Paper to the International Labour Process Conference, Routgers University, New Jersey, USA,
March 15th – 17th 2010
Helge Ramsdal and Mona Jerndahl Fineide,
Østfold University College, Norway
[email protected], [email protected]
Backstage Decision-Making - standardizing professional work performance
while coping with uncertainty.
Abstract.
For several decades the organization of health work has been influenced by new developments in the
standardization of work processes. In recent years this has been informed by Business Process
Reengineering and Lean-Production related approaches. In the health sector, scientific knowledge,
IT-systems and “Best-Practices” have been combined in order to standardize work performance by
Integrated Clinical Pathways (IPCs), potentially changing not only the quality of services but also the
strategic positioning of professionals in the work place. The ICPs are intended to prescribe and
control professional work. In theory, the introduction of ICPs contradict the professions’ distinctive
mark of autonomy and discretionary powers. Here we discuss to what extent the process of
producing and implementing standardized performance models like ICPs change professional work,
reporting from “backstage” decision making processes by studying the construction and
implementation of ICPs in mental health. In the paper, we identify organizational mechanisms that
facilitate construction and implementation of the ICPs in three phases where uncertainties are
eliminated or reduced. The introduction of ICPs are based upon the presupposition that a firm
knowledge base can be constructed. In the study we analyze how this knowledge base is made by
the creation of ”initiated ignorance”, thereby facilitating the design process as ”contextualization”,
and finally changing work performances when the ICPs are implemented.
Work in Progress – Please do not quote
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Introduction.
This paper addresses discusses the issue of to what extent and how standardization of work
processes by means of Integrated Clinical Pathways (ICPs) change inter-professional relations
and professional work performance. The health sector has been subjected to extensive
organizational changes for several years. These changes are partly related to NPM
approaches of political governance and management structures, partly to developments in
technological and medical knowledge. In Norway the hospital reform of 2002 reflects NPM
approaches in the first sense, while the concept of “high-tech 48 hours” hospitals are
embedded in ideas of lean hospitals (Ramsdal and Skorstad 2004, Sykehuset Østfold HF
2008). Here, the standardization of work processes through the introduction of integrated
clinical pathways (ICPs) has become the main strategy in order to provide high quality and
cost-efficient service provision (Timmermans and Berg 2004, Ramsdal and Ramsdal 2007,
Vikkelsø and Vinge 2004). “Process perspectives” on hospital organization designs now is the
main approach in planning new hospitals and restructuring excisting health services in
Scandinavia, including Norway. These developments leave several questions to research
regarding the nature of ideas of organizational design, implications for professional work
performances and working conditions, and how to cope with standardization and flexibility
in cure and care.
In our case study, as in mental health generally, disagreements, uncertainties and
ambiguities are prevalent, and paradigmatic controversies (over explanations and treatment
of mental disorders) is a major challenge for service provision (WHO 2002, Ramsdal 2009).
In addition the welfare state service system is highly complex, with several agencies at both
specialist and local levels, and with a number of professions taking part in treatment and
care for clients. And finally, the clients are differentiated regarding mental health illnesses
and problems, very often with more than one diagnosis, and also with health conditions that
change profoundly over time. These peculiarities of mental health work create an obvious
need for coordination and flexibility in service provision, but also represent dilemmas and
ambiguities in organizational matters. The introduction of ICPs thus potentially faces
problems when standardization of work performance reduces flexibility - in order to obtain
coordination. The paper reports from research on ICPs related to ADHD in Norway, this
being one of the first ICPs constructed in the health services of that country.
The processes of knowledge production, organizational designing and implementation of
ICPs are complex, often controversial within the professional community, interconnected
and usually non-linear. To obtain insights into these processes case studies seems the most
fruitful approach. Here, we report from a research project were these “backstage”
processes were studied by participant observation, in-depth interviews and document
analyses.
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Background.
An important reason for developing ICPs for ADHD patients is a 2004 report from Sintef
Health Services Research in Norway, arguing that children and youth suffering from ADHD
did not achieve the services needed from the health and social sector. To improve better
coordination and collaboration between service providers a ”pathway” approach to the flow
of tasks with respect to referrals, clarification, and diagnosis was perceived necessary. The
hospital in charge of specialist health services invited in one county invited the municipalities
to participating in establishing an ICP for this group of patients. The state run specialist
health services, represented by the Department of Children and Youth Psychiatry (CYP),
managed the project. The participants from CYP and the municipalities were recruited by an
open invitation or an individual invitation to attend one of five CYP-led local teams (the total
number of participants taking part in the project was about forty 40).
