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V. 37, No. 7, DECEMBER 2003, . 742 755

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Mergers and Acquisitions in the Private Sector: What Are

the Lessons for Health and Social Services?
Janet Field and Edward Peck

Abstract
In seeking a more seamless provision of health and social care, the government is promoting the
merger of the functions of primary and community health services and social services. In the private
sector, mergers have been commonplace. The primary aim of this paper is to identify the key
concepts and explanatory frameworks in the literature on mergers and acquisitions in the private
sector that are relevant to the development of new organizational structures in health and social
care. The evidence suggests that it is difficult to merge two organizations successfully. Reasons for
this are explored and the implications for health and social care mergers drawn out.

Keywords
Primary health services; Community services; Mergers; Private sector
Introduction
For several decades, politicians concerned about the lack of coordination
between NHS health care and local authority social care provision for clients
receiving community care services have been issuing regular exhortations
to encourage collaboration (e.g. DHSS ; DoH ) and attempting
structural innovations to enhance partnership such as the joint planning
arrangements introduced in the s. These exhortations and innovations
have met with limited success; for instance, Hunter and Wistow (: )
conclude that joint planning was marked by two features: the establishment
of substantial amounts of formal planning machinery, and widespread agreement that such machinery had failed to deliver the goods. This failure has
been blamed on a range of factors: professional and cultural differences,
disparate organizational structures, and divergent service objectives.
None the less, the current government is showing considerable resolve in
its determination to address this lack of coordination. Initially, Partnership in
Address for correspondence: Dr Janet Field, Institute for Applied Health and Social Policy, Kings
College London, Fifth Floor, Waterloo Bridge Wing, Franklin Wilkins Building, Stamford Street, London,
SE NN. E-mail: J.E.Field@btinternet.com
Blackwell Publishing Ltd. , Garsington Road, Oxford OX DQ , UK and
Main Street, Malden, MA , USA

Action (DoH ) offered new flexibilities around commissioning and the

provision of health and social services, for example the power to pool funds.
The necessary legislation was enacted in the Health Act , but the takeup of these flexibilities was slow. Undaunted, the strategy for advancing
joined-up service provision was further promoted by The NHS Plan (DoH
) in which the government introduced the concept of a care trust, a
new NHS organizational structure that would be able to commission and
provide primary and community health care as well as social care. At first,
the government proposed to give itself powers to impose care trust arrangements on localities perceived not to be pursuing partnership with sufficient
enthusiasm, although this was removed from the NHS and Social Care Act
() following pressure from local authority interests. The first care trusts
appeared in the summer of .
The creation of a care trust constitutes a merger of NHS health care and
local authority social care functions into one statutory body based on the
NHS trust model. This has led to suspicions that the NHS is acquiring social
care. In the private business world, new organizational forms are constantly
being created as a result of mergers, acquisitions and take-overs. This raises
the question: what can public services learn from the business arena about new
organizations created by mergers that is relevant to the changes now taking
place in health and social care? Or more specifically, from an academic
perspective, what are the key concepts and explanatory frameworks in the
world of mergers and acquisitions? Can these concepts and frameworks be
applied to the creation of new organizational structures in health and social
care? What are the implications for how we assess the progress, the success
or failure of these new organizations?
The literature on mergers and acquisitions is vast. A simple electronic
database search of the Web of Science, Institute for Social Scientific Information Citation Database, using the term mergers yielded almost
references for the period to . As a consequence, the review of the
literature undertaken for this paper has been essentially purposive in nature.
Articles have been examined and included if they introduce a new concept
or explanatory framework or if they support, or challenge, an existing one.
The intention is to identify ideas in one area of intellectual endeavour, i.e.
the theoretical analysis of private-sector mergers and acquisitions, that can
potentially be applied fruitfully to the process of merging health and social
care agencies.

