Change and Resistance in Welsh Postgraduate Medical Education: A Critical Realist Analysis

Transcription

1 Submission to the 7 th Biennial International Conference in Organisational Behaviour in Health Care (OBHC) Mind the Gap: Policy and Practice in the Reform of Health Care Change and Resistance in Welsh Postgraduate Medical Education: A Critical Realist Analysis Dr Andrea Herepath* and Professor Martin Kitchener Cardiff Healthcare Organisation & Policy Studies (CHOPS) Cardiff Business School, Aberconway Building, Colum Drive, Cardiff, CF10 3EU. *Herepathaj@cardiff.ac.uk

2 ABSTRACT Background Devolution has fractured the UK health care state into four sibling systems with alternative higher-order logics (belief systems) that underpin divergent policy trajectories (Greer and Trench, 2008; Moran, 1999). Despite this, policy conduits emanating from the Department of Health remain powerful over devolved nations in areas including the regulation and control of health care professionals (HMSO, 2006). In one important example, new public management (NPM)- inspired reforms to postgraduate medical education in England are creating path dependent pressures, in the devolved nations, for the adoption of systems in which funding follows the trainee (Department of Health, 2008a: 4). Whilst this policy is consistent with the prevailing logic of market coordination in NHS England, it sits less easily with the dominant logic of bureaucratic control in NHS Wales. Conceptual Framework This empirical study blends insights from critical realism (Leca and Naccache, 2006) and institutional theory (Hoffman and Ventresca, 1999) to view logics (e.g. market coordination, bureaucratic control) as generative mechanisms that can both shape, and be influenced by, emergent processes of change in postgraduate medical education in Wales. This conceptual framework is used to frame a study of the under-researched relations amongst institutional structure and agency (motivated action) in the field of postgraduate medical education. Study Design From documentary analysis and a purposive sample of nearly 30 interviews, particular attention is given to identifying and tracing the role of actors associated with dominant and emergent logics among stakeholder organisations including the Welsh Assembly Government, the School of Postgraduate Medical and Dental Education, and the constituent organisations of a newly reconfigured NHS Wales. Findings Preliminary findings indicate that acceptance of the need for a NPM-inspired model is palpable in some quarters; but it is challenged in a context where vested interests, informed by countervailing logics, generate mechanisms of resistance to change. 2

3 INTRODUCTION Following sub-national referenda, the UK s New Labour Government devolved facets of political power to Wales and Scotland in July 1999, and to Northern Ireland in December 1999 (Denver, 2002; Woods, 2002). This constitutional reform split the UK s National Health Service (NHS) into four sibling systems in which alternative higher-order logics (belief systems) underpin divergent policy trajectories (Mitchell and Bradbury, 2004). NHS England reaffirmed a market logic (emphasising individualism, choice and exit) that developed from earlier neoliberal reforms of Conservative administrations (Fairclough, 2000; Ludlam, 2001). NHS Wales initially espoused a collaborative logic (emphasising collectivism, voice and localism) that has now progressed to a more clearly bureaucratic underpinning set of values and beliefs (Welsh Assembly Government, 2007). In contrast, Scotland adopted a logic of professionalism whilst Northern Ireland maintained its logic of permissive managerialism (Greer, 2004). The UK s devolution reforms were, however, built upon the long-standing practices of differentiated territorial administrations (Drakeford, 2006). This foundation has fostered an unusual, and arguably unstable, institutional context. Given the resultant asymmetry of the settlements, and specifically the lopsided dominance of the English core, decisions taken in Westminster, for England, under a metrovincial mindset spill over into the devolved territories and constrain their autonomy (Jeffery, 2007). This occurs even though the dense array of ministerial and official committees through which the former territorial offices were tied to Whitehall s policy networks have been replaced, in part, by new concordats and non-statutory frameworks (Greer, 2008; Keating, 2002). In the context of health policy, an important exemplar of the operation of this new mode of control is the regulation of health care professionals, which remains a reserved power of the UK Government (HMSO, 2006, 2007). This empirical study addresses the development of a new funding model to support postgraduate medical education in Wales. Drawing from institutional theory, we frame this as the potential site of a battle between the regulative, normative and cultural-cognitive elements of the logics operating in the English and Welsh NHSs (Hoffman and Ventresca, 1999; Scott, 2008). There are two foci of potential tension. Firstly, the policy trajectory emanating from the UK Government fuses the regulatory and educational oversight of this facet of the labour market. Consequently, 3

