Lost in translation: a multi-level case study of the metamorphosis of meanings and action in public sector organisational innovation

This paper explores the early implementation of an organisational innovation in the UK National Health Service (NHS) - Treatment Centres (TCs) - designed to dramatically reduce waiting lists for elective care. The paper draws on case studies of eight TCs (each at varying stages of their development) and aims to explore how meanings about TCs are created and evolve, and how these meanings impact upon the development of the organisational innovation. Research on organisational meanings needs to take greater account of the fact that modern organisations like the NHS are complex multi-level phenomena, comprising layers of interlacing networks. To understand the pace, direction and impact of organisational innovation and change we need to study the interconnections between meanings across different organisational levels. The data presented in this paper show how the apparently simple, relatively unformed, concept of a TC framed by central government, is translated and transmuted by subsequent layers in the health service administration, and by players in local health economies and, ultimately in the TCs themselves, picking up new rationales, meanings, and significance as it goes. The developmental histories of TCs reveal a range of significant re-workings of macro policy with the result that there is considerable diversity and variation between local TC schemes. The picture is of important disconnections between meanings, that in many ways mirror Weick’s (1976) ‘loosely coupled systems’. The emergent meanings and the direction of micro-level development of TCs appear more strongly determined by interactions within the local TC environment, notably between what we identify as groups of ‘idealists’, ‘pragmatists’, ‘opportunists’ and ‘sceptics’ than by the framing (Goffman 1974) provided by macro and meso organisational levels. While this illustrates the limitations of top down and policy-driven attempts at change, and highlights the crucial importance of the front-line local ‘micro-systems’ (Donaldson & Mohr, 2000) in the overall scheme of implementing organisational innovations, the space or headroom provided by frames at the macro and meso levels can enable local change, albeit at variable speed and with uncertain outcomes

Health care management autonomy: Evidence from the Catalonian hospital sector in a decentralised Spain

The organisation of inpatient care provision has undergone significant reform in many southern European countries. Overall across Europe, public management is moving towards the introduction of more flexibility and autonomy . In this setting, the promotion of the further decentralisation of health care provision stands out as a key salient policy option in all countries that have hitherto had a traditionally centralised structure. Yet, the success of the underlying incentives that decentralised structures create relies on the institutional design at the organisational level, especially in respect of achieving efficiency and promoting policy innovation without harming the essential principle of ‘equal access for equal need’ that grounds National Health Systems (NHS). This paper explores some of the specific organisational developments of decentralisation structures drawing from the Spanish experience, and particularly those in the Catalonia. This experience provides some evidence of the extent to which organisation decentralisation structures that expand levels of autonomy and flexibility lead to organisational innovation while promoting activity and efficiency. In addition to this pure ‘managerial decentralisation’ process, Spain is of particular interest as a result of the specific regional NHS decentralisation that started in the early 1980’s and was completed in 2002 when all seventeen autonomous communities that make up the country had responsibility for health care services. Already there is some evidence to suggest that this process of decentralisation has been accompanied by a degree of policy innovation and informal regional cooperation. Indeed, the Spanish experience is relevant because both institutional changes took place, namely managerial decentralisation – leading to higher flexibility and autonomy- alongside an increasing political decentralisation at the regional level. The coincidence of both processes could potentially explain why some organisation and policy innovation resulting from policy experimentation at the regional level might be an additional feature to take into account when examining the benefits of decentralisation.Management autonomy, hospital innovation, National Health system, Spain, regional health service, Catalonia

Are Health Problems Systemic? Politics of Access and Choice under Beveridge and Bismarck Systems

Industrialised countries face similar challenges for improving the performance of their health system. Nevertheless the nature and intensity of the reforms required are largely determined by each country's basic social security model. This paper looks at the main differences in performance of five countries and reviews their recent reform experience, focusing on three questions: Are there systematic differences in performance of Beveridge and Bismarck-type systems? What are the key parameters of health care system which underlie these differences? Have recent reforms been effective? Our results do not suggest that one system-type performs consistently better than the other. In part, this may be explained by the heterogeneity in organisational design and governance both within and across these systems. Insufficient attention to those structural differences may explain the limited success of a number of recent reforms.Health system, Beveridge, Bismarck, reforms, performance

The politics of health sector reform in Eastern Europe: the actor-centered institutionalist framework for analysis

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Delivering reform in English healthcare: an ideational perspective

A variety of perspectives has been put forward to understand reform across healthcare systems. Recently, some have called for these perspectives to give greater recognition to the role of ideational processes. The purpose of this article is to present an ideational approach to understanding the delivery of healthcare reform. It draws on a case of English healthcare reform – the Next Stage Review led by Lord Darzi – to show how the delivery of its reform proposals was associated with four ideational frames. These frames built on the idea of “progress” in responding to existing problems; the idea of “prevailing policy” in forming part of a bricolage of ideas within institutional contexts; the idea of “prescription” as top-down structural change at odds with local contexts; and the idea of “professional disputes” in challenging the notion of clinical engagement across professional groups. The article discusses the implications of these ideas in furthering our understanding of policy change, conflict and continuity across healthcare settings

