Elsevier

Social Science & Medicine

Volume 80, March 2013, Pages 10-18
Social Science & Medicine

Achieving and sustaining profound institutional change in healthcare: Case study using neo-institutional theory

https://doi.org/10.1016/j.socscimed.2013.01.005Get rights and content

Abstract

Change efforts in healthcare sometimes have an ambitious, whole-system remit and seek to achieve fundamental changes in norms and organisational culture rather than (or as well as) restructuring the service. Long-term evaluation of such initiatives is rarely undertaken. We report a secondary analysis of data from an evaluation of a profound institutional change effort in London, England, using a mixed-method longitudinal case study design. The service had received £15 million modernisation funding in 2004, covering multiple organisations and sectors and overseen by a bespoke management and governance infrastructure that was dismantled in 2008. In 2010–11, we gathered data (activity statistics, documents, interviews, questionnaires, site visits) and compared these with data from 2003 to 2008. Data analysis was informed by neo-institutional theory, which considers organisational change as resulting from the material-resource environment and three ‘institutional pillars’ (regulative, normative and cultural-cognitive), enacted and reproduced via the identities, values and activities of human actors. Explaining the long-term fortunes of the different components of the original programme and their continuing adaptation to a changing context required attention to all three of Scott's pillars and to the interplay between macro institutional structures and embedded human agency. The paper illustrates how neo-institutional theory (which is typically used by academics to theorise macro-level changes in institutional structures over time) can also be applied at a more meso level to inform an empirical analysis of how healthcare organisations achieve change and what helps or hinders efforts to sustain those changes.

Highlights

► We report a secondary analysis of an evaluation of a whole-system change initiative. ► We apply neo-institutional theory to analyse changes in institutional logics. ► Enduring change depends on institutional pillars embodied and reproduced by human actors.

Introduction

Contemporary health services are characterised by near-continuous change on a relatively small scale. Less commonly, changes may involve inter-organisational and cross-sector components in a large-scale, whole-system transformation effort. Here, we consider transformational change, and the challenges of sustaining such change long-term, through the lens of neo-institutional theory, applied to a case study of an ambitious long-term change effort.

In 2003, the London-based Guys and St Thomas' Charity made £15 million available to support a four-year partnership (the ‘modernisation initiative’) between two acute hospital trusts, two primary care trusts, community groups, patient groups and the independent and voluntary sector in the context of a multi-ethnic, inner-city population with high turnover and multiple diverse health and social care needs. Three services – stroke, kidney and sexual health – were selected by competitive bidding to receive £5 million each for ‘wholescale transformation’ aimed at making healthcare more efficient, effective, and patient-centred. Our team were external evaluators of the modernisation initiative from 2003 to 2008. In 2010, we were invited by the Charity to return to the case and evaluate what if anything had been sustained and how the programme had evolved and adapted.

There are many versions of neo-institutional theory. The one proposed by DiMaggio and Powell (1983) and further developed in relation to healthcare by Scott, Ruef, Mendel, and Caronna (2000) has its roots in organisational sociology. Institutions, defined as social structures that have achieved a high degree of resilience, are influenced by three broad types of social forces or ‘pillars’: regulative (laws and contracts which stipulate what must happen), normative (assumptions and expectations about what should happen) and cultural-cognitive (taken-for-granted scripts and mental models about what generally does happen) (Scott et al., 2000). Each pillar offers a different rationale for legitimacy, by virtue of being (respectively) legally sanctioned, morally (e.g. professionally) authorised, or culturally supported. The three pillars are analytically separable, but at an empirical level they tend to be intertwined. Mirroring these three pillars, institutional change may be attempted by three fundamental mechanisms: coercive (by altering regulative pillars, as in top-down restructuring); normative (by altering the expectations of what is right and reasonable) or mimetic (for example, when organisations seek to copy what they consider to be a model of best practice) (DiMaggio & Powell, 1983).

Scott observed that healthcare systems sometimes seek to achieve ‘profound institutional change’, which he defined as follows: it is multi-level (involves new roles for individuals and/or new organisational forms), discontinuous (not merely incremental), and characterised by new rules and governance mechanisms (both informal norms and formal regulatory systems), new logics (that direct, motivate and legitimate the behaviour of actors in the field), new types of social actors (both individual and organisational), new meanings (associated with the attributes or the behaviour of actors in the field or the effects associated with them), new relations among actors (especially exchange and power relations), modified population boundaries (the boundaries separating organisational populations, organisations, customary activities, and personnel blend and blur), and expanded, reduced or realigned field boundaries (Scott et al., 2000). By ‘field’, Scott implicitly drew on Bourdieu's definition of the term as a “a space of [social] positions and position-takings” (page 30) (Bourdieu, 1993), thus emphasising the relational and cultural aspects of social systems.