Mergers Dont Work

One of the key messages in the literature on mergers is that they have
happened at an astonishing pace despite the fact that they do not appear to be
beneficial when judged on economic criteria (Carey et al. ; Kroll ;
Brouthers et al. ; Coopers and Lybrand ). Neo-classical economic
theory dictates that the primary purpose of a merger between two companies
is to deliver increased shareholder wealth. Successive surveys have demonstrated that, for the firms making acquisitions, the effect on shareholder
value is neutral or negative. These effects are similar whether the appraisal
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is made at the time of merger, one year later or five years later. It is frequently
the shareholders in the company being acquired that experience an increase
in shareholder value, albeit this is a temporary phenomenon that takes place
during the bidding stage of the acquisition process. Perhaps a simplistic
economic analysis of mergers does not reveal the subtle complexities of
business strategy and long-term market position, as suggested by Brouthers
et al. (). Unfortunately, surveys of company executives with acquisition
experience largely support the evidence delivered by the balance sheet; for
instance, Coopers and Lybrand () reported that per cent of acquisitions
were regarded as failures. Causes of failure were the attitudes and competence
of the target companys management, a lack of post-integration planning,
and a lack of knowledge of the target industry. If it is so difficult to merge
companies and make a profit, why do mergers continue to be so popular?

What Propels Mergers?

The rationalist view dictates that the merger of two companies is undertaken
to achieve one or more strategic objectives in the business plan of the acquiring
company. These strategic objectives may relate to the intention to increase
market share or to extend the companys activities into new geographical
areas. The objectives may also relate to the intention to expand the range of
products or services that the acquiring company offers or the intention to
develop new products or services that require the skills or infrastructure of
both of the merged companies. But many business objectives can potentially
be delivered by the creation of strategic alliances, or by the expansion and
diversification of the company rather than by merger. The bottom line is that
a merger must achieve added value. However, the potential gains and
losses from merger activity may be very different for the various stakeholders
in a company. What is in the best interests of the managers of a company
may not correspond with the best interests of the shareholders. What is
advantageous for the managers and shareholders may not be in the best
interests of a substantial number of employees. What is in the best interests
of the stakeholders in the acquiring firm may not be in the best interests of
the stakeholders in the company being acquired.
Managers in large companies wield considerable power and may have
their own motives for advocating merger activity. For many managers the
opportunity to increase their power, status and salary will be a function of
the size of the company and thus they may have a vested interest in empirebuilding. Increased company size may allow some managers to make greater
use of their managerial skills, delivering greater self-fulfilment. To be the
hunter rather than the hunted may also fuel merger activity, in that the
managers of the acquiring firm will have a greater sense of job security. In
large corporations, the role of monitoring senior management is the responsibility of the non-executive directors. But these controls can be weak as a
result of biased appointments, or an inadequate or incomplete flow of strategic
information. Sudarsanam () views the growth of shareholder activism in
the United States in the s as a direct response to the perceived inability
or ineffectiveness of non-executive directors to curb managerial excess.

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Fads and fashions in what is considered to be effective business strategy may

also play a role in promoting merger and acquisition behaviour (Abrahamson
). At any point in time, the modus operandi of the perceived market leaders
is likely to be copied by other organizations in the belief that this is the most
effective way of operating. Management consultants play an important part in
the packaging and promotion of fads and fashions within the business communities. Fads and fashions can be conceptualized as powerful rhetorics that
can shape management practice. To date, however, the theoretical analysis of
fads and fashions has focused on the strategies of the fashion supplier, rather
than on the processes whereby heterogeneous groups of actors adopt and interpret these rhetorics in their own specific circumstances (Newell et al. ).
In the main, the general body of literature on mergers and acquisitions
is relatively weak on theoretical frameworks to explain merger activity. In
instances in which researchers or commentators attempt more detailed
explanatory frameworks they usually invoke sociological models of organizations and organizational change. Typical of this approach is a critical review
of recent literature on the United States health care market undertaken by
Wells and Banaszak-Holl (). This market has seen considerable restructuring throughout the s and into the early years of this century. Large
numbers of health care organizations have merged. Much of this activity has
been prompted by health care insurers seeking more efficient and cheaper
sources of health care for their clients. The rich literature focuses primarily
on economic analysis of the outcomes of this merger activity; in other words,
which companies, if any, have seen an increase in shareholder value? Wells
and Banaszak-Holl conclude that greater use needs to be made of sociological models to adequately explain the observed merger activity. Regarding
acquisition motives and the forces propelling companies towards merger,
they suggest that institutional theory, organizational ecology and the social
movements literature may all offer relevant accounts.
Tolbert and Zucker () argue that there are three stages to the institutionalization of a new organizational form. Initially, patterns of response
emerge to deal with existing problemsthis is the habitualization of a new
organizational form. As these responses are formally recognized and given
legitimacy, objectification takes place. The final stage in the life cycle of an
organizational form is sedimentation. In essence, institutional theory
suggests that decision-makers will be substantially influenced by the accepted
way of doing things while also recognizing that this is constantly subject to
evolution. Organizational ecology looks at the way that organizations change
in response to a changing operating environment (Baum ). Wells and
Banaszak-Holl also suggest that social movements may play a role in determining the shape of organizational structures for delivering health care in
America. Social movements that attract counter-movements are those that
are powerful enough to threaten other peoples interests but not strong
enough to win the battle (Meyer and Staggenborg ). The implication of
social movements theory is that it is only when an organizational form is
beginning to become successful that it will receive opposition from other
groups. The merger of organizations can enable the philosophy of the
dominant organization to supplant that of the weaker one.
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Each of these explanatory frameworks emphasizes historical perspective in

