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Medical Sociology and Health Care Management

David J Hunter
Department of Community Medicine University of Aberdeen, UK

Originally published in MSN Volume 11, Issue 2, April 1986

The conceptual, empirical and methodological approaches that are the stock-in-trade of medical sociologists contain much of value for practising health care managers in furthering an understanding of the management process and its concern with policy formation and implementation. Yet I wonder if many medical sociologists or health care managers would agree that this is so.

Medical sociologists are most at home studying perceptions of symptoms, social class and inequalities in health, lay referral systems, the sick role, professional socialisation and a host of other similar issues. Without denying the importance of any of these for health managers and others, medical sociologists may have more to contribute than they realise to the study and development of health care management itself. My firm belief in this view took shape while engaged on a review and assessment of research relevant to the management role in the Scottish Health Service commissioned by the Chief Scientist’s Health Services Research Committee
1. The conclusion I reached is that the social sciences in general and medical sociology in particular, can bring new perspectives to the study of the organisation and management of health care.

Without becoming embroiled in an unproductive argument about what medical sociology is (I view it as an eclectic assemblage of interests and skills), it is apparent that the boundaries within the social sciences are becoming increasingly blurred. It is a development to be capitalised upon in terms of theoretical and empirical work on health care management without losing the basic integrity of each discipline. My concern is that medical sociology may be excluded, or may exclude itself, from making its own unique, albeit partial, contribution.

Improving management in the NHS has been a constant theme in its development and the Service is currently emerging from a further upheaval, one that has been hailed as the most far-reaching, for it is aimed at changing the management culture and not merely the structural apparatus.

The more the structure of the Service is rejigged, the less it appears to change. The failure of successive reforms across the public sector, including the NHS, over the past decade or so stems in large measure from the inadequacy of the approach adopted and the virtual absence of adequate empirical evidence that particular reforms and theories are soundly based and workable. Changing institutions in order to change behaviour is always likely to fail as a reform strategy, unless attention is given to the participants and their behaviour. The neat portrayal of organisations like the NHS in ‘charts and boxes’ bears little resemblance to their complexity.

Organisational research and analysis, in which medical sociologists can play a prominent part, can be of practical value in demonstrating how complex organisational life really is. Out of ignorance and a misguided faith in a conception of rationality that is at odds with practice, reformers have failed to recognise the NHS’s power structure, the capacities of groups to bargain and influence and the importance of historical legacy for the shape and character of organisational arrangements.

Health care policy and management issues rarely occur as simple economic, sociological, political, psychological or epidemiological problems, but as variants of all of these. The study of organisations ought to be approached from an interdisciplinary base. There is, I believe a danger of the medical sociologist not figuring in this disciplinary mix. Even if it is the case that ‘applied’ disciplines, like economics, are more comfortable doing research on issues of public policy importance, the situation is not immutable. There is a need to ensure that valuations, other than economic ones, are produced.

Medical sociology will not provide exact formulas or precise prescriptions to aid day-to-day decisions, nor should it. Its contribution is in providing illumination in order to sensitize managers to the reality (or realities) they confront. By providing knowledge and a critical perspective, or searchlight, the medical sociologist can make a useful contribution to the management of health care and to raising the level of public debate about health policy.

There is much to be done. To begin with, there is the activity of management itself. What is management in a health context? What is successful management? Who are the managers? What have been the achievements (and failures) of successive managerial reforms? Answers to these questions are not as straight-forward as the questions themselves. A growing body of literature, most of it American
2,3, has sought to explain what it is that managers do and to identify the ingredients of successful companies, managers and leaders. What emerges are organisations that operate quite differently from the dominant conception of the effective organisation. Our health care arrangements have not been subjected to such a searching inquiry. Medical sociologists are well placed to take part in an exercise of this nature, providing they genuinely want to, and invest in establishing relations with health managers.

Without allowing counsels of despair to dominate, one must not expect too much from medical sociology research. As in other areas of social life, social scientists’ findings in the sphere of health policy and management can be uncomfortable and may pose a threat to the existing order. Nevertheless, a contribution remains valid and one that will extend the traditional concerns of medical sociologists cited earlier.

Health care managers are presently confronted by a series of ambiguities, contradictions and tensions which go to the roots of what the NHS exists to do. These centre on the ability of the Service to adapt to changing demands and priorities; to innovate and implement change; to restructure internal relationships as the organisation is re-shaped to tackle the changed nature of its environment, e.g a shift from institutional to community care, an altered demographic profile, the public-private mix in health care provision.

At least five key issue areas in contemporary health policy may be identified as meriting attention from medical sociologists.

Environmental forces. The NHS cannot be detached from its social, political and economic setting, although it is invariably looked at in isolation.
Improved management performance. Before we can talk seriously about improved performance, we need to learn more about what it is that managers do, or think they do.
Medical technology and innovation. The use of technology is not merely a technical matter but also a major policy issue with social implications. Little is known about why some innovations are successful land why others fail, particularly in regard to the organisation and provision of services.
Internal organisational relationships. Within health care, there exists a whole range of important issues surrounding the management of services, e.g relations between clinicians and managers, between consumer groups and managers and between organisations involved in the provision of care. Without a sound understanding of the current dynamics of health care management and of the assumptions, views and behaviour of the participants, attempts to effect change can founder.
Intra-UK comparisons. It is not widely appreciated that the NHS operates differently in each of the four countries making up the UK in ways which might affect management performance. There is scope for comparative work aimed at assessing the significance of these differences.

In tackling this incomplete agenda of research issues, medical sociologists have an important input to make. But unless this is actively acknowledged, it is almost certain that the research endeavour will be dominated by other disciplines which will neither serve as effective substitutes, nor compensate for the loss of a unique critical perspective.

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1 Hunter, D.J. Managing the NHS in Scotland: Review and Assessment of Research Needs, Scottish Health Service Studies No 45, Scottish Home and Health Department, Edinburgh, 1985.
2 Kotter, J.P. The General Managers, Free Press, New York, 1982.
3 Peters, T.J. and Waterman, R.H. In Search of Excellence, Harper and Row, New York, 1982.