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Social Science & Medicine 74 (2012) 305e312
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Social Science & Medicine
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Addressing complex healthcare problems in diverse settings: Insights fromactivity theory
Gail Greig a,*, Vikki A. Entwistle b, Nic Beech a
aUniversity of St Andrews, United KingdombUniversity of Dundee, United Kingdom
a r t i c l e i n f o
Article history:Available online 1 March 2011
Keywords:ScotlandActivity theoryManagement practicePrimary healthcareHospital admissionsPolicyUK
* Corresponding author. Tel.: þ44 (0)1334 462875.E-mail addresses: [email protected] (G. Greig)
uk (V.A. Entwistle), [email protected] (N. Beech
0277-9536/$ e see front matter � 2011 Elsevier Ltd.doi:10.1016/j.socscimed.2011.02.006
a b s t r a c t
In the UK, approaches to policy implementation, service improvement and quality assurance treat policy,management and clinical care as separate, hierarchical domains. They are often based on the centralknowledge transfer (KT) theory idea that best practice solutions to complex problems can be identifiedand ‘rolled out’ across organisations. When the designated ‘best practice’ is not implemented, this isinterpreted as local e particularly management e failure. Remedial actions include reiterating policyaims and tightening performance management of solution implementation, frequently to no avail.
We propose activity theory (AT) as an alternative approach to identifying and understanding thechallenges of addressing complex healthcare problems across diverse settings. AT challenges the KTconceptual separations between levels of policy, management and clinical care. It does not regardknowledge and practice as separable, and does not understand them in the commodified way that hastypified some versions of KT theory. Instead, AT focuses on “objects of activity”which can be contested. Itsees new practice as emerging from contradiction and understands knowledge and practice as funda-mentally entwined, not separate. From an AT perspective, there can be no single best practice.
The contributions of AT are that it enables us to understand the dynamics of knowledge-practice inactivities rather than between levels. It shows how efforts to reduce variation from best practice mayparadoxically remove a key source of practice improvement. After explaining the principles of AT weillustrate its explanatory potential through an ethnographic study of primary healthcare teamsresponding to a policy aim of reducing inappropriate hospital admissions of older people by the ‘bestpractice’ of rapid response teams.
� 2011 Elsevier Ltd. All rights reserved.
Introduction
In the UK, theories of organisational learning and knowledgemanagement have been particularly influential in recent attemptsto reform health and other public services (Office for Public ServiceReform, 2002). Theories underpinned by notions of knowledgetransfer and/or knowledge translation (henceforth referred to as ‘KTtheories’) dominate current approaches to policy implementation,service improvement and quality assurance (Department of Health,2000; Scottish Executive Health Department [SEHD], 2000, 2001a).The applicability and usefulness of these theories are increasinglyquestioned given the distributed knowledge base, diverse settings
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and complex, fragmented nature of healthcare work (Marchington,Grimshaw, Rubery, & Wilmott, 2005; Tsoukas, 1996; Walker, 2007).
In this paper we propose activity theory (henceforth ‘AT’) as analternative theoretical approach which illuminates the contested,negotiated nature of healthcare policy, management and clinicalwork and accounts for some of the difficulties experienced withKT-informed policy and managerial practices. We suggest that anactivity theoretical approach enables the relations between policymaking, management and clinical work to be understood in newways, revealing the generative potential of tensions between thesethree interlinked and overlapping areas of practice. Rather thanseeking strict conformity to ‘best practice’, AT highlights the valueof variation and even contradictions for practice development.
We begin by outlining key features of KT theories and thenpresent AT as an alternative theoretical perspective. We thenillustrate the explanatory and practical utility of AT by drawing onan empirical study of collective learning in primary care teams. Inparticular we show how AT could account for and suggest ways of
G. Greig et al. / Social Science & Medicine 74 (2012) 305e312306
moving beyond failures of policy implementation that seem para-doxical according to KT.
Theories of organisational learning and knowledgemanagement
Knowledge transfer theories
In the field of organisation studies, there has been significantdebate concerning how knowledge is acquired and spread inorganisations. The notion of ‘knowledge transfer’, which originatedin literature on organisational learning and knowledge manage-ment (Argote, Beckman & Epple, 1990; Argote & Ingram, 2000), hasfeatured prominently in healthcare policy and management,particularly in the USA and UK (Harrison, Moran, & Wood, 2002). Ithas been augmented by the concept of knowledge translation,which in healthcare literature concerns translating research find-ings into more accessible terms to enable transfer into organisa-tional and/or clinical practice (Nutley, Walter, & Davies, 2007).