‘The nature of bad news infects the teller’: The experiences of envoys in the face to face delivery of downsizing initiatives in UK public sector organisations

Aim: This study builds on a previous research paper published by Acas (Ashman 2012) that explores the experiences of public sector employees that have been given the task of delivering the generally bad news of downsizing decisions face to face with the victims and then deal with the immediate repercussions – labelled downsizing envoys. The evidence from that paper is combined here with data gathered from envoys in the private sector in order to identify the similarities and differences in the experiences of envoys between the two sectors. The aim of this paper is to develop further our understanding of the envoy situation and to identify what instances of good practice can be garnered from either sector. Methodology: In combination with evidence from the public sector study a total of 50 envoys were interviewed; where 24 came from across 9 public sector organisations, a further 24 from across 8 private sector organisations and two independent consultants. The interviewees are all presently or recently based in the North West of England. Including the 2 consultants 30 envoys are HR professionals and the other 20 are envoys drawn from other organisational functions. Findings: A broad summary of the data gathered would indicate that in terms of how they undertake the role - that is, regarding attitude and personal conduct - the envoys are very similar irrespective of their sector or organisation. However, where the sector does have a differentiating influence is on how the role affects the envoys – in other words, the emotion and strain experienced in carrying out the task. Factors that make a difference here include how much support is available to envoys and what part they play in decision making processes. Suggestions for good practice: The suggestions for good practice include ensuring that envoys are involved in decisions that affect their role and impact upon their understanding of downsizing rationale; that envoys do not feel forced into the role; that realistic efforts are made to train and develop envoys – especially with regard to the emotional aspects of the role; and to ensure that envoys are properly supported throughout downsizing activity

Machines and machinations: The integrated care record service in the UK national health service

This paper examines the use of Actor Network Theory (ANT) as a lens to get a better understanding of the implementation of the Integrated Care Record Service (ICRS) in the UK National Health Service (NHS). Actor Network Theory has been deployed in various environments to achieve a better understanding of the roles of not only the humans but also the artifacts that constitute, in this case, healthcare networks of services and organisations. The theory is used as a means of supporting real world interventions, providing a richer understanding of complexities involved and thereby helps management to make better decisions. This study also explores Latour’s concept of machines as machinations, whose role is to translate other actors into the network. We propose ICRS as a fruitful empirical context for the use of ANT to support decision making for actors in health care provision. Actor Network Theory (ANT) is well-suited for use in the socio-technical evaluation of IS into the ICRS project because this approach treats human and non-human actors symmetrically. This approach facilitates a more thorough examination of the ways in which information technology is enabled or restricted in social processes

Professional self-regulation in a changing architecture of governance: comparing health policy in the UK and Germany

This chapter compares transformations in professional self-regulation in the UK and Germany through the lens of governance. We introduce an expanded concept of governance that includes national configurations of state–profession relationships and places selfregulation in the context of other forms of governance. The analysis shows that a general trend towards network governance plays out differently. In the UK, a plural structure of network governance and stakeholder arrangements is emerging in the context of stateled change. In Germany, partnership governance between sickness funds and medical associations shape the transformations and act as a barrier towards the entry of new players

Randomised controlled trials of complex interventions and large-scale transformation of services

Complex interventions and large-scale transformations of services are necessary to meet the health-care challenges of the 21st century. However, the evaluation of these types of interventions is challenging and requires methodological development. Innovations such as cluster randomised controlled trials, stepped-wedge designs, and non-randomised evaluations provide options to meet the needs of decision-makers. Adoption of theory and logic models can help clarify causal assumptions, and process evaluation can assist in understanding delivery in context. Issues of implementation must also be considered throughout intervention design and evaluation to ensure that results can be scaled for population benefit. Relevance requires evaluations conducted under real-world conditions, which in turn requires a pragmatic attitude to design. The increasing complexity of interventions and evaluations threatens the ability of researchers to meet the needs of decision-makers for rapid results. Improvements in efficiency are thus crucial, with electronic health records offering significant potential

Getting management accounting off the ground: post-colonial neoliberalism in healthcare budgets

Taking Sven Modell’s (2014, pp. 83–103) “societal relevance of management accounting” agenda forward, and based on a cost accounting initiative in a Sri Lankan hospital, this paper examines how management accounting is implicated in societal relevance. It reports on a postcolonial neoliberal state’s use of cost-saving experiments and the resultant emancipation of the individuals involved. It runs a bottom-up analysis, from micro events in the hospital to policymaking at the level of the Provincial Council. This analysis suggests that cost accounting acts as a mediating instrument: it begins to loosen the old Keynesian postcolonial bureaucratic budget confinements, creates a social space for individuals to consider cost-saving experiments, and addresses wider policy concerns about hospital resource management. The story is illuminated by Gilles Deleuze’s and Zigmund Bauman’s ideas on post-panoptic societies: old confinements are being problematized and new flexible, “liquid” spaces created, in which individuals are emancipated in terms of their ability to influence resource management within and beyond the organizational constituency