter and apply management knowledge, our study has focused on three main aspects: management and leadership in the health-care context, knowledge, knowledge mobilisation and learning processes, and NoPs and CoPs. In this final chapter, we summarise our main conclusions in each of these areas, preceding this with a consideration of the effects of organisational and managerial diversity, before turning to assess the limitations and implications for future research and, finally, drawing out the recommendations from our study.
Effects of organisational and managerial diversity
The study was designed to enable analytical generalisation reflecting the diversity in the range of trusts within the NHS and across the range of employees in the NHS charged with management responsibilities.
To capture organisational diversity, three case study organisations were chosen: an acute trust, a care trust and a specialist trust. Our assumption was that these trusts would vary in terms of geographical spread, the number of locations from which services are provided, the diversity of services provided and the number of organisations purchasing services from them. Empirically, these presumed differences were confirmed, although two of the three trusts did undergo substantial changes during the course of the research. However, contextual influences are not merely objective forces acting on organisations: their impact is moderated by individual and collective perception and interpretation in each case. Therefore, a core element of our study was to identify organisational factors and aspects of change which interviewees themselves saw as impacting most powerfully on management practice and knowledge sharing. Collectively, these differences provided a detailed and complex picture of the context within which our managers operated and represented a key element in developing our empirical and thematic analysis.
Managerial diversity was equally important, particularly in the light of the contested nature of management (and leadership) in the NHS discussed in Chapters 3 and 4. A key objective was to ensure that the study fully captured the distributed nature of the management and leadership in the modern NHS and avoided a too simplistic and misleading dichotomy between management and clinicians.
To ensure that this happened in a structured and meaningful way, a model of management in the NHS was developed and refined, based around a continuum of clinical and managerial training and experience (see Figure 1). The main purpose of this model was to guide us in the recruitment of research participants in each trust, using purposive and non-random samples to differentiate between broad clusters of clinical, general and functional managers in each trust. As with the selection of case studies, these differences were necessarily broad-brush, but the empirical research was then used to reveal the substantial richness and complexity encapsulated within this simple model. Nonetheless, these three broad management groups, alongside the three case study organisations, did provide a valuable analytical tool in our empirical and thematic analysis. Therefore, the model itself represents a novel feature and direct deliverable from our research as it provides a tool that allows us to differentiate between these three managerial groups.
Management and leadership in the health-care context
As noted in the discussion in Chapter 1, the study of management in health-care organisations faces a number of theoretical and empirical challenges, one of which is to work with the complex relationship between management and leadership, a theme that has been explored at long length in academic and practitioner literatures.27,28,89 This distinction typically contrasts visionary, strategic and transformative leadership, with a more procedural, operational and bureaucratic approach to management.28
Within the NHS, the management/leadership distinction is probably more sharply defined and has greater palpable weight and political significance than in many other sectors, for the reasons outlined in Chapter 4. In particular, historical tensions between management and clinical professions result in an ongoing suspicion of (and resistance to) management both as a function and as a cadre. Our analysis of health-care management, therefore, recognises the evolution of terminology in the NHS, in the first instance in the privileging of management over administration, and more recently in moves to celebrate leadership, including clinical leadership, over management.70,89
The consequence is a complex and delicate ontological landscape, in which many NHS employees who manage will, for a variety of reasons, be reluctant or conflicted over the title ‘manager’ and indeed may not recognise their practice as ‘managing’, typically identifying instead with the role of leader and the practice of leadership. To address management effectively, paying full recognition to its political complexity in this context, our approach in this study was to address management inductively: as a question, informed by extant research on management and leadership within the NHS, and more widely. The first aim of our empirical research was to draw out and differentiate understandings of management and leadership as understood and practised by respondents in our study, rather than imposing meaning externally. The result is a more complicated and contested, but nevertheless richer, picture of management in our subject organisations, as understood, practised and articulated by managers both formally and informally.
This mapping out of meanings of management in our study, assisted through the development of our selection framework for managers (see Figure 1), led to two key findings from our research. First, management in the NHS is not only a heterogeneous activity, but also a heterogeneous identity, in that it is distributed among a wide range of occupational groups (classified by ourselves into the aggregate categories of clinical, general and functional), which draw upon highly diverse sources of knowledge, learning and experience and who interact through very diverse and open distinct networks of interaction and CoPs. Second, in this milieu, it is general managers who face the greatest challenge in sharpening their sense of professional identity based around a distinct and coherent managerial knowledge base.