External forces for change can be categorised into two types of environments: material-resource (which includes demand-side factors such as demographics and supply-side factors such as physician availability, technologies and external grants) and institutional (comprising institutional logics, institutional actors and governance systems) (Scott et al., 2000). Institutional logics are socially shared, deeply held assumptions and values that form a framework for reasoning, provide criteria for legitimacy, and help organise time and space (Friedland & Alford, 1991). Through the duality of structure and agency, institutional actors function as both carriers and creators of institutional logics (Giddens, 1986). They participate in both the material-resource environment (as ‘consumers’ or ‘suppliers’ of health services) and in the institutional environment (possessing institutionally-defined identities, capacities, rights and responsibilities; and by making meaning from their perceptions and experiences) (Scott et al., 2000).

The UK National Health Service (NHS) is a collection of organisations that share, to a greater or lesser extent, a common mission and values. Until fairly recently, they also shared a common regulatory and funding structure, but from around 1998 the different countries within the United Kingdom developed different political-regulatory mechanisms (Hughes & Vincent-Jones, 2008). While the NHS is sometimes colloquially referred to as a ‘national institution’ and depicted by staff and patients as a homogeneous ‘brand’ maintained more or less continuously since 1948, it is more accurate to consider it as a heterogeneous and evolving organisational field which is exhibiting a growing degree of divergence (Checkland, Harrison, Snow, McDermott, & Coleman, 2012; Hughes & Vincent-Jones, 2008).

Early research on the NHS using neo-institutional theory considered how the field was changing (or not) as a result of coercive, normative and mimetic forces (Currie & Guah, 2007; Currie & Suhomlinova, 2006; Hughes & Vincent-Jones, 2008; McNulty & Ferlie, 2004). Recent critiques that neo-institutional analyses have tended to privilege the study of structure over agency and theory over empirical findings (Battilana, Leca, & Boxenbaum, 2009; Suddaby, 2010) have prompted a new research tradition focussing on empirical questions at the meso level of organisational life (such as how commissioning is enacted in the UK National Health Service (Checkland et al., 2012)) and/or on the micro level of how individual staff members, through their dispositions and actions, make organisational life meaningful and reproduce and/or change the field (Lockett, Currie, Waring, Finn, & Martin, 2012; Macfarlane, Exworthy, Wilmott, & Greenhalgh, 2011).

In this paper, we sought to contribute to this emerging tradition emphasising the empirical value of neo-institutional theory by undertaking a secondary analysis of a longitudinal study of whole-system transformational change.

Section snippets

Description of the case

The charity-funded modernisation initiative, introduced in Background Section, included over 30 work streams representing a diverse range of projects. Change methodologies used in the transformation programme in 2003–8 included [a] collecting and applying ‘best evidence’; [b] coordinating and streamlining services; [c] recruiting, redeploying and training staff; [d] promoting and supporting self care; [e] involving patients and carers in quality improvement; and [f] ensuring diversity of

Aims, objectives and research questions

In this secondary analysis, we sought to explore the institutional nature of whole-system transformational change in public-sector healthcare by re-analysing a unique and extensive dataset collected over an 8-year period (note: for the two years 2008–10, we had no direct observations, though we did obtain numerous first-hand retrospective accounts and historical documents). Both the original evaluation and the later follow-up study had been explicitly framed as ‘change management’ by the funder

UK healthcare: a changing institutional field

Healthcare is a complex organisational field characterised by conflicting and changing institutional logics. England, for example, has gone through four (partially overlapping) ‘eras’ in recent decades – professional dominance and social inclusion (1948–72); managerialism (1972–97); market mechanisms (1997–2010, characterised by the centrally-driven ‘new public management’: improved efficacy, cost-effectiveness and accountability of public services, and the quality improvement movement); and

Discussion

This case study of a long-term follow-up of a charity-funded service transformation effort has illustrated how neo-institutional theory can be applied empirically at the meso level of organisational life to illuminate and explore the challenges of achieving sustainable change in healthcare systems. Specifically, it allows transformational change to be defined and analysed in terms of (more or less enduring) changes in organisational members' cognitive scripts and schemas (‘logics’) and to

Funding

This work was funded by a research grant from Guys and St Thomas' Charity. Our funders were not involved in the selection or analysis of data, or in contributing to the content of the final manuscript.

Acknowledgements

We are grateful to Guys and St Thomas' Charity for research funding and to all study participants for their time and commitment to the evaluation. We thank Jonathon Hope who chaired the steering group for this study and students David Hill, Fatima Atif and Rob Macfarlane who assisted with data collection and processing. We also thank the editor and three anonymous reviewers for very helpful comments on an earlier draft of this paper.

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