4 postgraduate medical education and training in Wales has no escape from the path dependency ostensibly fostered through normative isomorphism. Though there is acknowledgement of local latitude to accommodate the distinct processes and systems in different parts of the UK, the complex array of coercive and mimetic forces also in play will inevitably further constrain the policy opportunity space in Wales (DiMaggio and Powell, 1991; Dobbin et al., 2007). Secondly, the post-devolution higher-order logics of the English and Welsh NHSs are markedly different (Friedland and Alford, 1991; Thornton, 2002). Whilst NHS England is emblematic of the new public management (NPM), NHS Wales is far more symbolic of new public service (NPS) (Beresford, 2002). The normative and cultural-cognitive elements in the English and Welsh NHSs therefore depict complementarity, though it is marred by fundamental incompatibilities (Archer, 1995; Thornton, 2002). The goal of this paper is thus to provide a critical realist analysis of change and resistance in the development of a new funding model for postgraduate medical education in Wales. However, in framing such a model through the UK Government s policy trajectory, attuned to the enduring logics and structures of Wales policy elites, NHS corporate management, medical professionals and partner agencies; it is to be anticipated that such stakeholders will adhere to situational logics which direct their strategic positions towards different goals (Archer, 1995). Accordingly, a subordinate aim is to examine the hegemonic power blocks within the organisational field (Joseph, 2000; Leca and Naccache, 2006). By drawing upon institutional theory and critical realism, the development of the model is thus viewed through both of these differently placed eyes (Shotter, 2005: 114). In this manner, a greater sense of depth may be gleaned into the process of organisational change in this politically mandated, yet inherently conflicted, collaborative context (Delbridge, 2007; Quinn, 2002). This rest of this paper is divided into five sections. The first section outlines this study s novel conceptual framework, which blends insights from critical realism and institutional theory to view logics as the generative mechanisms that can both shape, and be influenced by, the emergent process of change in postgraduate medical education in Wales. Section two defines the UK Government s logic for public service reform, exemplified through the NPM inspired transformation of the English NHS. Section three depicts an alternative; setting out the Welsh 4

5 Assembly Government s logic for the post-devolution NPS inspired transformation of the Welsh NHS. In section four, the UK Government s logic for the regulation of the medical profession is presented, encompassing the proposed change to the funding of postgraduate medical education and training in England. This exposes the friction generated with the logic of the Welsh NHS. Finally, the under-researched relations amongst structural and agential acceptance and resistance to change in the field of postgraduate medical education are examined through the interplay of two sets of countervailing logics: (1) competitive versus collaborative and (2) medical professionalism versus corporate managerialism. From this preliminary analysis we conclude that acceptance of the need for a NPM-inspired model is palpable in some quarters; but it is challenged in a context where vested interests, informed by countervailing logics, generate mechanisms of resistance to change. CONCEPTUAL FRAMEWORK: DEVELOPING A CRITICAL REALIST INTERFACE WITH INSTITUTIONAL THEORY Critical realism is a movement in philosophy, the human sciences and cognate practices that is most closely associated with the work of Bhaskar (e.g., 1978) and Archer (e.g., et al., 1998). This body of work does not presume to claim privileged access to the real world. Instead, it posits a world that is external to the knowing subject, where entities exist beyond human identification or understanding (for review see Fleetwood, 2005). Characterised by an objectivist social ontology that is stratified and transformational, critical realism conveys a world of virtual depth perceived through three domains: the real or deep, the actual, and the empirical. This perspective represents the conceptual space in which structures, mechanisms, powers and relations; events and actions; and experiences and perceptions manifest (Collier, 1994). Consequently, causal powers are located in the real domain, wherein their activation may give rise to patterns of events in the actual domain, which in turn, when identified, become experiences in the empirical domain (Tsoukas, 2000). Deeper structures or mechanisms therefore shape events and regularities at the more surface levels, such that emergent properties arise from the interactions of objects, which are irreducible to those of the objects, on which they depend (Fleetwood and Ackroyd, 2004; Reed, 2005). 5

6 In embracing this path, critical realism is positioned as a model of scientific explanation which avoids the traditional epistemological poles of positivism and relativism, stressing, instead, the mechanics of explanation that bridge context, mechanism and outcome (Pawson and Tilley, 1997). Centred upon the identification and explanation of the underlying generative mechanisms which shape structure, agency, and the social relations which are reproduced or transformed, the goal is to posit a mechanism (typically at a different level of the phenomenon being explained) which, if it existed and acted in the postulated manner, could account for the phenomenon singled out for explanation (Reed, 2005). However, given that such mechanisms act transfactually once set in motion they continue to have an influence even if other countervailing powers and mechanisms prevent this influence manifesting itself and that their existence and exercise is not dependent upon regularities among events, one cannot connect a power or causal mechanism to its manifestation at the level of events and perceptions easily or securely by simple inspection (Elder-Vass, 2005). Though informed by Leca and Naccache (2006), the interface between institutional theory and critical realism remains under theorised. At the higher-order societal level, institutional structure is depicted as the skeleton of society (Friedland and Alford, 1991). It is thus exemplified by the bureaucratic state, capitalism, democracy, marriage, and the family; in essence, a contingent set of historical social arrangements shaped by power, politics, and specific path dependencies (Mohr, 2000). Institutional structure therefore exists simultaneously as a symbolic system the multiple and potentially contradictory logics that manifest and as their aftermath in the form of those material practices embedded within social interaction which are informed by such logics (Fleetwood, 2008). As such, institutional logics comprise the cultural or normative patterns that define the expectations that agents hold about each other s behaviour, and that organise their enduring relations with each other (Lopez and Scott, 2000). However, when viewed objectively, there is surprisingly little unanimity in the terminology employed (Hodgson, 2007). The literature is merely marked by repetitive themes: habits (Hodgson, 2007), rules (Jepperson, 1991), norms (Scott, 2008) and patterns of human activity (Friedland and Alford, 1991). One outcome of this, it has been argued, is that institutions explain everything until they explain nothing (Thelen and Steinmo, 1992: 15). 6

