Marianna Fotaki

The recent turn to Lacan’s work in critically-oriented Organization and Management Theory signals a welcome focus on one of the 20th century’s most influential thinkers. This article introduces Lacan’s thesis on gender, making a case for its importance for understanding organizations. We discuss two contrasting receptions to Lacan’s Seminar XX, from pro- and anti-Lacanian feminists, offer our own interpretation which can be summed up as a Lacanian inspired parody of the phallic signifier, and argue that Lacanian theorists should turn Lacan’s ideas back upon them/ourselves to question critically our own positions. Further we review Lacan’s seminar XVII and its analysis of four dominant discourses—the university, the master, the hysteric and the analyst. The advantages of the discourse of the hysteric for a Lacanian politics of gender, enabling us to undo our arguments from outside of our own gender and identity, are then identified. We thus advocate conceptual and empathetic (hysterical) bisexuality for critical scholarship within organization studies that already, perhaps unawares, is hysterical. This allows us to avoid, as much as possible, slipping into the frozen and sterile discourse of the master.

Although it is widely accepted that public policies are difficult to implement, most analyses of policy failures are conceived of as predominantly rational processes. This article questions that assumption by introducing ideas of a desiring subject and socio-symbolic order drawn from Lacanian psychoanalytic theory to suggest that public policies are also a product of social fantasy, and to draw attention to the implications of this unrecognized function of policy-making. It also employs the idea of defensive splitting borrowed from Kleinian object relations theory to explain the difficulty of translating policy into public organizations, which have to perform often conflicting societal tasks. The example of patient choice in the UK National Health Service (the NHS) is used to illustrate theoretical arguments and to propose an alternative understanding of public policy-making by way of bridging fantasy with reality.

Choice and competition have been phased into many public health systems with the aim of achieving various and potentially exclusive goals such as improving efficiency, quality and responsiveness to users’ needs. Yet their use to promote equity of access as evidenced recently in the British National Health Service (the NHS) is unprecedented. Giving users the power of exit over unresponsive providers is meant to address the failures of previous policies. This paper shows that there is a potential conflict between choice and equity, in terms of both the values and the outcomes each policy is likely to produce. Using a multidisciplinary and multidimensional framework, drawn from Bourdieusian sociology, feminist theory and economics, the study highlights the implications of the simplistic and one‐sided conception of individual patient choice in relation to equity. It also uses the existing evidence on the impact of market competition and choice, in the UK and elsewhere, to emphasise the importance of socio‐economic and psycho‐social factors, which are left out of current policy considerations.

Objectives To assess the demand for, and likely impact of, increasing patient choice in health care. The study examined whether patients would like to exercise choice of hospital, primary care provider and treatment, and investigated the likely impact of policies designed to increase choice on equity of access, and on the efficiency and quality of service delivery. Method Theory-based literature review including an analysis of the intended and unintended impact of choice-related policies in health care in the UK, European Union and USA. Selected papers focused not only on offering choice to individual patients but also evidence of the impact of choice by patients' agents such as GPs, and on the impact of introducing choice in education and social services. Results Choosing between hospitals or primary care providers is not currently a high priority for the public, except where local services are poor, e.g. they have long waiting times and where individual patients' circumstances do not limit their ability to travel. When patients become ill, they are increasingly likely to wish to rely on a trusted health practitioner to choose their treatment. Better educated populations make greater use of information and are more likely to exercise choice in health care. The increase in inequality which this could produce might be reduced by specific provision of information and help, enabling less advantaged populations to make choices about health care. There was little evidence in the literature that providing greater choice will in itself improve efficiency or quality of care. Conclusion Although patients may themselves make limited use of choices, the existence of choice may, in theory, stimulate providers to improve quality of care. Patients do, however, want to be more involved in individual decisions about their own treatment, and generally participate much less in these decisions than they would wish.

Patient choice is at the forefront of the debate about the future of healthcare provision in many industrialized countries. It is argued that understanding the complexities and the multiple consequences involved in implementing individual patient choice in public health systems calls for an analytic framework extending beyond economic determinism and positivist social science paradigms. This study applies psychoanalytic concepts to illuminate policy dynamics and limitations, using the example of patient choice in the English NHS. It separates declared from unexpressed policy goals theorizing on the role of imaginary institutions and their defensive and less obvious functions in society, and reflects on the implications of policies that are formulated at a distance from operational reality on healthcare organizations. By focusing on the deeper primitive anxieties that are evoked and enacted in patient–doctor interactions, this article examines opportunities and limitations involved in developing individual patient choice.