The five teams of “ICP makers”, along with the other agents in the project, were directly
involved in the production-process transforming knowledge and interests into rules as they
were assigned to produce an instrument making prescription for professionals work
performance regarding children with ADHD. The ICP is not merely reflecting the relationship
between the professional and the individual patient, the instruments encompasses a generic
function as making a standard for professional work regarding the group of patients with
symptoms of ADHD. The ICP was established in 2006 by an agreement by representatives of
the municipalities and the specialist health services. The ICP is described online and in
pamphlets and manuals, tailoring each specific service such as Municipal Educational and
Psychological Counselling Services (EPCs), Family doctors (GPs), Child and Youth Psychiatry
(CYP), Schools, Kindergartens and Health centres.
Theoretical perspectives.
(Integrated) Clinical Pathways (ICPs) is one important strategy in the introduction of
“evidence based medicine”, often labelled ”scientific-bureaucratic medicine” related to the
development of “soft regulation” in modern welfare states (Timmermanns and Berg 2003,
Dent 2008, Brunsson 2000). The research on these developments in professional work
organizations – and the political implications – have been extensively studied (for an
overview in Norwegian: Ramsdal and Ramsdal 2007). The mechanisms by which knowledge
production takes place, the tranference from knowledge to organizational designs and
implementation are generally processes whithin the “the black boxes” of professional
communities - often inaccessible for social scientists. In the process of constructing an ICP a
selected group of professionals and staff/managers are assigned to decision making
“backstage”. This is a process of problem solving that is crucial in the overall creation of the
ICP, intended to improve the quality of health services by influencing inter-professional
relations and professional autonomy. Health care involves “expert labour” by professional
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groups with an historical background of autonomy in work performance. But since the
quality of services increasingly depends upon multi-professional coordination in complex
service provision systems Integrated Clinical Pathways (IPCs) is now a global strategy
embraced by governments in most Western countries. However, several issues arise from
thes strategies, not at leats about how standardization of professional work performance is
produced and implemented in a context of ambiguous and contested terrain. This paper
intends to identify elements of uncertainty and explore how ICP-makers are coping with the
problem-solving processes in “backstage” decision making.
The medical profession has a key role in the structuring of services and the performance of
health work in the Nordic countries as these welfare states have been described as
“profession states” (Byrkjeflot 2005, Eriksen 1996). However, since the 1980’s neo-liberalist
ideas on the organization and provision of health and social services have been introduced,
primarily as “privatization from within” – i.e. by importing theoretical concepts, steering
models and organization structures from private business enterprises (Ramsdal and Skorstad
2004). The trust (in professional/medical settlements) has been replaced with Governmentled, external regulation of the health profesions. Referring to Harrison and Smith (2003) he
points out to “clinical governance as a key instrument for managing clinical work, including
clinical guidelines” (Dent in Munzio, Ackroyd and Chanlat 2008: 103).
Clinical guidelines are seen as “species of bureaucratic rule, (reflect)… a transition … to… neobureauracy, in which… clinical activity has become the subject of surveillance and/or
incentives and sanctions aimed at securing compliance with the rules” (Cited from Harrison
and Smith (2003:249) in Dent (op.cit: 104). Courpasson (2000) understand these
developments as aspects of a new rationalist discourse which is not one of direct managerial
control, but more a case of “soft bureaucracy” where control is exercised through the
imposition of performance targets and other output measures. According to Fournier (1999)
this changes the professions position from institutional autonomy of self-regulation to a
situation of bargaining over autonomy. Fournier (1999) refers to this process as
“responsibilisation”, which could be understood as a new disciplinary technique inculcating
an internalized self-discipline, based upon a bargained legitimation of the (scientific)
knowledge base, and the “articulation of knowledge around the notions of efficiency and
technical competence” (op.cit:105).
