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Germany should reflect on its rich theoretical tradition

07.06.2021 10:55
Der 20. Deutsche Kongress für Versorgungsforschung (06.-08. Oktober 2021) findet unter dem Motto „Versorgungskontext verstehen – Praxistransfer befördern“ statt. Auf dem Kongress, dessen Kernthese es ist, dass Versorgungsgestaltung und -transfer ohne ein vertieftes Verständnis des komplexen Versorgungskontexts nicht erfolgreich gelingen kann, wird in einer prominent besetzten internationalen Session in das Thema einführen. Mit dabei werden Prof. Dr. Jeffrey Braithwaite (Director des Centers for Healthcare Resilience and Implementation Science, Macquarie University, Australia) und Prof. Dr. Russell Mannion (Chair and Research Director, Health Services Management Center, University Birmingham, UK) sein, die im Interview mit „Monitor Versorgungsforschung“ ihre jeweiligen Standpunkte vertreten.


>> Prof. Dr. Holger Pfaff invited you to speak at the 20th German Congress on Health Services Research. He argues that it is problematic that health services research does not establish enough theory. Is this, Prof. Braithwaite, a German problem or an international one?
Braithwaite: It‘s both a German and a general health services research problem. There’s quite a lot of health services research, including theory about health services, which emanates from Britain, the US, Australia, and some parts of Europe. But there’s not much health services research from Germany and therefore there’s not much health services theory in general in Germany. That’s why  Holger’s having the conference.

What is your opinion on this, Prof. Mannion?
Mannion: Health services research (HSR) internationally has tended to be under theorized. The reason for this is that much of HSR is applied, with a focus on measuring patient outcomes and performance indicators related to evaluating particular service interventions. Preferring to draw on methods which mimic the biological and clinical sciences, rather than the social sciences and humanities, HSR has developed as a largely technicist, value neutral and apolitical project. Consequently, it has neglected wider issues such as power, politics and the ideologies which underlie structural reforms. Yet, Germany has led the world in social and political
theory – Marx, Weber, Luhmann, as well as the Frankfurt school of critical theorists – Habermas, Marcuse, Horkheimer and Adorno – to name but a few. It would be a pity if the HSR community in Germany, in taking the discipline forward, did not draw on this rich theoretical tradition.

The Covid-19 pandemic affects all countries around the globe, and it has shown one thing very clearly: The resilience of social structures, especially regarding the economy and healthcare systems, are – to put it mildly – in need of improvement. What could a healthy organizational culture look like which is capable of increasing resilience of social and health care structures?
Mannion: Resilient health systems and organisations are characterised by styles of leadership, management practices and cultures which are able to rapidly absorb change and can adapt and cope effectively in times of sustained crisis. Health systems worldwide are demonstrating, to varying degrees, aspects of resilience during Covid-19 by the extraordinary rapid transformations of service delivery using digital and telehealth technologies. In many countries, the „digital front door“ has become the main point of access to healthcare services. Primary care in particular has seen a huge increase in remote appointments with as much as three-quarters of all consultations now taking place virtually.
What contribution can complexity science make here, which you are involved with?
Braithwaite: Complexity science draws attention to the multi-faceted nature of care delivery – a multiplicity of agents, interactions, treatments, procedures, drugs – the whole of the system when looked at in its entirety is extraordinarily complex, and built on many connections, referrals, relationships and interactions. The fact that we have been able to mobilise all this during Covid-19 to deal with large-scale challenges, even though health systems were very stretched in many countries, does exhibit the elastic, resilient and adaptive nature of the system. Some countries have navigated all this complexity very well, and complexity science has illuminated the ways in which this has been achieved.

The Covid-19 pandemic has also shown that politics – no matter in which country – listen to one direction of science, either epidemiology or virology. That was certainly correct at the beginning of the pandemic. Prof. Mannion: What can health care and public health researchers and scientists contribute to the evolution from pandemic to endemic?
Mannion: It is becoming clear that some countries have dealt with Covid-19 better than others and that it is the behaviour of governments, more than the behaviour of individuals, that shapes countries‘ experience of the crisis. Therefore, key areas for health service researchers to explore include how and why governments responded the way they have to the pandemic and how effective different responses have been in order to draw lessons for future pandemic preparedness. For example, right-wing populist government appear to have performed poorly with responses tending to coalesce around four common themes: initial denial and then mismanagement of the crisis; the pandemic being framed as primarily an economic rather than a public health issue; a contempt for scientific expertise/alignment with anti-vaxx groups; and the „othering“ of marginal groups for political ends.

What is your opinion on this, Prof. Braithwaite?
Braithwaite: We must always remember that politicians, even responsive ones, are interested in politics. Sometimes that takes a backseat to actually solving problems for the benefit of all. In democracies like Germany, the UK and Australia, politicians are focused on the next election or what their particular party or ideological group are thinking and saying. This has affected how countries have dealt with the pandemic. Most wealthy systems have politicians who at least say they are listening to the science but it is clear that they are also assessing their chances at the next election this sometimes leads to conflicting pressures on the decision makers.

