Lorelei Jones, Alec Fraser, and Ellen Stewart write that while the literature of large‐scale healthcare reform is dominated by competing forms of knowledge, social science in particular can offer new insights.
Major changes to the way clinical services are organised keep happening, despite a lack of evidence that it improves anything. Health services research often excludes important dimensions, such as politics and emotions, in favour of technical questions of more limited significance. Theoretically-informed research that is critical, and includes a greater diversity of perspectives, can aid understanding of these changes.
Ewan Ferlie argues that there has been a decline in social science-based analysis of organisational change in the context of public policy. He attributes this to the rise of new forms of knowledge, such as management consultancy and health services research. He describes health services research as having developed as something akin to a clinical science, focused on evaluating discrete service interventions in terms of clinical and financial outcomes.
When we searched for studies of large-scale change we found that most assumed that change was a good thing, and were primarily concerned with the question of ‘how do we make it work’? There were, of course, exceptions. One study distinguished between ‘top down’ and ‘bottom up’ approaches to healthcare planning. Top down approaches use rational, algorithmic models and prescribe standardised solutions, while bottom up approaches use community participation to develop plans that are customised to local priorities and context. Looking at examples of community participation in planning health services in rural Scotland, the study found this could be done within set budgets.
On the whole, however, we found that research in this area assumes a top down approach to healthcare planning. It is also broadly ‘technicist’ in orientation, concerned with finding technical solutions to healthcare problems. While this approach embodies some important values, such as effectiveness, other values are neglected or obscured.
In contrast, social science understands that healthcare change occurs within communities and places. Health services employ local people, sit at the centre of communities, and act as a symbol of the wider health system. Social science can offer valuable perspectives on how services change, and on what is left behind.
Healthcare facilities are often important to local communities, embodying a ‘sense of place’. Hospitals in particular, often hold important symbolic properties. In addition to providing support for local needs, healthcare facilities may represent a significant source of local employment, and embody the political identity of an area, fostering a sense of community ownership. Tim Brown for example, suggests that in the UK the district general hospital is often symbolic of the foundation of a post-war ‘welfare state’, through which the idea of communality or common citizenship has been defined, and of an ideological commitment to the provision of a comprehensive national health service.
Social science can contribute to an understanding of large-scale change by exploring the experiences and perspectives of patients, too often missing from existing research. For example, one study of proposed changes to shift care for diabetes from hospital to community settings, found that patients did not always value a transfer of care. Some patients associated the care provided by specialists located in hospitals with quality, while others assumed that a transfer of care meant that their condition was not serious, or that they were ‘better’.
Social science can also illuminate the political dimensions of healthcare planning, such as the interaction of powerful interests, and the strategies used by different stakeholders. One common tactic of healthcare planners is to convene a committee of doctors, not to contribute to decision-making, but to legitimise decisions that have already been taken. Another is to use health services research to ‘depoliticise’ changes. As the sociologist Ian Rees Jones observed in his ethnographic study of healthcare planning in London:
Hard political choices are transformed into technical solutions through focusing on mechanistic rational forms of health services research, thus imposing a rational scientific framework on what in reality is more complex, contested and ambivalent.
More recently, a study of the centralisation of stroke services in London showed how the practice of stakeholder consultation was manipulated to serve powerful interests. This study found that within ostensibly participatory forums management consultants were able to control how problems were understood and which solutions were adopted.
These perspectives from social science question many of the standard recommendations for implementing major change, such as ‘engage doctors’ and ‘involve patients and families’, showing how, in real world settings, these have often been used strategically, to manage opposition to controversial plans by co-opting stakeholders. To the extent that these strategies are recognized by other stakeholders they are likely to ‘backfire’ by eroding trust.
Studies that are theoretically informed, critical, and that include the views of all stakeholders are important because major change is, for many people, a troubling issue. Major change disrupts clinical teams, care practices and therapeutic relationships. It also consumes vast amounts of public resources in the pursuit of change that may never be realised. Healthcare staff currently spend significant amounts of time in planning meetings for changes that are either eventually abandoned or rolled into ‘the next thing’. One organisation in England reported being involved in 13 programmes of significant service change over the last 10 years. In only two cases were plans even partially implemented. A report from the Nuffield Trust found that in one locality in England a programme cost £24.9 million in the first three years, without any change to services. In the first two years £7.9 million was spent on management consultants alone.
Current models for evaluating major service change are too narrow – in terms of both theoretical perspectives and stakeholder perspectives. Future research needs to be both more critically-framed and inclusive of hitherto marginalized voices. Major system change retains near mystical attractiveness to politicians and decision makers, so we urgently need to understand it better.
Note: the above draws on the authors’ published work in Sociology of Health & Illness.
Lorelei Jones is Lecturer in Healthcare Sciences at Bangor University.
Alec Fraser is Assistant Professor in the Department of Health Services Research and Policy at the London School of Hygiene & Tropical Medicine.
Ellen Stewart is Chancellor’s Fellow in Social Studies of Health & Medicine at the University of Edinburgh.
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