7 In the context of building a critical realist interface to institutional theory, an ontological problem therefore surfaces. Institutional logics as a construct that draws upon such habits, rules, norms, and patterns of human activity abandons the ontic differentiation between structures, agents, and their ensuing practices. In this paper, the interface to institutional theory is thus further informed by assigning facets of structure to their relevant ontological strata. After Fleetwood (2008), rules and norms are apportioned to social structures and institutions, habits to human agents, and patterns to the practices that arise from the outcome of such interaction. Accordingly, the conception of institutional depth within the given temporal and spatial context is refined by disaggregating the institutional structure into its inherent schema and resources (Clemens and Cook, 1999; Leca and Naccache, 2006). As illustrated in Figure 1, and taking an explicitly state-centred perspective (Orloff, 1993: 41), it is posited that in the domain of the real, the institutional structure embedded at the higher-order societal level of the UK (English) health care state operates as the dominant logic. It thus functions as the orchestrating supra-organisational structure that gives rise to the institutions the rules and norms which shape its features by providing the cognitive frameworks for organisation and legitimacy in the domain of the actual (Scott, 2008). The logic of the UK (English) health care state is thus the source of a conceptual metamechanism (Bunge, 2004: 185) that functions to modulate the governmental control of NHS England (and for reserved powers, the Devolved Administrations). This then cascades from the domain of the real, through the conditioning institutions and resources of the actual, to manifest as the surface events in the empirical. In contrast, the Devolved Administrations, though tied through the governance framework of devolved and reserved powers, illustrate a degree of cognitive liberation (McAdam, 1982: 48-51). Consequently, the domain of the deep is congested with heterogeneous higher-order societal logics which underpin the divergent policy trajectories manifested by Wales, Scotland and Northern Ireland (Greer and Trench, 2008). For the Welsh health care state, its distinctive dominant logic is thus the source of a countervailing conceptual metamechanism that is embedded within, and emergent from, the dynamic interplay of structure and agency in contemporary Welsh public service. This emerges in the domain of the actual to modulate the 7

8 Welsh health care policy arena in accordance with the leftward political ideology of the Welsh Assembly Government (Chaney and Drakeford, 2004). Whilst at the interface with the empirical, a complex array of professional values, norms and assumptions only some of which are shared mould the micro organisational context for action (Kitchener, 2002; Morgan and Ogbonna, 2008). In the Welsh health care state, though intertwined with the vested interests of the policy elites, this distinctive dominant logic is nonetheless open to rebuttal by corporate and primary agents (Archer, 1995). These agents include: NHS corporate management, medical professionals and partner agencies, each of which adhere to disparate professional logics (Kitchener and Exworthy, 2008; Reay and Hinings, 2009). Therefore, in this study, concentric and interlocking critical realist frames are employed to examine the structural and agential conditioning in play (Fairclough, 2003, 2005). Emphasis is placed on the relational structure embedded within the extant financial model that supports postgraduate medical education in Wales (Elder-Vass, 2007, 2008). This draws into consideration the bureaucratic and hierarchical nature of this organised social space (Mouzelis, 2008). In so doing, the aligned or emic alternative stances of the policy elites, NHS corporate and medical professionals engaged in this study are exposed (Ailon, 2006), enabling the emergence of the hegemonic control that fosters resistance to, and advocacy for, change to the extant model to be explored (Delbridge, 2007; Joseph, 2000). < FIGURE 1> UK GOVERNMENT S LOGIC FOR PUBLIC SERVICE REFORM: NPM INSPIRED TRANSFORMATION OF THE ENGLISH NHS The UK Government s logic for public service reform is conveyed by notions of command and control, devolution and transparency, and quasi-markets (Barber, 2007, Cabinet Office, 2008). The classical notion of bureaucratic command and control is forwarded as the means of driving forward urgent change to address public service failure, policy or programme priorities, and to be demonstrably seen to be doing so by a wider public and political audience. The devolution of responsibility to frontline units, augmented by transparency and the overt communication of performance measures to enable informed comparisons to be made, is the logic of choice to reform a service where the conditions for the success of quasi-markets are not 8

