Elsevier

Social Science & Medicine

Volume 74, Issue 3, February 2012, Pages 356-363
Social Science & Medicine

The role of institutional entrepreneurs in reforming healthcare

https://doi.org/10.1016/j.socscimed.2011.02.031Get rights and content

Abstract

We draw on institutional entrepreneurship theory to analyse the dynamics of institutional change in a healthcare context. The focus of our interest is in the relationship between an institutional entrepreneur’s ‘subject position’, defined in terms of their structural and normative legitimacy within the existing institutional landscape, and the nature of the change enacted. We develop this approach through an examination of the implementation of new pathways for cancer genetic services within the English National Health Service. Employing comparative case analysis we show that those who have limited structural legitimacy under prevailing conditions are most willing to engender change, but also least able; whereas those who have strong structural legitimacy are most able, but often least willing. However, those who are able rhetorically to combine a balance of structural and normative legitimacy are most able to produce change. In doing so, we demonstrate the importance of the concept of institutional entrepreneurship to understand healthcare reform.

Introduction

Healthcare reforms are difficult to enact. The change envisaged by policy-makers is often elusive, or at best protracted, because of the influence of institutionalised working practices. In this paper we explore institutional change in healthcare delivery drawing on the concept of institutional entrepreneurship. The literature on institutional entrepreneurship, building on DiMaggio’s (1988) seminal paper, seeks to explain how individuals, groups and organizations shape (change or maintain) existing institutions so that they promote their particular ‘interests’. Resistance to change in healthcare is well documented, for example, in the way medical professionals strategically respond to reforms in ways that maintain or extend their influence over emerging service areas (Currie et al., 2008, Currie et al., 2010, Currie et al., 2009a, Martin et al., 2009). In this paper we focus on the activities of “institutional entrepreneurs” as agents of change, who are endogenous actors with an interest in changing or transforming existing or emerging institutional configurations (DiMaggio, 1988, Fligstein, 1997, Rao et al., 2000).

We contribute to the literature on institutional entrepreneurship by examining the issue of embedded agency in a healthcare context. Specifically, we address the question as to why and how actors are more likely than others to see and act on opportunities for enacting institutional change. In doing so we, first, heed the call by Battilana, Leca, and Boxenbaum (2009) for future studies of institutional entrepreneurship to be comparative, focusing on success and failure; developed within mature settings and focusing on the individual, rather than organizational level of analysis. Second, we examine the relationship between the subject position of an institutional entrepreneur (IE) and their ability to enact institutional change, focusing on the reform of healthcare services, specifically cancer services within the UK National Health Services (NHS). Third, in examining the enactment of institutional entrepreneurship we highlight the importance of language and rhetoric as mechanisms for constructing legitimacy to promote institutional change. To develop these contributions we examine four comparative cases of healthcare reform for the provision of cancer genetics services.

Section snippets

Institutional theory

Institutional theory examines how deeply embedded beliefs, roles and patterns of interaction structure social practice and compel organizations into forms of conformity (DiMaggio and Powell, 1983, Meyer and Rowan, 1977). Institutions are resilient social structures, sometimes enshrined in law, that specify field rules, membership and the appropriate behaviour of its constituents (Friedland & Alford, 1991). The more developed a field, the more likely institutions will have become entrenched with

The institutional problem of cancer genetics services

The NHS Cancer Plan (DH, 2000) highlighted that cancer and genetics service as individual service priorities, but found that inconsistencies in policy and institutions have restricted the development of integrated cancer genetics services. For instance, The Harper Report (DH, 1996) recommended that primary care should be the principal focus for cancer genetics services; with primary care nurses and doctors referring cases to specialist cancer centres in tertiary care. The problem facing the NHS

Study methods

We embarked on a two stage research process between 2005 and 2008, for which we were granted full ethical approval (05/MRE04/58). In stage 1 we conducted 21 interviews with a small representative sample of clinical leads and service providers across all seven cases to focus on the subject positions of the different IEs. Following Eisenhardt (1989) we then employed purposive sampling to select four cases for in-depth investigation. Each was selected to examine how differences in the subject

Subject position and institutional change

For each case we elaborate their sources of SL and NL to engender institutional change and outline the corresponding nature of the institutional change enacted (Table 3). The Kenilworth Model, as outlined earlier, aimed at restructuring field relations and challenging of taken-for-granted assumptions as to who should deliver cancer genetics services. Where successful, the institutional arrangements for the delivery of cancer genetics services will be funded by commissioners, following the end

Discussion

Drawing on the lead of DiMaggio (1988) our study highlights how IEs work to engender different forms of institutional change that promote interests they value highly. By examining SL and NL we cast new light on the paradox of agency within institutional entrepreneurship, which has traditionally focused on SL only (Greenwood & Suddaby, 2006). The major contribution of our research is to examine how the relationship between IE’s subject position shapes their capacity to envision and enact

Acknowledgements

We would like to thank the Senior Editor and reviewers for the time and energy put into the review of our manuscript. The comments and queries raised have helped us to develop our conceptual and empirical argumentation, and feel that by in doing so, the quality of the paper has been enhanced.

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