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We assume “Imaginary worlds” to be unreal and unfamiliar: high fantasy. I argue they are real and familiar to authors because they comprise memory elements, which blend experience, knowledge, beliefs and pre-occupations. These “bits and pieces” from memories can generate a world, which readers experience as pure imagination. I illustrate using J.M. Barrie's “Never Land” and J.R.R. Tolkien's “Middle-Earth.”

Purpose The purpose of this paper is to investigate the intricate ways in which accounting is implicated in the unfolding of strategizing in a pluralistic setting. The authors treat strategizing as a practical coping mechanism which begins in response to a problem and unfolds over time into an episode. This approach enables the authors to explore strategizing pathways and the ways they can mobilise accounting to advance from practical coping to explicit strategic intent. Design/methodology/approach The authors conducted semi-structured interviews with Clinical Directors, Business Managers and Finance personnel at three NHS hospitals. Documents were also collected, such as business cases and financial reports. The authors employed theories on strategizing agency, episodes and practical coping to select examples of strategizing and indicate how strategizing is constructed and performed. The authors present the results of this qualitative analysis in three strategizing narratives. Findings The analysis highlights how Clinical Directors’ strategizing with accounting, in response to their financial problems, can take on contesting, conforming and circumventing modes. As the strategizing pathway unfolds, accounting acts as an obligatory passage point through which Clinical Directors pursue their strategic intent. Along each pathway the authors identify, first, where practical coping takes on a clear strategic intent and, second, whether this emergent strategy proves efficacious. Originality/value The authors contribute to the nascent body of accounting and strategizing studies through seeing strategizing with accounting, not as the formulation of explicit organisational strategy as “done” in board rooms and strategy meetings, but as an impromptu response to a critical financial problem within a localised organisational setting. In response to a problem, actors may realise their immanent strategizing through their engagement with accounting practices.

Hospitals create public Vvalue creation happens when hospitals provide new services are provided or clinicians deliver existing services in better or more cost efficient ways. On the other hand, according to Mazzucato, those who deliver healthcare can extract financial value from the system. Cost-based prices are now potent measures of financial value for profit centres in English hospitals. Here, we focus on the ramifications of these cost-based prices for creating or extracting value at three different levels in the health care system. Our empirical data is drawn from: first, semi-structured interviews with Clinical Directors who head up profit centres in English hospitals; and, second, documentary sources which reveal how accounting drives costing for health treatments. From thesies data sources we identify three valuing activities which mobilise cost-based prices: “bubble” charts; “up-coding” and business cases in the context of a joint venture. We conclude that cost-based pricing can creates public value because it incentivizes clinical activity and can be used to enhance health care quality. But the traditional accounting mode for cost-based pricing advantages standardised care while disadvantaging complex care, this generates opportunities for value extraction for those, including some private sector providers, who deliver standardised care. Our analysis focus encompasses three different levels: the profit centre based on a specialty, the hospital and the entire health care system. This broad appraisal reveals that value creation at the level of the individual profit centre can become value extraction for the hospital and the health care system as a whole.

Freud famously thought dreams to be the ‘royal road’ to the unconscious. Do retained dream associations, which depict a probabilistic pattern inherent in experience, drive unconscious decision making and consequent action? This chapter focuses on this question. I argue that, across evolutionary time, retained dream images prompted unconscious decision making and action, archetypically, to approach or avoid the waterhole. Unconscious decisions may still drive our decisions and actions but, perhaps surprisingly, only when the decision is complex, with several things to be taken into account. When the decision is simple, with few variables, conscious decisions are best.

What is a dream? I think a dream identifies a complex pattern in experience and portrays this in a dream image. In other words, I argue for a complex pattern identification theory of dreaming. We can detect complex patterns in wake too, but our thought is convergent, sequential, and driven by more obvious associations, whereas, during dreaming, we see less obvious associations because we think in a divergent way. This chapter covers why, in our evolutionary past, we needed to detect complex, non-obvious, divergent patterns, and begins to explain why the dreaming state evolved to do this. I think complex pattern identification occurs during rapid eye movement (REM) sleep, with the pattern visualized in a REM dream.