9 present. The formation of a quasi market is the logic of choice for governments that wish to introduce market forces within a defined public service system to provide the individual with choice across a range of providers, thereby leveraging diversity and improving performance. However, as defined in Figure 2, this amalgamated institutional logic is buttressed by four subordinate logics or dimensions which function as the generative mechanisms of change (Leca and Naccache, 2006): (1) top down performance management; (2) market incentives to increase efficiency and quality of service; (3) building capability and capacity; and (4) users shaping services from below. Described as a self-improving system (Cabinet Office, 2006: 6), it is asserted that all such integrated logics are to be deployed within a government system if it is to balance equity and diversity with support for high quality. As depicted in Figure 2, top down performance management encompasses an array of structural system features which inculcate a performance measurement and management culture across the English NHS (Cabinet Office, 2008). This trajectory burgeoned at the start of the Blair decade engendering new systems for clinical governance, a statutory duty of quality, and evidence-based national service frameworks. It therefore laid the foundations for an array of arm s length bodies that retain the scope for direct intervention in the NHS. This trajectory has been perceived as a precursor to the legitimisation of the role of the state as the guarantor of social provision rather than the provider (Sullivan, 2005). Whilst such infrastructure imposes a sense of control, not all now view the NHS as a hierarchical command and control system (Exworthy et al., 1999). Importantly, there is a macro-micro bifurcation (Le Grand, 2002), with politicians and civil servants allocating resources at the macro level, whilst the efficient use of such resources resides within the gift of discrete professionals at the micro level. In acknowledging these caveats, performance management is, therefore, dependent upon the wielding of professional power from macro to micro at the individual and group level. This, therefore, falls prey to the conflicting incentive structures expressed across the professional cadres populating such organisational strata (Le Grand, 2002). The second dimension operating across the English NHS is marketisation, centred on competition, contestability and practice based commissioning (Department of Health, 2005, 2007). This logic aims to increase the efficiency, diversity, and quality of service provision, and 9

10 is a mildly distorted echo of Prime Minister Thatcher s neoliberal reforms (Ham, 2004). Rooted in the new public management that emanated from the USA and swept over mainland Europe, such logic is not confined to the English NHS (Christensen and Lægreid, 1999). The World Trade Organisation, the World Bank, the International Monetary Fund, the Organisation for Economic Cooperation and Development, and USAID collectively enact an institutional logic maintenance function directing capitalist economies to adopt marketisation as a response to the escalating provider-driven costs of health care (Lister, 2005). Individualisation, the third dimension in the English NHS, is closely aligned to marketisation. Although this notion appeared in the Conservative Party s General Election Manifesto of 1979, its apotheosis occurred during the first term of the New Labour Government. At this juncture, a new figure emerged within the policy arena: the demanding and sceptical citizen-consumer. Purposefully constructed from the political imagery of the individual in Western capitalist democracies and an egalitarian mix of liberty, equality and solidarity, this chimera emerged as the means to catalyse bottom up pressure for change (Newman and Clarke, 2009). In so doing, a slow maturation of policy ensued. Initially, openness and public involvement in the NHS was promoted (Department of Health, 1997), progressing to the heightened legitimacy and authority of lay voices (Department of Health, 2002). Later, the adoption of a Scandinavian model of explicit patient choice evolved into individualisation and co-production, consolidating in a complex policy array (e.g. Department of Health, 2003, 2004a; 2004b; 2005, 2006a, 2007). Yet in the English NHS, this agenda is now scarred by uncertainty and financial constraints (Thomson and Dixon, 2006). The final dimension depicted in Figure 2 is centred on building the capacity and capability of the English NHS. Leadership, organisation development and collaboration are collectively underpinned by workforce development through an on-going commitment to lifelong learning to engender individual, organisational and social capital. This echo of Blair s cry education, education, education (Tight, 1998: 478) is characterised by a depth of antecedent policy (e.g., Cabinet Office, 2001, 2002, 2008). However, this policy trajectory is entwined with a new pay system and skills framework for NHS Staff which operates across the devolved NHSs. This logic is thus interwoven with performance measurement to advance an employer led workforce 10

11 development agenda that manifests across the UK as a new architecture of control over the clinical professions within the NHS, subsuming their autonomy and self-regulatory oversight (HMSO, 2007). Notably, this contextual shift now also looms over its management cadre (Santry, 2010). < FIGURE 2> WELSH ASSEMBLY GOVERNMENT S LOGIC FOR PUBLIC SERVICE REFORM: NPS INSPIRED TRANSFORMATION OF THE WELSH NHS Following devolution, despite a New Labour Government in Westminster and the dominant position of the Welsh Labour Party within the Assembly Government, the relationship has been strained in matters of health care policy (Drakeford, 2005). As the UK s ideological well-spring of socialised medicine, the Welsh health care state wears this role with no small degree of pride (Drakeford, 2006). Indeed, as proclaimed repeatedly in the Manifesto of the Welsh Labour Party, it perceives itself as the self-appointed guardian of the NHS or rather the true NHS (Chaney and Drakeford, 2004). As expressed by the then First Minister, Rhodri Morgan (2002), the Welsh way is demarcated by clear red water. NHS Wales has thus adhered to the social democratic communitarian principles and values enshrined at the inception of the NHS (West, 2008). By its very nature, the National Health Service is political it was established by a political party that believed in socialist principles, and we must never move away from that. Edwina Hart, Welsh Assembly Government Minister for Health and Social Services And, as such, it is anchored by historical institutionalism (Thelen, 1999). The logics abandoned in Wales have therefore resulted in the re-emergence of a distinctive dominant logic that jars with aspects of the English NHS (Kitchener, 2002: 413). Moreover, in looking backward to see forward, the Welsh health care state is perpetuating a political vision of a health care system that is now of pensionable age (Oliver and Mossialos, 2005). As illustrated in Figure 2, the first substantive divergence is the unequivocal rejection of marketisation in favour of public service network collaboration (Welsh Assembly Government, 2004). Though ideally built upon trust and co-operation, in Wales, such collaboration is cemented together by quasi-statutory legal frameworks (Entwistle et al., 2007). It therefore constitutes a set of operational requirements for government not paralleled elsewhere in the UK (Quinn, 2002). 11

