Politics of Health Group,

Annual conference Merton College Oxford

8th-9th September, 2009

Abstracts

Organisational ‘culture’ viewed from the top: Is it a valid

measure?

Steve Harrison, University of Manchester*

Abstract
The ‘Competing Values Framework’ (CVF) provides a widely used conceptualisation
of organisational culture, presenting this as various degrees of clan, hierarchy,
developmental and market/ rational characteristics. CVF empirical data collection is
normally based on questionnaire responses of top managers, which raises the question
of how far such responses can serve as a valid measure of a social phemonenon that is
defined as something shared within an organisation. As part of a wider study of
organisational culture and performance in the English NHS, we collected CVF data
from board members and non-board members in hospital trusts and from different
types of staff in general medical practices. We found that board members and
equivalents in general practice were substantially more likely than expected to
emphasise clan culture, and that other staff were more likely that expected to
emphasise hierarchical culture. These findings were statistically significant. We
conclude that CVF may induce a systematic tendency for the most senior managers to
overestimate the importance of relationships and underestimate that of mechanistic
processes in shaping the culture of organisations as perceived by their less senior
members.

*Co-authors: Russell Mannion, Rowena Jacobs, Huw Davies & Fred Konteh

Is health management and practice, and does it matter?

Ian Greener, University of Durham

It has become fashionable to talk about management ‘practices’ and within NHS
research, healthcare management practices. This paper addresses the question of
whether healthcare management can be considered as a practice, and what the
implications of thinking about management in this way. Utilising theory including
John Searle’s social ontology, and David Bloor’s interpretation of Wittgenstein’s later
philosophy, a comparison of healthcare management as a practice is made with the
practice of medicine, and insights gained about the relative standing of the two
groupings, and the difficulties they often have in relating to one another.

Hope that makes some sense. It’s kind of a side-project I’ve got going at the moment
from an SDO-funded piece of work.
 . How can the consequences of voluntary organisations'
contributions to health policy be measured?
Mickey Wilmot London school of hygiene

Abstract
Voluntary organisations have a longstanding relationship with the National Health
Service and the number of voluntary organisations concerned with health issues has
grown since the 1970s . Evidence suggests that they are perceived as legitimate
policy actors who advocate on behalf of patients and carers and it is widely believed
that their “mere existence” has increased political pressure on the NHS . Moreover,
recent policy developments such as the legal duty on local NHS bodies to consult
their populations in planning services, the compact with the voluntary sector and
renewed mechanisms for patient and public involvement (e.g. Local Involvement
Networks, National Voices) may have increased opportunities for voluntary
organisations to participate in NHS policy. However, voluntary organisations’ role in
health policy has not been extensively researched. This paper reviews literature
which examines voluntary organisations’ contribution to health policy and suggests
what further research is required to better understand these organisations as policy
actors.
References
Baggott, R, J. Allsop and K. Jones (2004) "Representing the repressed? Health
consumer groups and the national policy process" Policy and Politics 32(3):317-331.
Klein, R (2006) The new politics of the NHS: From creation to reinvention. 5th Ed.
Abingdon: Radcliffe Publishing.
Taylor, M and D. Warburton (2003) "Legitimacy and the role of UK Third Sector
organisations in the policy process" Voluntas 14(3):321-338.

'Patient choice and referral management: the implementation of

patient choice policies in the UK'.

Marie Sanderson University of Manchester

Abstract
Patient choice is a central element of UK health policy, although the degree of choice
to be offered to patients and the policy context varies between and within the four
home countries of the UK. The increasing divergence of NHS policy within the UK
since devolution has created a natural laboratory and provides a unique opportunity to
examine policy differences between the constituent countries of the UK and compare
their consequences.

Drawing on ongoing research investigating patient choice policy in the UK (‘A

comparative study of the construction and implementation of patient choice policies
in the UK’, SDO/147/2007), this paper compares the implementation of policies
which offer choices to patients when they are referred on to secondary care in the
NHS in England, Scotland, Northern Ireland and Wales. The paper uses interviews
with those involved in the provision of choices to patients during the secondary care
referral process to illuminate the range of ways in which the differing patient choice
policies of the UK are implemented through referral management systems and
pathways.

The paper argues that the divergence of choice policy in the UK has not led to an
accompanying divergence in the referral management systems which deliver choice to
patients in the four countries, with each system exhibiting similar tensions in the
provision of options to patients and finding similar solutions to issues of choice. The
paper offers some tentative explanations for this apparent disconnect between policy
and practice, including that offered by the theory of the Street Level Bureaucrat
(Lipsky, 1980).