My argument is that dreaming depicts complex patterns but not ones we have actually experienced because a dream is composed of elements from different experiences. Consequently, dreams reveal hidden patterns in our experience. These complex patterns are associative. Associations create meaning. So dreams will reveal personal meanings we have forged through experience but weren’t aware of during wake. Dream associations are non-obvious. We need insight to detect complex, non-obvious patterns. Since Freud we think of this insight as dream interpretation we undertake during wake. But there is also experimental evidence that we have better insight into complex patterns during sleep, as compared with wake.

The previous chapter argues that creative people are in a hybrid, disordered state in-between dreaming and wake. In this chapter I propose that if this in-between, de-differentiated state becomes more severe and enduring, psychiatric disorders will result. De-differentiation of wake and dreaming has two sides: dreaming suffuses wake and wake permeates dreaming. The idea that madness results from dreaming invading wake is of long standing. So is the notion that highly creative people are somewhat crazy. But the conception of a wake-like state pervading dreaming hasn’t been explored. Chaos theory delineates the dynamics of de-differentiation, disorder, and madness. Madness is defined as mistaking a complex non-obvious pattern in your experience for your experience.

In this chapter we look at why we make non-obvious associations in dreams. Perhaps surprisingly, I argue the ability to recognize complex patterns in past experience, and portray them in dream images, was much more important for early humans than it is now—back then we dreamed to survive. I argue we retained dream images at an unconscious level so we could use them in dangerous situations, which required fast responses. As early humans, we risked extreme dangers whenever we visited dependable food or water sites that were also frequented by predators and competitors. We could reduce risk through identifying any associative patterns of their visiting behaviour. The evolutionary answer to the perplexing question ‘Why depict non-obvious associations in dreams’ was ‘To ensure survival’.

We no longer dream to survive. Our lives are no longer contingent on making non-obvious associations to identify a pattern in the behaviour of predators, competitors, and potential mates as they move around to secure resources in the world. Has this changed our dreams? Has it had an impact on our minds/brains?...

Dreaming happens during sleep. When we aren’t interacting with the world, our minds turn inwards. We dream. These dreams differ. Rapid eye movement (REM) dreams are visual, vivid, bizarre, emotional, and highly associative with embodied narratives, whereas non-rapid eye movement (NREM) dreams tend to be shorter and more thought-like. During REM dreams, the brain is as active, or even more active, than it is during wakefulness. In some dreams, during REM sleep, the dreamer is lucid—they become aware they are dreaming and can, sometimes control the dream content. These different types of dream happen at different times in the sleep cycle. Across the night, we experience NREM sleep (including light sleep and deep sleep) and REM sleep in a fixed sequence. The night isn’t a uniform period of rest. This introductory chapter explains these basic issues about sleep and dreams.

What is a dream? It’s a complex, non-obvious pattern derived from your experience. But you haven’t actually experienced it. Strange. Revealing complex, hidden patterns makes dreams odd. Dreams associate elements of different experiences to make something new: a pattern you didn’t know was there until you dreamt it. Patterns are discernible forms in the way something happens or is done. Some patterns are easy to spot, being certain and obvious: night follows day. Patterns in human/animal experiences are less obvious because, first, the patterned elements appear at different times or places and, second, the pattern exhibits tendencies not certainties. Spotting such patterns depends on non-obvious associations. If prompted with ‘sea’, while awake, your logical brain makes obvious associations, ‘beach’ or ‘boat’, with a seaside pattern i.e. beach-boat-seaside. But after awakening from dreaming, when your brain is still tuned to non-obvious associations, ‘sick’ may come to mind. A less obvious element of sea experiences. You tend to seasickness when it’s rough. But you also get sick if you eat shellfish, have a migraine, or travel in cars—but only if you read. Sea–rough–car–read–shellfish–migraine. Visualizing these non-obvious associations between elements of different experiences becomes dream-like. Dreaming brains evolved to identify non-obvious associations. Across evolutionary time, you didn’t want to get sick. Survival depended on being well enough to anticipate the non-obvious patterns of predators and human competitors, while securing access to food and water. Making associations drives many, if not all, brain functions. Dream associations support memory, emotional stability, creativity, unconscious decision-making, and prediction, while also contributing to mental illness. This book explains how.

