Health Policy & Politics Network (HPPN) Conference

University of Manchester
16 March 2010

ABSTRACTS
Repositioning the patient – Repositioning the professionals
Sue Llewellyn, corresponding author (The Herbert Simon Institute for Public Policy and Management,
Manchester Business School), Inga-Lill Johansson (Gothenburg University) & Ewa Wikström
(Gothenburg University)

Policy makers are seeking to reposition patients in the health care field, giving them additional rights and new
responsibilities for their own care- producing a patient whose identity is more ‘appropriate’ for the 21st
century. However, for this new positioning to be ‘performative’, it has to be negotiated within local
interactions between patients, doctors, nurses and managers. Thus, repositioning the patient, repositions the
professionals. We understand repositioning through ‘positioning theory’, ‘position-practices’ and ‘identity’.
Re-positioning is explored in two networks- one in the UK, the other in Sweden. We find that repositioning
embeds several story lines, reflecting and constituting differing emergent patterns of power constellations,
actions, meanings, rights and responsibilities- dependent upon whether the narrator is a doctor, a nurse or a
manager. We conclude that only a more consistent and coherent patient identity will make ‘repositioning the
patient’ a determinate policy agenda.

Acknowledgment: This work was partially funded by the Swedish Research Council, under the title of
‘Collaborative Care’

How the response to voice can stem exit: Testing the impact of the responsiveness of education, health
and local government services to individual complaints in the UK

Keith Dowding (Australian National University) & Peter John (University of Manchester)

This paper uses Hirschman’s framework of exit, voice and loyalty to understand how citizens react to public
services' attempts to respond to their individual voices (complaints). The paper argues that a perception that a
complaint is sorted out will prevent citizens from considering exit as a response to dissatisfaction, so
maintaining the constructive relationship between active citizens and public agencies. Equally the obverse is
true if the complaint is not responded or is responded to unsatisfactorily. The paper tests these ideas from a
five-year internet panel survey of citizens from 2004-9, analysing citizen complaints to education, health and
local government services and their subsequent behaviours. The paper finds that effective responses do stem
jurisdictional exits but there is no impact on exit to the private sector.

Going for Gold: The relationship between beliefs, evidence and public health policy

Alison Hann (Swansea University) & Stephen Peckham (London School of Hygiene & Tropical
Medicine)

There is a longstanding interest in the relationship between evidence and policy and a number of models and
frameworks have been developed to explain how policy makers make use of research knowledge and
evidence. In recent years the focus on evidence based policy has become a key focus of public policy. In
health care the drive towards evidence based medicine and practice has underpinned debates about evidence
based health policy. However, in many areas of health care there is a lack of evidence or the evidence is
highly contestable – often shaped by ideas related to medical practice. This is particularly so in the area of
public health policy as it involves decisions to be made about important questions relating to the degree or
distribution of health harm or benefit but also how to define those health harms and benefits and balance these
against issues such as individual freedom. Public health is, by its very nature, a more political process than
medicine as it deals with social processes and the wider population. Values are more explicit in relation to
public health than medical practice although it is clear that values are an important element of any system of
health care. In this paper we will present a framework “The Gold Effect” that provides a useful approach to
analysing the construct of many public health policies and how beliefs can shape both policy and also the
evidence used to support public health policy.
From apartheid to neoliberalism: Health equity in post-apartheid South Africa

Dr Peter Baker (Whipps Cross University Hospital NHS Trust)

In 1994, the African National Congress (ANC) won South Africa’s first ever democratic election. It inherited
a health service that was indelibly marked with the inequities of the apartheid era, highly privatized and
distorted toward the hospital needs of urban Whites. The ANC’s manifesto promised major improvements, but
this study finds only two significant health equity improvements: (1) primary care had funding increased by
83 percent and was better staffed; and (2) health care workers became significantly more race-representative
of the population. These improvements, however, were outweighed by equity losses in the deteriorating
public-private mix. Policy analysis of the elite actors attributes this failure to the dominance of the Treasury’s
neoliberal macroeconomic policy (GEAR), which severely limited any increases in public spending. The
ANC’s nationalist ideology underpinned GEAR and many of the health equity decisions. It united the ANC,
international capital, African elites, and White capital in a desire for an African economic renaissance. And it
swept the population along with it, becoming the new hegemonic ideology. As this study finds, the successful
policies were those that could be made a part of this active hegemonic reformation, symbolically celebrating
African nationalism, and did not challenge the interests of the major actors.