understanding organizational change and indicates a need to take a longitudinal perspective rather than use only cross-sectional techniques or shortterm studies. The next section provides a broad overview of the sociological
models that can be used to explain aspects of the merger process and their
implications for organizational structure and functioning.

Theoretical Frameworks
Wells and Banaszak-Holl () use a variety of theoretical viewpoints in
attempting to explain merger activity in the American health care market.
Using Reeds analysis (), these theoretical frameworks can be loosely
grouped as in table . The frameworks help organize how merger activity is
conceptualized and in understanding the driving forces determining mergers
and the shape of new organizations.
Systems theories view organizational structures as largely predetermined
by a range of external or internal factors. An organization will acquire
characteristics that are a function of its sheer size and the extent to which tasks
to be carried out by its employees are prescribed (Pugh ). Merger activity
will reflect broader changes within the operating environment that favour
some organizational forms over others (Hannan and Freeman ). External
regulation is an important factor in shaping the operating environment and
thus merger activity and organizational forms. The influence of government,
a key external factor, will be central to the reformulation of relationships
between health and social care organizations at a local level. But this theoretical position also implies that the emergent forms of new health and social
care organizations will mirror those of comparable service industries.
Symbolic interactionists (Friedson ) and ethnomethodologists
(Hassard ) understand organizational structures largely as the outcome
of patterns of negotiation between individuals within that organization. This
position suggests that the form and function of new health and social care
organizations created by merger activity will be affected by horse-trading
between senior managers and board members who seek to maximize their
gains and minimize their losses.
Table
Key theoretical groupings in organization theory
Key theoretical groupings

Organizational structure is a function of:

Systems theories
Symbolic interactionists/
ethnomethodologists
Labour process theorists/
post-structuralists
Institutional theorists

a range of internal and external factors

patterns of negotiation between individuals

power struggles between various professional,
managerial and political groups
culture/value systems, norms and beliefs
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The labour process theorists (Knights and Willmott ) and poststructuralists (Giddens ) describe the distribution of power between
different groups as a determinant of organizational structure. Their theoretical position suggests that the structure of new health and social services
organizations will be a product of the power struggles between the various
professional, managerial and political groups.
Institutional theorists see culture as the primary factor in determining the
nature of organizations (Meyer and Rowan ). The structure and modus
operandi of the organization will reflect the value systems, norms and beliefs
that have developed within that organization. Theoretical perspectives that
highlight the role of culture also acknowledge that cultures evolve and change
due to a range of factors that can be either internal or external to the organization. New health and social care organizations formed by merger will
initially reflect the culture of the pre-merger organizations until such time as
these cultures have merged or one has become dominant. Incompatible
organizational cultures emerge as a significant factor in the literature exploring the reasons for the poor performance of merged companies.
Lastly, it is important to reflect briefly on these different theoretical
accounts in the light of another conceptual schema: post-modernism. Postmodernism rejects meta-narratives in favour of an exploration of the interplay
of multiple narratives, where power and knowledge are seen as being intertwined and where ambivalence and diversity are celebrated (Hassard and
Parker ). This suggests that all of the perspectives outlined above may
have explanatory potential in relation to mergers, albeit they may illuminate
different aspects of the phenomenon at different levels of analysis, from the
individual through the organizational to the environmental.

What Is Going Wrong?