Dreams make non-obvious associations to depict complex patterns in past experience. These patterns are constructed from elements of different memories. This chapter illustrates this concept through a dream, ‘the white paper kite and the butterfly’. Dreams portray a complex, experiential pattern, but this pattern hasn’t been experienced, so dreams don’t depict what really happened. Memories can be semantic (for knowledge) or episodic (for experiences). They are held in brain networks composed of pathways and junctions. Episodic memories are represented along pathways. I argue rapid eye movement (REM) dream images, composed of elements of different experiences, are represented at junctions.

This chapter emphasizes the predictive role of dreams in the sense of depicting a non-obvious pattern in past events in an image that is retained at an unconscious level. When assimilated with sensory data, this unconscious image then drives expectations during wake about what’s going on in the world and what will happen next. Across evolutionary time this was particularly useful when there was any ambiguity in sensory data during potentially dangerous situations. But although dreams predict, they don’t usually come true. Their primary evolutionary role was to avoid dangers. Acting on informed expectations precludes possible futures, like being eaten at the waterhole.

This final chapter summarizes my ‘dreams as patterns’ theory and compares it with those of Freud, who thought dreams express wishes—albeit ones that are disguised through associations; Revonsuo, who believes dreams simulate threats; and Hartmann, who thinks dreams make creative, emotional associations between experiences, all of which bear a relationship to my own ideas. I use one of my own dreams, ‘the museum’, to illuminate my core concepts and some of Freud’s. I also briefly discuss the positions of those, Hobson and McCarley, Crick and Mitchison, and Flanagan, who think (or thought) dreams are just noise, nonsense, or epiphenomena, i.e. that dreams are without meaning or purpose—clearly, the antithesis of my ‘dreams as patterns’ theory.

Strategic planning (SP) is a widely-used practice within public sector organizations. However, SP does not only take place in strategy workshops and senior management levels. This paper explores how medical managers of English hospitals ‘do’ SP in their clinical directorates. The authors investigate the practices, the usage of strategy tools and the implications of medical managers’ strategizing. The paper argues that what makes financial sense to medical managers strategizing in the local circumstances of their directorates does not always equate to value for patients, the hospital or for the public sector as a whole.

At times of crisis we turn to experts—but news outlets and social media must be careful about the information they share, particularly informally, writes Sue Llewellyn

This article argues both rapid eye movement (REM) and non-rapid eye movement (NREM) sleep contribute to overnight episodic memory processes but their roles differ. Episodic memory may have evolved from memory for spatial navigation in animals and humans. Equally, mnemonic navigation in world and mental space may rely on fundamentally equivalent processes. Consequently, the basic spatial network characteristics of pathways which meet at omnidirectional nodes or junctions may be conserved in episodic brain networks. A pathway is formally identified with the unidirectional, sequential phases of an episodic memory. In contrast, the function of omnidirectional junctions is not well understood. In evolutionary terms, both animals and early humans undertook tours to a series of landmark junctions, to take advantage of resources (food, water and shelter), whilst trying to avoid predators. Such tours required memory for emotionally significant landmark resource-place-danger associations and the spatial relationships amongst these landmarks. In consequence, these tours may have driven the evolution of both spatial and episodic memory. The environment is dynamic. Resource-place associations are liable to shift and new resource-rich landmarks may be discovered, these changes may require re-wiring in neural networks. To realise these changes, REM may perform an associative, emotional encoding function between memory networks, engendering an omnidirectional landmark junction which is instantiated in the cortex during NREM Stage 2. In sum, REM may preplay associated elements of past episodes (rather than replay individual episodes), to engender an unconscious representation which can be used by the animal on approach to a landmark junction in wake.