References

Lipsky, M (1980), Street- level bureaucracy – Dilemmas of the individual in public

services, New York: Russell Sage Foundation.

In the name of participation: interpreting the relationship between

statutory public involvement institutions and NHS governance

Ruth Carlyle, Birkbeck College

Abstract
In the UK, there have been state-sponsored institutions for public involvement in the
NHS since 1974. Given the rise of alternative means for involving patients and the
public, and the emphasis in England on market mechanisms to determine patients’
preferences, the ongoing investment across the UK in funding and reforming these
statutory public involvement institutions is an empirical puzzle.

This paper considers four possible relationships between statutory public involvement
institutions and NHS governance. From a welfare state retrenchment perspective, the
institutions may be tools to prevent the mobilisation of opposition to reform.
Secondly, considered as state corporatist tools, the institutions may maintain state
control over public involvement. Thirdly, the institutional structures may enable lay
people to challenge professional ‘groupthink’. Finally, considered in terms of the
legislative oversight literature, the institutions may act as ‘fire alarms’ to alert political
actors to problems before they become disasters. These four approaches form the
basis of hypotheses against which two archived data sets are analysed.

Theorising big IT programmes in healthcare: Strong structuration

theory meets actor-network theory

Trisha Greenhalgh:

The UK National Health Service is grappling with various large and controversial IT
programmes. Researchers have struggled to find theories that allow them to get a
handle on the sheer scale, complexity and multiple dimensions of ‘big IT’ as it is
currently being played out in the NHS. We sought to develop a sharper theoretical
perspective on the question “What happens – at both macro and micro level – when
government tries to modernise a health service with the help of big IT?” This
presentation, based on a theoretical paper recently submitted for publication,
considers how structuration theory and actor-network theory (ANT) might be
combined to inform the empirical investigation of such questions.

Giddens argued that that social structures and human agency are recursively linked
and co-evolve. ANT studies the relationships that link people and technologies in
dynamic networks. It considers how discourses become inscribed in data structures
and decision models of software, making certain network relations irreversible.
Stones’ strong structuration theory (SST) is a refinement of Giddens’ work,
systematically concerned with empirical research. It views human agents as linked in
dynamic networks of position-practices. A quadripartite approach considers [a]
external social structures (conditions for action); [b] internal social structures (how
and what agents ‘know’ about the social world); [c] active agency and actions and [d]
outcomes as they feed back on the position-practice network. In contrast to early ST
and ANT, SST insists on disciplined conceptual methodology and linking this with
empirical evidence.

In this presentation, we will introduce an adaptation of SST intended for the study of
technology programmes. We extend Stones’ original model with elements from
material interactionism and ANT. We argue, for example, that the position-practice
network can be a socio-technical one in which technologies in conjunction with
humans can be studied as ‘actants’. Human agents, with their complex socio-cultural
frames, are required to ‘instantiate’ technology in social practices. Structurally
relevant properties inscribed and embedded in technological artefacts constrain and
enable human agency. The fortunes of healthcare IT programmes might be studied in
terms of the interplay between these factors.

How do you modernise a health service? A realist evaluation of

whole scale transformation in SE London

Fraser Macfarlane, university of Surrey

Abstract

Large-scale, whole-systems interventions in health care require imaginative

approaches to evaluation that go beyond assessing progress against predefined goals
and milestones. This project evaluated a major change effort in inner London, funded
by a charitable donation of approximately £15 million, which spanned four large
health care organizations, covered three services (stroke, kidney, and sexual health),
and sought to “modernize” these services with a view to making health care more
efficient, effective, and patient centred.

This talk draws out the key themes from a recent study in South East London (see:
Greenhalgh, T., Humphrey, C., Hughes, J., Macfarlane, F., Butler C., Pawson, R.
(2009) How do you modernise a health service? A realist evaluation of whole scale
transformation in SE London. Milbank Quarterly 87(2):391-416)

“25 years in the making - why is it difficult to push through health

care reform in Hong Kong?”

