Collecting and analysing data
Our study emerged from one author's (SS) experience of working in Think Tank B, an organisation based in central London who describe themselves as 'an authoritative and independent source of evidence-based research and policy analysis for improving health care in the UK' (mission statement 2013). The focus of their work is the provision of 'evidence for better health care', emphasising a technocratic process where the think tank role is to produce evidence, feed this into policy and so improve healthcare. SS worked at Think Tank B for two years, from February 2009 to March 2011, during which time she kept a journal reflecting on her role. Originally a personal project, this journal was resituated as an autoethnographic account as the study was conceived and SS, once again, took up an academic position. This process raised a number of ethical questions, in particular about the nature of consent and the accountability of the research - a detailed account can be found in Shaw (2015).
Think tanks remain largely hidden in existing analyses of health policy and planning. The reason for this stems, in part, from difficulties negotiating access to such dispersed policy practices. Through autoethnography, we were able to examine and retell events and activities related to health policymaking - in this case related to a substantial programme of reforms to the NHS in England (DH 2010), and the context in which think tanks' activities unfold. Take the following extract in which SS is trying to make sense of her working environment after close to a year in post:
I have been struck by the formality of some of the emails ... They often bring with them the sense of a 'formal managerial request' where I am required to act in some way, my response should also be formal and thought through and this will be recorded and filed somewhere for future reference or 'good record keeping'.
This approach to managing, decision-making and communicating all has a rather strange effect on me ... It makes me feel that research is dictated from 'on high' and that my role is simply to undertake and deliver rather than investigate and explore.
Journal, 5 January 2010
Such journal entries enabled us to move from personal experience of specific activities ('some of the emails', 'formal managerial request', 'requiring me to act in some way') to connect with particular cultural practices and approaches to planning that are grounded in an accepted way of doing things ('approach to managing', 'dictated from on high'). Hence what began as a personal project documenting experience of working within a think tank provided ethnographic insight into organisational practices and activities.
This auto-ethnographic account provided a useful, preliminary insight into the activities of think tanks. To examine the activities, artefacts, interactions, spaces, values and ideas (Yanow, 1996; Hajer, 2006; Wagenaar, 2011) allied to think tanks' work, we supplemented this account with documents and interview data drawn from across the think tanks in our sample.
Documents are important for those seeking to understand the meaning of policy (Freeman and Maybin 2011), in that they represent shared narratives amongst coalitions of actors (including decision-makers, think tank executives, practitioners and publics).
We included 30 documents drawn from across the four think tanks, allowing us to examine formal accounts and presentations of work, the content of arguments and discursive strategies (for instance, via formal publications and policy briefings) within our sample, and the interrelationship with emerging health policy. Take the following example from a document published by one of the think tanks in our sample outlining their work priorities at the time of the study:
The Health and Social Care Bill paves the way for an extension of competition and market mechanisms in the NHS in England.
We are contributing to the evidence base by taking forward a number of projects that will establish [Think Tank B] as an important source of independent information and analysis on the use of competition and market mechanisms in health care.
Project highlights include:
- • The Health Care Markets programme - a strategic partnership with the Institute for Fiscal Studies to undertake empirical research on the use of market mechanisms in health care
- • a project to assess how payment mechanisms can best be developed in future
• playing a prominent role in helping to influence the development of regulatory policy by the Department of Health and Monitor.
This extract focuses specifically on 'Competition' and situates this as a priority area of work. The extract explicitly references the governments' reforms ('The Health and Social Care Bill', 'the development of regulatory policy') and gives voice to proposed mechanisms for change outlined by the government ('an extension of competition and market mechanisms', 'the use of competition and market mechanisms in health care', 'how payment mechanisms can best be developed'). Such talk entails courses of action, seeking to guide health policy and health service delivery in particular ways and not others. This is achieved by, in this instance, foregrounding particular values allied to a market-oriented approach to designing and delivering healthcare services (for instance, via 'The Health Care Markets Programme'). The language used references formal government proposals (see, for instance, DH 2010), and situates Think Tank B as a legitimate contributor to the development and delivery of such proposals ('as an important source of independent information and analysis', 'playing a prominent role', 'helping to influence').
Such talk was most visible in the formal publications of think tanks in our sample. In theory these were publicly accessible documents (available via think tank websites) aimed at a 'universal' audience (Perelman and Olbrechts-Tyteca, 1971). In practice they used technical language that limited their accessibility and suggested that they were targeted at an 'ideal' audience of healthcare planners and decision-makers. For instance, echoing the content of proposed NHS reforms, they emphasised: 'reduced costs through integration and competition', 'improving productivity in the areas set out in the Operating Framework', and how 'Monitor and the supporting regulations for NHS procurement need to promote both competition and collaboration'. This highlights the interplay between documents and actors, with powerful individuals potentially able to provide legitimacy to policy and either establishing or reinforcing discourse coalitions (where actors come together around narratives that represent shared interests [Hajer, 2006]).
Think tanks in our sample did not overtly support government proposals: notable challenges included the likely negative impact of price competition on the quality of health services. Direct challenges were the exception rather than the rule. All appeared to use policy talk in an effort to address and engage decision-makers by emphasising shared beliefs (e.g. 'moves to increasing competition are right'); using similar terms and phrases (e.g. 'the Nicolson Challenge', a mandate from the NHS Chief Executive to find 'efficiency savings' of
?20 billion); presenting briefing papers and publications in the same genre as government documents; and citing many of the same sources (e.g. publications from other think tanks). This rhetorical work is key in providing legitimacy to publications (through authorship and referencing of policy talk) and in directing readers to particular policy narratives.