The Sociology of Health The Sociology of Health Care Organisation: the case Care Organisation: the case of Surgical Governance in of Surgical Governance in

the UK the UK

Jonathan GabeJonathan Gabe

Royal Holloway, University of London Royal Holloway, University of London

Introduction

Way health care organised / shaped by range of interests now well established focus in UK Medical Sociology

Involves sociologists a) engaging with policy developments b) Considering their impact on health care &

those who provide it

- Focus of talk on one policy concern in health care systems – clinical governance

- Surgical Governance a case study

Surgical governanceSurgical governance

What is clinical governance?What is clinical governance? Clinical governance in the UKClinical governance in the UK Explaining clinical governanceExplaining clinical governance Disclosure of surgical Disclosure of surgical

performance in England – a case performance in England – a case studystudy

What is Clinical What is Clinical Governance?Governance?

Elastic /multifaceted/range of meaningsElastic /multifaceted/range of meanings - quality – monitoring – accountability – safeguarding - quality – monitoring – accountability – safeguarding

standardsstandards

Involves changing the way the medical Involves changing the way the medical profession is made accountableprofession is made accountable

Self regulation no longer sufficientSelf regulation no longer sufficient World wide developmentWorld wide development Proliferation of special purpose Proliferation of special purpose

institutionsinstitutions - regulatory pluralism – e.g. UK- regulatory pluralism – e.g. UK

Clinical Governance in Clinical Governance in UK (1)UK (1)

BureaucracyBureaucracy Governing performance with Governing performance with

rules/proceduresrules/procedures Establishing clinical guidelines Establishing clinical guidelines

and patient pathwaysand patient pathways National Service Frameworks –National Service Frameworks – e.g. specific services for: children/mentally e.g. specific services for: children/mentally

ill/older peopleill/older people people with CHD, diabetes etc people with CHD, diabetes etc (Harrison and Smith (2003)(Harrison and Smith (2003)

Clinical Governance in the Clinical Governance in the UK (2)UK (2)

SurveillanceSurveillance

Inspecting/Monitoring/Evaluating Inspecting/Monitoring/Evaluating PerformancePerformance

Health Care Commission (now Care Quality Health Care Commission (now Care Quality Commission)Commission)

- inspects/reports performance of - inspects/reports performance of hospital/primary care trustshospital/primary care trusts

- rolling programme of reviews- rolling programme of reviews - checks compliance with clinical guidelines- checks compliance with clinical guidelines - investigates allegations of poor service- investigates allegations of poor service

(Harrison and Smith 2003)(Harrison and Smith 2003)

Clinical Governance in the Clinical Governance in the UK (3)UK (3)

InstrumentalityInstrumentality Evidence based practiceEvidence based practice Service provision more explicitly Service provision more explicitly

instrumentalinstrumental Clinical guidelines informed by Clinical guidelines informed by

cumulative research – RCT the gold cumulative research – RCT the gold standardstandard

NICE (National Institute for Health & NICE (National Institute for Health & Clinical Excellence)Clinical Excellence)

- evaluates new treatment for cost effectiveness- evaluates new treatment for cost effectiveness - endorses clinical guidelines- endorses clinical guidelines - approves clinical audit for all doctors (Harrison & Smith - approves clinical audit for all doctors (Harrison & Smith

2003)2003)

Clinical Governance in the Clinical Governance in the UK (4)UK (4)

ConsumerismConsumerism Service increasingly driven by itService increasingly driven by it Focus on developing professional Focus on developing professional

attitudes to support:attitudes to support: - choice- choice

- patient partnership- patient partnership

New bodies to involve patients in New bodies to involve patients in planning and service provision.planning and service provision.

(Harrison and Smith (Harrison and Smith 2003)2003)

Explaining Clinical Explaining Clinical GovernanceGovernance

1. New Managerialism1. New Managerialism• Managerialism as ideologyManagerialism as ideology

Values & principles of private sector adopted by public Values & principles of private sector adopted by public sectorsector

quantification of work/output, standardised tasksquantification of work/output, standardised tasks

2. Governmentality:2. Governmentality: Contemporary society disciplined and regulated without Contemporary society disciplined and regulated without

direct/oppressive interventiondirect/oppressive intervention Professionals crucial in rendering society governable Professionals crucial in rendering society governable

via monitoring etcvia monitoring etc Co-opted into `audit’ cultureCo-opted into `audit’ culture Clinicians active in own surveillanceClinicians active in own surveillance – control at a distance – control at a distance