12 For example, the Government of Wales Act 2006 expressly requires the Welsh Assembly Government to work in formal partnership with the voluntary sector, local government and businesses. Enacted through a Partnership Council, this governance structure enables partner agencies interests to be represented in policy making. For NHS Wales, adherence to such collaboration stands solidified in policy (Welsh Assembly Government, 2007: 9). Nevertheless, despite this entrenched ideological commitment, it is acknowledged that the operationalisation of this institutional logic may prove to be extremely hard to deliver in practice (Welsh Assembly Government, 2006). However, given the rejection of marketisation, provider pluralism and ensuing choice are stymied. The second substantive divergence is thus the adherence to a Bevanesque notion of collectivism and standardisation directed by a choral Welsh voice (Welsh Assembly Government, 2004). Undoubtedly, this anti-consumerist citizen-centred model is characteristic of the traditional Labour values of equality, social justice and social inclusion in policy, and underpins the NPS management ethos of the Welsh health care state (Whitfield, 2001). In contrast, the residual subordinate logics illustrated in Figure 2 display a degree of complementarity with the English NHS. Performance management in NHS Wales is embedded within a traditional hierarchical bureaucracy (Hughes and Vincent-Jones, 2008). This ensures that the line from the Minister to the bedpan runs directly between Cardiff and Tredegar, as it ever did in Aneurin Bevan s day between Tredegar and Whitehall (Drakeford, 2006: 545). Performance in NHS Wales is guided by an annual operating framework, and national service frameworks with explicit targets (Welsh Assembly Government, 2009). External inspection and regulatory oversight is provided by Healthcare Inspectorate Wales, augmented by concordats with the arm s length bodies that service NHS England (Department of Health, 2004c). However, the public reporting of such performance is far more muted. The naming and shaming of a cause célèbre in the local press is a poor comparator to the transparency of the English NHS (Connolly et al., 2010). The leadership and workforce development agenda for NHS Wales is championed by the National Leadership and Innovation Agency for Healthcare, working in partnership with the newly reconfigured Health Boards and the Welsh Assembly Government. 12

13 UK GOVERNMENT S LOGIC FOR THE REGULATION OF THE MEDICAL PROFESSION The recent history of the English NHS is punctuated by scandals which enter the collective memory as socially constructed metaphors for the failings of the service (Butler and Drakeford, 2005). Without question, the professional malevolence and malfeasance exemplified by Harold Shipman represents a fundamental catalyst for policy change in the regulation of the medical profession (Smith, 2005). However, the UK Government s legacy in this specific policy stream is deeply entrenched, though the direction of travel is explicit (Department of Health, 2008a, 2008b, 2008c; HMSO, 2007; Tooke et al., 2008). The UK Government s logic for change within this policy arena is buttressed by the four dimensions which function as the generative mechanisms of change. Heightened top down performance management is to be attained through the reconfiguration of the General Medical Council (GMC) and the Postgraduate Medical Education and Training Board (PMETB). However, in subsuming the PMETB, the GMC will be burdened by increased Parliamentary accountability, augmented by liaison with the Council for Healthcare Regulatory Excellence and Care Quality Commission. Bottom up pressure from lay voices is to be delivered by ensuring that all councils that regulate health professionals have, as a minimum, parity of membership between lay and professional appointees (HMSO, 2007). Horizontal pressure derived through capability and capacity building is, however, inescapably interwoven with performance management (Department of Health, 2006b, 2008c). This is manifested through a new process for medical revalidation that has three elements: (1) to confirm that licensed doctors practise in accordance with the GMC s generic standards (relicensure) 1 ; (2) for doctors on the specialist or general practitioner registers, to confirm that they meet the standards appropriate for their specialty (recertification) 2 ; (3) to identify for further investigation, and remediation, poor practice where local systems are not robust enough to do this or do not exist. Finally, the use of market incentives to increase the efficiency and quality of postgraduate medical education is to be driven by a new body: NHS Medical Education England (NHS: MEE). This organisation is to act as the key point of liaison for the medical workforce advisory infrastructure. It will therefore modulate policy development and implementation with respect to postgraduate medical education and training in a system where the money will follow the trainee, guided by tariffs which ensure that 13