KT theories share a rational and cognitive emphasis. They havebeen influential in management practices including BusinessProcess Re-engineering (Hammer, 1990) and Lean management(Holweg, 2007), and now widely inform generalised responses toperceived common problems.
Their adoption in healthcare policy incorporates two influentialassumptions: first, that it is possible and desirable to develop ‘bestpractice’ solutions to organisational problems (Szulanski, 1996),either by recognising a local ‘best practice’ or by running pilotprojects to discover one; second, that knowledge in the form of ‘bestpractice’ can be spread across organisational settings, with localpractitioners learning memetically as they implement importedsolutions (O’Mahoney, 2007). These assumptions are linked toa conceptualisation of policy, management and clinical activity asthree discrete macro, meso and micro levels of organisation acrosswhich knowledge must be shared (Hanney, Gonzalez-Block,Buxton, & Kogan, 2003; Walshe & Rundall, 2001). Knowledgesharing can, when effective, have the advantages of reducingresearch and development costs (Cohen & Levinthal, 1990) andduplication of effort (Epple, Argote, & Devadas, 1991). KTapproaches also promise to facilitate standardised practice andenhance quality assurance (Bate & Robert, 2002). In health servicesresearch the development of the field of ‘implementation science’,to facilitate knowledge translation and transfer (Sobo, Bowman, &Gifford, 2008; Soper & Hanney, 2007; Ward, House, & Hamer,2009) indicates the strength of attachment to KT theories.
However, a large and diverse inter-disciplinary literature atteststo the difficulties of operationalising knowledge transfer, particu-larly in healthcare (Greenhalgh, Potts, Wong, Bark, & Swinglehurst,2009; Greenhalgh, Robert, Macfarlane, Bate, & Kyriakidou, 2004;Nicolini, Powell, Conville, & Martinez-Solano, 2008).
Various explanations for this have been offered. Knowledge canbe ‘sticky’ and therefore difficult to share with people beyond animmediate group or work setting (Szulanski, 1996, 2000). This maylimit an organisation’s ‘absorptive capacity’ and ability to maximisethe benefits of internal knowledge (Cohen & Levinthal, 1990),rendering some practitioners unaware of knowledge that existswithin the organisation. An understanding of how to supportcomplex processes of knowledge sharing between organisationalgroups can be crucial (Newell, Edelman, Scarborough, Swan &Bresnen, 2003), especially if an overall corporate social identity islacking (Kane, 2010).
Notwithstanding the developments in KT theories, difficultiespersist in ‘non-linear’ and complex settings such as healthcare andthis will be illustrated in the vignettes we introduce later. Efforts toidentify alternative theoretical approaches have begun (Greenhalgh
& Stones, 2010; Kontos & Poland, 2009). Practice-based theories,including AT, have been developed to analyse knowledge andpractice sharing in complex, dynamic contexts (Nicolini, Gherardi, &Yanow, 2003; Schatzki, Knorr Cetina, & Von Savigny, 2001) and arepotential candidates for framing analyses and developing insights.In the next sectionwe introduce aspects of AT that we suggest offerexplanatory and practical advantages.
Practice-based theories e activity theory (AT)
Practice-based theories share the view that organisationallearning is collective, social and situated, and its product is nota commodity called knowledge (Nicolini et al., 2003). They rejectthe assumption that knowledge is an abstract and acontextualentity which can be transferred, readily or otherwise, betweensocial settings (Lave, 1993). In this paper we consider a particularpractice-based theory, cultural historical AT (henceforth referred tosimply as AT).
ATconcerns the study of practices (Chaiklin, 2011) and considersknowledge e or knowing e to be achieved through participation inpractice (Blackler, 1995). AT was introduced to organisation studiesas one alternative to KT theories of organisational learning andknowledge management (Blackler, 1993).
AT focuses on an “object of activity” (Blackler, 2009). Put simply,the object of activity is the aim towards which people workcollectively to meet an identified need (Chaiklin, 2011; Engestrom,1999). It encapsulates the mutual motivation around which peoplecoalesce (Axel, 1997) and provides a focus towards which peoplefrom various organisational and professional backgrounds androles may work together (Engestrom, Engestrom, & Vahaaho, 1999)in more or less stable groupings.