This article argues that rapid eye movement (REM) dreaming is elaborative encoding for episodic memories. Elaborative encoding in REM can, at least partially, be understood through ancient art of memory (AAOM) principles: visualization, bizarre association, organization, narration, embodiment, and location. These principles render recent memories more distinctive through novel and meaningful association with emotionally salient, remote memories. The AAOM optimizes memory performance, suggesting that its principles may predict aspects of how episodic memory is configured in the brain. Integration and segregation are fundamental organizing principles in the cerebral cortex. Episodic memory networks interconnect profusely within the cortex, creating omnidirectional “landmark” junctions. Memories may be integrated at junctions but segregated along connecting network paths that meet at junctions. Episodic junctions may be instantiated during non–rapid eye movement (NREM) sleep after hippocampal associational function during REM dreams. Hippocampal association involves relating, binding, and integrating episodic memories into a mnemonic compositional whole. This often bizarre, composite image has not been present to the senses; it is not “real” because it hyperassociates several memories. During REM sleep, on the phenomenological level, this composite image is experienced as a dream scene. A dream scene may be instantiated as omnidirectional neocortical junction and retained by the hippocampus as an index. On episodic memory retrieval, an external stimulus (or an internal representation) is matched by the hippocampus against its indices. One or more indices then reference the relevant neocortical junctions from which episodic memories can be retrieved. Episodic junctions reach a processing (rather than conscious) level during normal wake to enable retrieval. If this hypothesis is correct, the stuff of dreams is the stuff of memory.

Writing about dreaming, the poet Raymond Carver said “I feel as if I’ve crossed some kind of invisible line”. In creative people, the “line” between wake, dreaming and psychopathology may be porous, engendering a de-differentiated, super-critical, hybrid state. Evidence exists for a relationship between creativity and psychopathology but its nature has been elusive. De-differentiation between wake, sleep and dreaming may be the common substrate, as dream-like cognition pervades wake and wake-like neurophysiology suffuses sleep. Chaos theory posits brain states as inherently labile, transient and dynamically unstable. Over and above transient dissociations, an enduring and, sometimes, progressive, de-differentiation may be possible. Evidence indicates that sleep and dreaming facilitate creative insight. In consequence, a mild to moderate form of de-differentiation may enhance creativity but if wake-like neurobiology permeates sleep this may disrupt sleep-dependent memory processing and emotional regulation. If de-differentiation is progressive and enduring, various forms of psychopathology may result.

PurposeThis article aims to focus on one of the most intriguing issues related to the public sector reforms: the accountability systems. In particular the paper aims to deal with the relationships between accounting‐based reforms, forms of accountability, and people‐changing or people‐processing approaches to service provision within Italian social work.Design/methodology/approachThe paper draws on the accountability and people changing/processing literature to interpret and discuss the evidence gathered in an in‐depth longitudinal case study conducted in a social service public organization between 2007 and 2009.FindingsThe article reveals that the case study site had developed two distinct groups of services: “Territoriali” and “Residenziali”. “Territoriali” engage in a traditional mode of social care, they provide professional support to clients with, sometimes, quite intractable problems, and aim to modify clients' characteristics, behaviour and attitudes. In contrast, “Residenziali” deal with, and often outsource, more standardized care packages in the form of residential care, day care and some home‐based services. The accounting reforms were received very differently in these two areas. “Territoriali” was resistant to the changes but, in large part, “Residenziali” embraced them. The article then argues that this reflected the extent to which each service area was willing and able to implement a people‐processing rather than a people‐changing approach. The adoption of the people‐processing method had profound implications for the ways that accountability was both experienced and delivered in the services.Originality/valueThis article deals with the under‐researched area of social care. It integrates two literatures not previously articulated together: accountability and people changing/processing. A three‐year longitudinal study is presented, enabling an in‐depth appreciation of the changes affecting social services and the differential responses to accounting and consequent shifts in accountability in two contrasting service areas.