14 the money dedicated to education and training is spent appropriately and to the best effect (Department of Health, 2008b). Notably, across each of these policy aspects there is enforced alignment, as the Devolved Administrations in Wales, Scotland and Northern Ireland are to work with the GMC, the Academy of Medical Royal Colleges and the Department of Health in England to agree appropriate systems that are consistent in outcome across the UK. That NHS Wales will absorb these policy changes is thus inescapable. The complex and on-going debate on the changing nature of the role of the doctor, and that of reformed postgraduate education and training pathways which will encompass modular credentialing are, after all, an on-going UK wide debate (Department of Health, 2008b). However, in fostering broad discussion across the UK Medical Schools Council, Royal Colleges, and the British Medical Association (BMA); tensions between the competing logics of the medical profession and its regulators, source universities, commissioners and NHS employers are also to be anticipated. Yet, for NHS Wales, there is added complexity. The politically mandated collaboration and rejection of marketisation grate against the UK Government s logic for the reform of postgraduate medical education. Therefore, Wales provides an interesting contextual arena in which to explore the under-researched relations amongst structural and agential acceptance and resistance to change in the field of postgraduate medical education. STUDY DESIGN This study is situated within the Welsh healthcare state, centred upon the organisational field that encompassed the extant financial model to support postgraduate medical education in Wales. It therefore engaged with key actors in the Welsh Assembly Government, NHS Wales hospital infrastructure embedded within the newly reconfigured Health Boards, the School of Postgraduate Medical and Dental Education, and wider academe. Data were sourced to inform the performance improvement capability of the existing financial model, and drawn from a documentary analysis (Barry et al., 2006), underpinned by a purposive sample (Kuzel, 1999) of nearly 30 key stakeholders predominantly elites in the aforementioned organisations positioned at chief executive or director levels. Data collection was focused on the organisational structures, systems, skills and cultures enmeshed within the extant financial model; thereby examining the 14

15 relations amongst structural and agential acceptance and resistance to change in the field of postgraduate medical education. Three phases of data collection are scheduled. However, the data presented in this draft paper relate to I, with limited insights gleaned from II. Phase I: a preliminary scoping stage engaging with staff within the School of Postgraduate Medical and Dental Education to map the current pattern of financial flows from the Welsh Assembly Government, through the School to NHS Wales constituent organisations. Phase II: a deeper exploratory stage engaging with staff within the Welsh Assembly Government and NHS Wales to examine the transparency, accountability and performance management of the funding flow for doctors in training grade roles and that for the postgraduate centres and libraries across NHS Wales. This stage will therefore aim to ascertain the real costs incurred in the delivery of postgraduate medical education and training within NHS Wales constituent organisations. Phase III: a reengineering stage engaging with key stakeholders to debate the existing funding model s exposed issues, mitigate potential threats, and thus hone relevant strategic opportunities for change. This multi-professional stakeholder analysis (Brugha and Varvasovszky, 2000) therefore enabled an understanding of key stakeholders perceptions of the present financial model, and the features desired within a new model to support the training of doctors in Wales to be ascertained across the current and near future inter-organisational terrain. PRELIMINARY FINDINGS The Funding Model for Postgraduate Medical Education and Training in Wales The extant funding model that supports postgraduate medical education in Wales is defined in a service level agreement between the Welsh Assembly Government and the School of Postgraduate Medical and Dental Education (hereafter the Wales Deanery). At this level, there is transparency in the governance systems (financial and performance). This is augmented by latitude for change, which reflects the close working relationship that exists across this organisational interface. The Wales Deanery is in receipt of over 95 million in public funds. It 15

16 has financial and managerial accountability for the funding flows to its constituent business units. Moreover, as illustrated in Figure 3, through its advisory role to the Department of Health and Social Care in the Welsh Assembly Government, it is financially accountable for determining the budget apportioned to NHS Wales hospital infrastructure for: doctors in training grade roles ( 50 million); and the network of postgraduate centres and libraries ( 6 million). These latter flows, too, are transparent. However, in moving beyond these top line budget figures, as expressed by a Medical Director in a Health Board: There is so much conflict in the system. The trusts rather the new health boards are target driven; their reputation is dependent on achieving Assembly targets. So, there s enormous conflict between, on the one hand, the pressure on service provision to deliver to target; and, on the other hand, the burgeoning pressures within the system for postgraduate medical education and, most of the tension between service provision and education and training is driven by money. < FIGURE 3> Acknowledging the provisional nature of these findings, the need for fundamental reform to the extant funding model that supports postgraduate medical education in Wales is palpable. Medical professionals, both within the Wales Deanery and NHS Wales hospital infrastructure, expressed the desire for fundamental reform to the system for postgraduate medical education: an argument that extends the debate in this study far beyond the limitations of the traditional funding model. Basically, we are trying to make a 1970s model fit the demands of a 21 st century process of postgraduate medical education and training. It needs to change. There will inevitably be change to the system of postgraduate medical education. And, NHS Wales is going to have to decide whether there are organisations, or patient pathways, that are just dedicated to pure service delivery the achievement of targets and not postgraduate training. In England, this is being cherry picked by private providers. They can pick and choose the routine, the fast through-put cases, leaving the NHS to pick up the more complex and problematic cases. But, there is an important counter argument to all this: I believe education and training can make the service more efficient, more innovative. It depends where your priorities where your values lie. This desire for change to the funding model is echoed by the management cadre in NHS Wales, with a Director of Finance and a Chief Executive Officer in a Health Board commenting that: It s unduly complicated and bureaucratic. Frankly, when I meet up with the Medical Director, I don t know if I should be bawling him out, or if he should be bawling me out. And, after thirty odds years in the NHS, if I can t understand the current system, it doesn t say much for it, does it? It s too complex; it s too complex for our needs. The system we have for undergraduate education is far easier to operate. It s more transparent, we know where we are in terms of 16