3. Changing relations between State, 3. Changing relations between State, Medicine & Civil SocietyMedicine & Civil Society

Public loss of trust in medicine State forced to act (Salter 2003)

The disclosure of surgical The disclosure of surgical performanceperformance

An example of clinical governanceAn example of clinical governance

Aims of disclosure of surgical Aims of disclosure of surgical performanceperformance to: to:

- enhance transparency of professional - enhance transparency of professional activitiesactivities

- identify `poorly’ performing individuals or - identify `poorly’ performing individuals or organisationsorganisations

- improve performance- improve performance - aid user decision-making (as part of - aid user decision-making (as part of

`choice’ policies)`choice’ policies) - secure accountability for public spending- secure accountability for public spending

Disclosure questionsDisclosure questions

Unit of analysis:Unit of analysis: Is it the individual and/or organisation?Is it the individual and/or organisation?

Locus of control:Locus of control: Who defines `acceptable’ Who defines `acceptable’

performance?performance? Who monitors performance?Who monitors performance? Who takes (remedial) action?Who takes (remedial) action?

Attribution:Attribution: What’s the link between disclosure and What’s the link between disclosure and

outcome (improved performance?)outcome (improved performance?)

Drivers of disclosureDrivers of disclosure

11. Naming and shaming strategy elsewhere. Naming and shaming strategy elsewhere Education, criminal justiceEducation, criminal justice

22. Freedom of information. Freedom of information FOI Act 2000FOI Act 2000 – applied in UK since 2005– applied in UK since 2005 33. Media reporting of medical scandals. Media reporting of medical scandals

Bristol Royal Infirmary, Shipman, Alder Hey etcBristol Royal Infirmary, Shipman, Alder Hey etc4. 4. Patients’ revoltPatients’ revolt

Consumerism in health care – internetConsumerism in health care – internet5. 5. International policy diffusionInternational policy diffusion

Tried in US since late 1980s, now widespreadTried in US since late 1980s, now widespread 6.6. Changing ProfessionalismChanging Professionalism PProfessional re-stratification, re-rofessional re-stratification, re-

professionalisationprofessionalisation

Changing Changing ProfessionalismProfessionalism

1.1. PProfessional re-stratificationrofessional re-stratification - new strata of doctor managers pro audit- new strata of doctor managers pro audit - increasing divisions between rank and file, knowledge - increasing divisions between rank and file, knowledge

(research) and administrative elites(research) and administrative elites

2. 2. Re-professionalisationRe-professionalisation

- organisational values replacing professional values- organisational values replacing professional values

e.g. accountability & audit over service & dedicatione.g. accountability & audit over service & dedication

- if impetus for - if impetus for change change comes comes from withinfrom within medicine medicine maintains greater autonomy.maintains greater autonomy.

- if impetus comes - if impetus comes from abovefrom above - the state – medicine - the state – medicine loses autonomyloses autonomy

Disclosing surgical Disclosing surgical performance - historical performance - historical

backgroundbackground

Surgeons used to assess their performance Surgeons used to assess their performance through a combination of professional “ideals”, through a combination of professional “ideals”, peer review and maintaining their own journals of peer review and maintaining their own journals of performance. performance.

1977 - 1977 - The metric auditing of surgical The metric auditing of surgical performance was initiated in the United Kingdom performance was initiated in the United Kingdom - used hospital administrative data. - used hospital administrative data.

19941994 the case mix and the severity of the the case mix and the severity of the patients’ condition were taken into account.patients’ condition were taken into account.

Even so, auditing of performance remained Even so, auditing of performance remained internal to the profession (Exworthy, 1998). internal to the profession (Exworthy, 1998).

Recent History of Attempts to Recent History of Attempts to Publish Surgical Outcome Data in Publish Surgical Outcome Data in

EnglandEngland 2002 Health Secretary promises to publish hospital death Health Secretary promises to publish hospital death

rates for individual cardiac surgeons by 2004. Deadline rates for individual cardiac surgeons by 2004. Deadline missed.missed.

