Negotiating the dilemmas of health system governance: A decentred analysis of integrating care systems
Keywords:
health system governance, integrating care systems, health system reform, decentred theory, negotiated order thesisAbstract
Across high income countries, policy makers seek to reform their health systems to promote public health, address long-term care needs, and reduce the burden on acute care. Policy narratives articulate a model of health system governance premised on multi-agency collaboration and service integration. Combining decentred theory with the negotiated order thesis, this paper examines how local policy actors interpret and negotiate the dilemmas presented by such reform in the context of their customary ways of working. Reporting on the findings of a three-year study of the introduction of Sustainability and Transformation Partnerships in the English health and care system, we focus on how policy actors negotiate the dilemmas manifest around the vision and priorities for, and the governance of, health system change. In each area, we show that structural interests and governing traditions shape actors’ orientation towards system change. This results in tensions that are resolved (or not) through localised negotiations between policy actors, which vary according to whether they were open or closed, structured or emergent, and whether they had a significant or limited impact on system governance. The paper shows that health systems reform is contingent upon how local policy actors translate and negotiate policy narratives.
References
Allen, D. (1997) The nursing-medical boundary: a negotiated order? Sociology of Health & Illness, 19(4), 498–520. https://doi.org/10.1111/j.1467-9566.1997.tb00415.x
Ansell, C., & Gash, A. (2012) Stewards, mediators, and catalysts: Toward a model of collaborative leadership. The Innovation Journal: The Public Sector Innovation Journal, 17(1), 2012, article 7.
Ansell, C., & Gash, A. (2008) Collaborative governance in theory and practice. Journal of Public Administration Research and Theory, 18(4), 543–571.
Bevir, M., & Richards, D. (2009) Decentring policy networks: A theoretical agenda. Public Administration 87(1), 3–14. https://doi.org/10.1111/j.1467-9299.2008.01736.x
Bevir, M., & Waring, J. (2017). Decentring health policy: traditions, narratives, dilemmas. In M. Bevir & J. Waring (Eds.), Decentring health policy: Learning from the British experience in healthcare governance. Routledge.
Bevir, M., & Waring, J. (2017) Decentring health policy. Routledge.
Bishop, S. (2020) Space and place in network governance: Putting integrated care into place. In M. Bevir & J. Waring (Eds.), Decentring Health and Care Networks: Reshaping the Organization and Delivery of Healthcare (pp. 95-120). Palgrave. https://doi.org/10.1007/978-3-030-40889-3
Buck, D., Baylis, A., Dougall, D., & Robertson, R. (2018) A vision for population health. King’s Fund.
Day, R., & Day, J. V. (1977) A review of the current state of negotiated order theory: an appreciation and a critique. The Sociological Quarterly, 18(1), 126–142.
Ferlie, E., Mcgivern, G., & FitzGerald, L. (2012) A new mode of organizing in health care? Governmentality and managed networks in cancer services in England. Social Science & Medicine, 74(3), 340–347. https://doi.org/10.1016/j.socscimed.2011.03.021
Glasby, J. (2017) The holy grail of health and social care integration. BMJ, 356, j8-1. https://doi.org/10.1136/bmj.j801
Glasby, J., & Miller, R. (2020) Ten lessons for integrated care research and policy – a personal reflection. Journal of Integrated Care, 28(1), 41–46. https://doi.org/10.1108/JICA-11-2019-0047
Goodwin, N., Stein, V., & Amelung, V. (2021) What is Integrated Care? In A. Volker, V. Stein, E. Suter, N. Goodwin, E. Nolte, & R. Balicer (Eds.), Handbook of integrated care (pp. 3-25). Springer.
Hall, P.M., & Spencer-Hall, D.A. (1982) The social conditions of the negotiated order. Urban Life, 11(3), 328–349. https://doi.org/10.1177/089124168201100305
Kaehne, A. (2018) Values, interests and power: the politics of integrating services. Journal of Integrated Care, 26(2), 158–168. doi 10.1108/JICA-01-2018-0007
Klijn, E.H., & Koppenjan, J. (2012) Governance network theory: Past, present and future. Policy & Politics 40(4), 587–606. doi.org/10.1332/030557312X655431
Maines, D., & Charlton, J. (1985) The negotiated order approach to the analysis of social organization. Studies in Symbolic Interaction, Suppl 1, 271–308.
McKee, M., Dunnell, K., Anderson, M., Brayne, C., Charlesworth, A., Johnston-Webber, C., … & Watt, R.G. (2021) The changing health needs of the UK population. The Lancet, 397(10288), 1979-1991. https://doi.org/10.1016/S0140-6736(21)00229-4
Mesler, M.A. (1989) Negotiated order and the clinical pharmacist: the ongoing process of structure. Symbolic Interacteraction, 12(1), 139–157. https://doi.org/10.1525/si.1989.12.1.139
Moran, V., Allen, P., Sanderson, M., McDermott, I., & Osipovic, D. (2021) Challenges of maintaining accountability in networks of health and care organisations: A study of developing Sustainability and Transformation Partnerships in the English National Health Service. Social Science & Medicine, 268, 113512. https://doi.org/10.1016/j.socscimed.2020.113512
Mouffe, C. (2011) On the political. Routledge.
Newman, J. (2001) Modernising governance: New Labour, policy and society. Sage.
NHS England (2019) The NHS Long Term Plan. NHS England.
Osborne, S.P. (2006) The new public governance? Public Management Review. 8(3), 377-387. DOI: 10.1080/14719030600853022
O’Toole, R., & O’Toole, A.W. (1981) Negotiating interorganizational orders. Sociological Quarterly, 22(1), 29–41. https://doi.org/10.1111/j.1533-8525.1981.tb02206.x
Strauss, A. L. (1978) Negotiations: Varieties, contexts, processes, and social order. Jossey-Bass
Strauss, A., Schatzman, L., Bucher, R., Ehrlich, D., &. Sabshin, M. (1963). The hospital and its negotiated order. In E. Freidson (Ed.), The hospital in modern society (pp. 147-69). Free Press.
Valentijn, P.P., Schepman, S.M., Opheij, W., & Bruijnzeels, M.A. (2013) Understanding integrated care: A comprehensive conceptual framework based on the integrative functions of primary care. International Journal of Integrated Care, 13. e010. doi: 10.5334/ijic.886
Waring, J., Bishop, S., Black, G., Clarke, J. M., Exworthy, M., Fulop, N. J., ... & Roe, B. (2023) Navigating the micro-politics of major system change: The implementation of Sustainability Transformation Partnerships in the English health and care system. Journal of Health Services Research & Policy, 28(4), 233-243. https://doi.org/10.1177/13558196221142237
Waring, J., & Crompton, A. (2020) The struggles for (and of) network management: an ethnographic study of non-dominant policy actors in the English healthcare system. Public Management Review, 22(2), 297–315. https://doi.org/10.1080/14719037.2019.1588360
Waring, J., Roe, B., Crompton, A., & Bishop, S. (2020) The contingencies of medical restratification across inter-organisational care networks. Social Science & Medicine, 263, 113277. https://doi.org/10.1016/j.socscimed.2020.113277
World Health Organization (2016) Health system transformation: Making it happen. World Health Organization.
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