17 numbers and the service uplift for training, so it offers far greater accountability. But for postgraduate education well, it s just a legacy of the past but the Department of Health s policy agenda in England is precipitating change, so something will have to give. Importantly, this receptivity for change is replicated within the Welsh Assembly Government, as a policy lead expressed: The funding system for medical education is too complex. It s too complicated. It has evolved over decades, growing in complexity with each reconfiguration so that it has become sedimented the residue of the old ways of working have not been revised. There are layers: layer upon layer of complexity. In some respects it reflects the old structure, all those years ago when there were Strategic Health Authorities in Wales that had a close relationship with medical education. Given such frank desire for change, the inertia in the current system is perplexing. As expressed by both a non-medical manager and a medical professional within the Wales Deanery, the current model results from ad hoc accretion over a number of decades. It is therefore deeply embedded within the systems of Welsh Assembly Government, NHS Wales, and the Wales Deanery; engendering a degree of structural resilience that, despite policy path dependent pressures for change, will inevitably prove to be a significant barrier to be overcome. All of this is historic: patterns of funding that have been established years ago and just left to drift. I want a system that offers accountability, that s fit for purpose, that s based on activity doctors in training and fit for the future for a reconfigured NHS Wales. And that s half of the problem: the systems can t keep up with the reconfigurations. The Deanery s budget is based upon organisations that have been subsumed into new organisational structures time and time again. When I started, monies were allocated on our budget to a hospital that had been knocked down! The current financial model frustrates me. The main problem is accountability...this system...needs to change but people keep telling me: it s a can of worms don t rock the boat... just don t go there. No one is interested: no one seems to want to know. Part of the problem is the money is just something the Deanery advises on so it s not managed internally the money is just allocated by the Deanery. So as a funding flow, it s intangible. We just need clarity; but, as I said, people keep saying it s a can of worms. But for me, the systems unsustainable it s going to explode, crash in a few years time and people are going to ask well what are we actually funding, and the hard answer isn t there. I don t think there is a model, as such. There are three or four in operation, each reflecting the pressures on the system at different periods in time. That s why it s now so complicated. They can t be unpicked. It would be a waste of time. The funding model needs to be rebased. Just draw a line under the past and start over. Dominant Logic and the Emergence of Countervailing Logics Though at a preliminary stage of analysis, the dominant and countervailing logics which generate mechanisms of structural and agential acceptance and resistance to change in the field of 17

18 postgraduate medical education are emergent. Drawing upon the interpretive scheme illustrated in Table 1, and the associated narratives depicted in Table 2, the dominant logic that appears to orchestrate control within postgraduate medical education and training across NHS Wales is collaboration. This manifestly resonates with the higher-order societal logic of the Welsh health care state. However, given the Wales Deanery s unique position in the Welsh health care state (it lacks a competitor in the field) contextual factors must be acknowledged. This collaboration is embedded within and emergent from medical professional networks; principally that spanning the bureaucratic and hierarchical relationship between the Welsh Assembly Government and the Wales Deanery. Hence, this organisational configuration exerts hegemonic control over the system for postgraduate medical education in NHS Wales. Consequently, competition per se is largely inter-professional. This is evident in the desire of NHS Wales management cadre to reassert a degree of control over the funding flow, and the number of junior doctors employed in training grade roles. However, in probing the underpinning logic of collaboration logic across organisational arenas, an intra-professional combative stance between medical professionals within the Wales Deanery and those within NHS Wales hospital infrastructure is also evident. This stance is polarised by the conflicted vested interests of the Medical Director role, being inherently torn between adherence to two logics: medical professionalism and corporate managerialism. Yet other vested interests also seek to modulate the hegemonic block in an organisational field now under considerable churn. Notably, within the Wales Deanery, the perception of a potential loss of control over the funding flows is counterpoised by the desire to strengthen its position as the final arbiter of the quality of postgraduate medical education. Interestingly, this perception is not echoed by the Welsh Assembly Government. Rather the desire to squeeze the Wales Deanery is voiced in forcing adherence to overtly NPM inspired notions of VFM and Best Value. Therefore, acceptance of the need for a NPM-inspired model is palpable in some quarters; but it is challenged in a context where vested interests, informed by countervailing logics, generate mechanisms of resistance to change. < TABLES 1 AND 2> 18