The analytical unit of AT is the activity system (Engestrom,2001). This comprises the mutual aim of practice (the object), allthose who are involved in working towards it (the subjects), thematerial and psychological tools used in the work, the rules whichgovern thework, theway people are organised to achieve their aim,and the wider community of practitioners.
The complexity of much contemporary work results in peoplebeing involved in a various projects simultaneously, which mayhave different aims. Thus, they participate in multiple activitysystems (Blackler, 2009). The object-oriented focus of AT can revealthe range of overlapping activity systems involved in workingtowards any particular mutual aim. Therefore, it can accommodate(theoretically) the increasingly fragmented and distributed char-acteristics of contemporary work practices (Hutchins, 1993). Themetaphor of “knots” reflects the more or less temporary entan-glements of inter-organisational, inter-professional dimensions ofwork groupings (Engestrom, 2006).
For the purposes of this paper, we focus on the idea of the ‘objectof activity’, using it to shed new light on ideas about best practice inhealthcare, noting in particular the frequently contradictory natureof many overlapping objects of activity. Tension and contradictionare central to AT, and we turn to these issues next.
Contradictory, contested and negotiated objects of activity
Although they encapsulate mutual aims and provide a focus forgroupings to work together, objects of activity should not beregarded as harmonious. On the contrary, they highlight theintrinsically contested, negotiated and inherently contradictorynature of collective work practices (Blackler & Regan, 2006).
The power of the concept of activity lies in the way it canaccount for how contrasting or divergent actions can achievemutual aims in practice: in Leont’ev’s (1974) example of theprimeval hunt, the object of catching a deer (meeting the need of
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providing food for everyone) involved one group apparentlychasing the deer away. In fact they were enabling other huntparticipants, lying in wait, to kill it using weapons. Without themutual object of catching the deer this would not be collectiveactivity, but the disconnected actions of two groups.
AT can illuminate the different conceptualisations of thoseinvolved in activity concerning the object or mutual aim. It canfacilitate exploration of differing values underpinning their views(Blackler, 2009; Engestrom, 1999). In healthcare, the presence ofcontradictions between objects of activity is sometimes illustratedby pointing out that it is the doctor’s object to treat patients whoneed medical help, but also to earn a living whilst doing so. Whenmultiple people are involved, there are manifold contradictions.
Whereas similarity is central to KT-inspired efforts to transferone best practice across contexts, AT offers an alternative byfocussing on differences which operate around objects of activity.Contradictions are taken to be indicative of the changing nature ofobjects of activity, which may or may not endure over time(Engestrom & Blackler, 2005). Objects of activity are partly given(reflecting the way things were done up until now), but also partlycreated and emergent (reflecting new ways of doing things to meetnew, changing or re-emerging needs) (Miettinen & Virkkunen,2005).
The contradictions that arise in relation to objects of activitywithin and across activity systems are potentially transformative:when they become too great and all the possibilities for resolvingthem are unattractive to participants, activity itself may be trans-formed giving rise to newaims andways of working (Bateson,1972;Engestrom, 1987).
AT therefore offers an alternative perspective of knowledgesharing within and across organisations. The key differencesbetween KT and activity theories are summarised in Table 1.
Some studies have drawn upon AT, examining mainly either theclinical/medical aspects of healthcare practice, or the way it isorganised (for example, Blackler, Reed & Kennedy, 1999;Engestrom, 2008; Nicolini, 2007). In this paper, we focus on rela-tions between health and social care policy and management andclinical practice. We seek to show how object-oriented AT offersnew insights into these relations by revealing both contradictionsand learning across what are understood as levels in KT.
We use an empirical example concerning the policy aim ofreducing hospital admissions amongst older people. Specifically,we draw upon the Scottish Government’s introduction ofcommunity-based ‘Rapid Response Teams’, or ‘RRTs’ (unrelated toacute hospital teams dealing with cardiac arrests, etc), which isoutlined next.
Empirical example
Many Western countries have high levels of acute hospitaladmissions of older people which are considered inappropriate:older people may need care and support due to health-related
Table 1Key differences in perspective between knowledge transfer theories and AT.
Knowledge Transfer Theories AT
View practices as commodified, portable entitieswith predictable outcomes
Views practices as d
Consider learning to be achieved through knowledge transfer.Assumes knowledge transfer is achieved by ‘roll-out’
of selected best practice to new settings.