Knowledge, knowledge mobilisation and learning
To examine these knowledge processes further, the report drew upon a classical differentiation between explicit and tacit forms of (management) knowledge and between abstract learning and learning that is situated in practice. This enables us to distinguish between four primary types of knowledge in our study:125
knowledge encultured in the norms, values and practices of managers
knowledge embedded in local management systems and processes
knowledge encoded in management tools and techniques
knowledge embodied in the skill sets of individuals.
In turn, this system helps to draw out the challenges involved in attempting to mobilise knowledge between contexts and to abstract it from, and translate it into, practice, through processes of socialisation, externalisation, combination and internalisation.37 As a consequence, our study focused substantially on issues of knowledge translation, of putting encoded knowledge such as lean thinking into practice, for instance. Equally, however, there was the challenge of translating local and embodied solutions and innovations into generalisable and transferable knowledge. Similarly, this focus enabled the identification of particular barriers and gaps in this mobilisation process. A particular theme of interest in light of this framing was the role of formal training and development in management and its impact and importance when compared with other, more experiential modes of learning.
Although focused on management knowledge, the elephant in the room throughout our discussions has been the particularly influential body of professional knowledge associated with clinicians, against which managerial knowledge and understanding are often juxtaposed. It was therefore necessary to pay attention to the ways in which management knowledge was perceived to be in competition with, or judged against, medical bodies of knowledge in the process of collective decision-making, for example. At the same time, as many of our managers were simultaneously, or formerly, clinicians, the performance of their role often relied as much on their clinical or other professional knowledge and experience (and the credibility it gave them) as it did on their managerial know-how.
Taking these two aspects together points to a third key finding to emerge from the research, namely the strong tendency for managerial knowledge, particularly that harnessed by general managers, to be more home grown (situated in local practices) and experiential. Local pressures associated with trust reporting and management requirements combined with the hegemony of clinical know-how and the influence of a financial discourse tended to create a strong reliance on local and experiential knowledge (notwithstanding the potential value of alternative, external forms of knowledge and learning).
Although our theoretical framing was substantially informed by contemporary thinking on knowledge sharing and learning, which emphasises the socially situated nature of knowledge, it also emphasises the importance of learning or knowing through social interaction in NoPs and CoPs and this is what we turn to next as the third of our major themes.
Networks and communities of practice
An understanding of flows of knowledge requires an insight into the nature and dynamics of the networks and communities within which practitioners are located, opening up a consideration of the various NoPs and CoPs to which managers may belong, their role and organisation, the relationship between the interactions they enable (or constrain) and associated processes of socialisation and learning (or exclusion and non-learning).
Despite the value of the substantial literature on CoPs that highlights the interpenetration of socialisation and knowledge-sharing processes, we also recognise the limitations of too exclusive a focus on this type of arrangement.151 Membership of a CoP revolves around shared narratives of experience, shared paradigmatic modes of analysis and shared modes of representation.46 Although CoPs are typically defined as closely related groups of practitioners who develop and share common understandings through frequent and close interaction, we aimed to remain sensitive to the variety of groups and communities to which managers may belong and to potential interplays between them. Therefore, we focus on a broader and more extensive concept of networks, a concept which allows for a greater diversity in terms of their degree of co-ordination and cohesion, strictures on membership, the ways in which they are formed and their location within or across organisational boundaries. To be clear, several of the networks examined empirically in the study do indeed display the cohesion of a CoP, but many are significantly more informal, loose, open and flat or distributed networks, which nonetheless play a key role in knowledge mobilisation and socialisation for the managers in our study.
To capture the meaning and significance of these networks, we set out to discover what networks exist, how they function and what purpose they serve for the managers in each trust. In other words, the process was an inductive one of ascertaining the network connections of salience and importance to managers, rather than a narrow but more constrained focus on formal, closed or centralised networks and, especially, those with a highly performative focus on narrow instrumental goals. Through this flexibility, we were able to explore the diverse range of inter-related purposes served by networks, including not only knowledge acquisition but also career advancement, influencing policy and practice, and personal/emotional support. We examined these outcomes in terms of both individual and organisational benefits, cognisant of recent and on-going debates on the value of social capital but, again, without reducing networks and the activity of forging relationships to narrowly instrumental motives.
Perhaps the key general finding to emerge in this respect was the challenges faced by general managers in being able to access fully and be actively engaged with wider networks of professionals (not only across trusts but within them too). Not only did this mean that general managers had less opportunity to gain potentially valuable knowledge and support, but also that it tended to reinforce any reliance on local and experiential knowledge, adding to any inward-looking tendencies.
Limitations and directions for future research
Our research has lent strong support to the framework developed in Figure 1 as a means of differentiating between relatively distinct managerial groups and the quite different NoPs and CoPs they tend to engage with. It has also demonstrated the value of situating analysis of management knowledge mobilisation and utilisation in the context of the particular organisational conditions and challenges facing those diverse managerial groups. However, that very complexity and diversity also inevitably creates limitations for how qualitative research is able to tap into the processes concerned.