The emphasis is now primarily on New Public Management (NPM) related governance, and
strategies in order to subordination of professions to state managed systems of surveillance
(what is labelled “Governance I). Governance I refer to the fact that “scientific bureaucratic
medicine” was embraced by the medical profession as a response to loss of legitimacy and
public condfidence. New Public Management governance initiatives included the
introduction of Evidence Based Medicine (EBM) and ICPs, thus directing clinical
performances in ways that are transparent – and thus potentially exposed to political and
managerial control. The idea was that ICPs are introduced “to be obeyed rather than as
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navigational aides. Directing rather than informing clinical practice” (Dent op cit: 108).
Governance II refers to “knitting together”of guidelines of the different professional groups
involved along a common timeline with the aim of delivering effective and efficient care.
This is regarded as the next stage in the erosion of medically controlled clinical autonomy.
They cross the “Governance I/II border from professionally autonomous systems of clinical
governance to inter-professional and state-managed (or at least guided) systems of
prospective management of patient care and treatment.
The difference between Governance I and II approaches to CPs seems, however, difficult to
decide regardless of (national) contexts and the organization of health care systems (Dent
refers primarily to UK experience). The answer to the question on whether CPs should be
regarded as a managerial instrument targeted at reducing medical professional autonomy
(Governance I) at the workplace or whether the expansion of the CP approach (from the
clinic/uniprofessional) by ICPs - “integrated pathways” (to a number of health services as a
tool for obtaining coordinated services provided by several agencies, should be regarded as
a (further?) erosion of medical professional autonomy seems to be open. Clinical
Governance II thus, is not exclusively an evidence-based approach within the control of
medical doctors, but an instrument for coordination of health services based upon “best
practices”, and – in relation to state policies – as an example of “soft regulation”.
The introduction of “process perspectives” on health services rests upon the combination of
three approaches to knowledge: the knowledge of “best practice” in medical treatment,
based upon “evidence-based medicine”, new IT technologies based upon modern versions of
Business Process Engineering, and contextual knowledge, as (Integrated) Clinical Pathways
((I)CPs) where the global knowledge related to EBM and ICPs is translated in order to fit in a
a local context (Ramsdal and Ramsdal 2007). Notwithstanding the history of standardization
of procedures in medical (and other health) work, the introduction of ICPs represent
challenges for professional autonomy in work performance for two reasons: they are
intended to restrict individual professionals’ opportunity to consider what to do, when and
how, and it organizes collective work processes in order to achieve coordinated action,
primarily by standardizing actions at each “work station” sequentially. Standardization of
work processes by the introduction of ICPs rests upon some fundamental assumptions:
firstly, that an unambiguous (scientific) knowledge base can be established (as a basis for
“best practice”), secondly, that there is a successful contextualization of procedures by IPC
design, and thirdly, that professionals accept that performance must change according to
standardized procedures.
In spite of the political and professional implications of these processes, producing and
implementing standardized performance models usually take place as “backstage” decision
making where actors representing technological, (medical) professional and organizational
knowledge construct and respond to the regulatory instruments. In this paper we report from
case studies intending to shed some light upon the actual processes by which standardization of
professional work take place, by studying the construction and implementation of Integrated Clinical
Pathways (ICPs) in mental health.
The process of making and implementing ICPs take place through the use of high level
professional expertice. For analytical purposes the process might be separated into three
parts, reflecting the major decisions that take place in the process. Even though different
5
approaches are seen in the process decisions in the initial phases are often made by a small
selected group of professionals. These individuals are “ICP-makers”, directly involved in the
production process transforming knowledge and interests into rules presented as “ready to
use” for utilization by professionals at the work place. To what extent the process of
producing and implementing standardized performance models changes professional work
thus take place ”backstage” where actors representing (medical) professional, IT
technological and organizational knowledges construct the ICPs.
In accordance with Fernler and Helgesson (2006) and Timmermanns and Berg (2003) the
process of making ICPs takes place in three stages: Firstly, the knowledge basis must be
defined. “Knowledge” is a social contruction, and in this context at least, ambiguous and
contested. The way the knowledge basis is established consequently implies a selection
process. As mentioned above, ICPs are generally based upon “evidence-based medicine” for
best practice – i.e. medical treatment/therapies, either produced by expert comittees within
the professional (medical) community or – increasingly - by RTCs, presented in global
medical data bases like Cochrane and Campell (Ekeland 2009). ICPs presuppose a medical
diagnosis as a “starting point” for the next phase, and the design thus represents the
contextualization of “best practice”. In ICPs the knowledge base is not necessarily a
diagnosis, and often multi-professional knowledge must be integrated in the design process.
