Social theory and data analysis
Our focus on different sources of data provided a rich picture of the context, people, activities, artefacts, ideas and values that make up think tanks' work in relation to health policy and planning. Our early analysis revealed how different ideas and values appeared to be talked about in different ways in different contexts (e.g. formal publications, actors' accounts of their work), and that this process needed to be managed via a range of neutralising strategies. To make sense of our emerging analysis, we introduced two 'sensitising concepts' to our work as a means of extending analysis and 'suggesting] directions along which to look' (Blumer, 1954:8). Having engaged with wider theory about the context in which policy and planning take place, we introduced concepts of 'front-stage' and 'back-stage' healthcare planning (Degeling, 1996, following Goffman, 1959) and 'sacred' and 'profane' language (Degeling, 1996, following Durkheim, 1964). These concepts drew us to examine the more public and private settings in which health policy and planning take place; and to distinguish the theory of policymaking - with its claimed values of objectivity and rationality (see above) - from accounts of how things work in practice. Take the following extract, from an interview with a senior executive at one of the participating think tanks, discussing what has enabled them to influence evolving NHS reforms:
I have come to realise that writing it down actually does matter a great deal, oddly.
Why do you think that is?
So, I think it gives you the authority. And in a lot of the process, well, people either want something to go, you know, in a lot of these processes they want something to go back to - 'why are you doing this?', 'in response to ...' - and with a kind of, a kind of audit trail ... There's a sort of seemliness to that process. So I think, I think it's very difficult actually to influence without the sort of, without having the written analysis to underpin it, which you have published. And actually, of course, in the parliamentary discussions where our work was quoted, they don't quote a conversation they've had with you, they quote what you've written ... And that discourse is a very important part of this. Now what is really helpful is combining that writing with the explaining personally. And also the warming people up to the fact that you're going to write, and in many cases I had prior conversations with people about how I was going to word this - sought their advice on [discussion about specific reforms]. And I changed some of the wording too, having reflected on their advice.
Okay, almost framing of what you were going to say?
Yes. So I iterated. So I did, I didn't, I didn't do things quite so sequentially ... I guess the engagement with people was a two-way process where I was trying to influence them, but I was also taking their advice. So that what we would say was capable of being more influential.
Okay. And you felt that process worked very well with what came out at the end of it?
Yes. Because I mean I think what we recommended then was things that, you know, and that is a classic Civil Service, you know, kind of: 'So if I change that word here, will you sign up to that? Right, I'll check that with that person there'. And 'if we do that, can you live with that?' 'Yes, check that back.'
This interviewee emphasises the importance of formal written accounts in providing legitimacy and weight to think tanks arguments ('writing it down actually does matter a great deal', 'it gives you the authority') and a citable source of ideas ('they quote what you've written', 'a kind of audit trail', 'having the written analysis to underpin it') that decision-makers are able to draw on ('in the parliamentary discussions', 'classic Civil Service'). The production of formal front-stage accounts involved an interactive process ('a two-way process', 'combining that writing with the explaining personally', 'warming people up'), establishing common ground between think tank actors and decisionmakers ('changed some of the wording', 'reflected on their advice') and working together 'back-stage' to co-produce accounts of NHS reforms ('So if I change that word here, will you sign up to that?'). This production of written accounts was visible in the activities of each of the four think tanks to varying degrees (dependent on their capacity and resources).
Think tanks' formal accounts of their work linked with 'sacred language' of policy and planning (Degeling, 1996), drawing on modernist conceptions of health policy that describe the policy process as an exercise in informed problem-solving (Parsons, 2002), and in which a problem is identified, data collected and analysed, and evidence provided to policymakers on which they can then base decisions. In their 'front-stage' accounts think tanks emphasised a set of technical skills and activities (for instance, 'experimental intervention', 'innovative quantitative analysis'), which informed precise 'research and policy analysis', which then fed into 'the administrative machinery' of government. This was underpinned by an emphasis on evidence-based research and policy, with all four think tanks emphasising standards of rigour underpinned by instrumental rationality.
By employing such 'sacred' planning discourse front-stage, think tanks publicly deferred to values such as rationality, objectivity and due process and established a sense of commonality with healthcare planners and decision-makers. This reinforced think tanks' self-presentation as independent organisations, and situated them as legitimate advisors on the problems - and potential solutions - of NHS reform.
To return to the two narratives that we described at the start of our chapter, on the one hand think tanks' deference to 'sacred' planning discourse signalled to decision-makers that they knew about and adhered to the rules of the game 'front-stage'. On the other, this enabled think tanks to identify and interact with decision-makers 'back stage', and to speak about and practise planning in ways that gave more explicit recognition to its political dimensions.