Ethical principles and approaches to research governance in health care systems: Conceptual and
methodological implications

Walter Flores (Centre for the Study of Equity and Governance in Health Systems)

Governance refers to strategic decisión-making processes in which power relations and individual interests of actors and
organizations play a major role. Conflict and consensus situations are inherent to those processes. In addition, the
decision-making occurs within ethical and incentives’ framework that may be either explicit or implicit. Most countries
in the Latin American region state (legally) that the principles of equity, solidarity, social participation and the right to
health are foundational to their health care systems. Therefore, those principles should direct the governance processes.
However, this is not always the case and it is frequently observed decisions that contravene those principles. Hence,
studying the governance of health care systems is relevant to understand the politics of public health policy-making and
to identify actions and strategies that can be implemented to influence decisions towards equity, accountability and
transparency in health care systems.

Researching governance in health care systems imposes several challenges. First, one need to part from the idea of “good
governance” pushed by international cooperation agencies that is very much aligned with neo-liberal policies and have
even been denounced as an ethnocentric approach to development and policy-making. It requires also separating from
the “new public management” approach that sees governance as a group of technical tools and procedures to administer
decentralized governments (de-politicized processes). Instead, governance is a political process whose main purpose is to
promote decision-making supportive of equity and social justice. Some authors called this approach as “democratic
governance” to differentiate from the other two approaches. This paper will describe the type of indicators, tools and
source of information that each of the approach uses and will discuss why they arrive to different conclusions. The paper
makes an emphasis on applying the democratic governance approach since is the only one that explicitly states issues of
power relations and the need to pursue equity, social justice and citizen participation. Finally, examples will be provided
of ongoing research in Latin America using that approach.

Governance in Municipal Development Councils of Guatemala: Analysis of actors and power relations

In most countries from Latin America and the Caribbean, new public spaces for participation in public polices have been
created through decentralization and other policies. In these spaces, community representatives, municipal and other
ministries authorities, debate and agree social investment plans, including health care infrastructure and other services.
One of the best known experiences is the participatory budgeting of Porto Alegre, Brazil. Similar experiences exist
throughout Latin America. In Guatemala, this public space is the “Municipal Development Council (MDC)”, which is a
structure at municipal government level, that set priorities and plans for resource allocation at the municipal level. This
study analyzes the “governance” of the MDC with an emphasis on actors and power relations. Governance is understood
as the strategic decision-making in public policies aiming to improve equity, transparency and accountability. Six rural
municipalities were studied, applying quantitative and qualitative techniques around three analytical categories: a)
strategic actors participating in MDC b) rules of the game (both formal and non-formal rules) c) levels of asymmetrical
power among social actors participating in MDC.

The key findings revealed inconsistencies between the social actors that must participate (as stated in the legal
framework) and the ones that do it in practice. There is also conflicting interest among social actors: Not all of them seek
improved equity, transparency and accountability. This imposes limitations to reach consensus. The analysis of rules of
the game identified both formal and non-formal rules that provide greater capacity of influencing decision-making to
some actors. In general, the rules of the game favor the status quo and places many barriers to implement public policies
that will involve re-allocation of resources towards population groups and regions that face large inequities. Finally, the
analysis of asymmetrical power revealed that community representatives face a major disadvantage to participate and
influence the decision-making in MDC. As results, investment priorities emerging from those public spaces are not
consistent with the aim of improved equity, accountability and social participation in public policy (which are the
founding principles in the law that created the MDC). Overall, this study provides evidence of the politics of public
policy-making and the importance of acknowledging and researching asymmetrical power relations as a major barriers
toward public health policies promoting equity, accountability and social participation. The presentation at the
conference will also describe the innovative indicators and data collection tools applied to study asymmetrical power
relations.

Opening up the ‘black box’ of local delivery to improve health and reduce inequalities: A sociological
study of one local public health system

Rebecca Mead (University of Chester)

The election of a Labour Government in 1997 signalled a significant policy departure from the previous
administration in that there was a strongly expressed commitment to improving health at the population level
and reducing inequalities in health. Whilst these objectives have become established in policy rhetoric the
Government has expressed concern about policy implementation in relation to the delivery of improvements
in health and the narrowing of health differentials. Further, focusing on the wider determinants of health has
led to a sustained emphasis in policy documents on the need for partnership working in order to engage and
mobilise the local public health system so that social and environmental factors that influence health can be
addressed. There has been a plethora of research over the last decade that has shown partnership working to
be problematic for a variety of reasons. A key concern for the Government, not only with regard to health, is
the ability to get policies and decisions implemented effectively. Within policy analysis this often results in
what numerous authors refer to as the policy ‘implementation gap’. This paper will explore policy
implementation at a local level, the overall aim of which is to understand how the local public health system
works in translating public health policy aspirations into local delivery plans and activities with the aim of
improving population health and reductions in health inequalities. It is anticipated that the study will focus on
the following research questions: 1) how local priorities emerge, given the background of national targets; 2)
how the formal structures – the Local Strategic Partnership (LSP), thematic groups and area boards – facilitate
the operationalisation of local priorities; and 3) how is the LSP investing in prevention and early intervention?
One local public health system will be the focus of this research, which will be used as a case study. Using a
sociological approach the project will make use of sensitizing concepts in order to explore the processes,
networks and pathways that mediate the work of the public health system.
‘Implementation is not always easy’? Revisiting Matland’s Ambiguity-Conflict Model of Policy
Implementation to understand Lord Darzi’s Next Stage Review

