Kim Putters

Griffins or chameleons? Hybridity as a permanent and inevitable characteristic of the third sector

Abstract The term “third sector” is increasingly used, but it is also increasingly difficult to define. It is characterized by fragmentation, fuzziness, and constant change. Furthermore, the bordering domains of community, market, and state are equally difficult to define and are becoming more blurred. One may have to accept that hybridity and change are permanent features of the organizations and arrangements involved. They could be classified not with reference to the structural characteristics of abstract domains but on the basis of how they cope with conditions of hybridity and change. The search for a valid empirical definition of the third sector, however modestly ambitious, must focus on the fringes of the domain where the “hard cases” can be found—the phenomena that are most difficult to identify and therefore most likely to reveal what is essential to the different domains.

Linking research and policy in Dutch healthcare: infrastructure, innovations and impacts

The call for ‘evidence-based health policy’ in the Netherlands has to date been accommodated by the consensual policy tradition in this country and by the institutionalised arrangements for research funding, researcher career development and research accountability systems. The aim of this paper is to describe and explain from a sociological perspective how these arrangements for two-way research–policy interactions enable the co-production of ‘useable knowledge’ for ‘doable problems’ in health policy making. We conclude that many arrangements function as boundary objects that allow for mediation between research and policy. This mediation occurs via both frontstage and backstage processes. The backstage processes are an essential precondition for the co-production of acceptable evidence, policy advice and policy in the frontstage. However, as a result of the increasing emphasis on evidence-based policy, and an accompanying instrumentalisation of research use in the policy process, some of the characteristic, and until now productive, elements of the Dutch system are threatened.

Co-production in healthcare: rhetoric and practice

Co-production in healthcare is receiving increasing attention; however, insight into the process of co-production is scarce. This article explores why hospitals involve patients and staff in co-production activities and hospitals’ experiences with co-production in practice. A qualitative study with semi-structured interviews (N = 27), observations (70 hours) and document analysis was conducted in five Dutch hospitals, which involved patients and staff in order to improve services. The results show that hospitals have different motives to involve patients and staff and have adapted existing methods to involve patients. Interestingly, areas of improvement proposed by patients were often already known. However, the process of co-production did contribute to quality improvement in other ways. The process of co-production stimulated hospitals’ thinking about how to realize quality improvements. Quality improvements were facilitated by this process as seeing patients and hearing their experiences created a sense of urgency among staff to act on the improvement issues raised. Moreover, the experiences served to legitimatize improvements to higher management bodies. Points for practitioners Different participation methods can bring patients’ experiences with healthcare services to the fore, which can be used for quality improvement. Our study shows that adapting existing methods to local hospital resources is likely to be beneficial for co-production processes within a given context. However, adapting and tailoring also poses risks. Tailoring activities, such as using criteria to select patients, influence what is considered to be legitimate patient input. In addition, as the co-production process is important, the method should consist of an organized trajectory in which patients and staff are involved and personal experiences are presented. Therefore, project teams need to critically reflect on the consequences of adaptations and tailoring actions, and their desirability, when carrying out quality improvement projects.

Professional Talk: How Middle Managers Frame Care Workers as Professionals

This paper examines how middle managers in the long term care sector use the discourse of professionalism to create ‘appropriate’ work conduct of care workers. Using Watson’s concept of professional talk, we study how managers in their daily work talk about professionalism of vocationally skilled care workers. Based on observations and recordings of mundane conversations by middle managers, we found four different professional talks that co-exist: (1) appropriate looks and conduct, (2) reflectivity about personal values and ‘good’ care, (3) methodical work methods, (4) competencies. Jointly, these professional talks constitute an important discursive resource for middle managers to facilitate change on the work floor. Change involves the reconfiguration of care work and different managerial-worker relations. Middle managers use professional talks in both enabling and disenabling ways vis-à-vis care workers. Based on these findings, we suggest a more nuanced portrayal of the relationship between managers and professionals. Rather than being based on an intrinsic opposition, i.e. ‘managers versus professionals’, this relationship is flexibly reconstructed via professional talk.

Public Health Knowledge Utilisation by Policy Actors: An Evaluation Study in Midden-Holland, the Netherlands.

A comprehensive report has been prepared on the state of public health and healthcare in the Midden-Holland region of the Netherlands. This study describes the development of the report and the mechanisms behind public health knowledge utilisation by three groups of health policy actors: local authorities, public health professionals and regional care providers. The processes are studied in various qualitative ways. The mechanisms explaining the use of the report were found to be complex and different for each group of policy actors. Interaction between researchers and users is not the only factor that explains usage, but rather serves as an intermediate factor.

Utilization of epidemiological research for the development of local public health policy in the Netherlands: A case study approach

The use of epidemiological research in local health policy development is claimed to be problematic. In three in-depth case studies in Dutch municipalities, we examined the interface between local epidemiological research and local health policy development, and the use of epidemiological reports, published as Local Health Messages (LHMs). The qualitative study design is based on an earlier developed theoretical framework of extended interaction. We collected data about 129 actors, via face-to-face semi-structured interviews, telephone interviews, internet questionnaires, observations, and organizational documents. Local health report development was characterized by multiple interactions between Regional Public Health Service epidemiologists, policy advisors, and local health officials. The LHMs as well as the policy memoranda can be considered as socially constructed. Preliminary interaction helped to manage the expectations of the local health officials and improved a specific type of use of LHMs in the policy process. However, we discovered a lack of use of the LHMs by specific groups of actors within the policy network, which could be explained by factors influencing the actors, such as personal belief systems and values, institutional interests, and contextual factors such as the design of the policy processes. We concluded that the necessity of interactions depends on the frames of references of the potential users and as a consequence it is difficult to give a single solution for improvement of epidemiological research utilization for local health policy. Different interaction mechanisms between researchers and policy actors can be active at the same time and may differ between municipalities. Therefore it becomes important to obtain insight in the policy process and tailor strategically promising ways of interaction.