2006 Guardian newspaper uses Freedom of Information Guardian newspaper uses Freedom of Information Act to gain and publish results – data variable and Act to gain and publish results – data variable and sometimes raw sometimes raw

2007 Healthcare Commission requires all hospitals doing Healthcare Commission requires all hospitals doing heart surgery to publish risk adjusted data on death rates heart surgery to publish risk adjusted data on death rates for individual surgeons.for individual surgeons.

17 units provide data on individual surgeons – 13 units only 17 units provide data on individual surgeons – 13 units only provide aggregate data – 3 fail to provide any data by deadline.provide aggregate data – 3 fail to provide any data by deadline.

2008 Healthcare Commission (now CQC) website publishes 2008 Healthcare Commission (now CQC) website publishes results for units results for units Rate of survival said to be well above expected range – Rate of survival said to be well above expected range – overall survival 96.6% - expected range 93.7% to 94.5%overall survival 96.6% - expected range 93.7% to 94.5%

Comparison – organisationComparison – organisation

Comparison – specialtiesComparison – specialties

Comparison: individualComparison: individual

Comparison: individualComparison: individual

International International experienceexperience

SwedenSweden National quality registries, mainly since National quality registries, mainly since

20002000 AustraliaAustralia

Public hospital reports announced 2008Public hospital reports announced 2008 GermanyGermany Hospital reports, since 2005Hospital reports, since 2005

USAUSA Report scorecards. Eg. New York from `89Report scorecards. Eg. New York from `89

Professional PerformanceProfessional Performance

Professional resistance to:Professional resistance to: External accountabilityExternal accountability Systematising workSystematising work Managerial controlManagerial control

Minimalist strategy:Minimalist strategy: Notion of equality of competence (stifling Notion of equality of competence (stifling

overt criticism)overt criticism) Only peer review permissibleOnly peer review permissible

New frontiers of control?New frontiers of control? From internal to external, implicit to From internal to external, implicit to

explicitexplicit Performance = test of professional Performance = test of professional

powerpower

Professional performance is Professional performance is about powerabout power

TraditionalTraditional IncreasinglyIncreasingly

Who sets standards of Who sets standards of acceptable performanceacceptable performance

Individual Individual doctorsdoctors

Medical Medical ProfessionProfession

Who monitors standards?Who monitors standards? Medical Medical PeersPeers

External External AgentsAgents(e.g. Care (e.g. Care Quality Quality Commission)Commission)

Who takes remedial Who takes remedial action if required?action if required?

Local Local Medical Medical PeersPeers

External External AgentsAgents

Managing medical Managing medical performance: performance:

multi-level analysismulti-level analysis

Micro-level:Micro-level: Inter-professional relationsInter-professional relations Socialisation of surgeonsSocialisation of surgeons

Meso-level:Meso-level: Use of data by managersUse of data by managers Impact on organisational cultureImpact on organisational culture

Macro-level:Macro-level: Impact of / on regulatory regime of Impact of / on regulatory regime of

performance disclosureperformance disclosure

The StudyThe Study

One year study (2008 – 2009)One year study (2008 – 2009)

Aim:Aim: “To explore how the use “To explore how the use and publication of performance and publication of performance data impacts on Professional and data impacts on Professional and Managerial relations at micro, Managerial relations at micro, meso and macro levelsmeso and macro levels

Methodology Methodology

Observations of cardiac Observations of cardiac surgeons:surgeons:

- M&M meetings – who spoke and what was - M&M meetings – who spoke and what was discusseddiscussed

- Shadowing surgeons – how they managed their - Shadowing surgeons – how they managed their own and team’s performanceown and team’s performance

Interviews with cardiac Interviews with cardiac surgeons:surgeons:

- - to explore views of performance measurement/its to explore views of performance measurement/its managementmanagement

- impact of disclosure on the net - impact of disclosure on the net

SampleSample

Case Study:Case Study: NHS hospital in the South East of EnglandNHS hospital in the South East of England 9 interviews9 interviews - 3 consultant cardiac surgeons - 3 consultant cardiac surgeons

- 3 trainees cardiac surgeons- 3 trainees cardiac surgeons - 1 cardiac theatre nurse- 1 cardiac theatre nurse

- 1 Data Manager - 1 Data Manager - 1 Hospital Chief Executive- 1 Hospital Chief Executive 3 Surgeons shadowed in theatre and in staff meetings3 Surgeons shadowed in theatre and in staff meetings 8 Mortality and Morbidity meetings attended 8 Mortality and Morbidity meetings attended

