Beyond ‘firefighting’ health inequalities in times of austerity: local authorities as ambidextrous organisations

Aim: This study takes a unique approach to understanding the implementation of a whole-system place-based strategy to improve health and reduce health inequalities, using ambidextrous organisational theory. Methods: The data consisted of the secondary analysis of 23 strategy documents in one local authority, and interviews (n = 22) with local decision-makers, front-line workers, and service users. Results: Our analysis highlights the tensions inherent in British Local Authorities (LAs), which in times of austerity have increasingly been expected to perform as financially self-sufficient, while meeting their health inequalities targets. Increasingly, LAs can be seen as being characterised by goal incoherence, with competing institutional logics. This leads them to exist in a paradoxical reality, leading to ambiguity and unease in the workforce, which can be reconciled through the generation of creative solutions. Conclusion: Organisations such as LAs can meet both of their social and financial performance ambitions by acknowledging, and working through, simultaneous strategic and operational needs, which capitalise on the potential of both exploration of new solutions and the exploitation of what already works well. Decision-makers need to see goals as not mutually exclusive, and instead engage in strategy discussions that lead to coordinated actions across the full range of ambitions. We highlight the potential contribution of the concept of ambidexterity to help LAs manage their competing priorities. It puts forward the concept of LAs as hybrid organisations with politically appointed boards and professional organisational units that intrinsically manoeuvre between mission and market orientation.