Martin Powell, Ross Millar and Abeda Mulla (Health Services Management Centre, University of
Birmingham)

Reflecting on his report 'High Quality Care for All' 'one year on', Lord Darzi recognised that 'implementation
is not always easy'. The paper aims to critically examine the Matland model of implementation drawing on the
Darzi Report. It uses interview material from six case study sites to illuminate how the implementation of
Darzi can be associated with Matland’s four categories of implementation: administrative, political,
experimental and symbolic. The reforms illuminate the problems of the Matland model (e.g. defining
ambiguity and conflict) and suggest that a fifth category of ‘going with the grain’ can be advanced.

Organisational failure and flourishing following health system reform: Cases from primary care

Sheaff, R: Child, S : Schofield, J: Pickard, S: Mannion, R. (Universities of Plymouth, Exeter,

Context: The statutory framework and funding systems for English NHS primary care were substantially
changed in 1991,1998 and 2004, altering both the incentives for primary care providers and the range of
organisations permitted to provide primary care, in particular those providing primary medical care outside
working hours (out-of-hours (OOH) services). The 1991 changes stimulated the formation of general
practitioner (GP) co-operatives to provide OOH services. Subsequent NHS reforms were however followed
by organisational failure for some of these cooperatives but expansion for others. Since the changes to
primary care financing and regulation were uniform, the causes of these different organisational outcomes
must include more particular managerial and organisational factors which mediated the effects of financial
reforms differently for different providers. This paper aims to identify these factors and explain their
operation.

Method: Multiple longitudinal case study comparing three English OOH cooperatives purposively selected for
differences in the consequences of NHS primary care reforms for them:
A) Failure: Cooperative (A) ceased to operate and converted into a for-profit firm.
B) Retrenchment: Cooperative (B) survived but with greatly reduced activity.
C) Flourishing: Cooperative (C) expanded and diversified its activity
Data were collected by interview, site visits, content analysis of documents and web-pages, . Framework
analysis using a conceptualisation of the relationships between organisational environment, structure and
work-processes developed in previous studies. Additionally a systematic literature review was undertaken.

Results:
1. All three co-operatives initially had similar organisational structures. A board (or equivalent) was
elected by subscribing GPs on a one-GP-one-vote basis. It managed a hierarchy of support staff and
organised voluntary (but paid) inputs by member-GPs.
2. The organisational failure was caused by weaknesses in governance structures which enabled leading
cooperative (A) members to 'capture' control of the cooperative and its resources; and by a 'garbage
can' approach to management by their local Primary Care Trust (PCT).
3. The retrenchment resulted from the financing of primary care shifting towards competitive tendering,
so that cooperative (B) lost activity to competitors (both commercial and other cooperatives).
In both cases (A) and (B) the commissioning organisations (local PCTs) played an important role, either
accommodating (case A) or instigating (case B) events which led to organisational failures in the
cooperatives. Conversely cooperative (C) flourished because its commissioning PCTs were satisfied with its
services (partly because of the networking style of communications strategy which it adopted) and senior
managers on both sides supported the cooperative model.
Discussion

The cases of organisational failure and organisational retrenchment illustrate Michel's 'iron law of oligarchy'
in settings which have not previously furnished much evidence about the validity of that 'law'. They have
implications for the internal governance and management of cooperatives more generally. A policy of
competitively selecting and financing health care providers implies - and in one sense is intended to cause -
the organisational failure of weaker competitors. However the precise rules of competition, local managers'
discretion, competence and normative policy preferences appeared to determine whether, in practice, the
competition was predisposed to favour commercial or third-sector providers.
The neglected milk of the neo-liberal cow: A crisis of ethical practice

Mervyn Conroy (Health Services Management Centre, University of Birmingham)

This paper looks at what a ‘crisis of ethical practice’ means for leadership of healthcare reform policy through
the accounts of managers in the midst of neo-liberal reforms to the NHS. It traces the narratives of a group of
leaders from a number of NHS trusts, who begin by constructing powerlessness in their situation and then
through a leadership education programme, which helped them question the ideological workings of neo-
liberal reform, begin to construct their courage to discern what will serve their communities and the greater
well being of society. The paper broadens existing debates associated with the contested purpose of public
organisations (for example, Hogget 2006) by highlighting dissonance between leadership of reform ethics and
practice ethics. A call is made for the ethical dimension of public sector reform leadership theory, education
and practice to be given more attention.