Views ‘best’ practiceand learning as an in
Onward adoption of (the same) best practice is regardedas a logical extension of its discovery.
Learning is seen as aand between activity
Policies influenced by KT theories view difference/variationin practices across settings as a problem to be eliminated.
Policies influenced b
problems, but not necessarily high-tech hospital care. Inappro-priate admissions arise against a backdrop of increasingly frag-mented service provision (World Health Organisation, 2008). Theirvarious unwanted personal, organisational and policy-relatedimplications include iatrogenic harm, ‘blocked’ hospital beds, andescalating healthcare costs (Kerr, 2005; SEHD, 2005a). In Scotland,RRTs e comprising nursing, allied health professionals and ancil-lary social care personnel e were to provide flexible, immediate,short term health and social care support, enabling older peoplewith emergent problems to remain at home while an appropriatecare package was arranged. Policy makers hoped to reduce inap-propriate hospital admissions by implementing this one bestpractice solution across Scotland. Mimicking the format from onearea, local council social work departments were to introduce RRTsby mid 2001e2002 (SEHD, 2001b). This required joint workingbetween Health Boards and Councils and a transfer of services andfunding from Health Boards to Councils.
Although analysis demonstrated that the implementation of RRTswas problematic (Kendrick & Conway, 2003), policy makers subse-quently strengthened this requirement (Joint Future ImplementationAdvisory Group, 2003; Scottish Executive/COSLA, 2004). Recentfigures suggest that inappropriate hospitalisations continue(Information and Statistics Division, Scotland, 2009).
Methods
We analysed attempts to achieve the policy aim of reducinginappropriate hospital admissions by spreading ‘best practice’(introducing RRTs across Scotland), as part of a broader multiplecase study of organisational learning. Using an ethnographicapproach the study was conducted among three Scottish primarycare teams over two years (2005e2006). Teams were purposivelysampled (Mason, 1996) to ensure varied professional and organ-isational mixes, geographical settings, patient populations andcharacteristics associated with learning, including willingness toembrace or initiate new forms of practice or organisation.
All teamswere located in the same NHS Board area. One coveredan urban area, while two served rural populations. Two had DistrictGeneral Hospitals (DGH) within their geographical ambit, and onefeatured a community hospital with both long-stay Care of theElderly beds (nominally the responsibility of a consultant froma DGH) and short-stay beds for GP admissions.
Two teams worked within the same local Council area and weremembers of the same Community Health Partnership (CHP). Theyliaised with the same social work manager whowas also associatedwith their CHP. (In all teams, CHP and social workmanagers workede on behalf of their Health Board and local Council employers e onlocal arrangements for introducing RRTs.) The key features of eachprimary care team are summarised in Table 2.
The first author undertook observations in the primary carepremises and their surrounds, attended meetings, analysedNHS and team documents and conducted a total of 56 in-depth
ynamic activity with less predictable outcomes.
as context-specific and practice-centred,herent aspect of participation in organisational activity
rising from contradictions and differences withinsystems and practices. Contradictions are potentially transformative of practice.
y AT would view difference/variation as likely and not necessarily problematic.
Table 2Primary care team settings and key features.
Harebell Primrose Thistle
Area and population Urban (post-industrial town).Significant levels of deprivation
Rural (large, sparsely populatedarea with three villages).Pockets of deprivation,poor transport infrastructure
Rural (including small townthat serves as local council base).Pockets of deprivation, poortransport infrastructure
Hospital facilities Local District GeneralHospital (DGH1)
Local District General Hospital(DGH2) at one end of the areacovered by the team
Community Hospital (CH1) withlong stay (consultant) and short stay(GP) beds
Community HealthPartnership
A B B
Local Council V W WPrimary care premises
and staffingBased in large Health Centrewith a range of other clinical services.Team has access to additional‘treatment room’,nurses for dressings etc
Three premisesDispensing Practice (2 premises)Staff recruitment and retentiondifficulties
Initially based in Health Centre in town.Relocated during study to Community Hospital (CH1).In CH1, team has access to AlliedHealth Professionals, GP (acute) beds, A&E trauma(back up from distant tertiary hospital), cover for long-staybeds under consultant from DGH2.
GP out of hoursarrangements
Out of hours regional rota participation Out of hours regional rotaparticipation e located at DGH1.