Fernler and Helgesson emhasize the necessity to make the knowledge base “firm”, and
defines “knowledge selection and exclusion” and “knowledge compromise” as mechanisms
of creating what they call “initiated ignorance” where ambiguity and disagreements over the
knowledge base is reduced or eliminated. These mechanisms are partly expressed as
exclusions of professionals with alternative views in the ICP groups, or as neglect of or
compromise between differing views in the discussions “backstage”. The third phase is the
implementation of the ICPs by professionals working in the services. Reviews of the research
on ICPs clearly indicate that this phase is most problematic as professionals often find the
ICP guidelines uneccessary as they do not change practices already being used or disagree
with the paradigmatic approaches to treatment. Often – which is often the case when ICPs
encounter the peculiarities of mental health work – the guidelines are considered too rigid
as experience makes the professional resting more on “Kunst” than Cochrane” in their work
performances (Ramsdal 2009). Thus, on line with Ackroyd and Thompson (1999) the
responses to the introduction of ICPs might vary from commitment, engagement,
compliance, to withdrawal, denial and even hostility.
Research design/methods.
The research was undertaken in one Regional Health Enterprise (specialist health services)
and eight municipalities in a Norwegian County in 2008 and 2009 as these organizations
have created a methodology of developing ICPs for the past few years. In the hospital ten
ICPs have been put into practice as of January 2009, and new ones are continuously being
produced (the total is estimated to be 44). The ICPs in this enterprise is considered as a
frontrunner in strategies to improve quality by the introduction of ICPs countrywide.
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We used qualitative methodological principles for research. Data were gathered from
nineteen “semi structured”/open-ended interviews of maximum one and a half hour.1 The
professionals interviewed are from three divisions of specialist health services and eight
municipalities.2 With the exception of one person holding a managerial function and
another person being involved in project management the professionals all worked closely
with patients or clients on a daily basis. All of the informants had experience with at least
one specific ICP within the past two years. Furthermore, we used participant observations of
three meetings (recorded audio including one meeting videotaped) and participant
observations of three conferences arranged by Regional Health Enterprise. The professions
represented as informants are clinical psychologists, clinical pedagogues, psychiatrists,
paediatricians, health visitors, supervisor pedagogue, nurses holding further education
within mental health and one council physician. Supplementary to the interviews and
observations, we gathered policy documents of reforms, reports and presentations from
conferences, and archival records from the organizations e.g. organizational charts and
minutes from meetings. Most of the data are collected from the ICP for children with ADHD
(Attention-Deficient hyperactivity disorder) and the ICP for adults with ADHD.
The techniques of analyzing are inspired by the Concept-indicator model (Glaser 1978) and
Case studies and display (Miles & Huberman 1994, Yin 1994). By an inductive approach we
constructed models that made the analysis close to the database as a data-driven analyze.
Complementary to Grounded theory, we used cognitive and linguistics models as
interactional analysis of talk, utterance and behaviour (Cicourel 1980, Måseide 1982).
Findings.
As indicated above, the analysis was separated into three parts, referring to the decision
processes scetched out above. The initial phase in the construction of the ICP is to settle a
”firm” knowledge base, as this is the starting point for the ”best practices” approach in the
design process. I the design phase, the ICP is constructed as manuals for work
performances, and the implementation phase focus upon the ICP – work encounter.
1ADHD
children: the production process was organized by a Regional Health Enterprise (RHE) led project, 5 local groups rep.
RHE and municipals, each group managed by a RHE rep. 2006 ADHD adult: the production process is organized within RHE
divisions, nf
2
There are 18 municipals in the County, each working within structural, organizational, and financial aspects. There are 219
family doctors in the county, who are self-employed and therefore have quite loose couplings to the municipalities as a
result of restructuring (the reform Regular General Practitioner Scheme being established in 2001).
7
Constructing a ”firm” knowledge base.
