Decentring Health and Care Networks

Reshaping the Organization and Delivery of Healthcare

Mark Bevir, Justin Waring, Mark Bevir, Justin Waring, Mark Bevir, Justin Waring

• Publisher: Palgrave Macmillan
• Year: 2020
• ISBN:
  9783030408893
• Topic: Business
• Subtopic: Pharmaceutical, Biotechnology & Healthcare Industry
• Index: Business

Networks have become a prominent template for public service governance. Often seen as an alternative to hierarchies and contracts, networks cross institutionalized organizational or sectoral boundaries to promote collaboration and the sharing of resources when addressing complex problems. Nowhere is this more the case than in the field of health services modernization and improvement.

Comprising unique empirical contributions, drawn primarily from the experience of the UK National Health Service (NHS), this edited collection develops a 'decentred' analysis of health and care networks. Contributors look beyond particular structures or patterns of governance and focus instead on the interpretation of the meaningful practices of policy actors as they encounter and enact policy instruments and structures. The approach offers a distinct form of analysis that deepens and enriches more traditional public policy accounts of network governance. It recognizes the influence of local history, highlights the influence of dominant economic, technical and corporate narratives, and acknowledges the continued influence of biomedical knowledge and professional expertise.

Offering practical insight for current and future service leaders about the challenges of implementing, managing and working within networks, this book draws out key messages for practitioners and researchers alike.

© The Author(s) 2020

M. Bevir, J. Waring (eds.)Decentring Health and Care NetworksOrganizational Behaviour in Healthcarehttps://doi.org/10.1007/978-3-030-40889-3_11

Begin Abstract

Professional Pastoral Work in a Kenyan Clinical Network: Transposing Transnational Evidence-Based Governmentality

Gerry McGivern¹ , Jacinta Nzinga², Mehdi Boussebaa³ and Mike English⁴

(1)

Warwick Business School, University of Warwick, Coventry, UK

(2)

KEMRI Wellcome Trust, Nairobi, Kenya

(3)

Adam Smith Business School, University of Glasgow, Glasgow, UK

(4)

Nuffield Department of Medicine, University of Oxford, Oxford, UK

Gerry McGivern

Email: [email protected]

End Abstract

Introduction

Health care management research has recently drawn on the Foucauldian (2007) concept of governmentality to examine and explain the way health professionals have internalised evidence-based medicine (EBM) (Ferguson and Gupta 2002; Bejerot and Hasselbladh 2011; Ferlie et al. 2012, 2013; Ferlie and McGivern 2014; Martin et al. 2013; Martin and Waring 2018; Waring and Martin 2016; van Rensburg et al. 2016). EBM is defined as ‘the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients… integrating individual clinical expertise with the best available external clinical evidence from systematic research’ (Sackett et al. 1996: 71). EBM was developed and has become institutionalised in Western health care systems as the ‘gold standard’ of health care provision (Timmermans and Berg 2003). Consequently, most Western health professionals, and many professionals globally, now draw on its governing principles when they think about and enact clinical work.

However, research on the rise of this ‘evidence-based governmentality’ in health care (Ferlie et al. 2013; Ferlie and McGivern 2014) has given limited attention to the micro-level work entailed in the construction and promotion of, or resistance to, the internalisation of EBM. We also know little about the historical context in which governmentality unfolds. Significantly, most literature on governmentality in health care is based on studies conducted in Western high-income countries, neglecting low- and middle-income counties (LMICs) where transnational evidence-based governmentality regimes, originating in the West, shape health care systems (Ferguson and Gupta 2002; Lemke 2011). So, how is EBM developed, internalised and used by health professionals working in LMIC health systems?

Network organisations provide a key mechanism through which government policy, EBM, evidence-based practices and standards have been developed and implemented into health care practice at local level, with professional leaders responsible for and also adapting this process in local contexts (Ferlie et al. 2012, 2013). In LMICs networks are also often more transnational, diffusing evidence between Western countries and LMICs (Ferguson and Gupta 2002), although most research on health care networks has been conducted in the former, again neglecting LMICs.

Addressing this oversight, in this chapter we examine the development and implementation of an evidence-based governmentality in Kenyan paediatric care nationally and, more specifically, in a ‘Clinical Information Network’ (CIN) spanning paediatric departments in 14 Kenyan district hospitals. We trace the roots of this evidence-based governmentality in Western transnational organisations and its development and implementation in Kenya, examine how CIN made visible and transformed local clinical practices and professional identities, and highlight the central role and work of key medical professional network leaders (‘pastors’) within this process.