Amy Po-ying Hong Kong Polytechnic University

Abstract
Over the past 15 years, the Hong Kong Government has sent out a clear signal to the
public that the existing health care system will no longer be sustainable without health
care reform. At least three major attempts have been made to put forth health care
financing reform amidst the financial and health care crisis from 1997 to 2009. The
failure to actualize health care reform in Hong Kong is an unfortunate combination of
moral pluralism, a lack of political legitimacy, and bad timing. Hong Kong citizens
enjoyed highly subsidized public health care services since the British colonial time, it
seems that no one is better-off under the new reform plans. Moral pluralism is a
reality and there are different views of distributive justice in the society. While people
realized that social values of equity and wealth distribution come with a price tag, the
status quo was obviously a preferred option for the poor and the middle class alike.
The HKSAR government missed a golden opportunity to push forth the reform when
the economy was blooming a few years ago. The lack of political will to do so is
somehow related to the legitimacy of the HKSAR government which was elected out
of an endorsed pool of voters by the Chinese Government under the Basic Laws. The
2008 financial tsunami and the Swine Flu Pandemic, at best, provide a convenient
excuse for the inertia to change the status quo.

Moral Discourses, Health and Old Age: Some continuities and

disjunctures from the History of Stroke

Katherine Daneski Swansea University

Abstract
It could be argued that while History is mainly concerned about social change it also
throws up continuities and circularities from the past. This is particularly true in
relation to the understanding of Stroke where connections between increased risk
factors and individual responsibility have taken on a moral component which has
parallels with older ‘moral’ discourses about apoplexy where maintenance of the body
is a key concern. At the same time the discussion of stroke connects with
epidemiological concerns regarding the impact of the obesity crisis on the health of
ageing populations. As with other chronic conditions, the main principle of medical
management of stroke is prevention through individually focused strategies that focus
on dietary measures and increasing activity levels. These recommendations resonate
with a public debate on what has been termed the ‘obesity epidemic’ where the
availability of cheap food and the decline in individual fitness are seen to be problems
for the health of society as well as individuals within it. Both discourses have strong
moral components relating to individual responsibility and personal agency. This
paper draws from original socio-historical research on the management of stroke and
shows how historically similar judgements were made in the 18th and 19th centuries
where the lifestyles of individuals came under scrutiny and similar recommendations
for individual action were also made. However times change as do moral starting
points and this paper argues that while there are lessons to be learnt from history for
policy makers there are also crucial differences.

Slaying sacred cows: Is it time to pull the plug on water

fluoridation?

Stephen Peckham

Abstract
Water fluoridation has been seen as a key public health measure to prevent tooth
decay for over 50 years. However, it is only widely implemented in very few
countries including the USA Australia, New Zealand, Eire and Canada. In the UK
10% of the English population receives fluoridated water but in 2008 the government
re-emphasised the need for water fluoridation and the current Secretary of State for
Health in his first major speech at the NHS Confederation Conference in June 2009
argued that “We’ve been too timid at times on the public health agenda. Let’s press
ahead with fluoridation of water supplies, given the clear evidence that it can improve
children’s dental health.” His choice of pushing water fluoridation is interesting
especially as at the time of the speech Andy Burnham was still vice-president of the
British Fluoridation Society. It is also interesting, as despite the Department of
Health’s long standing commitment to extending water fluoridation and current
attempts to introduce water fluoridation in Southern England there is no scientific
consensus that water fluoridation is either safe or effective. This paper will briefly
review the state of the evidence and questions whether uncritical support for water
fluoridation is either evidence based or in fact ethical.

Obama and the Politics of National Health Insurance in the

USA.....or..... if Truman, JFK, LBJ, Nixon, and Clinton failed - and
Eisenhower, Ford, Carter, Reagan, and both Bushes didn't try -
then why should he succeed?)

Calum Paton, Keele University

Abstract
One of the most exciting things about the Obama Administration has been the
resurgence of the search for greater equity in US health care. To be in New York in the
first week of June – Tuesday was ‘D day’ for the presentation of Obama’s reform
proposal and his ‘letter to Senators’ – was almost, after the eight dismal years of
Dubya, like the young Wordsworth’s characterisation of 1789…. ‘to be young was
sheer heaven’ (well, almost. So I’m told by those lucky enough still to be young.)

The idea of national health insurance (NHI) came back onto the agenda in 2008, with
mainstream Democrat Presidential candidates Obama, Clinton and Edwards all
presenting a version. This was its first appearance since the Clinton plan was buried in
Congress without dignity in 1994. Always without much hope of passing, the Clinton
plan had merely been the latest in a long line of failures since 1948. Along the way,
the only occasion in ‘modern times’ when passage was even barely imaginable was
ironically in 1974 under a Republican President (Nixon), albeit one looking in 1973-4
for an unorthodox distraction from his Watergate travails. In recent years, Senator Ted
Kennedy has expressed regret that the liberal wing’s visceral hatred of Tricky Dicky
prevented a leap of faith by himself and others.