Drawing on the work of Žižek (1989-2004), de Cock and Bohm (2007) offer an insight into the Janus faced
nature of neo-liberalism that our society has sanctioned as the saviour of morality, the answer to quality of life
for all and the defence against the fear of totalitarianism. One face presents personalisation, freedom and
innovation and the other a controlling hegemony allied to market brand maintenance: ‘You are free to do
anything you want as long it involves shopping’ (ibid: 828). MacIntyre (1985) suggests that the harbinger of
such misdirected good intentions was the enlightenment and that we now exist in a post virtuous era coping
with the loss of a binding narrative of ethical practice in our dealings with others. Operating outside social and
historical traditions people have had placed upon them the impossible burden of becoming their own moral
authority. Practices in private and now our public and third sector institutions have succumbed to the
corrupting influence of money, status and power. Recent events in the financial markets, MPs expenses and
fixing of TV voting, Formula 1 and football games would seem to concur with Žižek’s and MacIntyre’s
theses. The perverse effects (Pidd 2005) on hospital practices in response to targets setting and recent claims
of high mortality rates would suggest that the healthcare sector is not immune.

International recruitment of health professionals in the NHS in the early 2000s: Between human rights
and managerial discourse

Evgeniya Plotnikova (University of Edinburgh)

Cross-border labour mobility in the health sector is portrayed as both an opportunity for health professionals
immigrating to developed countries, and as a challenge for patients remaining in low-income countries with
restricted access to health care provision. In policy debate, this problem is articulated as the opposition
between, ‘the right to freedom of movement’ and ‘the right to health’. The underlying layers of this dilemma
expose competing institutional interests of source and destination countries, international organisations,
private recruitment agencies, trade unions and professional organisations. To resolve some of these tensions,
and in response to accusations from source countries and international organisations about the active
recruitment of health professionals, an ethical recruitment policy was adopted in the UK in the early 2000s.

This paper focuses on three aspects of this ethical recruitment policy: its origin, the instruments of
implementation and its ability in reconciling the dilemma between the ‘right to health’ versus the ‘right to
freedom of movement’.

The qualitative content analysis, employed in this study, refers to policy documents produced by international
organisations, government bodies, professional nursing organisations and trade unions in Britain. The
theoretical framework of analysis uses a policy instruments approach. This study contributes to the discussion
on the potential of the ‘soft law’ instruments to invoke human rights at the national level.

The key findings reveal the transformation of the human rights discourse in national policy implementation.
This article argues that the policy of ethical recruitment, originated initially in the discourse of human rights,
is translated at the national level in the managerial discourse regarding the ethical responsibilities of
employers in Britain. This transformation is reflected in policy instruments (Code of Practice and
government-to-government agreements), which mainly protect the reputation of institutional stakeholders
rather than the individual right to health of patients in developing source countries.

Understanding organisational and economic change in general practice: Shifting the focus from
professionals to workers

Sudeh Cheraghi-sohi (National Primary Care Research & Development Centre, University of
Manchester)

Much of the burgeoning empirical literature on the impact of the new UK General Medical Services Contract
(nGMS) and it’s performance-related-pay scheme (the Quality and Outcomes framework or ‘QOF’), has
adopted the well-established analytical viewpoint of treating physicians (in this case general practitioners
(GPs)) as professionals. In contrast to such monolithic approaches, this paper seeks to add to the literature by
taking an alternative approach, one that illuminates the impact of the reforms from a micro-level ‘worker’
perspective. The work of Lipsky (1980) allows for such a focus and is employed in the present study. Lipsky’s
analysis and his classification of public service workers as ‘street level bureaucrats’ (SLBs) has been widely
cited and used as a theoretical framework in order to analyse policy changes in other areas of public sector
work, such as social work and education; as well as to understand the responses of GPs to previous primary
care policies (Checkland 2004; McDonald 2002). The current work seeks to understand the impact of the
QOF on the work of ‘street-level’ GPs and uses Lipsky’s SLB framework within which to view these
findings.