So what kind of treatment is considered adequate and satisfactory if patients suffer from
Attention-Deficient Hyperactivity Disorder (ADHD)? A literature review3 illustrates that
several paradigms of treatment are recognized. A number of RCT studies focus upon a biomedical approach where prescription of medicine (mainly Rhitalin) acting on the central
nervous system, and has led to an increasing number of children being treated with such
medicine (Åsheim et al. 2007). However, this is not the only paradigm: After consulting with
relevant literature, published research papers and discussions regarding evidence based
treatment of children with ADHD, the most prominent article referred to is a RCT study
identifying the advantages of a diet based on fatty acids (Richardson & Montgomery 2005).
In 2005, also an additional RTC study showed advantages in the use of a computer program
training the child’s memory. According to this research group, the computer software has
the same level of influence on ADHD as medication (Klingberg et al. 2002). From the
literature review, we can identify at least three paradigms of treatment that - according to
RTC studies – have been recognized as the ”best” option for children with ADHD. The first
approach is based upon a ”conventional” bio-medical paradigm, the second is represented
by the fatty-acid diet paradigm and the third is represented by a pcychosocial paradigm. In
addition, there are several other approaches to treatment, several combine psychosocial
treatments and ADL often in a combination of medical treatment. There is a strong
assumption that prevailing paradigms influence the outcome of the specific ICP.
In general, there are difficulties of diagnosing within mental health care, as one informant
(psychiatrist) expressed:
Mental health is more fluid. If you suffer from a physical health condition, you can
determine your condition by taking an x-ray, but for mental health, one will need to
consult with different sources
Use of different sources includes different views and perspectives from professionals,
managers, parents, the children and other. Formal activities around clarification and
diagnosing put the professions and organizations to the test of collaboration. How did the
ICP process reflect this?
According to Fernler and Helgesen (op.cit) a firm knowledge base is constructed by three
organizational mechanisms: a) exclusion of actors with differing paradigmatic approaches, b)
by exclusion of arguments in the CP groups, and c) compromise between differing views by
negotiating. In our study we found these mechanisms at work in the first phase of the ICP
process:
The selection of members in the project reflected this. The majority of the members in the
local ICP-teams already knew each other well and had collaborated concerning patients on
previous occasions for years. Most of them were also familiar with the ICP project manager
who represented specialist services (Child and Youth Psychiatry (CYP)). A number of the ICP
makers expressed that in the work groups beliefs in bio-medical approaches, and medication
3 PubMed, ISI Web of Science, PsycINFO and Cochrane Database of Systematic Reviews. Ex. of ISI: Search key words; adhd and evidence* and (organization*
or coordination) and (child* or youth NOT adult)) (Fineide, 2007)
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by Rithalin as the common treatment, had strong support from those recruited to the teams.
According to the data analysis, these beliefs were strengthened by mutual confirmations of
the approach from the participants’ stories about working with clients. One of the
informants – at hindsight – expressed that at meetings the ICP approch was presented to
colleagues as ”religious beliefs” and there were no opportunities to argue against the ICP
makers. Those who expressed some doubts about the knowledge base were strictly
stopped. Interviews with members of the teams confirm that it was considered imminent to
express loyalty to the knowledge base in order not to open up for the ”ADHD discourse”.
Alternative approaches to treatment in this discourse were not discussed in the teams. The
problem was that the scepticism (to Rithalin in particular) excisted ”out there” – at the work
places. The ICP makers were confronted with these alternative views when coming back to
their work places, in discussions with parents and colleagues. By mechanisms related to
exclusion and – to a modest degree – compromise – the ”initiated ignorance” in the
knowledge base for the ICP was established. The ICP-makers thus created a kind of “quasicertainty”, i.e. evidence-based certainty established as a precondition for making the ICP
instrument, even though they were fully aware of the controversies in the ”ADHD discourse”
out there – in the services.