External to the hospital: External to the hospital: 8 interviews8 interviews - 3 - 3 cardiac surgeons cardiac surgeons

(2 from the Society for Cardiothoracic Surgery, 1 from the(2 from the Society for Cardiothoracic Surgery, 1 from the

Department of Health) Department of Health) - 2 PCT Commissioners of acute services- 2 PCT Commissioners of acute services - 1 member of the General Medical Council - 1 member of the General Medical Council - 2 members of the Care Quality Commission- 2 members of the Care Quality Commission

Cardiothoracic Surgical Conference attended and observed Cardiothoracic Surgical Conference attended and observed

AnalysisAnalysis

- Framework approachFramework approach

- familiarisation- familiarisation

- thematic identification- thematic identification

- indexing- indexing

- charting- charting

- interpretation- interpretation

Key issues Key issues

1. Is 1. Is clinical autonomyclinical autonomy seen by individual seen by individual surgeons as being threatened?surgeons as being threatened?

2. Is there evidence of 2. Is there evidence of resistanceresistance or or gaming by surgeons?gaming by surgeons?

3. Are 3. Are managersmanagers using performance data using performance data to limit professional autonomy?to limit professional autonomy?

4. Are the 4. Are the surgical elitesurgical elite embracing PPD embracing PPD and if so what are the consequences?and if so what are the consequences?

Is Clinical Autonomy seen Is Clinical Autonomy seen as being threatened?as being threatened?

Differences between Differences between surgeons about the surgeons about the consequences of disclosureconsequences of disclosure

Senior Surgeons more criticalSenior Surgeons more critical Trainees generally acceptingTrainees generally accepting

Critical surgeons and Critical surgeons and autonomy (1)autonomy (1)

‘ ‘But basically when I signed up to But basically when I signed up to being a consultant it was the buck being a consultant it was the buck would stop with me, yeah know. That would stop with me, yeah know. That was the deal, in heart surgery was the deal, in heart surgery certainly… In some respects many of certainly… In some respects many of us would not be keen that the buck us would not be keen that the buck would be stopping somewhere else would be stopping somewhere else because we have the autonomy to because we have the autonomy to make a lot of decisions and things.’ make a lot of decisions and things.’ (David, Consultant Surgeon)(David, Consultant Surgeon)

Critical surgeons and Critical surgeons and autonomy (2)autonomy (2)

‘‘.. I think it has become an industry and .. I think it has become an industry and I think I think there are more people involved in monitoring there are more people involved in monitoring cardiac surgical performance than there are cardiac surgical performance than there are people doing it.. I think it has got seriously people doing it.. I think it has got seriously out of control.. Of course the worry is that it out of control.. Of course the worry is that it stifles risk taking. (John, Consultant Surgeon) stifles risk taking. (John, Consultant Surgeon)

‘ ‘ Performance data should be about long term Performance data should be about long term quality: that is what should be measured not quality: that is what should be measured not mortality. Mortality rates are really for the mortality. Mortality rates are really for the bad apples… Surgeons are also all different, bad apples… Surgeons are also all different, with different skills – how can we all be with different skills – how can we all be measured the same? (Charles, Consultant measured the same? (Charles, Consultant Surgeon)Surgeon)

Trainee surgeons and Trainee surgeons and autonomyautonomy

‘ ‘ I don’t have a particular strong feeling as such, but I do very much agree with a point that performance needs to be monitored, because without monitoring of performance … then you don’t really have an accurate idea as to where you’re going, whether you’re going through a difficult period, a bad patch. And I think it’s a way of quality improvement as well, so you can always strive to aim higher and become better at what you do …So it is quite a good thing to have a monitoring of performance. (Ian – Trainee Surgeon)

Is there evidence of Is there evidence of resistance/gaming by resistance/gaming by

surgeons? surgeons? Some senior surgeons acknowledge Some senior surgeons acknowledge

that colleagues may seek to minimise that colleagues may seek to minimise the negative impact of high risk the negative impact of high risk patients on their performance datapatients on their performance data

Some claim they refuse to ‘play the Some claim they refuse to ‘play the game’game’

Apparent actions of seniors may Apparent actions of seniors may restrict trainees’ chances of operating restrict trainees’ chances of operating on high risk patientson high risk patients