In the landmark year of 1965, during the most liberal Congress in American history,
Medicare, Medicaid and Disability Insurance was passed, when LBJ was President.
But even this Congress could only pass what was atbest a half-way house to NHI, and
at worst a diversion down another path. Prior to that, the late 1940s under Truman’s
lead had marked the only politically mainstream proposal of NHI.

So why did the US diverge in its health policy from other Western nations in the
second half of the twentieth century? Is this a cause for surprise, or par for the course?
But diverge it did, such that in the 1970s the then-leader of the AFL-CIO union
movement, George Meany, could lament that only the USA and apartheid South
Africa were the only industrialized nations without national health access. Earlier on,
before WW2, the USA had not been exceptional, nor had its health industry’s
problems and needs been so different. What are the possible explanations for these
phenomena?

Candidate Explanations

(1) ‘US exceptionalism.’ This theory posits that the US polity is fundamentally
different from those in Europe, Australasia and Canada. Attributable notably to Louis
Hartz, this perspective sees the US as liberal (in the classical, European sense):
without a feudal past, there is neither European conservatism nor a historical dialectic
towards social democracy. A related view points to the ‘frontier’, as in the work of
Daniel Boorstin: the answer to scarcity is to move on rather than to seek a share of the
spoils (exit, rather than voice; flight, rather than fight!) Even with the frontier closed,
the ethos lives on, in this argument – and one can note that Kennedy’s programme
was styled as the ‘New Frontier.’ This postulate of hostility to collectivism is not
however unchallenged.

(2) The US political structure. Samuel Huntington (1972) memorably and accurately
described the US as having a ‘new society but old state’ as opposed to developing
countries with ‘old societies and new states’, countries which aped Lenin and Mao
(even when not Left) rather than Jefferson and Madison. Thus Lipset’s
characterization of the US as ‘the first new nation’ was plain wrong. The US never
had a feudal society (except in the South) but it had – and has – a feudal polity,
designed as such quite deliberately by Founding Fathers such as Hamilton and
Madison who were keen to proscribe the tyranny of the majority and the ascendancy
of the elite respectively ie wanted powers separated into different legislative,
executive and judicial institutions. In the founding days, this meant the quarantining
of the elite in the Senate. In modern days, it means that the ‘fastest law in the West’ is
in the UK and New Zealand, and certainly not in the USA where domestic reform is
sticky and often impossible even in liberal times. Redistribution and a strong state for
administration of federal social programmes requiring social planning are very
difficult to achieve.
(3) The US power structure. On this view, the nature of US capitalism militates
against universal welfare programmes. The weak state means that companies organize
their own welfare, for self-interested rather than altruistic reasons. Firms see (for
example) health insurance as a perk or as a means of disciplining and reproducing the
workforce. Political power is more instrumentally in the hands of elites than in
European corporate states…or at least in the hands of plural elites and coalitions of
corporate and managerial interests.

(4) US political parties. Party political culture militates against unified party
programmes and tight discipline, making domestic reform difficult. Note the Blue
Dog Democrats today, and their predecessors the Boll Weevils.

(5) Path dependency. This perspective points to the legacy of the past, in particular the
legislation of the past, itself conditioned by political structure and culture, and the
structures of public administration which they create and which are difficult to
overthrow for various reasons – inertia and the interests created being two prominent
ones. Of course this view may involve either an infinite regress or a truism/tautology,
and may require associated explanations from which it is a ‘composite.’ For example,
why was the path chosen in the first place, in an earlier era? Are US institutions more
prone to path-dependency thay others – say in the UK – and is the explanation
derivative or contingent rather than radical?

(6) ‘Mobilisation of bias.’ This view builds on a variety of the above (ie like the
others above, is not mutually exclusive from other explanations) to suggest that
policy is biased in a particular direction which is not ideologically or politically
neutral. The phrase is Schattschneider’s (1960), with the subtitle of his book, the
‘semi-sovereign people’ giving a clue to his concerns.

(7) The ‘policy paradigms’ approach. This is my composite term for the views of
Allison (1971) and the ‘Harvard Kennedy School’ orthodoxy: policy is either rational,
bureaucratic or based on log-rolling. The focus is on the executive and US legislative
politics are taken by and large as a given; the normative concern is with good
leadership in practice.