Sociological frameworks may provide useful analytical tools, but there is little
evidence that they are consciously used by senior managers when devising
their business strategies. From their perspective, if there is a high failure rate
for mergers, there must be something going seriously wrong with either the
strategic planning for, or the implementation of, the merger.
Haspeslagh and Jemison () suggest that there is a need to adopt an
organizational process perspective at both the pre-acquisition and postacquisition stages of the merger. They draw a distinction between the
rationalist and the organizational process view of acquisitions and argue
that too much emphasis has been placed on the conventional rationalist
approach that views merger activity as the pursuit of logically derived strategic
goals and sources of value gains. The rationalist view of mergers fails to take
into account all the sources of conflict that will impinge on both the acquisition decision and the implementation of the merger. The organizational
process perspective sees the organizational context as critical throughout the
acquisition process. Haspeslagh and Jemison identify four significant factors
in the decision-making process that introduce uncertainty or discord: firstly,
the differing perspectives on the acquisition held by different managers;
secondly, the escalating momentum that can occur in the decision-making
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process; thirdly, ambiguous expectations of the benefits; and, fourth, different

motives for the acquisition. The process of selling the merger plan to
various key players during the decision-making process can result in conflicting priorities and claims on resources in the post-acquisition stage. In their
review of American health care mergers Wells and Banaszak-Holl ()
similarly argue that the speed of change, the sequence of events, patterns of
communication and resistance by the people affected can all influence how
amalgamation evolves.
In exploring the post-acquisition integration process, Haspeslagh and
Jemison () draw attention to the trade-off between the need for strategic
interdependence between the two companies and the need for organizational
autonomy. They argue that if the need for strategic interdependence is low
and the need for organizational autonomy is high, both companies will be
preserved. If the need for strategic interdependence is high and the need for
organizational autonomy is low, there will be full absorption of the two
companies. If the need for both strategic interdependence and organizational
autonomy is high then symbiosis should result whereby the boundary
between the two companies is both protected and permeable. In the merger
of health and social care organizations there is likely to be a need for a high
degree of strategic interdependence. However, there may be less consensus
about the need for a high degree of organizational autonomy. Such autonomy
is likely to be an important factor in preserving the philosophy underpinning
the provision of social care services, but this view may not be shared by
health care organizations.
Cartwright and Cooper (, ) have focused attention on the cultural
characteristics of companies and how these affect the outcomes of merger
activity. The term culture refers to collective beliefs and ideology, commonly
accepted ways of doing things, and the myths and rituals of the organization.
The degree of cultural fit can be critical in determining the outcome of the
merger. A poor cultural fit can create considerable stress and result in staff
experiencing a loss of morale, and of commitment. While some commentators doubt whether organizational cultures are amenable to management
manipulation (Willmott ), there is clearly a need for merging health and
social care organizations to pay at least as much attention to these issues as
to structural form.

How to Make Mergers Work

There is no shortage of books (Feldman and Spratt ; Marks and Mirvis
), booklets (Health Education Authority ), and articles (Carey et al.
; Kroll ; Bramson ; DiFonzo and Bordia ) delivering
advice on how to achieve a successful merger of companies or organizations.
The central themes in this literature are: good management, especially in
facilitating transitional structures; paying adequate attention to cultural
differences between the two organizations; establishing clear, consistent and
frequent communication about change; and keeping the human resources
dimension central throughout the merger process. These themes are consistent with the main concerns expressed by employees of NHS organizations

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undergoing change (Caspe Healthcare Knowledge Systems ; Bevan