Is there evidence of Is there evidence of resistance/gaming by resistance/gaming by

surgeons? (1)surgeons? (1) Senior Consultant:Senior Consultant:

‘‘There is probably situations where I have a private There is probably situations where I have a private conversation with individuals and they will say I had conversation with individuals and they will say I had two deaths in the past three months and I’m not two deaths in the past three months and I’m not going to take on anything risky for the next six going to take on anything risky for the next six months.’ (John, Consultant Surgeon)months.’ (John, Consultant Surgeon)

I’ve never visited any of these websites and have no I’ve never visited any of these websites and have no interest in visiting them and I will do what I think is interest in visiting them and I will do what I think is best for the patient and if at some point my mortality best for the patient and if at some point my mortality is deemed to be unacceptable and then they put me is deemed to be unacceptable and then they put me out to grass I will go – it has had no impact on me at out to grass I will go – it has had no impact on me at all. (John, Consultant Surgeon)all. (John, Consultant Surgeon)

Is there evidence of Is there evidence of resistance/gaming by resistance/gaming by

surgeons? (2)surgeons? (2)

Trainee Surgeon:Trainee Surgeon:

‘‘What I mean is that in terms of experience What I mean is that in terms of experience that we receive, we’re getting less compared that we receive, we’re getting less compared to the consultants of old... This is partly to the consultants of old... This is partly because of the audit culture, the monitoring of because of the audit culture, the monitoring of performance at an individual level with the performance at an individual level with the consultant’s name published in newspapers, so consultant’s name published in newspapers, so there’s an element I suppose of paranoia in there’s an element I suppose of paranoia in that sense, with the consultants less likely to that sense, with the consultants less likely to be so free giving the cases to the registrar’ be so free giving the cases to the registrar’ (Ian, Trainee Surgeon)(Ian, Trainee Surgeon)

Are Managers using PPD to Are Managers using PPD to limit professional limit professional

autonomy? autonomy?

Hospital managers yet to use Hospital managers yet to use performance data to limit surgeon’s performance data to limit surgeon’s autonomyautonomy

Custodial mode of control continues – Custodial mode of control continues – seniors informally monitor juniors but seniors informally monitor juniors but don’t tell managersdon’t tell managers

Performance measures not linkedPerformance measures not linked Could see benefits to hospital of using Could see benefits to hospital of using

evidence of low mortality rates to evidence of low mortality rates to attract patients in a increasingly attract patients in a increasingly competitive market place.competitive market place.

Are Managers using PPD to Are Managers using PPD to limit professional limit professional

autonomy? (1)autonomy? (1) Hospital CEOHospital CEO

In terms of openness, accountability, generally In terms of openness, accountability, generally confronting issues and bringing stuff out around confronting issues and bringing stuff out around performance generally, I think is to be welcomed… performance generally, I think is to be welcomed… I’m I’m really quite passionatereally quite passionate about this now in terms of about this now in terms of the longer I’ve been in the health service, the more I the longer I’ve been in the health service, the more I see see people squirming people squirming about whether they’re about whether they’re held to held to accountaccount. And actually, I’ve also been in the health . And actually, I’ve also been in the health service long enough to know. (Derek, Hospital CEO)service long enough to know. (Derek, Hospital CEO)

We’ve done mortality [performance measurement] in We’ve done mortality [performance measurement] in isolation and we’ve looked at rates of complaints or isolation and we’ve looked at rates of complaints or something, we’ve something, we’ve never quite brought the whole never quite brought the whole thing togetherthing together to really use to improve what we to really use to improve what we we’re doing’ (Derek, Hospital CEO)we’re doing’ (Derek, Hospital CEO)

Are Managers using PPD to Are Managers using PPD to limit professional limit professional

autonomy? (2)autonomy? (2) RegulatorRegulator

One of his (CEO’s) views about One of his (CEO’s) views about publishing was that we should publish publishing was that we should publish it because in the world of Foundation it because in the world of Foundation Trusts and… extended choice, you Trusts and… extended choice, you know, to be that know, to be that hospital which is open hospital which is open and honestand honest about its mortality rates.. It about its mortality rates.. It gives the sense of `this is a hospital gives the sense of `this is a hospital with nothing to hide’. (Robert, with nothing to hide’. (Robert, Regulator)Regulator)

Are the Surgical Elite Are the Surgical Elite embracing PPD? embracing PPD?