Provide 24/7 service for Practice patients
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semi-structured interviews with primary care team members froma range of professional backgrounds including associated managersfrom health service and local government organisations. Forty-eight of the interviews (including two group interviews) exploredthe ‘who, what, where, when and how’ of organisational orcollective learning (Huysman,1999). Emergent findings highlightedsimilarities in learning processes but differences in practicesbetween the teams.
To investigate further, we presented a vignette depictinga normal clinical encounter in primary care to multi-professionalgroups of practitioners (clinicians and managers) from each teamand asked them to discuss what would happen if the followingoccurred:
You receive a call from the family/relatives of an 80 year oldwoman, their mother, about whom they are concerned. They donot live locally/near her. She has fallen a few times at home, butthere is no clear indication of why she has fallen. She is not verywell and is not managing very well at home, her mobility isn’tvery good and they are generally worried about her. Whatwould happen upon receipt of such a call?
This enabled team members to discuss their activity in relationto an ‘object of activity’, namely meeting the healthcare needs ofthe elderly woman. Group interviews were augmented by fivefollow-up interviews with key respondents from each team.
All interviews were transcribed and data from all sources wereanalysed using two approaches. First, material relating to eachprimary care team was analysed holistically, revealing an in-depthview of each case through which internal processes were identified(Langley, 1999). Second, emergent themes within each case wereanalysed across all cases (Mason, 1999). These within- and cross-case analyses allowed similarities and differences in teams’ activi-ties to be identified and explored.
The study was approved by the Multi Centre Research EthicsCommittee for Scotland.
In the next section, we present empirical data to illustrate theinsights AT offers to understanding complex healthcare problems.
Responses to the vignette
The primary care teams discussed the vignette five years afterthe introduction of RRTs had become a policy recommendation.
In the Harebell area, an RRT had been partially introduced butprimary care personnel would not call upon it in the vignettesituation, because RRT staff were unavailable between 6pm and
8am to organise team input. Patients would be admitted to DGH1overnight and referred to the DGH outreach service which helpedsupport people at home thereafter, which constituted a form ofhospital “admission”.
In the Primrose area, an RRT had also been partially introduced,but clinicians did not immediately think of it when consideringhow best to meet the needs of the woman in the vignette, becauseavailability of the service was limited: it could only be arrangeduntil 9.30pm, and then only for patients living in the part of thePrimrose area nearest the town where both the RRT and the localDGH were located. In practice, therefore, most patients wereadmitted to DGH2.
In the Thistle area there was no RRT, and only limited socialwork support generally. Here, patients would usually be admittedto the local community hospital by their own GP or the Thistleteam’s GP ‘on-call’ (depending on whether in- or out-of-hours).Their needs would be met by the local extended primary care teamduring their hospital stay and after discharge, to their own homespreferably.
Contradictions and tensions in the object of activity
Our data consistently indicated that clinicians and managersassociated with all teams strongly endorsed the goal of avoidingunnecessary hospital admissions of older people who were notseriously unwell, by providing the additional care and support theyneeded at home. However, this goal proved difficult to achieve andRRTs e insofar as they were introduced - did not have the trans-formative effects envisaged by policy makers.
The planned introduction of RRTs was consistent with a broaderpolicy intention to ‘shift the balance of care’, from hospitals tocommunity-based services, through better integration between‘health’ and ‘social’ care (SEHD, 2001b). This required the re-allo-cation of resources from hospitals to community-based services.These services were delivered by two different organisations: NHSBoards/Community Health Partnerships for ‘health’, and localcouncils for ‘social’ care. Since no additional central governmentfunding was available, this involved redistribution of funding andservice reconfiguration.
Introducing the best practice solution of RRTs was problematicpartly because of managerial and political tensions entailed inresource transfer and service redesign. From an AT perspectivethese difficulties can be understood as arising from the contestednature and competing aspects of the object of activity of meetingthe woman’s healthcare needs, as described next.
G. Greig et al. / Social Science & Medicine 74 (2012) 305e312 309
Financial focus
Managers in each of the key organisations talked about (andwere said by others to be particularly concerned with) balancingtheir budgets. Since this represented a keymanagerial performancearea, sizeable transfers of funds between organisations e andbetween services within organisations e posed significant chal-lenges for those carrying official financial responsibility.
The Primrose and Thistle areas’ local council was working toreduce the number of continuing care hospital beds it funded (forpeople needing long term personal and nursing care) and wasapparently struggling to fund community support arrangementswhile the reduction was ongoing:
.social work are having their problems in terms of fundingcommunity packages, and that certainly impinges on what wedo in the community. It comes back to budgets in the end.
