Introduction
Social care is experiencing a period of rapid, radical change: shifts in policy have emphasised integrated and multi-agency working; a drive towards citizen focused services has introduced the concepts of personalised and self directed care; and greater emphasis has been placed on preventative, rather than remedial, service delivery. Implicit in this policy agenda, which advocates personalised, person-centred care and encourages cross agency, seamless service provision, lies an expectation that information technology will enable both effective practice and integration across the organisations and professions involved in its delivery. This expectation has featured in a number of strategic information initiatives over recent years (SCIPU, 2001; Department of Health, 2003, 2010, 2011), highlighting the roles that information and information systems play in the delivery of care services (Harlow and Webb, Reference Harlow and Webb2003; Wilson et al., Reference Wilson, Walsh and Vaughan2008).
The implementation of these policies, and the achievements of their aims, depends on the ability of the sector to implement innovative information systems across health and social care. Yet very little research has been undertaken into the contribution that information and information systems make in supporting care practices, or how they will need to change in order to respond to these new initiatives (Rigby et al., Reference Rigby, Hill, Koch and Keeling2011).
This article draws on a recent study looking at information issues underpinning social care process and practice within one English Local Authority (Countyshire), and uses it to examine some of the challenges that arise when attempting to translate the expectations of policy into day-to-day practice.
Background and context
Information and ICT in social care
There are three primary types of information utilised within the social care sector, each of which play a role as knowledge resources (identifying signification, assuring legitimation and enabling domination) in the structuration of front line practice.
1. Sector related, professional/practice knowledge – such as how need impacts on the quality of life and the interventions that may be effective in addressing that impact.
2. Personally identifiable information – data relating to specific individuals, their needs, the care they are receiving, and details of their families and carers.
3. Performance and business intelligence – providing insight into demand on and effectiveness of services, and the outcomes of interventions.
ICT provides mechanisms for the capture, storage, retrieval and manipulation of these information resources, with the organisational decisions concerning the allocation and domination of these resources being delivered through a range of modalities, such as security and access controls, functionalities of forms and tools, formats of data presentation, workflow rules and automated processing.
Social care practitioners engage with ICT in a number of ways, including the use of generic software such as email and word processing, but their primary interactions focus on the recording and retrieval of client data, which is collected and used in the formal activities of day-to-day practice: assessment, care planning and review (Hill, Reference Hill2012).
Although the dictates of policy and the formulation of national guidance play a substantial role in the signification of social care practice and the legitimation of its application, the control of the resources which enable that practice lies with the individual local authorities, which are empowered to distribute their allotted resources in line with their own local governance, determining both their internal organisational arrangements, and their approach to local external partnerships. The existence of this organisational agency, albeit overseen by inspection regimes and regulatory requirements, inevitably leads to a level of flexibility concerning the implementation and interpretation of law and policy, which, in turn, contributes to and shapes local structures.
Structuration theory
In structuration theory, ‘structure’ is regarded as rules and resources recursively implicated in social reproduction; social structure and human action are two aspects of the same whole, ‘the duality of structure’ (Giddens, Reference Giddens1984). An important feature of the theory is its recognition of the time–space dimension and its role in the reinforcement and/or the evolution of structure properties. Structure refers, in social analysis, to ‘the structuring properties allowing the “binding” of time space in social systems, the properties which make it possible for discernibly similar social practices to exist across varying spans of time and space and which lend them a “systemic” form’ (Rose, Reference Rose and Baets1998: 3).
Human agency, in Giddens’ formulation, is the ‘capacity to make a difference’ (also known as ‘transformative capacity’) (Giddens, Reference Giddens1984: 14), and within structuration theory agency is intimately connected with power. Power involves the exploitation of resources (Rose, Reference Rose and Baets1998).
Dimensions or modalities of structuration, the theoretical elaboration of how power is used, include patterns of communication (signification), use of power (domination and the control of resources) and norms of behaviour and conduct (legitimation) (Stillman, Reference Stillman2006). The splitting of the duality of structure into these three dimensions is simply an analytical device; in practice, they are inextricably interlinked and should not be considered in isolation. The framework tool developed for the research (Figure 1) utilised this analytical approach to assist in categorising the factors and components impacting on and influencing the emergence of structures observed in both the day-to-day activities of practice, and in the subsequent implementation of change. Modalities act as the locus of interaction between the knowledgeable capacities of actors (rules and resources) and the structural features of social systems (interactions). For example, when human actors communicate in interaction they draw upon different interpretive schemes that are defined by Giddens as ‘stocks of knowledge’ about what actors are doing and why. Actors employ these interpretive schemes in order to make sense of the interactions, to understand them. In employing the schemes they (re)produce structures of significations (or meanings) (Chisalita, Reference Chisalita2006).