It is the aim of this article to understand what it means to be an agent , actor or person in an organization using theoretical arguments from Giddens and Archer.

This paper proposes that schizophrenia is a state of mind/brain 'trapped' in-between waking and dreaming. Furthermore, it suggests that both waking and dreaming are functional. An in-between state would be disordered; neither waking nor dreaming would function properly, as the mind/brain would be attempting two, ultimately incompatible, sets of tasks simultaneously. In support of this hypothesis, evidence is synthesised across four different domains: the chemistry of the dreaming state; work on dreaming as functional for memory; the membrane theory of schizophrenia; and chaos theory. The brain produces itself; self-organizing through its modulatory systems. Differentiation between dreaming and waking is achieved through aminergic/cholinergic/dopaminergic reciprocity. Chaos theory indicates that self-organizing systems function most creatively on the 'edge of chaos'; a state which lies between order and disorder. In the mind/brain 'order' represents rigid differentiation between waking and dreaming, whereas 'disorder' results from their interpenetration. How could the latter occur? In sum, the causal sequence would be as follows. Genetic susceptibility to schizophrenia is expressed through fatty acid deficiencies which precipitate neuronal cell membrane abnormalities. In consequence, all neurotransmitter systems become disrupted. Ultimately, the reciprocal interaction between aminergic/cholinergic neuromodulation breaks down. Disrupted cholinergic input interferes with the reciprocal relationship between mesolimbic and mesocortical dopaminergic systems. Loss of reciprocity between aminergic, cholinergic and dopaminergic neuromodulation results in chronic interpenetration; a 'trapped' state, in-between waking and dreaming results. This would be 'schizophrenia'. Currently, imaging techniques do not capture dynamic neuromodulation, so this hypothesis cannot yet be tested inductively. However, the paper suggests that further evidence would be gained through a closer attention to the phenomenology of schizophrenia in the waking and dreaming states.

Evidence is accumulating that schizophrenia and bipolar disorder are related conditions. This paper proposes a particular form of relatedness. If 'schizophrenia' is a mind/brain 'trapped' between waking and dreaming, in a disordered in-between state, then bipolar 'disorder' could actually be an attempt to restore order. The mind/brain is a self-producing, self-organizing system. Autopoiesis applies to such systems. Neuromodulation accomplishes self-organization in the mind/brain. If schizophrenia is a state in-between waking and dreaming, characterized by aminergic/cholinergic interpenetration and dopaminergic imbalance then bipolar 'disorder' could be a modulatory response. This autopoietic reaction may take the form of either aminergic hyperactivity aimed at producing a purer waking state, (precipitating mania in the waking state), or cholinergic hyperactivity aimed at producing a purer dreaming state, (producing depression in the waking state), or both, resulting in rapid cycling bipolar disorder. Thus bipolar activity may be an autopoietic response aimed at restoring differentiation to the in-between state of schizophrenia.

PurposeThe paper aims to provide a response to commentaries in this issue by Andrew Sayer, and Robert W. Scapens and ChunLei Yang on “Case studies and differentiated realities” a paper by Sue Llewellyn published in Qualitative Research in Accounting & Management Vol. 4 No. 1, 2007.Design/methodology/approachDiscusses issues raised in the commentaries around “differentiated realities”, “pluralist ontology” and the “single reality” of social constructivism.FindingsReiterates an understanding of the idea of “differentiated realities” and discusses the methodological implications that arise from it.Originality/valueClarifies Llewellyn's original discussion of differentiated realities and case studies.

