Redrawing boundaries within healthcare: Scandinavian experience

Article Type: Introduction From: Journal of Health Organization and Management, Volume 22, Issue 4

About the Guest Editors

Signe Vikkelsø Associate Professor at the Centre for Health Management at Copenhagen Business School. Signe Vikkelsø does research on the uses of information technology in healthcare organisations, and on how technologies and the social expectations towards them reshape work practices and identities in the healthcare field.

Peter Kjær Associate Professor at the Center for Health Management at Copenhagen Business School. Peter Kjær’s research focuses on media and organisations, on strategic communication in the hospital field, and on the role of patients in processes of healthcare governance.

In the last two decades, Scandinavian healthcare systems have experienced profound processes of change on many dimensions, e.g. structural reforms of hospital fields, new types of healthcare organisations, an explosion of new quality standards, and altered relationships between healthcare professionals and patients. It is difficult, even at a cursory level, to describe these changes without noticing that our healthcare terminology has also changed. We talk of “networks” rather than “administration”, we talk of “organisations” rather than, for example, “hospitals”,and we are increasingly talking about “users” rather than “patients”. Organisational and institutional changes seem accompanied by changes in vocabularies that bring new distinctions and concerns to the fore. This Special Issue is dedicated to the topic of change in Scandinavian healthcare. The joint heading for the articles presented in the following is “Redrawing boundaries within Scandinavian healthcare”, which was also the theme of a conference held in Copenhagen in December 2006. The theme was selected to signal a particular approach to change, namely that the understanding of processes and outcomes of change may benefit from considering more carefully the notion of a boundary.

In health policy debates and academic discourses it is often stated that changes in health policy objectives and instruments contribute to shifts in important boundaries of the field. This statement has the implicit point that we are not just witnessing changes in the quality and efficiency of treatment and organisational performance, or changes in the flow of knowledge and resources. We are also observing changes in overall structures, spheres of action and jurisdictional divisions. One example is the redrawing of boundaries between public and private through the introduction of free choice of care provider and outsourcing of basic public services. Another is the shift in professional domains and roles as nurses are given new access to general management positions. Evidently, boundary changes are important because they interfere with the basic relations between actors and entities within healthcare. In this way boundaries are not peripheral but central to organisations, and reflect substantive organisational issues (Thompson, 1967; Hernes and Paulsen, 2003;Hernes, 2004).

However, the task of describing and understanding changes in boundaries involves a number of analytical challenges. First of all, we need to consider the contingent nature of boundaries. Rather than operating with general distinctions concerning the field of healthcare, we may gain important new insights by asking: what are the boundaries that have historically been considered vital to the operation of healthcare organisations, and which boundaries tend to assume a stable versus a transient character? Second,boundaries are often intangible, and may only be visible during periods of open conflict or contestation. We need, therefore, to be particularly sensitive to controversies, including controversies that at first sight appear to be strictly technical, clinical or political. Third, boundaries are relational achievements and thus intricately coupled to the matter that they bound. How are changes in healthcare boundaries related to transformation of substantial entities and qualities of healthcare? In order to take these analytical challenges seriously,we should, finally, reconsider the adequacy of theoretical concepts and explanatory models. How can the analysis of boundary change benefit from new theoretical and methodological approaches?

Boundaries and boundary work

Boundaries and their consequences have been classic themes within healthcare research. How is the sick role demarcated from the non-sick (Parsons, 1951)? How does the division of work in healthcare create coordination problems and gaps in patient pathways (Glouberman and Mintzberg, 2001)? How have new public management programmes challenged clinical and institutional boundaries (Ferlie et al., 1996)? Also, the division between professions has attracted interest. Here, the work of Andrew Abbott has been central as an analytical framework for studying dynamics related to the establishment, sharpening,contestation and revision of professional autonomy and jurisdictional domains(Abbott, 1988). This has spurred a rich body of research analysing the “battle of the professions”, for example the specific professional strategies of doctors and nurses to demarcate their professional territories vis-à-viseach other and against “intruding” professional groups such as administrators and general managers (see Allen, 1997).