Self Inflicted Wounds- Professional Politics and Child Protection

in Scotland

Chris Nottingham

Abstract
There is broad agreement that the future successful development of health and welfare
services in Scotland, as elsewhere, rests on the capacity of different groups of
professionals to cooperate successfully. However it seems clear that at present the
social work profession, necessarily a key actor in the process, is, in spite of the best of
intentions and ever increasing levels of expertise, ill prepared to meet the challenges.
I shall consider a number of explanations of why social work has performed badly in
terms of professional politics; for example the decline of specialised expertise which
followed the development of the generic profession and a risky alignment with
particular political structures and outlooks, but focus mainly on the issue of child
protection which compounded all other difficulties. I shall suggest that there are three
key factors which should be considered in attempting to rectify the situation – an
attention to the black arts of news management, a ‘federalisation’ of the profession to
encourage specialisation, and, not least, a necessity for politicians to restrain their
populist instincts, recognise the vital role of professions in effective public policy and
accept their responsibilities for the state/profession partnership.

I shall conclude with some tentative thoughts on the comparative politics of

professions; why some become burdened with near impossible duties and how some
manage even the most difficult of responsibilities more successfully than others

The need for ‘balanced reporting’: From fact to opinion

Imelda McDermott, University of Manchester

Abstract
The advent of medical journalism was initially felt to be an answer to the problem of
communicating health and medical information to the public. However, there is a
concern among scientists that the media distort health and medical information. I offer
a way of looking at the concern for ‘distortion’ using a discourse analytic
methodology of Genre Analysis. Comparison between the genre of Health and
Medical News Reports with the genres of Research Articles, News Texts, Popularised
Texts and Press Releases show that one of the differences between them is the need to
show ‘balanced reporting’ in Health and Medical News Reports. However, when
showing ‘balanced reporting’, journalists present the reaction of users instead of
‘fact’. Thus, I argue that the need to show ‘balanced reporting’ can contribute to the
discourse of ‘distortion’.

Clinical commissioning then and now: what’s the difference?

Dr Kath Checkland, Manchester University

Abstract
The so-called internal market was introduced into the NHS in the early 1990s by the
then Conservative government. Separating ‘purchasing’ health care from ‘providing’
was intended to ensure greater transparency and efficiency, as well as improving the
planning of services. In 1997 ‘New Labour’ announced an end to the ‘divisive’
internal market, but in fact purchasing (now called ‘commissioning’) carried on under
other guises, with Lewis and Gillam arguing that the 2002 publication ‘Delivering the
NHS Plan’ represents the explicit ‘re-invention’ of the internal market.

From the outset, there have been a variety of attempts to involve front-line clinicians
in the commissioning (or purchasing) of care, with a view to not only ensuring that
care is appropriate, but also in the hope of alerting clinicians to the cost-implications
of their decisions. These have successively included: GP fundholding, Total
Purchasing Pilots, PCGs, PCTs and, most recently, Practice-based Commissioning. In
this presentation we will draw together evidence from the past and the present,
comparing the results of historical studies of Health Authority purchasing and of Total
purchasing Pilots with our recent study of Practice-based Commissioning. This
comparison suggests that had those designing PBC studied the available evidence,
some problems might have been avoided. However, it also demonstrates the existence
of important wider contextual factors affecting the practice of clinical commissioning,
some of which have changed in ways that could have been neither designed nor
predicted. The implications of this for policy research and development will be
discussed.

Co-authors:
Dr Anna Coleman & Prof Steve Harrison

User Involvement in Research for Policy Making: Involving Stroke

Survivors in Research and Policy Agenda Setting.

Lucy O’Driscoll, University of East Anglia

Abstract
The ‘National Stroke Strategy’ espouses research into the ‘needs of the patients at
different time points, post-stroke’. The most legitimate voices on the needs of these
patients must necessarily be stroke survivors themselves. Health and social care staff
are exposed to and familiar with patients views and needs but are not the only people
involved in service provision. Policy makers (at a local and governmental level) and
service managers must understand patients’ needs and wants in order that they may
contribute to crafting the services really needed. To this end, the researcher seeks not
only to collect stroke survivors’ insights/understandings of their rehabilitation and
community support needs, but to identify ways to maximise effective communication
of these needs to those with policy making and service delivery responsibilities.

This paper seeks to explore the utility of using ‘Reader’s Theatre’ to give policy
makers and service managers deeper insights into stroke survivors needs and wants.
The researcher proposes collecting the views and experiences of stroke survivors in
relation to rehabilitation and community support and then presenting them in the form
of a reader’s theatre script (a theatre script comprising only the context and dialog and
no stage directions) for policy makers and managers to read. Readings would involve
individuals each taking a part and reading it out loud alongside other ‘players’ so that
each hears the story and participated in the story telling. The researcher would then
seek to explore the extent to which participating policy makers and managers felt that
they had gained additional insights into the issue and to what extent these might
influence their policy decision making, implementation and service management
actions.