Figure 1. Framework tool for structuration analysis
Using structuration theory as an active analytical tool supports an iterative exploration of both the observed praxis and of the theory itself, grounding the associated epistemology within the realities of practice while at the same time enabling new perspectives on both theory and practice to emerge. As Jones and Karsten (Reference Jones and Karsten2008) suggest, the focus of this work was on the agency of the ensemble as it is instantiated in practice, rather than seeking to isolate discrete influences of technology on social practices (or vice versa.)
Research and analysis
The study in Countyshire took place between 2004 and 2010. It focused on the observation of practitioners and their practice, but was undertaken in the context of reviewing the information needs of practice, in order to develop a greater understanding of how systems and services supported those needs. Data were collected through tape-recorded workshops and one-to-one interviews with selected social care practitioners (in both Adult and Children's Services), supplemented by the collation of responses to a questionnaire sent to all Adult Services staff, and then enriched through participant observation in the transformation projects for Adult Services.
The author, employed as Information Strategy Manager supporting Social Care ICT in Countyshire at the time of the research, held the role of lead supplier for IT systems in both the initial ACT project and the subsequent transformation work. This role enabled observation of the approach to, and delivery of, the project, including the interpretation of policy requirements, the involvement of practitioners, the commissioning of tools and IT services and the implementation and subsequent evaluation of the new tools and practices. Data collected included field notes, minutes of meetings, project and progress reports, specification documents, emails, supervisory sessions with ICT staff, evaluation reports and one-to-one interviews with management and operational staff. This rich collation of data enabled further reflection on informatics policies, practices and systems, and the way they impacted on the practice identified in the earlier phases of the research.
The data distilled from this range of sources were viewed and analysed through the ‘practice lens’ of structuration theory (Giddens, Reference Giddens1984; Orlikowski, Reference Orlikowski2000), seeking to understand the role that information and information systems have played in the way that care needs have been ‘traditionally’ assessed, while exploring the implications of that role in helping to shape the expectations of policy and the delivery of change. A framework tool, developed to support this analysis (see Figure 1), assisted in the identification of the factors influencing the creation and reproduction of structure, and the way these factors interacted within and between the micro levels of day-to-day activity, the meso levels of organisational management and change, and the macro levels of policy, community and professional culture.
Translating policy into practice: the ACT project
The ACT (Assessment and Care Planning Tools) project was established in Countyshire in September 2006, with a project team that included both fieldwork and support services practitioners and managers. The project was aimed at overseeing the reshaping of adult assessment practice within the Authority's existing business process, in line with the expectations expressed in Independence, Well Being and Choice (Department of Health, 2005), and reflecting some of the emerging shifts in the scope and nature of the modernisation agenda within adult social care (Newman et al., Reference Newman, Glendinning and Hughes2008).
The objectives were to develop new e-tools, with an improved client focus, for assessment, care planning and review. The intention was to utilise new software facilities to develop the operational tools, ensuring that relevant information could be easily passed from one stage to the next, with all of the necessary data for monitoring process, performance and outcome being captured alongside the requirements of practice.
The initial work was focused on providing better support for practitioners, rather than intending to generate major process change. However, 2006 saw a statement of expectation that there would be a national transformation in social care (Department of Health, 2006). This was followed by the publication of a number of policy documents (Department of Health, 2007) promoting the need for further change and including encouragement to engage more proactively and collaboratively in delivery system change and to show progress in personalisation practice (Foster et al., Reference Foster, Henman, Fleming, Tilse and Harrington2012).
In contrast to a relatively low key response to earlier initiatives, such as the development of the Electronic Social Care Record (ESCR) (SCIPU, 2001), or the implementation of Single Assessment Processes (SAP) (Department of Health, 2001, 2002), the senior managers in Countyshire considered these newer, transformational policies to have greater significance; their focus reflected and reinforced many of the cultural and practice based beliefs with which social work practitioners and managers were familiar. Many practitioners also welcomed the idea of this new approach, seeing in it a closer alignment with the rules of signification expressed in social work training than with the heavily process-driven structures they were working within at the time (Coulshed and Orme, Reference Coulshed and Orme2006; Milner and O'Byrne, Reference Milner and O'Byrne2009).
The changes required to effectively deliver the new approach, along with the structures needed to ensure that it became a sustainable change, were known to be challenging (Newman et al., Reference Newman, Glendinning and Hughes2008). Countyshire chose to utilise their allocated funding by establishing a programme of change aimed at a radical transformation, and the ACT project became part of a much larger portfolio for change in Adult Services. It also shifted focus and approach, adapting the work in order to respond to the demands of the new, developing policy agenda (Newman et al., Reference Newman, Glendinning and Hughes2008; Fisher et al., Reference Fisher, Baines and Rayner2012; Foster et al., Reference Foster, Henman, Fleming, Tilse and Harrington2012).
