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Health Research Policy and Systems
Published in: Health Research Policy and Systems 1/2017

Open Access 01-12-2017 | Research

‘Holding the line’: a qualitative study of the role of evidence in early phase decision-making in the reconfiguration of stroke services in London

Authors: Alec Fraser, Juan I. Baeza, Annette Boaz

Published in: Health Research Policy and Systems | Issue 1/2017

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Abstract

Background

Health service reconfigurations are of international interest but remain poorly understood. This article focuses on the use of evidence by senior managerial decision-makers involved in the reconfiguration of stroke services in London 2008–2012. Recent work comparing stroke service reconfiguration in London and Manchester emphasises the ability of senior managerial decision-makers in London to ‘hold the line’ in the crucial early phases of the stroke reconfiguration programme. In this article, we explore in detail how these decision-makers ‘held the line’ and ask what the broader power implications of doing so are for the interaction between evidence, health policy and system redesign.

Methods

The research combined semi-structured interviews (n = 20) and documentary analysis of historically relevant policy papers and contemporary stroke reconfiguration documentation published by NHS London and other interested parties (n = 125). We applied a critical interpretive and reflexive approach to the analysis of the data.

Results

We identified two forms of power which senior managerial decision-makers drew upon in order to ‘hold the line’. Firstly, discursive power, which through an emphasis on evidence, better patient outcomes, professional support and clinical credibility alongside a tightly managed consultation process, helped to set an agenda that was broadly receptive to the overall decision to change stroke services in the capital in a radical way. Secondly, once the essential parameters of the decision to change services had been agreed, senior managerial decision-makers ‘held the line’ through hierarchical New Public Management style power to minimise the traditional pressures to de-radicalise the reconfiguration through ‘top down’ decision-making.