19 Figure 1: CONCEPTUAL MODEL Devolved health policy DOMAIN OF THE REAL UK (English) Health Care State Dominant Logic: marketisation individualism, choice and exit Reserved powers Supra-organisational structure that gives rise to the rules and norms of the UK (English) health care state Welsh Health Care State Dominant Logic: collaboration collectivism, voice, localism state centric Dimensions: Performance management Collaboration Collectivism Capacity and capability Scottish Health Care State Dominant Logic: professionalism Northern Ireland Health Care State Dominant Logic: permissive managerialism The distinctive dominant logic of the Welsh health care state is nested within the heterogeneous higher-order societal logic in the domain of the real. Here, it functions as a countervailing conceptual metamechanism, giving rise to the institutions which shape the features of the Welsh Health Care State by providing the cognitive frameworks for organisation and legitimacy in the domain of the actual. DOMAIN OF THE ACTUAL Institution: Performance management Institution: Collaboration Institution: Collectivism Institution: Capacity and capability Exemplar mechanisms: Exemplar mechanisms: Exemplar mechanisms: Exemplar mechanisms: Annual operating framework Partnership council Democratic participation Workforce development Arms length bodies Statutory frameworks Patient engagement Education and training Generative mechanisms modulate the governmental control of the Welsh health care state at the interface with the domain of the empirical. DOMAIN OF THE EMPIRICAL These generative mechanisms interact with complex array of professional logics (embedded in the domain of the real and manifesting in the domain of the empirical). Competing professional rules, norms, values and assumptions thus function as either harmonising or countervailing mechanisms. This is modulated by the hegemonic power of the professional group policy elites, NHS Wales corporate managers, medical professionals, or its partner agencies as each seeks to enhance its vested interests. 19

20 Figure 2: UK Government s Logic for Public Service Reform A Self-Improving System NHS England DH Public Service Agreements Nation Service Frameworks Healthcare Commission: Inspection Top Down Performance Management Intervention in Failing Hospitals *Encouraging Entry of New Providers *Commissioning Hospital Services Purchaser/ Provider split *Market Incentives to Increase Efficiency & Quality of Service Better Public Services for All Capability & Capacity NHS Leadership Qualities Framework Agenda for Change; Role Redesign NHS NIII Continuous Improvemen t *Giving Patients Choice over Treatment Personalised services through empowered citizens and professionals working New Professionalis Patients Shaping Health Care Patient Satisfaction Surveys; Expert Patients Programme, Co-production Citizen Empowerment Excellence and Fairness *Payment by Results Strategic Leadershi Blair Decade Brown Transition Greater accountability and transparency enabling citizens to hold services to Government enabling change through incentives and support without micro- Key: (*) Reform mechanisms not employed in the Welsh NHS. (DH) Department of Health. NHS III NHS National Institute for Innovation and Improvement 20

21 Figure 3: Schematic of the Extant Funding Model for Postgraduate Medical Education and Training in Wales Department of Health & Social Care, Welsh Assembly Government Service level agreement between the Welsh Assembly Government and the School of Postgraduate Medical and Dental Education School of Postgraduate Medical and Dental Education The Wales Deanery is in receipt of over 95 million in public funds. Through its advisory role to the Department of Health and Social Care in the Welsh Assembly Government, it is financially accountable for determining the budget apportioned to NHS Wales hospital infrastructure for: doctors in training grade roles ( 50 million); and the network of postgraduate centres and libraries ( 6 million). Reconfigured NHS Wales: Abertawe Bro Morgannwg University Health Board formerly Abertawe Bro Morgannwg University NHS Trust and Swansea, Neath Port Talbot and Bridgend Local Health Boards. Aneurin Bevan Health Board formerly Gwent Healthcare NHS Trust and Blaenau Gwent, Monmouthshire, Newport, Torfaen and Caerphilly Local Health Boards. Betsi Cadwaladr University Health Board formerly North Wales NHS Trust, North West Wales NHS Trust, and Anglesey, Conway, Denbighshire, Flintshire, Gwynedd and Wrexham Local Health Boards. Cardiff and Vale University Health Board formerly Cardiff and Vale NHS Trust, Cardiff and the Vale of Glamorgan Local Health Boards. Cwm Taf Health Board formerly Cwm Taf NHS Trust, Rhondda Cynon Taf and Merthyr Tydfil Local Health Boards. Hywel Dda Health Board formerly Hywel Dda NHS Trust and Ceredigion, Pembrokeshire and Carmarthenshire Local Health Boards. These reconfigured organisations are augmented by: Velindre NHS Trust and Powys Teaching Health Board, which remained unchanged; Public Health Wales NHS Trust, and the Welsh Ambulance Services NHS Trust. 21

22 Table 1: Summary Comparison of NHS England and NHS Wales Interpretive scheme: NHS England NHS Wales Dominant logic Competition, individualism Collaboration, collectivism Countervailing logics Competitive versus collaborative Individualism versus collectivism Medical professionalism versus corporate managerialism Collaborative versus competitive Collectivism versus individualism Medical professionalism versus corporate managerialism Organisational purpose Organising principles Structures Evaluation criteria Health care delivery Disease prevention Education and training of junior medical staff Regulated market Statutory frameworks Independent regulatory agencies Limited consumer sovereignty, choice and competition Purchaser-provider split Plurality of public and accredited private providers Target driven performance frameworks Public transparency Health care delivery Disease prevention Education and training of junior medical staff Bureaucracy Traditional hierarchical integration Independent regulatory agencies State centric Public Target driven performance frameworks Public opacity Table informed by: Connelly et al., 2010; Hughes and Vincent-Jones, 2008; Kitchener and Harrington,