The work of making networks work: exploring the interplay between institutional work and network orchestration in the implementation of new healthcare service models

Networks have emerged as prominent model for public service modernisation. They are typically conceived as bringing together diverse policy actors to promote more collaborative policy making and service delivery. Research... [ view full abstract ]

Networks have emerged as prominent model for public service modernisation. They are typically conceived as bringing together diverse policy actors to promote more collaborative policy making and service delivery. Research suggests, however, that inter-organisational and inter-professional boundaries continue to complicate policy networks. Our paper looks at the work of ‘orchestrating’ networks in public service contexts. Network orchestration describes the tasks of brokering relations, coordinating activities, shaping boundaries and forging shared values. However, the concept can appear under-socialised, focusing primarily on tasks and capabilities of network leaders, and not the work of changing prevailing social institutions. Drawing upon the concepts of relational leadership, network leadership and network orchestration, our study examines the micro-sociological work of ‘street-level’ policy actors in creating and maintained new networked models of public service organisations.

Our paper investigates the implementation of service delivery networks in the English National Health Service (NHS). Here, networked service models have become common in a number of priority areas, such as stroke, cancer, and critical care, where limited specialist resources together with growing demand necessitate new forms of service organisation. One such model is the introduction of ‘hub-and-spoke’ networks, where specialist care is provided within regional ‘centre of excellence’, with preliminary and follow-up care supported by a network of providers. The rationale for this network model is that increasing the number of specialist cases in a regional centre reduces variations, promotes quality and enables economies of scale. Our study draws upon the findings on a three-year ethnographic study of the implementation of a major trauma network in one English region, carried out between 2013 and 2016. This involves over 200 hours of observations in seven different hospitals and interview with over 120 individuals.

Our findings focus on three stages in the implementation of the major trauma network, each involving different examples network orchestration and institutional work. These correspond with the stages of network formation identified in other research settings, and in keeping with the orchestration metaphor, we focus on the processes of determining network leadership and governance arrangement (the composer and conductor); network membership and roles; (the musicians and structure of the orchestra); and network relationships and processes (the performance). In each stage, policy actors not only had to identify and tackle practical challenges, such as leadership duties, reporting channels or care processes, but also need to address wider institutional influences (so they agreed on the style and tone of the music, the venue of the performance, and the expectations of the audience). This included, for example, addressing divergent understandings of trauma care through the strategic use of evidence and regulatory pressures. It also involved building relationships through aligning different normative assumptions. Through this case study, our paper elaborates the everyday practices of network orchestration, and shows how the success of networking hinges on creating, disruption and maintenance of social institutions.