One obvious limitation is in the restriction in the range of case organisations to three types of trust. The research has adopted standard and accepted protocols for case study design and selection that emphasise the importance of choosing cases that show variation in key conditions (in this research, expected variation in managerial knowledge networks) and which rely on analytical, rather than statistical, generalisability to extrapolate findings to different types of setting.52,53 Consequently, it becomes possible to conclude, for example, that challenges to management networking may equally be found in other highly differentiated forms of trust. However, the importance of a holistic understanding of case conditions and their effects also alerts one to the possibility that different constellations of conditions may create different outcomes in other types of trust. Only by extending the research systematically to consider all potential types of trust would it be possible to conclude that the range of likely conditions are fully captured in the research design.
Second, a similar limitation is in the number and range of participants included in the research. Again, the research has applied small-scale purposive sampling, rather than large-scale random sampling methods to systematically select participants for interview. As such, the findings are inevitably restricted to the range of experiences and conditions faced by the selected group of managers. The qualitative nature of the study has allowed us to choose our participants carefully in order to ensure an appropriate range of respondents and then to examine their experiences in considerable depth. Moreover, respondents have also effectively acted as key informants on the issues faced by managers generally and we have been able to augment interview data with direct observation of management practices. However, there is clearly scope here for more extended research that explores the issues raised through larger-scale systematic or random sampling of respondents both within and across trusts. This could be based on the use of the framework of management types developed in our study.
Third, the ethnographic study of the managers, their access to knowledge sources and their involvement in networks is also inevitably constrained by the resources available to conduct such research in the depth that would be required to get a complete picture of managerial knowledge mobilisation and utilisation. The data obtained have provided rich insights into the ways in which different managers access, share and use managerial knowledge and how this relates to diverse organisational and professional circumstances. However, each of these networks of interaction in which specific groups of managers are involved is worthy of study in their own right. Studying wider networks of activity has been beyond the scope of the current study, as the emphasis has been on managers’ perceptions. Consequently, there is clearly further scope for exploring in greater depth any or all of the networks of interaction that involve the managers we studied (and others) effectively in their own right. Research of this type may employ similar ethnographic methods, but could also use more quantitative techniques, such as social network analysis. This research has signposted areas in which further research may reveal important details about the structure and dynamics of such networks of interaction, knowledge creation and sharing, but has not been able to capture these in full.
Fourth, the ethnographic element of the research has been important in helping to understand and situate management knowledge and learning processes in practice. But there is more that could be done to extend this type of work to get deeper insights into these processes. Resource constraints meant that it was not possible to extend this aspect of the work fully, for example through extended periods of stay or shadowing of managers or tracking interaction further into external NoPs and interaction. Selection of managerial events and encounters to observe also means that a standard criticism of ethnography (that findings from observations are inevitably restricted to what is observed) apply to this research as well. More extended ethnographic study is one way to build on the insights from this study to get further insights into the processes involved.
Last but not least, recent changes to the relationships between primary and secondary health care pose a number of further important potential questions about the nature, sources and application of management knowledge in a changing health-care environment. The scope of this research has not extended to primary-care organisations, so there is a need for further research to explore management knowledge and learning processes in the primary-care domain as well as in the changing interface between secondary and primary care.
There are seven general recommendations that emerge from the research, each of which has a number of implications for practice at, variously, national, regional or trust level. These are particularly in the realm of management training and development, but also encompass steps that trusts and other agencies might take to improve the structural context within which managers work and are embedded.
Value management as well as leadership. The research points to a widespread tendency to denigrate management in favour of heroic conceptions of leadership. There are benefits to be gained from a clearer recognition of the contribution of effective management and the necessity of explicitly presenting management and leadership as equal partners in managing complex and changing organisations.
Leadership training and development programmes (e.g. via the NHS Leadership Academy) need to ensure that the development of leadership takes account of the complex relationship between leadership skills and management practice on the ground.
Such programmes also need to balance an emphasis on leadership with continued attention to the importance of management skills (especially leadership-related skills, such as interpersonal communication).
Local trust training and development programmes can help maximise the transferability of context-specific leadership training to management practice by ensuring that analysis of leadership challenges and solutions continue to be firmly situated in management problem-solving and decision-making scenarios.
Balance experiential learning. The research indicates that the challenge of codifying and translating management knowledge leads to an over-reliance on experience and localised, situated knowledge and/or a tendency to privilege other forms of knowledge, such as clinical or financial. The evidence underlines the value of networks and other social modes of engagement to overcome these epistemic boundaries and assist the circulation of knowledge.
