Making Wicked Problems Governable? The Case of Managed Networks in Health Care

An initial perusal of the two books, Making Wicked Problems Governable and Transforming Culture, is not likely to reveal the common themes of the books. However, reading and reflection highlight similar concerns among the authors of the two books. Specifically, both books address organizational reforms in given industries over a common time period. Making Wicked Problems Governable examines health care organizations; Transforming Culture examines manufacturing organizations, specifically automobile manufacturing. Ferlie et al. write, “Over the last thirty years or so, scholars of health care organizations have been searching for concepts and images to illuminate their underlying – but also perhaps changing – modes of organizing” (2013, p. 1). In the preface to Transforming Culture, the President of General Motors (GM) North America, Troy Clarke, writes, “The auto industry of the last thirty years has not been for the faint of heart. The US domestic industry, in particular, has been in continuous transformation for most of that time period” (2010, p. xi). Defining “wicked problems” as those problems without obvious policy solutions but with many stakeholders who disagree (2013, p. 30), Ferlie et al. explain that such problems require behavior changes and involve multiple agencies as well as “managed networks” (2013, p. 28). Although Briody et al. do not examine “wicked problems,” as such, their book addresses people and culture – rather than the latest manufacturing technology. The point is that both books are behavioral studies, and both books seek organizational reforms that are post-Fordist (Ferlie et al., 2013, p. 11; Briody et al., 2010, p. 19): i.e. the post-Weberian organization.

Ferlie et al. situate their study of health care organizations during the New Labor (post-Thatcherite “New Public Management”) period in the UK, and they adopt a Foucauldian perspective, that of “governmentality” (2013, p. 34). Governmentality refers to the capacity for modern states to govern without resorting to direct rule by a sovereign. Rather than using physical force to control subjects, the modern state controls by means of a network of institutions, procedures, and apparatuses. Just as Foucault's concept can be applied to the modern state, Foucauldian perspectives can be applied to the post-bureaucratic organization. Rather than a Weberian implementation of line management and detailed regulations (the “cage”), the post-bureaucratic organization selects its workforce carefully and implements extensive training as well as sophisticated evaluations (the “gaze”) (Ferlie et al., 2013, pp. 38-39). A governmentality perspective is applicable to health care organizations, argue Ferlie et al. because such organizations rely upon a scientific base and systems of patient classification that “control the body” (Ferlie et al., 2013, p. 42).

Ferlie et al. provide several case studies of managed networks in health care. For example, Genetics Translation Networks (GTNs), a pseudonym, are networks of academic scientists, clinicians, and health care providers, private companies, patient groups, and ethical/legal experts (2013, p. 53). GTNs (GTN1 and GTN2) were formed as a component of the UK Government's initiative to promote genetic science as well as identify the social, ethical, and practical issues that arise with advances in genetic science. Ultimately, GTN1 and GTN2 were not re-funded and closed. The GTNs illustrate “wicked problems”; they involved multiple stakeholders and concerned problems without obvious solutions; they failed, according to the authors, because the scientists retained their professional autonomy, resisted governmentality, and found other funding. On the other hand, the Managed Cancer Networks, a pseudonym, illustrate “’high performing’ networks,” according to the Ferlie et al. (2013, p. 93). Improved cancer services are “wicked problems” in that changes in patient behavior are required and, again, multiple stakeholders are involved in a problem without an obvious solution. According to the authors, key elements in the success of the cancer networks include evidence-based guidance and enhanced data collection – both elements indicative of governmentality. Other case studies included by Ferlie et al. are Sexual Health Networks and Networks for Older People's Care. Moreover, the authors examine the role of Information and Communication Technologies (ICTs), but conclude that ICTs were not “a major driver of organizational transformation towards network forms” (Ferlie et al., 2013, p. 161). Significantly, the authors conclude, “Managed networks were a practical and achievable reform to public policy consistent with basic academic work on the perceived dysfunctional effects of earlier NPM reforms” (Ferlie et al., 2013, p. 226). Such networks in health care “were an important governance reform under New Labor” and “respond well to ‘wicked problem’ conditions” (Ferlie et al., 2013, p. 248).

Just as Ferlie et al. addressed reform of a system, Briody et al. address reform, specifically a cultural transformation at GM manufacturing sites in the US Briody and her co-authors are anthropologists, and their research relies upon ethnographic data (e.g. stories) that the authors collected at GM at two different points in time: the mid-1980s and the mid-2000s (2010, p. 6). GM is a US organization and, hence, influenced by US culture. Briody et al. distinguish the patterns of “low-context” cultures from “high context” cultures (2010, pp. 6-7). In a low-context culture, such as the US, fellow workers develop “transitory” rather than “close” relationships with co-workers (Briody et al., 2010, p. 6), and the organization relies heavily on the written word (p. 7). On the other hand, in a high-context culture, such as Japan, interpersonal relationships are emphasized “in everything they do, including work” (p. 7), and nonverbal communication is emphasized. According to Briody et al. the high-context culture of Japan is “an important reason” that firms, such as Toyota, have been able to outperform GM (p. 7). Given the low-context culture of the US, can a manufacturing firm transform its production culture in order to create and sustain a better organization?

In order to answer the above question, Briody et al. embarked on an ethnographic study of four GM plants, including three assembly plants and one stamping plant, two union locals, corporate manufacturing offices, and offices of the UAM-GM Quality Network (2010, p. 67). Sponsored by Tony Clarke, the Briody et al. project had three objectives: document the characteristics of an ideal plant culture; apply the project's insights to a new plant; and develop recommendations and applications to improve GM's North American operations. As part of the project, Briody et al. developed and applied a “bridge model of cultural transformation” (2010, p. 73). The “bridge” spans the “old way” and the “ideal culture” within the broader cultural context. They develop an “ideal culture model” (2010, p. 75), which is compared and contrasted to three GM manufacturing programs (the quality network, GMS, and Starpoint), and analyze obstacles to cultural change (2010, p. 96). A significant contribution of Briody et al. is the analysis of “enablers for cultural transformation” (2010, p. 116). For example, enablers within the plant environment include the following: comfortable workstations, areas for community building, improved ergonomic standards, preventative maintenance, accountability, rebalancing the work pace, shared responsibilities, sharing and using lessons learned, and providing support (2010, pp. 121-122). And, perhaps, the most significant contribution of Briody et al. is the development of “tools” for cultural transformation (2010, p. 137). Together with the enablers, the tools provide “takeaways” for the readers of Transforming Culture.

Making Wicked Problems Governable and Transforming Culture are interesting and informative analyses of post-bureaucratic organizational issues. Because both books include ethnographic data, the organizations that are studied come alive for the readers. For example, Ferlie et al. include the following comments from the Cancer Network's Director:

And Briody et al. include the following story of Janie, an assembly line operator. This story is told by the employee who trained Janie:

In summary, both books are enriched by the ethnographic data. Both books provide compelling analyses of organizational reforms over a common time period. Both are instructive and theoretically informed.