and Seccombe ). Staff want managers to communicate openly, to be
sensitive to employees concerns, to provide clear information about changes
in the running of the organization, to help staff deal with stress, and to
provide better information about changes in the NHS (Health Education
Authority ). Adequately responding to these staff concerns appears to
be a critical determinant of whether or not the merger is a success or
failure. Devine and Hirsch () show that the behaviour of managers is
important in determining how well staff adjust to change. They highlight
the way in which staff experience stress and anxiety during major change
and the need for staff to be supported throughout the transition. Devine and
Hirsch also identify culture clashes between the two merging organizations
as inevitable; if this is not appropriately dealt with it becomes the main cause
of failure.
Marks and Mirvis () emphasize the importance of temporary transition structures created specifically for the purpose of managing the merger
process. These transition structures should exist for between three and six
months and should focus on the integration process. The transition team will
consist of managers who support the coordination of a range of functions,
usually by steering the work of a number of taskforces consisting of managers
and professionals from both organizations who study integration options and
make recommendations.
Tetenbaum () advocates a detailed audit of the cultures of the two
organizations prior to merger. She produces examples of the types of questions that should be asked as part of this audit; for example, what does the
company value? what gets celebrated? what gets rewarded? how is leadership
expressed? how does the company handle conflict? how does it handle
decision-making? what are the interactions like? how is work monitored?
how are people held accountable? A key task for the integration team is to
create a new cultural identity for the merged organization, that is, a new set
of values, norms, beliefs and behaviours. These must be consistent with the
strategic goals of the new organization and promoted throughout the new
organization. Tetenbaum notes that any organization can expect to see a
to per cent drop in productivity while it is undergoing large-scale change
and emphasizes the importance of clear and consistent information flows to
staff to minimize the negative effects of change on motivation levels.
Very little of the literature delivering advice and guidance on achieving
successful mergers is written specifically for the public sector. In Healthy Ever
After? Supporting Staff through Merger and Beyond, the Health Education Authority
() made a valiant attempt to draw together research findings and
consultancy advice from the business world and apply it to merger activity
in the NHS. The Nuffield Institutes Partnership Assessment Tool (Hardy
et al. ) is an attempt to generate an instrument that can be used to both
anticipate and address the barriers to joint working in a range of new
structures. In its design it appears to draw heavily on the literature that has
been amassed over the years describing the pitfalls of collaboration between
health and social services, but no attempt appears to have been made to
incorporate lessons from the world of business.
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Current Research on New Organizational Structures in

Health and Social Care
To what extent have research findings, key concepts, or explanatory
frameworks from the business arena been applied to the exploration of new
organizational structures emerging in the world of health and social care?
The answer is: only to a very limited degree.
The late s saw considerable merger activity between NHS trusts, and
some research explored this process. Goddard and Ferguson () reviewed
the findings from mergers in the NHS at a time when government policy
viewed NHS trusts as competitive provider units that could merge to remove
excess capacity in the market and to provide economies of scale. Reflecting
this agenda, Goddard and Ferguson focus their analysis on economic
considerations and conclude that predicted efficiency gains of mergers do
not always appear and that unexpected costs often arose. These conclusions
mirror the general findings from the world of business that mergers habitually
do not deliver the financial benefits that were predicted. Bojke and colleagues
() explore the outcome of primary care group mergers and conclude that
there is no evidence to suggest that economies of scale can be produced by
PCGs serving a population of more than , people. Haigh ()
explores the merger process between three NHS trusts using in-depth interviews with senior managers and board members and finds that merger was
considered by most participants not to have been the best vehicle to achieve
change. These views echo those of managers in company mergers. Peck and
Hills () monitored the emerging provider arrangements for the delivery
of mental health services in the NHS during by reviewing documents
relating to the proposed reconfiguration of mental health services in
England. They note that none cite any evidence in support of the benefits
that are alleged to accrue from the proposed reconfiguration. Radically
different reconfiguration proposals claim the same benefits.
The Local Government Association () revealed that over per cent
of local authorities were actively pursuing partnership arrangements with
their health colleagues in that year. Yet the application of key concepts and
research findings from the world of business to the exploration of new joint
health and social care organizations appears to be almost virgin territory.
In the most detailed study to date, Gulliver and colleagues () report an
evaluation of a mental health NHS trust that merged health and social care
provision in . To some extent, the findings reflect the familiar patterns
reported from company mergers, notably that service users find no improvement in service satisfaction and staff morale decreased immediately after the
merger. Although senior managers noted that the creation of the trust, and
joint health and social care commissioning arrangements, had led to mental
health services receiving more favourable financial settlements than might
otherwise have been the case, the underlying financial pressures, which had
been one factor prompting the innovation, were no less severe months later.
To a significant extent, the focus of the implementation became the creation
of the merged organization, with other objectives being overlooked. However,
the two major parallel mergers involved, of providing and commissioning,