As results of the processes of recruiting the ICP makers they already shared the same
paradigm of knowledge in diagnoses and treatment of children with ADHD. The majority of
ICP makers expressed thus the support for the biomedical paradigm, and approved it as the
best option for treatment of these children. Consequently the ICP makers did not feel any
need for argumentation in favour of alternative methods of treatment, as the biomedical
treatment was regarded as indisputable. They were dedicated and eager to help the
children by the best option they were able to offer. The team-meetings seemed to
strengthen the belief in the paradigm, and an additional arena for sharing the approach was
regional conferences where the five teams met. The lectures of studies and reports from the
field were welcoming topics as these conferences contributed to a mutual understanding of
knowledge in diagnosis and treatment. Some speakers at the conference were
“heavyweight” in the field. However, not all participants were convinced during the long
lasted period of production this ICP. One informant who joined a ICP team was sceptic to
the number of children diagnosed and medicated, as he experienced from a conference:
“They were so convinced.. Had a little feeling that the conference was next to a hallelujah
meeting”….. and said to my colleague next to me that I was not exactly in the group of
followers.. ”
The informant tried to express the doubt he felt, but his questions fell on stony ground. He
felt the attitude of the other ICP makers was to keep the work, heading forwards and he did
not want to “throw a spanner in the works” and refrained from attempts of further
discussion.
The ICP teams did hardly ever discuss the dilemmas of the biomedical approah, and the
informants express that the paradigm was adopted as the ”natural” one. Thus, while the
”ADHD” discource had caused heavy debates in media and services generally, with strong
proponents of the bio-mediacal approach among parents, teachers and GPs. The public
debate was put forward to the team members and a number of ICP makers experienced
from their workplaces that theirs colleagues were reluctant towards the biomedical
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treatment. Hoever, these arguments were not discussed nor taken into account in the
teams’ work.
Making the ICP design - contextualization.
The contextualization process refers to how ”knowledge” becomes ”rules” for professional
performances. Here, medical knowledge, IT-technology and the identification of
actors/agencies in charge of service provision are combined into the actual ICP design. The
complexity of the design is indicated by the flowchart. Here the standardized procedures of
a number of specialized and municipal services were structured in order to obtain an
efficient and evidence-based sequence of activities. The findings indicate that the IT systems
played an important role in the structuring process, however, the bio-medical approach
proved to be highly compatible to the underlying cost-effiency considerations that were built
into the IT-system part.
The five teams of “ICP makers” along with the other agents in the project were directly
involved in the production-process transforming knowledge and interests into rules as they
were assigned to produce an instrument making prescriptions for work performances as
manuals. The ICP did not not merely reflect the relationship between the professional and
the individual patient, the instruments also encompasses a generic function as making a
standard for professional work regarding the group of patients with symptoms of ADHD as a
whole. The ICP is described online and in pamphlets and manuals, tailoring work tasks and
sequences in treatment for each service agency, such as Municipal Educational and
Psychological Counselling Services (EPC) Family doctors (GPs), Child and Youth Psychiatry
(CYP), Schools, Kindergartens and Health centres. One important aspect was that the ICP
stated the distribution of work tasks between specialized and municipal services, an issue
generally considered as a major problem in the coordination of health serivces in the
country.
In the manuals, however, the ICP makers ignored not only problems of knowledge/paradigm
controversies mentioned above, but also contested professional domains in the multiprofessional service system and ethical issues. In the problem solving processes, the ICPmakers thus created a kind of “quasi-certainties”. The ICP makers did not identify the
problems mentioned above, and neglected the dilemmas of making the generic standardized
instrument within a “highly complex environment”. In addition evidence-based medicine
based upon RTC/Cochrane meta studies guided the rationality in medical problem solving attempts of negotiation between these approaches and professional experience at the
workplaces also were neglected. Organizational problems related to the coordination of
services – particularly the traditional controversies between specialized and municipal
services – were ”talked around”, and the data showed that analyzes by the ICP makers of
these issues were shallow, like “quick fixes” in order to get on with the process.
Responses – the implementation phase
Decisions about the distribution of work were made by the professionals in the ICP teams,
confirmed by the management in specialized services, but there was an absence of
10
managers’ involvement in the process. The managers of health and social services in the
municipalities were not involved at all. Not surprisingly, as the ICP decisions included a
number of actors who were not involved in the process, continuous inter-organizational
conflicts prevailed.