The widespread use of Abbott’s theoretical framework indicates a growing awareness that social, cultural and organisational boundaries – in healthcare and elsewhere – are not essential or universal, but have emerged as result of concrete historical and political processes. However, we may gain further insight into the nature of boundaries and boundary change by moving even closer to the specific practices related to boundaries. Within sociology of science, Thomas Gieryn has proposed the term “boundary-work”for describing the practices and dynamics related to drawing and defending boundaries between science and non-science. Gieryn argues that science is demarcated from non-science by attributing selected characteristics to the institution of science (i.e. to its practitioners, methods, stock of knowledge,values and work organisation), and that “boundary-work occurs as people contend for, legitimate, or challenge the cognitive authority of science –and the credibility, prestige, power, and material resources that attend such a privileged position” (Gieryn, 1995, p. 405). Extending this proposition to the field of healthcare, we may engage in a more close examination of the practices through which organisational and managerial territories and authorities are drawn and redrawn. This may both imply cases where boundaries are explicitly debated and changed (e.g. the recent “structural reform”of Danish regions and municipalities) and cases where boundaries are inconspicuously maintained, negotiated or undermined (e.g. changes in the amount of patient care provided by the hospital, the primary sector and relatives). Whereas there has been a fairly long tradition of studying the division of work in healthcare, an explicit focus on boundary work entails that we also study the recurrent “work of divisions” in health care (Cooper, 1987). What kind of practical and political work is, for instance, involved in the redrawing of boundaries between the primary and the secondary sectors? Furthermore, we may begin to explore more systematically how activities unfold across such borders,and how the emergence of new types of coordination mechanisms and boundary objects (Star and Griesemer, 1989) work to integrate or allow for the peaceful co-existence of practices within and across healthcare boundaries.

Analyses of boundary work in healthcare are even interesting as means to identify the particular zones and specific objects of conflict among healthcare actors. Analysing more carefully the particularities and pragmatics of professional, administrative, and institutional conflicts and compromises, we measure not only the current balance of power in the battle of forces or interests. We also become sensitive to subtle or radical changes of the battlefield. Thus, for example, most countries are not simply experiencing a growing privatisation of healthcare services, but also a concomitant development, whereby the nature of health services changes towards a focus on the “experience-quality” of services. Such refocusing may come to enact entirely new boundaries between good/bad treatment and between legitimate/illegitimate professional knowledge.

This brings to the fore how changes in the division of professional domains,administrative areas, or clinical activities can only be superficially understood by measuring the effects in terms of pre-given variables such as distribution of patients, expenditure, or output. Redrawing boundaries tends to change not only relations among entities but even their “insides”. Accordingly, when boundaries within healthcare are questioned, broken down or modified and new demarcation lines are being drawn, we may even expect to find changes – small or profound – in the definition of health problems,in the character of health services, in clinical ambitions, and in administrative logics. Boundaries must be conceptualised not as separate entities but as constitutive of the matter or the entities they bound.

New boundaries in Scandinavian healthcare

We address the issue of boundary change by analysing changes in Scandinavian healthcare. Scandinavia constitutes an interesting setting for at least three reasons. The Scandinavian welfare states have constituted an internationally recognised “model” that is currently experiencing dramatic changes on several dimensions, some of which have been claimed to change the very foundations of that “model”, even in the field of healthcare. Scandinavian healthcare sectors also constitute interesting laboratories of change because they are quite similar in terms of size, culture and political organisation. It is thus possible to compare reform processes in different, but in many aspects similar, contexts and to consider more systematically the dynamics of change in healthcare. Finally, research on health organisation and management in Scandinavia has benefited from extensive collaboration across national boundaries, whereby it is possible to talk of a Scandinavian research tradition. This tradition has, in particular, engaged in qualitative and in-depth studies of processes of organisational change and political reform. Although they differ in empirical emphasis and theoretical approach, the articles of this special issue represent this ongoing dialogue among Scandinavian researchers on health organisation and management. The papers deal with boundaries and processes of change in healthcare at three different levels:

• 1.

  at a macro and meso level, involving, in particular, boundaries related to political authority and responsibility;

• 2.

  at the level of individual healthcare institutions, involving boundaries related to concrete organisational structures and routines; and

• 3.

  at the level of specific work practices, involving boundaries between professional domains and between healthcare providers and patients.