The motto of the 20th German Congress on Health Services Research is „Understanding the health care context – promoting practice transfer“. This requires a theoretical foundation for implementation and transfer of complex interventions. What outstanding developments have there been in this regard in recent years, Prof. Braithwaite?
Braithwaite: Context is extremely important for anyone wanting to improve health care. The culture and ways of organising, and the relationships and ways of doing things in one hospital differs from another, for example. This has taught us that we should not think that „one size fits all” is going to work. Universal take up, adoption and spreading out of new evidence, practices, ideas etc. will always be challenged by context. What implementation science has contributed is many models, ideas and frameworks by which to make change in health care but we know that this always needs tailoring to the specific circumstances of the particular organisation or institution. In terms of complex interventions, we have learnt that we are not just dealing with complex interventions but complex settings in which we are intervening and therefore we should not treat these as linear. Mechanistic, unidimensional solutions typically do not work very well in health care. So just telling clinicians to use a new piece of equipment, IT-system or guideline will not work for everyone, and perhaps not even many people in health care.

Your area of expertise, Prof. Mannion, is the development of organizational culture in health care. What are the most important developments in this regard in recent years?
Mannion: Despite the growing number of approaches, frameworks, and tools available to inform understanding of culture and change at different levels in healthcare systems and organisations, the literature suggests that the supporting evidence base is still rather thin – to the extent that in many areas, empirical data are largely absent. Empirical studies and theoretical frameworks which shed light on how healthcare organisations can become more open and receptive to a wide diversity of voices, and build a broad consensus around the cultural destinations sought and the mechanisms that will carry organisations towards these destinations, may be key to unlocking sustained change in complex health systems. Of particular concern is the need to be alert to the role of local subcultures, which at different times may be driving forces for change, defenders of the status quo, or covert counter-cultures quietly undermining necessary reforms.

Prof. Braithwaite, what are the key and success factors for change?
Braithwaite: For change to be effective we have to tailor the solutions to the circumstances, not think that simplistic solutions will work, realise that change takes more time than we imagine, that multiple stakeholders need to be brought on side, and that people need incentives and motivation to adopt new practices or ways of working. We have also learnt that there are natural tendencies not to necessarily embrace new things – what sometimes people call „resistance to change”. My paper in the BMJ, changing how we think about healthcare improvement, discusses these ideas (1).

Prof. Mannion, how can organizational culture be linked to the quality and performance of care?
Mannion: Cultural aspects of healthcare delivery are now widely regarded as important to quality of care, whether through fostering excellence or contributing to failure. Implicit in this thinking is the notion that there are good and bad cultures, and that creating the right kind of culture will facilitate high-quality care. As a result, policy rhetoric frequently invokes the need to create and sustain a whole range of desirable cultures (eg. open, compassionate, resilient, learning) and stamp out so-called „toxic” cultures (eg. blame, fear, bullying, silence, club). Numerous empirical research studies suggest that there is no single, „best” culture which is always associated with successful outcomes across a range of organisational dimensions. Rather, organisational culture seems to be linked to quality and performance in a contingent manner, with those aspects of quality and performance most valued within the dominant culture being the aspects on which the organisation performs best.

Prof. Braithwaite and then Prof. Mannion, what are our personal lessons learnt from the Covid-19 pandemic?
Braithwaite: Follow the science. Have widespread testing avai-lable for the population. Take people with you so when lockdowns, quarantine and mask wearing are required, people can see the benefit. Realise that you can’t just stay open for the good of the economy because you need to tackle the infection first. Otherwise you won’t have an economy. There’s much more but these are some of the things I think we’ve learnt from my perspective.

Mannion: It is probably too early to draw any hard and fast conclusions, but a number of strategies appear to be effective in controlling the virus. These include; shielding older people and vulnerable groups; taking early and effective action to control borders and monitoring of arrivals; develop effective and timely testing, tracking and tracing of everyone suspected of being infected; provision of welfare support for those in quarantine; the efficient roll out of mass vaccination programmes and consistent public health messaging which is able to challenge conspiracy theories and ani-vaxx rhetoric. But a global pandemic requires global cooperation and there should be no room for vaccine nationalism. Until we are all safe, no one is safe!

Dear Professors Braithwaite and Mannion, thank you for talking to us. <<

The interview was conducted by MVF editor-in-chief Peter Stegmaier.

Braithwaite, J., Mannion, R., Stegmaier, P.: „Germany should reflect on its rich theoretical tradition“, in „Monitor Versorgungsforschung“ (03/21), S. 6-9.



Understanding organisational culture for healthcare quality improvement“, BMJ 2018;363:k4907 doi: 10.1136/bmj.k4907 (Published 28 November 2018)
Populism, pestilence and plague in the time of coronavirus“, DOI 10.1108/IJHRH-10-2020-0091

Ausgabe 03 / 2021


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