Training and development programmes provided at trust level need to ensure a balance of emphasis on learning from experience with the use of more codified systems of knowledge that can effectively challenge received wisdom and accepted practices.
Trusts need to be aware of the need to capture and share knowledge and learning that may be localised in specific parts of the organisation (e.g. tender bidding skills), such knowledge may be particularly important to generalise across trusts in the light of recent changes to the organisation of primary, secondary and tertiary health-care provision.
Facilitate clinical–managerial relations. The challenge of managing the relationship between clinical and managerial communities is pervasive across health-care organisations. Our trusts each adopted distinct structural, relational or personally embodied means to manage this relationship, each reflecting their organisational contexts. The research suggests that there is no universal solution and that trusts need to tailor their approaches to manage this divide.
Trusts need to carefully consider how they attempt to bridge the clinical–managerial divide and tailor their approaches to achieving this to match the specific context of interaction (e.g. by combining structural adjustments with the relational skills of key individuals for whom status differentials are high, or by relying on embodied experience when there is more of a blending of clinical and managerial orientations).
National leadership programmes should be considered as an opportunity for cultivating networked interaction between distinct types of managerial groups (especially clinical and general). This approach would encourage development of shared perspectives between the CoPs on the use and application of specific types of managerial knowledge.
There may also be opportunities for trusts to develop mechanisms for such networked interaction focused on management issues and solutions at a more local level, provided that they occur away from immediate operational pressures. Such initiatives may be particularly important in the context of significant recent changes in the relationship between secondary and primary care.
Enable reflective learning. In the light of the evidence on translation gaps in health-care organisations, our research suggests that receptivity to management knowledge, and the innovative or creative use of this knowledge, is enhanced by training and development that allows space and time for reflection and knowledge translation. This applies across all managerial groups, but especially to general managers.
Middle managers, especially those in general management positions, need more access to leadership development and training opportunities that are better synchronised with the demands of their role and the stage of their career. There is currently a gap in the more strategic (as opposed to operational) training opportunities that tie in with middle managers’ needs.
Wider (national) leadership training programmes can help bridge that gap, provided that the knowledge base they impart (e.g. lean thinking, strategic analysis) is not abstracted from health-care practice but used instead in a more heuristic way to inform analysis of health-care management problems.
Trusts also need to find ways of giving middle managers time out from busy schedules to take up any opportunities afforded by more advanced training and development programmes that are based on such reflective learning processes.
Encourage strong network ties. The research indicates that networking for knowledge acquisition/sharing, support, career development and influence are closely inter-related. Therefore, recognition of the embeddedness of knowledge processes in social networks points to the importance of supporting the formation of strong network ties to enhance knowledge sharing and learning.
Opportunities provided for networking through national leadership development programmes are recognised as valuable but can also be sporadic or limited in their availability. More could be done to encourage continued interaction through these networks at a regional or local level following core programme activities.
Recognition needs to be given (in national and more local training programmes) to the importance and benefits of both formal and informal networks of interaction as sources of knowledge and support for managers and how specific mechanisms for middle managers may help significantly (e.g. mentoring).
Extend general management networks. Given the evidence pertaining to isolation and inward-looking tendencies among general management groups in health care, trusts may consider the advantages of providing greater opportunities for internal and external networking to assist knowledge sharing and learning.
Initiatives at national, regional or individual trust level need to recognise that networked interaction among managers, when it occurs, does so largely within the distinct CoPs associated with general, clinical and functional managerial groups (as opposed to there being one distinct and coherent CoP).
External (regional, area) networks of managers could be actively cultivated (either by individual trusts or through intertrust collaboration). These external networks should be focused on particular knowledge and learning themes (e.g. aspects of management best practice), as opposed to being driven primarily by operational requirements.
Trusts that are highly differentiated (geographically, organisationally, professionally) may benefit particularly from taking their own internal networking initiatives that have the dual advantage of helping managers share best practice as well as improving organisational integration.
Trusts faced with recent challenges associated with changes in secondary/primary care may find managerial networking of increased relevance and importance to the achievement of their goals.
Strengthen professional communities of practice through leadership development. The research underlines the challenges posed by the extreme diversity of managers’ responsibilities and skills owing to task and organisational differentiation and the fragmentation this creates within managerial CoPs. This supports the value of a widely available management and leadership development programme that meets the needs of the whole spread of middle managers more effectively.
National leadership development programmes should continue to build on the networking opportunities they offer and networking skill development they aspire to provide.
In addition, such programmes should also build on the potential they offer for greater collective development and further institutionalisation of a distinct body of health-care management knowledge and practice.