(Clinician manager, Primrose)Participants experienced substantial difficulties in moving
services to the community despite efforts to transfer funding:
We have to plan for sufficient community care services to bethere in the community infrastructure to enable as to managewithout those beds.We’re trying to make those local, but if wedo that, there’s not enough money to put anything in thecommunity. we’re trying [ ] to carry on working, but redesignthe service at the same time. And that obviously takes you downtwo different roads simultaneously.
(Social work manager, Primrose/Rowan)Although managers could agree on the kind of endpoint
arrangement that was needed, the transition was problematic,requiring disinvestment in some services to establish others.
The corollary of these tensions was that GPs faced with theimmediate needs of older people had little choice other thanhospitalisation.
Accountability
Tensions associated with accountability included service inte-gration and politics. While both NHS Board and local Councilmanagers sought to provide forms of care that would reduceinappropriate hospitalisations, they worked within several activitysystems with different objects and were subject to contradictorypolicies:
I don’t think the centre’s joined up. They keep sending us thingsto respond to individually rather than together as a ‘JointFuture’. So I don’t think they [Scottish Executive] know wherethey’re going. There’s a.feeling that.we all know what thepolicy’s suggesting but we don’t knowwhat the destination is.We don’t know whether they want us to be one organisation,cos they’re saying “resist that e you’re still two organisations.
(Social work manager, Primrose/Rowan)In addition, plans to reduce numbers of hospital beds, or even
close particular hospitals, attracted public opposition and werepolitically sensitive. In the Harebell area, local people campaignedvigorously to oppose the closure of DGH1, encouraged by theirelected Member of Parliament, who rebelled against party policy to“fight the cuts”.
Meanwhile, primary care clinicians from the Thistle area wroteto national newspapers supporting the proposed service reconfi-guration (which would improve the sustainability of their services),which attracted public support within the Thistle area (fieldnotes,2005). However public support in the wider local council andoverall Health Board areas for the proposed service reconfiguration
was equivocal at best. This did not facilitate the introduction ofalternatives to hospitalisation.
Participants identified tensions over accountability within andbetween Health and Council organisations. The dearth of socialservices in the Thistle areawas perceived to be linked to healthcareinvestment in DGH2. Participants felt this should be shared acrossthe CHP area if funding transferred to the Council. They suggestedthat redesigning services could render Councillors politicallyvulnerable due to the independent nature of the Council.
Votesmight be lost if serviceswere no longer available in their partof the electoral “patch”, especially where accountability transferredwith (inadequate) resources and heightened electoral expectations:
.Councillors won’t want to be seen to be accepting theresponsibility that’s formerly Health’s, and then getting theblame for non-performance.
(social work manager, Primrose/Thistle)As the same participant explained, this reflected the apparently
different foci, and related levels of accountability, between healthand social work managers:
.it’s not that they [NHS managers] don’t know what theirbudgets are, but, they’re more concerned with duty of care e
which we [Council] are e but because we’re accountablethrough policy committees, we actually have to justify ouractions inwriting every time we do it. So you’ve got two parallelsystems working differently to try and achieve the same aim.
This contrasted with healthcare participants’ views (see above)that their managers shared an interest in budgetary issues withtheir council colleagues.
Control and performance targets
Meanwhile, the contradictory effects perceived in policymakers’ attempts to exert control over clinical services, throughmanagement implementation of policy, drew a dubious responsefrom one experienced NHSmanager, who identified different viewsabout primary care teams’ objects of activity:
I think where management has not succeeded is in believing thatitwill control everything and that it can get clinicians to heelwithpolicy. Bits of policy will get taken forward e and will work e ifyou let clinicians do it, but none of it will if you just leave it tomanagers .Surely we all have to be saying “Well the GPs’workload is our workload” e it’s not something totally different.
(NHS manager, Primrose/Thistle)This reflected a concern raised by clinicians throughout the
research e about the futility of not linking clinical activity with theorganising activity of managers charged with implementingpolicy:
[Managers’] whole value system is based on a differentmanagement codee various bottom lines that aren’t my bottomline. a fantastic example: breachingwaiting time targets. If you[manager] breach a waiting time target, then potentially there isa sanction on your operation from the Scottish Exec, whichcould cost your organisation a lot of money and potentially youyour job e certainly your career. But you don’t even speak tous e we’re the people who.instigate the referrals.
