McKee, L., Ferlie, E. and Hyde, P. ( eds ). Organizing and reorganizing: power and change in healthcare organizations . Basingstoke : Palgrave Macmillan , 2008 £58 272 pp . ISBN 13: 978-0-230-542945 ( hbk ).
Health services are constantly evolving in response to internal and external stimuli, including the availability of resources, bright ideas, public need, medical innovation and ideological shifts in power. The nature of such large organizational structures is necessarily complex and many challenges arise when we attempt to understand how they are managed and how change can be productive. This edited book represents a range of applied academic work that aims to describe and explain change processes in health care management, focusing on issues arising around important but often slippery interfaces, particularly between research and the policy.
The book comprises 16 short but detailed chapters that critically describe and discuss different aspects of organizational change in health services in the UK and other Anglophone countries, drawn from a conference on organizational behaviour in health care. The authors all appear to be strongly engaged with, and highly knowledgeable about, the fields in which they work. A key theme is the relationship between evidence and decision-making about health service delivery. This incorporates the production of evidence and its use and status, including its relationship with knowledge and power. In line with this theme, the papers are grouped around three sub-themes. The first is what research tells us about organizing and reorganizing in health care. The second is the research/policy interface. The third is developing a theoretical and empirical research base for handling organizational politics and change. These sub-themes are examined against a backdrop of factors such as limited resources, devolved decision-making and professional morale and motivation.
The authors are from a range of disciplinary backgrounds, including sociology, policy, politics, management research and psychology. Consequently a large number of theoretical perspectives are drawn upon. Each paper considers a different aspect of health care delivery, generally using one or more case study from the field. The examples are taken from studies of health care in diverse settings, including primary care services, hospitals, medical treatment centres, and nursing homes. This mix of research and theory works well to give the reader an understanding of how organizational processes work in relation to particular cases and also what can be learned and applied in other areas.
David Hunter provides an interesting review of the highly politicized nature of health policy in the UK National Health Service (NHS) and its delivery, using examples from the introduction of general management policy in the mid-1980s, and the more recent introduction of the Private Finance Initiative (PFI). He argues that, although there is considerable talk of ‘evidence-based health care’, policy is being driven through by ideology rather than evidence. Decisions about major change initiatives such as the PFI have entailed considerable investment in management consultants compared with research. In addition, research evidence that does not fit well with ideology is often hidden away or ignored. Hunter further argues that the PFI is an example ‘of the perceived creeping privatization of the NHS that is being undertaken largely by stealth in the absence of public debate’ (p.94). He also calls for more qualitative research that helps to elucidate the dynamics of organizational life, rather than research which produces quick prescriptions. Interestingly most of the research discussed in this book is qualitative.
The difficulties inherent in critically evaluating health care organizations which often turn into moving targets when attempts are made to evaluate them is clearly described by Pope et al. They examine the pragmatics of evaluation research in health care in a case study of a new model of health care delivery in the NHS, treatment centres (TCs). A challenge in the analysis was that ‘our subject was metamorphosing, continually, during the research’ (p.115). In fact, the object of study, the TC, did not appear to exist, or certainly not in the form it was expected to. Only one of the nine case study sites was deemed to fulfill the defining criteria of a TC as set out in policy. A key question arising from the project was ‘how did a clearly prescribed initiative give rise to such diversity of product?’ (p.120). The authors highlight an important factor in considering organizational change, that what is set out in policy nationally may not be valid in local settings.
The potential value of ‘systems thinking’ as a way of providing new models for policy-research collaboration is explored by Best et al. Their interest in systems models stems from a perceived need to move on from linear and relationship models of knowledge dissemination or transfer, by taking into account different systems, actors and perspectives. This approach leads to knowledge integration in which the use of knowledge gained through research is said to be ‘a function of effective integration with the organization and its systems’ (p.159).
The intricacy of health care organization described and examined across these 16 papers can be taken as a reflection of the spider’s web of inter-related issues and interests that constitute health services. The book contains considerable insights into a number of different aspects of health management including how different methodologies for researching organizational processes can be applied, discussions of competing interests and power relationships, theorization and modelling of organizational processes, and the value of inter-disciplinary research. Many incisive questions are raised by the book’s contributors. For example, can health service management be evidence-based in the same way that health technologies are expected to be? From a sociological perspective the papers emphatically bring out the need to attend to context when studying organizations and identifying lessons to be learned.