One major problem was that the ICP for children was created to fit into the agenda of the
specialist services. Standardization based upon diagnosis is required within the new funding
system in the specialist health services as an aspect of cost-containment strategies. In these
services the Diagnosis-related group (DRG) classififications were part of the funding system
(White paper, Department of Health, 2003). DRG is a method which aggregates patterns of
treatment for similar health conditions, resulting in payment structures that are based on
medical diagnoses instead of the nature and type of treatment provided. This was followed
up by Classification of medical procedures (NCPM/NCSP) which was compulsory within all
divisions of specialist health services from 2006. Within Child and Youth Psychiatry (CYP) the
procedures used for diagnosis such as Multi-axial classification ICD 10 was compulsory from
2008.
In the data we gathered the responses to the introduction of the ICP can be separated in two
cathegories: Firstly, there was various responses among the professionals working in the
services regarding the bio-medical (particularly Rhitalin medication) knowledge base.
Secondly, the responses revolved around issues of distribution of work among specialized
and municipal services. The analysis on the first point shows how the service providers
disagreed on the knowledge base – and implicitly with the very ICP idea in the first place. In
the ICP teams and the project management group the responses where overwhelmingy
positive, what might be labelled ”cultural dopes”. To these actors, the nessecity of
improving the quality of treatment by standardization was imminent, and in effect thay
acted as missionaries. As indicated by the figure 2, the farther away from this group the
professionals were located in the service system, the more scepticism could be observed.
Fig. 2. Actors’ responses to ADHD ICP
Systemic – optimizing paradigm,
instruments (DRG/ICD 10 etc.)
Disciples (planners, heads of ICP teams)
Missionaries (ICP makers)
Followers (are convinced)
The doubters (not convinced, are
conducting other paradigms)
Opponents
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At the top of the figure, the following statement – related to the bio-medical approach – is
representative:
Medicating patients is considered a safe form of treatment with few side effects.
Appropriate medication is not addictive. A number of prominent examinations have
revealed that there is a reduced risk of developing drug substance-abuse problems when
patients suffering from ADHD have been medicated.
As we have seen nearly all of the ICP makers supported the bio-medical paradigm, and
shared the view that medication of children with ADHD is the best treatment available, it is
considered safe, and refer to a number of RTC studies. This paradigm of knowledge appears
esoteric, as it is restricted and understandable within the group of ICP makers; nevertheless,
they enumerate the comments and remarks in public and on their workplaces.
One distinctive mark of the ICP makers is the enthusiasm they demonstrate of having the
potential to improve the quality of these patients lives. One informant expressed:
I am witnessing the significant improvement of some children being treated with the
correct level of Ritalin or equivalent.
Those closer to the bottom of the fig. 2 expressed that they were ”strangers” to this ICP, and
particularly a number of family doctors (GPs) question the diagnosis and the use of
medication. Several of the informants mentioned that some family doctors preferred to
make a reservation against the medication of children:
It is an agent acting on the central nervous system, a narcotic drug. If it was not, this
would have been a whole lot easier. Doctors make this objection. It is narcotics. It is
strong.
Thus, scepticism, some times resistance, to the ICP were stronger in the municipalities than
in the specialized services, and was strenghtened by the municipal actors being conserned
over inter-organizational issues as well.
Inter-organizational issues.
On the second issue, the distribution of tasks between specialized and municipal services,
professionals from the latter generally were sceptic to the effects of the ICP on their work. A
psychologist in Municipal Educational and Psychological Counselling Services expressed:
… the diagnoses had to be determined at an early stage in order for the patients to be
treated as soon as possible…. the patients were also to be medicated as soon as
possible, and consequently discharged… R: Discharged from what? I: From the Specialist
Health Services.”
An informant in the Child and Youth Psychiatry (specialized services) agrees:
The entire concept (of ICPs) was designed in order to avoid work … there is no point of
having us (in the specialist services) spend a lot of time doing the job of municipal
12
services. This would lead to a greater accumulation of tasks as we would have to
complete the basic clarification, anamnesis, and so forth, to then finally produce the
diagnosis.
Another informant in the specialized services:
..... there were several tasks that the municipalities now had to do that previously were
prepared by us.
Specialist services at this time generally had a focus on cost-containment, and
simultaneously to reduce waiting lists as the government had decided about a policy of
“waiting list guarantee” to all patients. In Municipal Educational and Psychological
Counselling Services, however, there is no such guarantee and a number of children wait for
months for clarification. This issue resulted in conflicts betwen specialized and municipal
serivces, and undoubtedly the ICP was expected to reduce the pressure on specialized
services, as seen from their perspective.