The two first articles describe processes of change at the macro and meso level and emphasise that boundaries are both outcomes of and inputs to processes of change. In their article, Byrkjeflot and Neby discuss recent large-scale reforms in light of the long history of the Scandinavian decentralised model of governance in the hospital sector. Traditionally, hospital systems in Norway,Sweden and Denmark have been strongly decentralised to the local or the county level both in terms of political control, economic autonomy and the administration of service delivery. Recent reforms, however, seem to involve a greater political and economic involvement of the state challenging the traditional decentralised model. When accounting for these changes, the authors show how patterns of each country reflect different historical “institutional constellations”, i.e. systems of responsibility, relations of authority and power, and the ways of handling interactions across political and administrative boundaries. In a similar vein, Burau and Vrangbæk discuss how recent changes in how clinical work is being governed in Denmark, Britain, Italy and Germany are related to “pre-reform pathways of governing medical performance” constituted by sector-specific institutions in national healthcare field. Emphasising the non-linear character of governance change, the authors show how there is both variation in governance forms and a common trend towards the strengthening of hierarchical governance of medical performance that, among other things, redraws the boundaries between the state and the medical profession.

The next two articles describe how individual healthcare institutions engage with boundaries and boundary change. Two types of boundaries are considered:

• 1.

  economic boundaries; and

• 2.

  organisational boundaries.

In both cases we see that the drawing of boundaries entails considerable effort to construct healthcare as a particular activity and to compromise and juggle different concerns. Sjögren’s article addresses the difficulty of a Swedish governmental agency in determining a unequivocal boundary between drugs that are state-subsidised and drugs that are not. The agency is to decide on subsidisation based on a rational cost-benefit analysis of drug effects and price. However, these features are not so easily determined, and it becomes a central prerequisite to decision making to remove ambiguity of economic and clinical evidence – or sometimes to delegate ambiguity to other places in healthcare decision making. Hereby, the agency diverges in crucial aspects from a strict economical and clinical rationality. Also, the agency engages in the definition of key elements in healthcare, such as “drug use”. Juul Nielsen, Knudsen and Finke emphasise the organisational work involved in handling a “boundless” concept of “new public health” in Denmark. In their analysis of two phases of public health initiatives in the City of Copenhagen from the late 1980s onwards, the authors show how the ideals of new public health result in two radically different processes of organisational boundary drawing – first in an extremely expansive and unfocused organisation, and next in a strongly delimited and self-contained organisation, both of which face serious challenges in relation to how one relates to the environment in which one is to operate. This finding makes the authors call for “boundary management”, i.e. more systematic reflections and strategies to compensate for the built-in problems of particular ways of drawing organisational boundaries.

The last two papers deal with the everyday practices of clinicians, managers and patients and consider two additional boundaries:

• 1.

  between and within professions; and

• 2.

  the boundary between patient and professional.

In her article, Mo focuses on the way a reform of Norwegian hospital management leads to changes in the boundaries between clinical and managerial roles. She argues that it is very difficult to move managers with a physician background towards a general management logic. Physicians typically define their managerial role in medical terms. However, Mo shows that the new physician-manager role cannot be built on a constant presence in the clinic, and that this fact is handled very differently by the physician managers. Some managers enact an individualist type of managerial responsibility, whereas others enact a more collectivist type. Mo concludes that these variations in managerial strategy may become central to the way in which the clinic/administration boundary is drawn in the future. Finally, Winthereik addresses the way in which new information technologies in healthcare come to disturb common sense assumptions of the boundary between patients and professionals. Analysing an attempt to establish a shared maternity care record,which should bridge the gaps between patients and professionals, Winthereik shows that the record did not make patients behave the expected way – as better informed patients. Rather, patients became focused on disciplining the professionals to keeping proper records and thereby bridge gaps within the professions. In this way, the shared maternity record was simultaneously a failure and an eye-opener, and Winthereik concludes that we should be sensitive to the way boundaries are assumed, negotiated and created in any socio-technical arrangement – also in projects that explicitly aims at transgressing boundaries.

Signe Vikkelsø, Peter KjærGuest Editors