Conclusions

We problematise the concept of ‘holding the line’ and explore the power implications of such managerial approaches in the early phases of health service reconfiguration. We highlight the importance of evidence for senior managerial decision-makers in agenda setting and the limitations of clinical research findings in guiding politically sensitive policy decisions which impact upon regional healthcare systems.
Literature
1.
Fulop N, Walters R, Spurgeon P. Implementing changes to hospital services: Factors influencing the process and ‘results’ of reconfiguration. Health Policy. 2012;104(2):128–35.CrossRefPubMed
2.
Brown T. Towards an understanding of local protest: hospital closure and community resistance. Soc Cult Geogr. 2003;4(4):489–506.CrossRef
3.
Ahgren B. Is it better to be big? The reconfiguration of 21st century hospitals: Responses to a hospital merger in Sweden. Health Policy. 2008;87(1):92–9.CrossRefPubMed
4.
Oborn E. Legitimacy of hospital reconfiguration: the controversial downsizing of Kidderminster hospital. J Health Serv Res Policy. 2008;13 Suppl 2:11–8.CrossRefPubMed
5.
Choi S, Brommels M. Logics of pre-merger decision-making processes: the case of Karolinska University Hospital. Health Organ Manag. 2009;23(2):240–54.CrossRef
6.
Castel P, Friedberg E. Institutional change as an interactive process: The case of the modernization of the French cancer centers. Organ Sci. 2010;21(2):311–30.CrossRef
7.
Imison C, et al. Insights from the clinical assurance of service reconfiguration in the NHS: the drivers of reconfiguration and the evidence that underpins it–a mixed-methods study. Health Serv Delivery Res. 2015;3:9.
8.
Turner S, et al. Lessons for major system change: centralization of stroke services in two metropolitan areas of England. J Health Serv Res Policy. 2016;21(3):156–65.CrossRefPubMedPubMedCentral
9.
Fontana L. Health planning and the closure of a community hospital. Int J Health Plann Manag. 1988;3(4):273–89.CrossRef
10.
Lepnurm R, Lepnurm MK. The closure of rural hospitals in Saskatchewan: method or madness? Soc Sci Med. 2001;52(11):1689–707.CrossRefPubMed
11.
Cameron JI, et al. Development and implementation of the Ontario Stroke System: the use of evidence. Int J Integr Care. 2007;7:e30.PubMedPubMedCentral
12.
Denis J-L, et al. Escalating indecision: Between reification and strategic ambiguity. Organ Sci. 2011;22(1):225–44.CrossRef
13.
Ko M, et al. Whose social capital matters? The case of US urban public hospital closures and conversions to private ownership. Soc Sci Med. 2014;114:188–96.CrossRefPubMed
14.
Spurgeon P, et al. Evaluating models of service delivery: reconfiguration principles. London: National Institute for Health Research Service Delivery and Organisation Programme; 2010.
15.
Fulop NJ, et al. Explaining outcomes in major system change: a qualitative study of implementing centralised acute stroke services in two large metropolitan regions in England. Implement Sci. 2016;11:80.CrossRefPubMedPubMedCentral
16.
Flyvbjerg B. Five misunderstandings about case-study research. Qual Inq. 2006;12(2):219–45.CrossRef
17.
18.
19.
Morris S, et al. Impact of centralising acute stroke services in English metropolitan areas on mortality and length of hospital stay: difference-in-differences analysis. BMJ. 2014;349:g4757.CrossRefPubMedPubMedCentral
20.
Fairclough N. New Labour, New Language? Abingdon: Psychology Press; 2000.
21.
Newman J. Modernizing Governance: New Labour, Policy and Society. London: Sage; 2001.
22.
Addicott R, Ferlie E. Understanding power relationships in health care networks. Journal of health organization and management. Health Organ Manage. 2007;21(4/5):393–405.CrossRef
23.
24.
Fleming P, Spicer A. Power in management and organization science. Acad Manag Ann. 2014;8(1):237–98.CrossRef
25.
Jones L, Exworthy M. Framing in policy processes: A case study from hospital planning in the National Health Service in England. Soc Sci Med. 2015;124:196–204.CrossRefPubMed
26.
Timmermans S, Berg M. The Gold Standard: The Challenge of Evidence-Based Medicine and Standardization in Health Care. Philadelphia: Temple University Press; 2010.
27.
Goldenberg MJ. On evidence and evidence-based medicine: lessons from the philosophy of science. Soc Sci Med. 2006;62(11):2621–32.CrossRefPubMed
28.
Ferlie E, McGivern G. Bringing Anglo-governmentality into public management scholarship: the case of evidence-based medicine in UK health care. J Public Admin Res Theory. 2014;24(1):59–83.CrossRef
29.
Smith KE, Stewart E. 'Black magic' and 'gold dust': the epistemic and political uses of evidence tools in public health policy making. Evid Policy J Res Debate Pract. 2015;11(3):415–37.CrossRef
30.
Abbott A. The System of Professions: An Essay on the Division of Expert Labor. Chicago: University of Chicago Press; 2014.
31.
32.
Foucault M. Security, Territory, Population. Basingstoke: Palgrave Macmillan; 2007.
33.
Dean M. Governmentality: Power and Rule in Modern Society. London: Sage Publications; 2010.
34.
Bernier NF, Clavier C. Public health policy research: making the case for a political science approach. Health Promot Int. 2011;26(1):109–16.CrossRefPubMed
35.
36.
37.
Stake RE. The Art of Case Study Research. London: Sage; 1995.
38.
39.
Bryman A. Quantity and Quality in Social Research. Abingdon: Routledge; 2003.
40.
London NHS. Healthcare for London: A Framework for Action. London: NHS; 2007.
41.
Martin GP, Learmonth M. A critical account of the rise and spread of ‘leadership’: the case of UK healthcare. Soc Sci Med. 2012;74(3):281–8.CrossRefPubMed
42.
Bowling A. Research Methods in Health: Investigating Health and Health Services. London: McGraw-Hill Education; 2014.
43.
London NHS. Stroke Project Governance Arrangements. London: NHS; 2008.
44.
Murphy E, Dingwall R. Qualitative methods in health services research. Health services research methods: a guide to best practice. London: BMJ Publishing; 1998.
45.
Fulop N, et al. Changing organisations: a study of the context and processes of mergers of health care providers in England. Soc Sci Med. 2005;60(1):119–30.CrossRefPubMed
46.
47.
Doolin B. Enterprise discourse, professional identity and the organizational control of hospital clinicians. Organ Stud. 2002;23(3):369–90.CrossRef
48.
Steier F. Research and Reflexivity. London: Sage; 1991.
49.
Alvesson M, Deetz S. Doing Critical Management Research. London: Sage; 2000.CrossRef
50.
51.
Baeza JI, et al. The roles of specialisation and evidence-based practice in inter-professional jurisdictions: A qualitative study of stroke services in England, Sweden and Poland. Soc Sci Med. 2016;155:15–23.CrossRefPubMed
52.
London NHS. Preliminary Stroke Strategy Document. London: NHS; 2008.
53.
London NHS. The Shape of Things to Come: Developing New, High-Quality Major Trauma and Stroke Services for London. London: NHS; 2008.
54.
55.
Tomlinson B. Report of the Inquiry into London's Health Services, Medical Education and Research. London: HMSO; 1992.
56.
London NHS. The Shape of Things to Come: Consultation Strategy, Appendix 2A. London: NHS; 2009.
57.
London NHS. London Stroke Strategy (Final). London: NHS; 2008.
58.
National Audit Office & Department of Health. Reducing Brain Damage: Faster Access to Better Stroke Care. London: DoH; 2005.
59.
Smith J. Conflict without change: the case of London's health services. Political Quarterly. 1981;52(4):426–40.CrossRef
60.
Appleby J, Ham C, Imison C, Boyle S, Ashton B, Thompson J. Improving Health and Health Care in London. Who Will Take the Lead? London: King’s Fund; 2011.
61.
Turnberg L. London Strategic Review. London: DoH; 1997.
62.
Hood C. A public management for all seasons? Public Adm. 1991;69(1):3–19.CrossRef
63.
Ferlie E. The new public management in action. New York: Oxford University Press; 1996.CrossRef
64.
London NHS. Acute Stroke Services Designation: Overview of Designation Process Appendix 4. London: NHS; 2008.
65.
Ten Have H. Re-evaluating professional autonomy in health care. Theor Med Bioethics. 2000;21(5):503–13.CrossRef
66.
Numerato D, Salvatore D, Fattore G. The impact of management on medical professionalism: a review. Soc Health Illn. 2012;34(4):626–44.CrossRef
67.
Alderwick H, Dunn P, McKenna H, Walsh N, Ham C. Sustainability and Transformation Plans in the NHS. London: King’s Fund; 2016.
68.
Stewart E. Publics and Their Health Systems. Abingdon: Palgrave Macmillan; 2016.CrossRef
Metadata
Title
‘Holding the line’: a qualitative study of the role of evidence in early phase decision-making in the reconfiguration of stroke services in London
Authors
Alec Fraser
Juan I. Baeza
Annette Boaz
Publication date
01-12-2017
Publisher
BioMed Central
Published in
Health Research Policy and Systems / Issue 1/2017
Electronic ISSN: 1478-4505
DOI
https://doi.org/10.1186/s12961-017-0207-7

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