(Clinician manager, Harebell)As this clinician became more involved in the redesign and
management process, his awareness of the tensions entailedtherein grew:
The pressures for the Health Board to deliver are reallytough. Things cut right across [legitimate management
G. Greig et al. / Social Science & Medicine 74 (2012) 305e312310
aims] in terms of expert opinion and vested interests andlocal politics.
Although clinicians could highlight plans which would probablye unbeknown to managers e be unsuccessful, managers’ andclinicians’ perceived priorities and practices seemed likely tocontinue to differ regardless of overlapping mutual interests.
Discussion
From a KT perspective, the problems of implementing the RRTsolution may indicate failure of those along the communicationchain (from policy through management to clinical practice) toappreciate and enact best practice fully. The politics, disputes overaccountability and persistence of GPs in making hospital referralscould suggest breakdown either in the transfer of the knowledge orthe translation of its meaning across different groups (or both).Breakdowns in the flow could be deliberate (resistance) or unin-tentional (inefficiency or a lack of focus). Implicit within thisunderstanding of the situation is a potential solution: greaterclarity of translation and more effective roll-out and reinforcementof transfer. This, however, was not effective.
The alternative AT perspective asks somewhat different ques-tions and focuses on how things come to be as they are, does notpresume a linear flow of communication from policy to practice asthe norm, and hence derives potentially different insights.
First, from an AT perspective actors were participating in threeactivity systems. Exploring the particular ‘object of activity’ pre-sented in the vignette revealed the distributed nature of activity(Tolman, 1999; Hutchins, 1993) and the relational nature of activitysystems (involving primary care teams, local and national policymaking, social work and NHS management), working together in‘knots’ (Engestrom, 2006). However, the relationships were notones of transparent agreement but involved rather differentunderstandings of what the object of meeting an older woman’sneeds entailed. Clinicians focused on diagnosing her healthcareproblem and organising her treatment and care. Through thisactivity, contradictions arose related to the foci of co-participantswhich emphasised budgetary, public accountability and perfor-mance assessment issues. National policy makers focused onproviding cost-effective, responsive services, using policy guidanceto introduce RRTs and performance management indicators toengender the integration between health and social work organi-sations that they deemed necessary to establish RRTs. Local Coun-cillors, although responsible for social work services, wereconcerned with accountability to voters and not losing localservices or overspending, which could be electorally damaging.NHS and social care managers, charged with enacting policymakers’ aims and managing service delivery, focused mainly onbudgetary issues, regulatory responsibilities and performanceissues. Object-oriented AT revealed that each grouping wasinvolved somehow in the woman’s care and the practical resultreflected the balance e or tensions e between the different aspectsof this object of activity. Groups of actors were able to tolerate thehospital referral/RRT balance to the extent that it met the purposescentral to their particular practice and involvement in activity.
Hence, although there was broad agreement between the actorsthat reducing inappropriate hospital admissions was desirable, thepractices through which this was achieved entailed contradictionsarising between different groups involved in working to producethis particular object of activity (Blackler, Kennedy, & Reed, 1999).From an AT perspective, policy implementation was not simplyresisted or ineffective. Rather, the object of activity emergedthrough a balance of the tensions between differing groups’involvement in it, and their participation in its co-constitution.
Therefore, pushing the RRT solution ever harder was unlikely tosolve the apparent problem of non-implementation. It seems theapparent problem emerged as people strove to achieve the mutualaim of reducing inappropriate hospital admissions. AT highlightsthe importance of analysing and revealing the inherent differencesand tensions involved in particular objects of activity. These are notimmediately obvious when all involved apparently espouse thepurpose of the best practice implementation. Once the generativenature of tensions and differences is recognised, working with andlearning from them becomes possible.
The second significant insight from AT is that the groupsinvolved are not best understood as hierarchically separate macro(policy), meso (managerial) and micro (clinical) levels of practice.Although these groups signify different practices, they ‘hangtogether’ (Schatzki, 2003), coalescing around the object of activity(Engestrom, 2006). The macro level does not simply cause whathappens ‘downstream’ at the micro level via the meso level. In ourcase, as actors participated in practice, their talk, thinking andaction were imbued with perceptions of others which were bothused to gain legitimacy, and experienced as constraints. Forexample, voters were invoked in political discourse as a reason formaking the policy and as a reason for not acting to realise it.Patients, public and ‘bottom lines’ all crossed discursive boundariesand featured in groups’ decision making. Hence in AT, it is better toregard practices (incorporating policy, management and clinical) asmutually constitutive and mutually influential through collectiveactivity. This is not to say that they are totally integrated but thatattention should focus on agreement and contestation betweenpractices surrounding particular object(s) of activity, not on a seriesof temporally ordered, hierarchically separated steps in the flowfrom idea via communication to action.