Thus open and latent inter-organisational conflicts created uncertainties, likewise conflicts
reflecting power-relations among professional groups and between medical professionals,
technical experts (on IT-systems) and managers.
Discussion.
The question we discuss here is to which extent, and in which way, the design and
implementation of ICPs effect professional autonomy in work performance – and how interand intra-professional relations are changed by the introduction of ICPs. In our context ICPs
(in the sense of integrated pathways in complex systems) seems not to reflect an idea of lost
credibility in professional/medical self-regulation. The process we studied was initated by
professionals, and the knowledge base was established primarily by psychiatrics and
psychologists. The contextualization process added competencies in IT-technologies and
systems perspectives as well as funding systems, but still was based upon mental health
competencies and professional expertise. The production and implementation of the ICP
was initiated and performed by representatives of the professional groups that where acting
as service providers, and the process was initiated by the professionals’ concern over lack of
quality and coordination in the services. The decision processes we studied represent a kind
of “soft governance” as governmental policies wanted the health professions to design the
ICP in accordance with scientific knowledge on “best practices”. In the ICP design phase,
however, the nature of the approach proved to be highly compatible to managerial and
financial steering systems and political and administrative leaders concurred to the
outcomes of the design process. The “streamlined” process modelling also was compatible
to the specialist services’ DRG funding system. Obviously, these compatabilities are major
motivations for governmental priorities on ICPs in general.
The main issue – and the focus in this study – has been the way professionals relate to
uncertainty about the knowledge base and design of the ICP, and how the standardization of
performance reduces the relative autonomy in professional work. In the three phases of the
process of making and implementing the ICP we have seen how the way disagreements,
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dilemmas and uncertanties have been addressed in decision processes where the outcome
has been a reduction in professional autonomy.
In the first phase, where the knowledge base for the ICP was established, paradigmatic
controversies in the “ADHD discourse” were eliminated by mechanisms of exclusion of
actors and arguments that represented critical views on the bio-medical approach. Thus, the
basic idea of identifying a “firm” knowledge base – as “initiated ignorance” - paved the way
for guidelines where the individual professional could not use any paradigmatic approach in
his work with the ADHD clients (even though sanctions were, at the time of the study,
vaguely formulated). In the second phase, the knowledge base was contextualized through
a design process. Here, the flow chart models adopted from BPR process modelling
combined IT-based steering systems, the scientific knowledge base and knowledge on the
specific organizational context of agencies and services. By selecting the bio-medical
approach as the knowledge base the manuales for the work process included a “firm”
definition of ADHD based upon diagnosis, and medication (Rhitalin) as the primary
treatment. By combination of competencies related to IT and bio-medical knowledge the
design was compatible to the specialist services’ interests in shifting work loads over to the
municipalities. Thus, professionals in the municipalties saw their autonomy becoming
reduced as they were regarded as “receivers” of clients and work tasks from the specialist
services.
The mechanisms at work in the knowledge basis production, contextualization and
implementation phases reduced uncertainty through decisions mostly being taken
“backstage”, i.e. behind the scenes of politics. But when adopted to an increasing number of
patients in both mental and somatic health, ICPs have profound significance for health
policies. Implications also include a differentiation within and among professional groups,
which will be scrutinized in coming reports from the project.
In sum, the study reported from here shows that restrictions on professional autonomy were
related to
a) the manuals in the ICP implicated that professional work at every “work station” in the
flow chart was described as specific guidelines for how, when and where tasks were to be
performed. This reduced the options of professional discretion based upon personal
experience, and made work performance based on professional discretion less legitimate.
b) professional work had to become based upon a bio-medical approach, both in specialized
and municipal services. This obviously is a powerful coordinating mechanism. However, it
implicated that personal views held by the individual professional was to become personal
ethical problems, and also had implications for the way specialized and municipal services
collaborated. In particular, professionals in the municipalities reacted upon taking order on
“scientific” issues from specialized services.
c) professionals working in municipal services saw an increase in the work load as more tasks
were transferred to these agencies without their participation or concent. This, it was
argued, was embedded in the general sentiments by professionals working in the
municipalities that specialized services felt superior to the municipal ones.
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Appendix: The ADHD flow chart
Source: Østfold HF (2005)
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