Imperfect Performance A Case Study on the Pay-for-Performance Instrument for Physicians in Dutch Hospitals

Within the complex context of the Dutch health care system, the Ministry of Health introduced a policy that shows parallels with pay-for-performance (P4P). It enabled hospital boards to differentiate between physicians’ individual wages. This study addresses the following question: What effects did this P4P instrument have on the relationship between hospital boards and physicians? We conclude that it had no positive effects on the relationship but did put it under a considerable degree of stress. Furthermore, its introduction - isolated to the market sphere only - lacked alignment with other spheres, designated as a “value gap.” This study adds empirical findings that P4P leads to inappropriate behavior and should be accompanied by proper side policies.

The Smothering Embrace : Competition in the Implementation of Social Policy

One element of recent welfare state reform has been the introduction of market coordination in the implementation of social policy. The authors of this article have conducted a comparative study of social security, health care and housing policy implementation in the Netherlands, focusing on the conditions necessary for an effective mechanism of competition. The most important condition is that clients should be able to switch between providers without difficulty. Evidence shows that the providers in these fields of social policy engage in activities that undermine the potential for future competition. While this is not uncommon in itself, the new markets in social policy appear to be particularly vulnerable to such activities. This can be explained on the basis of two variables: (1) the institutional characteristics of the policy fields as they existed before the introduction of market coordination, and (2) the characteristics of the products that providers distribute. The combination of path dependency and product characteristics strengthens efforts to reduce competition.

De Academische Werkplaats als grensorganisatie

SamenvattingEen belangrijke uitdaging in de publieke gezondheidszorg is het coördineren van onderzoek, beleid, en praktijk. Het ZonMw programma Academische Werkplaatsen Publieke Gezondheid is erop gericht om deze coördinatie te verbeteren, om op die manier enerzijds het onderzoek binnen de gezondheidszorgsector lokaal relevant te maken, en anderzijds het beleid en de praktijk binnen de publieke gezondheidszorg meer op wetenschappelijk bewijs te stoelen. De negen Academische Werkplaatsen die inmiddels zijn opgestart, hebben verschillende (maar ook overlappende) thema’s, zoals Gezondheidsbevordering, Jeugdgezondheidszorg en Infectieziekten. Het instituut Beleid en Management Gezondheidszorg analyseert in opdracht van ZonMw de wijze waarop aan de interactie tussen wetenschap, beleid en praktijk binnen de Werkplaatsen wordt vormgegeven. De Academische Werkplaatsen worden in dit onderzoek geconceptualiseerd als grensorganisaties: organisaties die verschillende ‘sociale werelden’ coördineren en tegelijkertijd verantwoording naar iedere wereld blijven afleggen. Dit artikel beschrijft de eerste resultaten van het onderzoek. De organisatiestructuren, instrumenten, ervaren opbrengsten en genoemde randvoorwaarden van de Werkplaatsen worden vergeleken. Op basis van deze bevindingen worden de interessante spanningen en aandachtspunten in kaart gebracht die in een aantal verdiepende case studies nader worden onderzocht.AbstractThe Academic Collaborative Centre as boundary organizationA major challenge within the area of public health is the coordination of scientific research, policy, and practice. The program Academic Collaborative Centres for Public Health is aimed at improving this coordination. By doing so the program aims both at making scientific research within the public health sector more locally relevant, and to increase the use of evidence-based methods within public health policy and practice. The nine Academic Collaborative Centres that have started all have different (yet also overlapping) themes, such as health promotion, youth health care and infectious diseases. In this article we analyze the ways in which the interaction between science, policy and practice is organized within these centres. This article describes the first results of the research. It compares the goals and the organizational structure of the centres as well as the instruments used and the conditions that are perceived to be central in attaining those goals. On the basis of these findings we address tensions within and points of attention for the centres, which will be elaborated in further research.Keywords: Academic Collaborative Centres, relation of science, policy and practice, public health

Population health management guiding principles to stimulate collaboration and improve pharmaceutical care

Purpose A range of strategies to improve pharmaceutical care has been implemented by population health management (PHM) initiatives. However, which strategies generate the desired outcomes is largely unknown. The purpose of this paper is to identify guiding principles underlying collaborative strategies to improve pharmaceutical care and the contextual factors and mechanisms through which these principles operate. Design/methodology/approach The evaluation was informed by a realist methodology examining the links between PHM strategies, their outcomes and the contexts and mechanisms by which these strategies operate. Guiding principles were identified by grouping context-specific strategies with specific outcomes. Findings In total, ten guiding principles were identified: create agreement and commitment based on a long-term vision; foster cooperation and representation at the board level; use layered governance structures; create awareness at all levels; enable interpersonal links at all levels; create learning environments; organize shared responsibility; adjust financial strategies to market contexts; organize mutual gains; and align regional agreements with national policies and regulations. Contextual factors such as shared savings influenced the effectiveness of the guiding principles. Mechanisms by which these guiding principles operate were, for instance, fostering trust and creating a shared sense of the problem. Practical implications The guiding principles highlight how collaboration can be stimulated to improve pharmaceutical care while taking into account local constraints and possibilities. The interdependency of these principles necessitates effectuating them together in order to realize the best possible improvements and outcomes. Originality/value This is the first study using a realist approach to understand the guiding principles underlying collaboration to improve pharmaceutical care.