The third insight derived from an AT analysis is that althoughcontradictions may highlight difficulties, they may be explored asbeing potentially transformative. If difficulties are experienced assufficiently serious, and currently available means for resolvingthem are equally unsatisfactory, new ways of working are morelikely to emerge through a process of transformative or expansivelearning (Engestrom, 1987). For example, the need to reduce inap-propriate hospital admissions generated difficulties between healthand social work funding and accountability structures. In ourillustration KT-informed ways of dealing with such tensionsentailed transferring control to one party and making problemsunsayable, as policy unintentionally encouraged and discouragedcloser working between health and social work. From an ATperspective, serious difficulties indicate the need to abandon oldways of addressing problems and try newways ofworking. Thismayproduce local practices that can achieve the agreed ends, though notnecessarily as anticipated (Beech, Burns, de Caestecker,MacIntosh &MacLean, 2004). In our example, the community hospital, nursinghome and outreach DGH service provided limited local solutions forreducing hospital admissions whilst each area grappled with thepractical problems associated with introducing the centrally-proposed RRT solution. The effort to transfer best practice raisedtensions and downgraded local solutions, whereas the AT approachis to capitalise on these rather than eliminate (or disguise) them.
Conclusion
Our aim was to develop and illustrate the utility of AT inproducing insights for addressing complex problems in healthcare.AT can accommodate the uncertain, unpredictable nature ofhealthcare service provision, policy making and management. Itanticipates unintended consequences (Hinings et al., 2003) becauseof competing priorities entailed in the co-constitution of an objectof activity, even in settings where there is apparent agreement
G. Greig et al. / Social Science & Medicine 74 (2012) 305e312 311
about it. This supports a tentative, ‘trying out’ approach to enactingpolicy (Schofield, 2004).
Through our exploration of an example of a clinical encounterwehighlight three main insights. First, in order to understand howthings come to be as they are, it is helpful to reveal the differentviews of objects of activity which are often present, like those wesaw between policy makers, managers and clinicians. This reflectsthe contested, negotiated nature of objects of activity (Blackler,Crump, & McDonald, 2000). Second, although there is a focus ondifference, it is not a transfermodel of linear temporality and powerhierarchy. Rather, actors form “knots” through which they are ableto work together using discursive and material resources(Engestrom, 2006), towards achieving a particular mutual aim orobject of activity (Blackler &McDonald, 2000). Through this process,overlapping practices may be seen to be mutually constitutive andinfluential. Third, contradictions and tensions are seen as a normalpart of the process in which new balances are achieved betweendifferent groups, objects of activity are (re)produced and refined,and practices potentially develop and transform (Engestrom,1987).
The practical implications of adopting an AT approach includeviewing policy aims e and suggested methods of achieving them e
as the framework for stimulating necessary local ‘variation’. Ratherthan seeking adherence to a uniform version of practice, ATsuggests variation could be seen as a method of illustrating a rangeof possible ways of enacting policy and achieving mutual aims.Rather than seeking to avoid or disguise tensions and relatedvariations, these could become real opportunities for learning. Thisimplies an inquiry-based rather than a transfer approach, focusingon learning from local practice and developing a repertoire ofalternatives rather than evaluating conformity. In our case, thevariations revealed to researchers would probably have beenobscured in a KT-informed internal formal review process, whichwould have regarded them as problems. Policy, management andclinical activity are all forms of knowledge-practice and insightscould be derived from understanding the tensions in the develop-ment of knowledge-practice locally. However, this does requirea mutual aim of trying out ideas within a framework and learningthrough inquiry by all participants.
Acknowledgements
G. Greig: Original empirical work funded by Chief ScientistOffice, Scottish Executive Health Dept. Greig, G., Beech, N. andEntwistle V.: Paper prepared during time funded by UK ESRC PostDoctoral Fellowship Grant, ref PTA-026-27-2255; N. Beech: paperprepared through grant from UK ESRC grant: RES-331-27-0065.
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