Our chapter highlights the importance of a ‘decentred’ (Bevir 2013) approach to analysing health care networks, showing in particular how the dynamics of power need to be situated within particular contexts, traditions, practices and norms. As explained in the introduction to this collection, this approach seeks to look beyond the grand narratives or discourses of policy, to look instead the situated and enacted meanings and beliefs of local actors, albeit in the context of prevailing traditions and in the face of new circumstances or dilemmas. Without understanding the different practices and norms of Western EBM and philanthropic organisations and Kenyan health care, CIN’s leaders would have been unable to transpose transnational evidence-based governmentality into Kenya paediatric practice. Using a decentred approach, we explain the pastoral work of these network leaders’, and the situated dilemmas, with implications for personal and professional identity, which they faced about how to engage with divergent local circumstances and governmental practices.

Evidence-Based Governmentality and ‘Pastoral’ Professionals in Health Care

Michel Foucault developed the concept of ‘governmentality’, defined as ‘the ensemble formed by institutions, procedures, analyses and reflections, calculations and tactics… that has the population as its target, political economy as its major form of knowledge and apparatuses of security as its essential technical element’ (Foucault 2007: 108), to explain government in neoliberal states. For Foucault, and subsequent theorists of governmentality (Rose 1999; Dean 1999; Lemke 2011), this ensemble leads subjects to internalise the mentality of government, interpret their identities and behaviours as part of a (national) population, and so freely act in its collective interest. Thus, neoliberal states could govern ‘at a distance’ by inciting, seducing and making actions easier or harder, negating the need for direct control. Theorists later explained how a governmentality could be actively constructed and managed to control citizens (Rose and Miller 1992; Dean 1999) and organizational employees (Miller and O’Leary 1994; McKinlay and Taylor 2014; McKinlay and Pezet 2010) from afar. Similarly, in health care contexts, governmentality and the mundane ‘grey sciences’ of ‘enumeration, calculation, monitoring, evaluation’ (Miller and Rose 2008: 212) quietly reshaped professional work (Ferlie and McGivern 2014).

Foucault’s (2007) related concept of ‘pastoral power’ explains how individuals internalise external (governmental) discourses; by externalising (‘confessing’) inner thoughts and hidden behaviours to ‘pastors’ who then help them internalise external discourses reconceptualising their thoughts and behaviours. Using the analogy of Christian priests leading their ‘flock’ to ‘salvation’, Foucault showed pastors’ key roles as intermediaries in governmentality (Martin and Waring 2018). Pastoral power thus operates at the intersection between disciplinary discourses, pastors’ and other individuals’ agentic attempts to cultivate their own identities in ways that align with (but also depart from) such discourses (Martin et al. 2013; McKinlay and Pezet 2010). Today, pastoral power can be understood as about cultivating ethical behaviour benefitting collective social welfare. Contemporary pastors include experts and therapists, promoting and inculcating socially desirable behaviour among their patients, clients and the public and medical professionals (Dean 1999; Rose 1999). Foucault (2007: 199) notes: ‘in its modern forms, the pastorate is deployed to great extent though medical knowledge, institutions and practices… medicine has been one of the great powers that have been the heirs to the pastorate’.

The concepts of governmentality and pastoral power have been usefully deployed to explore and explain governance and leadership in Western health care and clinical networks, where evidence-based medicine (EBM) has been institutionalised (Ferlie and McGivern 2014). Ferlie and colleagues (2013) describe an ‘evidence-based governmentality’, which underpinned effective service reconfiguration and quality improvement in health care networks. This evidence-based governmentality contained four elements: an evidence-based clinical episteme; clinical audit making local practices visible; local technical processes enacting evidence and audit into practice and ways in which they shape professionals’ identities. Clinical professionals internalised, constructed and regulated their professional identities and behaviours in relation to the governing principles of EBM as a consequence of network leaders’ work assembling these four elements (Ferlie et al. 2013).

We suggest that understanding of the work involved in constructing evidence-based governmentality can be furthered through engagement with Foucault’s notion of pastoral power. In their study of EBM and health care networks, Ferlie and McGivern (2014) show how pastoral power operates during collective professional discussions of clinical outcomes, which reinforce evidence- and audit-based professional identities and behaviours. The authors explain how...

Table of contents

• Cover
• Front Matter
• Decentring Networks and Networking in Health and Care Services
• The Contested Practice of Networking in Healthcare Management
• Analysing the Micro Implementation of Health Care Reforms: A Decentred Approach
• Buddies and Mergers: Decentring the Performance of Healthcare Provider Partnerships
• Space and Place in Network Governance: Putting Integrated Care into Place
• Situating Practices of Human and Non-human Networks in the Delivery of Emergency and Urgent Care Services
• Sharing Stories or Co-Constructing Practice? Challenges to Undertaking and Researching Innovation Using Evidence from the English NHS
• Networking for Health, Networking for Wealth: A Study of English Health Innovation Policy in Practice
• Tensions Between Technocracy, Scientific Knowledge and Co-production in Collaborative Health and Care Networks
• Is Co-production Just Really Good PPI? Making Sense of Patient and Public Involvement and Co-production Networks
• Professional Pastoral Work in a Kenyan Clinical Network: Transposing Transnational Evidence-Based Governmentality
• Back Matter