Acceptance of PPD from elite leaders Acceptance of PPD from elite leaders (Society for Cardiothoracic Surgery - (Society for Cardiothoracic Surgery - SCS)SCS)

Some internal dissentSome internal dissent SCS co-sponsored Heart Surgery SCS co-sponsored Heart Surgery

website with Care Quality commissionwebsite with Care Quality commission A number of former leaders of SCS A number of former leaders of SCS

now in senior policy / regulatory now in senior policy / regulatory positionspositions

Are the Surgical Elite Are the Surgical Elite embracing PPD? (1)embracing PPD? (1)

President of Society for President of Society for Cardiothoracic SurgeryCardiothoracic Surgery

I suppose with my President’s hat on and I suppose with my President’s hat on and wanting to drive forward the quality of care, I wanting to drive forward the quality of care, I would argue people measure and we can would argue people measure and we can improve it. So we have to have some sort of improve it. So we have to have some sort of measurement and measurement and far better that we do it and far better that we do it and do it professionally and well, than have it do it professionally and well, than have it imposed on us.imposed on us. I suppose some people would I suppose some people would feel it’s being imposed on us but I don’t think feel it’s being imposed on us but I don’t think that’s…I would reject that. I think we are that’s…I would reject that. I think we are still still leading the wayleading the way with it and we get other people with it and we get other people to help us with it… I know there’s a to help us with it… I know there’s a bit of bit of resentmentresentment, certainly amongst our members, , certainly amongst our members, that we’re scrutinising ourselves so closely and that we’re scrutinising ourselves so closely and indeed, being scrutinised from outside. indeed, being scrutinised from outside.

Are the Surgical Elite Are the Surgical Elite embracing PPD? (2)embracing PPD? (2)

President of SCSPresident of SCS

We’ve deliberately teamed up with the We’ve deliberately teamed up with the Health Care Commission (now Care Quality Health Care Commission (now Care Quality Commission) and, again, that caused a Commission) and, again, that caused a certain amount of uneasecertain amount of unease amongst some amongst some folk in our society, this whole issue has been folk in our society, this whole issue has been quite controversial and in some areas, quite controversial and in some areas, some some members have actually resignedmembers have actually resigned from the from the Society…. they flag up as being inadequate Society…. they flag up as being inadequate surgeons and poor performers when it was a surgeons and poor performers when it was a bit like a statistical problem rather than bit like a statistical problem rather than anybody’s performance. anybody’s performance.

Conclusion (1)Conclusion (1)

Division of views among surgeons about Division of views among surgeons about whether PPD a threat to clinical whether PPD a threat to clinical autonomy.autonomy.

Some talk of resistance/gamingSome talk of resistance/gaming Managers yet to use PPD to limit Managers yet to use PPD to limit

autonomyautonomy

- custodial form of control still operates- custodial form of control still operates Surgical elite prefer to lead than have PPD Surgical elite prefer to lead than have PPD

imposedimposed

Conclusion (2)Conclusion (2)

Professional re-stratificationProfessional re-stratification reinforcedreinforced - divisions between seniors and juniors- divisions between seniors and juniors - internal divisions within the elite but - internal divisions within the elite but

leadership winsleadership wins - divisions between elite leaders and senior - divisions between elite leaders and senior

rank and filerank and file Re-professionalisationRe-professionalisation in the face of in the face of

governancegovernance - state co-opted elite or elite leading to - state co-opted elite or elite leading to

maintain professional autonomy?maintain professional autonomy? - acceptance of organisational values among - acceptance of organisational values among

junior surgeons a sign of things to come? junior surgeons a sign of things to come? Control at a distance?Control at a distance?

Conclusion (3)Conclusion (3)

In terms of ‘governmentality’ In terms of ‘governmentality’ process has affected surgeons process has affected surgeons unevenlyunevenly

Surgical elite has subjected Surgical elite has subjected others to managerialist agenda others to managerialist agenda while benefiting themselveswhile benefiting themselves

Some senior rank and file have Some senior rank and file have attempted to resist by appealing attempted to resist by appealing to professional valuesto professional values

Conclusion (4)

Surgical Governance provides a good example of the contribution of sociologists to studying health care organisations.

It shows how different theories can be employed/tested to make sense of policy changes & their consequences

Reveals things don’t always develop as expected by policy makers

People embrace / resist change Role of sociologists to describe and

explain what happens in practice.