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did not reduce the quality of services provided. To some extent this achievement reflected continuity within the system: continuity of decision-making
within the commissioning board; continuity of personnel in the locality and
of team management within the trust; and continuity of professionals in the
system. It was the new elements, in particular the combined trust and the
multidisciplinary community teams within that trust, which struggled most
to establish identities. Organizational culture emerged as a key explanatory
concept (Peck et al. ). The evidence indicated that far from achieving the
local aspiration for a shared culture, the anxieties of some groups of staff
were leading to more pronounced professional boundaries within the new
organization. At the management level there appeared to be ambiguity
regarding the outcome that was being soughtwhether to achieve one new
culture through the merger of elements or to maintain and enhance the
existing professional cultures by increased mutual understanding and respect.
In Northern Ireland, social services and health functions have combined
for almost three decades within the integrated structure of health boards and
trusts. The evidence suggests that far from the creation of a seamless, joinedup service, community care service provision suffers from the same difficulties
as in mainland Britain. The Social Service Inspectorate () reported in
Northern Ireland serious deficiencies including delayed discharges from
hospital, waiting lists for day care and respite care, inappropriate placements
in residential care and variations across boards and trusts in their eligibility
criteria and charging policies. These are typical of the range of problems that
in England the Department of Health asserts will be resolved by the creation
of new organizational structures such as care trusts. A paper challenging
the evidence for care trusts (Henwood and Hudson ), commissioned
by the National Association of Directors of Social Services, was particularly
scathing about the reliance on the example of Northern Ireland.
Ferlie (), anticipating another argument used by Henwood and Hudson
(), argues that much of the literature on large-scale restructuring programmes in health care remains conceptually naive. The term reform is
value-laden and used by politicians as a rhetorical device to promote change,
much as shared culture was used by managers in the study by Peck et al. ().
Programmes of reform frequently fail to deliver the expected benefits, and
shortcomings are usually explained as resulting from deficits in the implementation process rather than shortcomings in the policy itself. Reflecting
writings about policy implementation that date back to the classic study of
Pressman and Wildavsky () of the Oakland project, Ferlie argues that, to
understand the reasons for implementation deficits, greater attention must be
paid to the behavioural, cultural and political aspects of health care organizations. Equally, reforms that are intended to change professional practice are
more likely to succeed if they receive active professional support and leadership.

Conclusion: The Implications for New Organizational

Structures in Health and Social Care
The central thrust of this paper has been to identify lessons for new organizational structures in health and social services that can be drawn from the
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literature on mergers and acquisitions in the private sector. The experience

of company mergers suggests what to expect when health and social care
organizations merge: that is, strategic objectives are rarely achieved; financial
savings are rarely attained; productivity initially drops; staff morale deteriorates; and there is considerable anxiety and stress among the workforce. The
only study to date of a health and social care merger confirms these findings,
with issues around culture playing the central role (Gulliver et al. ). The
correlation between this study and private-sector accounts of mergers is
potentially important in establishing a link between health and social care
mergers, currently consensual and inevitably horizontal, with those in the
private sector which are more varied in nature.
The business world delivers plenty of good advice on how to manage the
merger process, especially from the human resources angle. There is limited
evidence that the advice is heeded in the public sector. Indeed in the locality
studied by Gulliver et al. () it was not. In terms of understanding what
propels mergers, and what happens during the merger process, the empirical
accounts and theoretical explanations introduced in this paper indicate that
particular attention needs to be paid to: the roles played by individuals,
especially senior managers, non-executive directors and elected members;
the roles played by professional groups; and the role of organizational cultures.
It appears very likely that the how to do mergers texts cited in this paper do
contain some wisdom from which health and social care managers should draw.
Of course, it would be unwise to overstate the points of comparison between
the private sector and the health and social care organizations. Perhaps the
most important difference is the regulatory framework within which the merged
organizations operate. For many private-sector companies, proposals for merger
and performance post-merger are to a very large extent, notwithstanding any
formal regulatory framework, the responsibility of senior managers, the corporate board, and, often to a lesser extent, shareholders. In contrast, the pressure
for mergers in health and social care is primarily driven by Department of
Health policy. Furthermore, proposals for the creation of a care trust must be
the subject of consultation with the local community and staff, and scrutinized
and approved, or otherwise, by a number of different government agencies. The
performance of the merged agency will also be closely monitored, arguably
more so now than at any point in the history of health and social care (Peck ).
It would perhaps be unrealistic to expect any health and social care
managers involved in a merger to draw upon all the sources of evidence
brought together in this paper. It is surely important, none the less, for them
to be familiar with the broad messages in the merger literature so that they are
aware of what they are accepting and rejecting. From a research perspective,
however, there is a strong case for more studies of these new organizational
forms and the use of a wider range of theories to interpret the data.

Acknowledgements
The authors would like to acknowledge the financial support of Westminster
Health Care and Priory Healthcare for Dr Fields post. Dr Perri made
helpful comments on an earlier draft.

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