‘Holding the line’: a qualitative study of the role of evidence in early phase decision-making in the reconfiguration of stroke services in London

Abstract

BackgroundHealth service reconfigurations are of international interest but remain poorly understood. This article focuses on the use of evidence by senior managerial decision-makers involved in the reconfiguration of stroke services in London 2008–2012. Recent work comparing stroke service reconfiguration in London and Manchester emphasises the ability of senior managerial decision-makers in London to ‘hold the line’ in the crucial early phases of the stroke reconfiguration programme. In this article, we explore in detail how these decision-makers ‘held the line’ and ask what the broader power implications of doing so are for the interaction between evidence, health policy and system redesign.MethodsThe research combined semi-structured interviews (n = 20) and documentary analysis of historically relevant policy papers and contemporary stroke reconfiguration documentation published by NHS London and other interested parties (n = 125). We applied a critical interpretive and reflexive approach to the analysis of the data.ResultsWe identified two forms of power which senior managerial decision-makers drew upon in order to ‘hold the line’. Firstly, discursive power, which through an emphasis on evidence, better patient outcomes, professional support and clinical credibility alongside a tightly managed consultation process, helped to set an agenda that was broadly receptive to the overall decision to change stroke services in the capital in a radical way. Secondly, once the essential parameters of the decision to change services had been agreed, senior managerial decision-makers ‘held the line’ through hierarchical New Public Management style power to minimise the traditional pressures to de-radicalise the reconfiguration through ‘top down’ decision-making.ConclusionsWe problematise the concept of ‘holding the line’ and explore the power implications of such managerial approaches in the early phases of health service reconfiguration. We highlight the importance of evidence for senior managerial decision-makers in agenda setting and the limitations of clinical research findings in guiding politically sensitive policy decisions which impact upon regional healthcare systems.

Exploring the neglected and hidden dimensions of large‐scale healthcare change

“…For example, in the study by Turner et al (2016) of large-scale changes to clinical services in England, a service commissioner describes their strategy for managing stakeholder differences as 'not letting people out of the room if I thought they were actually disagreeing but they weren't disagreeing in the room' (Turner et al 2016, p161). Another strategy was for regional managers to link their organisational goals to the appraisal (and by implication, employment) of subordinate staff (Fraser et al 2017). Looking at the data in this way affirms Latimer and Monro's insight that 'for all the emphasis on reform, hierarchy remains the main mechanism at work along which credit and rewards travel upward while blame and responsibility are divested down' (2015, p 427).…”

“…Another strategy was for regional managers to link their organisational goals to the appraisal (and by implication, employment) of subordinate staff (Fraser et al . ). Looking at the data in this way affirms Latimer and Monro's insight that ‘for all the emphasis on reform, hierarchy remains the main mechanism at work along which credit and rewards travel upward while blame and responsibility are divested down’ (2015, p 427).…”

“…In this account the strategic use of these participation forums is explicit:

We had our first pan London conference and that was attended by representatives across London … and we mixed everyone up and we eventually workshopped ideas … but we kind of had the answers in our back pocket … And we were able to guide that conference to an answer that we had already, I suppose, decided on … (Fraser et al . , p45).

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“…Fraser et al . () also employ Foucauldian perspectives in a study of the London reconfiguration of stroke services, showing how practices of stakeholder consultation were manipulated to serve powerful interests. They found that within ostensibly participative forums management consultants were able to control how problems were understood and which solutions were adopted.…”

“…In one instance the ability of local commissioners to define plans as 'clinical best practice' allowed them to avoid pubic consultation at the same time as government policy established a range of new mechanisms and structures for involving the public in decisions about service change. Fraser et al (2017) also employ Foucauldian perspectives in a study of the London reconfiguration of stroke services, showing how practices of stakeholder consultation were manipulated to serve powerful interests. They found that within ostensibly participative forums management consultants were able to control how problems were understood and which solutions were adopted.…”