The dream as prediction seems inherently improbable. The bizarre occurrences in dreams never characterize everyday life. Dreams do not come true! But assuming that bizarreness negates expectations may rest on a misunderstanding of how the predictive brain works. In evolutionary terms, the ability to rapidly predict what sensory input implies- through expectations derived from discerning patterns in associated past experiences- would have enhanced fitness and survival. For example, food and water are essential for survival, associating past experiences (to identify location patterns) predicts where they can be found. Similarly, prediction may enable predator identification from what would have been only a fleeting and ambiguous stimulus- without prior expectations. To confront the many challenges associated with natural settings, visual perception is vital for humans (and most mammals) and often responses must be rapid. Predictive coding during wake may, therefore, be based on unconscious imagery so that visual perception is maintained and appropriate motor actions triggered quickly. Speed may also dictate the form of the imagery. Bizarreness, during REM dreaming, may result from a prospective code fusing phenomena with the same meaning- within a particular context. For example, if the context is possible predation, from the perspective of the prey two different predators can both mean the same (i.e. immediate danger) and require the same response (e.g. flight). Prospective coding may also prune redundancy from memories, to focus the image on the contextually-relevant elements only, thus, rendering the non-relevant phenomena indeterminate- another aspect of bizarreness. In sum, this paper offers an evolutionary take on REM dreaming as a form of prospective coding which identifies a probabilistic pattern in past events. This pattern is portrayed in an unconscious, associative, sensorimotor image which may support cognition in wake through being mobilised as a predictive code. A particular dream illustrates.

Purpose – This paper aims to challenge the conventional wisdom in qualitative case study research that the findings of the case depend on the identification of common themes across the statements of multiple case informants (usually, as expressed at interview).Design/methodology/approach – This is a methodological paper that uses a published work to illustrate its arguments. It explores research on the meaning and significance of politically and culturally sensitive emergent change.Findings – The paper finds that, during such change, many respondents may not accurately discern the “direction of travel” in their organization and, hence, gathering evidence on common views may not be a productive research strategy.Research limitations/implications – It was only possible to use one illustration (politically and culturally sensitive emergent change); other scenarios where the “singular view” may be significant were, therefore, not covered.Practical implications – Ultimately, the findings of a case study may ha...

PurposeThis paper aims to introduce the AAAJ special issue on “Accounting as codified discourse”, explicate the idea of codification and locate the notion of a “codified discourse” within the broader tradition of discourse studies in management.Design/methodology/approachThe approach is conceptual and discursive, and provides a theoretical framework for understanding codification and a discursive context for the accepted papers in this special issue.FindingsTheoretically, consideration of the more determinate relationship between codified discourse and practice can add to the general understanding of the discourse/practice dynamic in organisation studies. Several issues are identified that call for further empirical investigation. First, some of the broad‐spectrum accounting codes (e.g. historic cost) are currently under review in the expectation that change will enable constructive accounting innovation. Second, the impact of more codified accounting on management practice in organisations requires evaluation. Third, how far “intangibles” and “externalities” can be codified is a pertinent current agenda. Fourth, work is needed on whether and to what extent professional power is curtailed when politicians and policy makers introduce more codified discourses.Research limitations/implicationsCurrently “codification” is not well understood in the literature. This AAAJ special issue opens up the debate but there remains considerable scope for future work to take this agenda forward – to enable more detailed understanding of accounting as codified discourse.Originality/valueAlthough “discourse studies” and “discourse analysis” are now firmly embedded in the organisational/management literature, “codified discourses” have not featured in the debate. This is a significant omission as codification is a key feature of many discourses – especially in professional fields like accounting, law, and medicine. Moreover, codified discourses are becoming more widespread. The value of this paper lies in its exposition of accounting as codification in relation to discourse.

PurposeAlthough the case for case studies is now well established in accounting and management research, the exact nature of their contribution is still under discussion. This paper aims to add to this debate on contribution by arguing that case studies explore not one reality but several.Design/methodology/approachThis is a theoretical paper that discusses ontology using a deductive approach.FindingsThe paper argues that reality is differentiated into physical, structural, agential, cultural and mental realms.Research limitations/implicationsThe paper begins to draw out some of the implications of “differentiated realities” for case studies, but there is much more that could be said.Practical implicationsBecause case studies encompass differentiated realities, the paper discusses how expectations about the contribution of case studies should be intimately linked to the nature of the differentiated realities being researched.Originality/value“Differentiated realities” provides a fresh look status of case study findings and challenges the idea of a single social reality – as portrayed by both social positivism and social constructivism.

The target article argues memory reconsolidation demonstrates how therapeutic change occurs, grounding psychotherapy in brain science. However, consolidation has become an ambiguous term, a disadvantage applying also to its derivative – reconsolidation. The concept of re-association (involving active association between memories during rapid eye movement [REM] dreams followed by indexation and network junction instantiation during non-rapid eye movement [NREM] periods) brings greater specificity and explanatory power to the possible brain correlates of therapeutic change.

This paper explores the ways in which technological innovation becomes adopted and incorporated into healthcare practice. Drawing upon the notion of ‘field of practices’, we examine how adoption is subject to spatially and temporally distributed reconfigurations across a multi-level set of practices, ranging from the policy level to the micro-level setting of individual action. The empirical backdrop is provided by a case study of the adoption of Breast Lymph Node Assay (BLNA), a diagnostic technology innovation for the treatment of breast cancer patients. Our aim is to contribute to the development of a more comprehensive analysis of the processes surrounding the adoption and incorporation of complex healthcare technologies into routine practice.

This article aims to expand our understanding of what it is to be an agent within an organization. To do this, the views of both Archer and Giddens on the constitution of the agent are analysed. These expositions are used to differentially illuminate the specifics of an empirical case, where it is argued that a team of ten agents were crucial in taking forward a merger between two pharmaceutical companies (‘A’ and ‘ω’). A discussion compares the insights into how agents are constituted that arise from the conceptual frames offered by Archer and Giddens. The article concludes that the constitution of the organizational agent encompasses both agential positioning (vis-à-vis organizational resources) and agential powers (where these powers can be appropriated from the organization and incorporated by the agent).

The political reforms of the public sector, termed “new public management” (NPM), now have a 20-year history. This paper looks at local differences between England and Scotland over a particular dimension of NPM — performance management in health care. In the context of the dynamic reform agenda in the UK, it is expected that these “local” lessons will have some global relevance. This paper elaborates on these inter-country differences and proposes how the approaches in England and Scotland may affect productivity and innovation in health care delivery. It does this by exploring research into the behaviour of the most powerful of health care providers, the senior clinicians in hospitals.

In 1998, the UK government introduced the National Reference Costing Exercise (NRCE) to benchmark hospital costs. Benchmarking is usually associated with “excellence”; the government emphasised the raising of standards in the 1997 White Paper “The New NHS: Modern, Dependable” that heralded the NRCE. This paper argues that the UK “New Labour” government's introduction of, and increasing reliance on, hospital cost benchmarking is promoting “averageness”. Average hospitals will be cheaper to run and easier to control than highly differentiated ones; they may also score more highly on certain measures of service improvement. The paper aims, through empirical investigation, both to demonstrate how the activities and processes of hospital life “become average” as they are transformed to comply with the cost accounting average and to indicate how the “average” is being promoted as the norm for hospitals to aspire to. To benchmark to average costs, comparisons are necessary. To compare hospital costs involves the creation of categories and classification systems for clinical activities. Empirical evidence shows that as doctors, patients and clinical practices are moulded into costed categories, they become more standardized, more commensurate and the average hospital is created.

Management accounting, inter alia, gives information on how resources are allocated within organisations. If managers wish to change patterns of resource allocation, accounting knowledge is pivotal to any change processes. In health care organisations resources follow decisions made by clinicians, hence to have an impact on resource allocations managers must influence them. Direct managerial control over clinicians is not possible or desirable in health care organisations. This article suggests that incentives are an alternative to control in health care and investigates the impact of financial incentives within hospitals, utilising a naturally occurring experimental situation that has arisen between the UK and Canada.