Findings
Moving from a simple development project, building on knowledge and understanding of existing structures, to one requiring the implementation of tools associated with new processes and new approaches to practice, created huge challenges. The timescales outlined for the transformational programme added further complications, limiting both development and testing time. It had been hoped that the research study would demonstrate how the introduction of IT tools based on better understanding of practice would also evidence greater appropriation and engagement from practitioners, with new structures emerging from a more effective use of and access to information resources. In reality, the progress of the ACT project mostly served to illustrate the difficulties inherent in managing innovative change. It particularly highlighted how new structures cannot simply be planned and delivered as envisaged, but emerge from the articulation of new rules, the accessibility and alignment of resources that support them, the modalities employed in their development and delivery and the interactions that are enabled, or disabled, by the approach to the implementation of the change.
An analysis using the structuration framework tool illustrates the extent of the changes identified from expectations in policy and the objectives of Countyshire's transformation project (Figure 2).
Figure 2. Structurational analysis of change emerging within the transformational project
From this, it can be seen that the changes in design and use of the information tools impacted on both the modalities and interactions in the domain of legitimation, while acting as key enablers (or potentially disablers) in that of domination.
Although the focus of the project was on the frontline business process and delivery of practice, shaped as a shift in domination (increasing client agency) and supported by new approaches to interactions (through co-production and supported planning tools), it was the changes in the underpinning rules (signification and legitimation) and the implementation of the new information tools (resources) that were to be the primary drivers of the change. Changing culture (signification) would be one of the biggest challenges facing the project.
Implementation
Because the new transformation work was project managed using highly formalised methodologies, the ICT work became severely constrained by rigidly described product specifications and delivery timescales. The tools were predefined as paper forms, limiting opportunities to revise or innovate as they were translated into electronic format. In addition, there was no time allowed for systems prototyping, user testing was minimal and the potential to streamline information flow was also lost.
However, systems were developed and delivered: the initial training took place over two days, covering the intended changes in practice as well as process, along with the use of the tools. This was followed by a period of on-site support, with the project team working with the practitioners to address questions, respond to concerns and to monitor technical issues. Although the training attempted to introduce the new concepts and demonstrate the use of the tools, the post implementation support was to prove vital in helping to embed the changes into the day-to-day working of the team.
The majority of the implementation and learning actually took place during the period of on-site support; it provided field testing for the primary tools, and subsequently supported the introduction of those which had still been in development when the initial training took place. It also enabled the re-iteration and reinforcement of the new rules, helping them become embedded in day-to-day activity.
Despite the limitations in their design and the issues associated with their development, the project evaluation presented the new tools as positive changes, both capturing the new requirements and directing practitioners to work in the new way and to engage with the cultural changes. However, the interviews undertaken post implementation identified that a number of practitioners, reluctant to lose some of the narrative they had been recording, particularly with regard to risk, were making (and keeping) notes in addition to completing the new forms. It is possible that the note keeping was an indication of a resistance to change, evidencing a ‘traditional’ mindset that favoured established behaviours and therefore tried to revert to, and recreate, the old structures. On the other hand, as Orlikowski (Reference Orlikowski1992) noted, users interpret, appropriate and manipulate technology in various ways, being influenced by a number of individual and social factors; the author's observations, from both field notes and interviews, suggest that the reasons for retaining the additional information might lie in a dissonance arising between the streamlined approach expected from the new organisational procedures, and the practitioners’ understanding of the professional rules underpinning social work practice.
Discussion
Policy implementation in the public sector
The structuration perspective posits that as policy attempts to shape the day-to-day delivery of services, it is, in turn, shaped and influenced by the experiences of implementing it, along with the outcomes it engenders. In services and sectors (such as care or health) where professional judgement and understanding is a core part of service delivery, this structuration is subject to additional rules, inscribed in professional and practice cultures through shared schemas and accepted norms (Kouroubali, Reference Kouroubali2002), and which themselves influence and shape policy at all levels. The overlay of culture and national identity, within which the constructs of policy and legislation sit, are also factors which contribute to the overall structuration of profession, service and supporting organisations.
The activities of social workers are therefore strongly influenced by their training in, and understanding of, social work as a profession, although the research identified that the overarching rules shaping the delivery of public sector services are primarily those set by government policy and enshrined in national legislation. These define the powers which enable services, and describe the constraints within which they are expected to be delivered. Together they provide both signification (through the aims and intentions of policy) and legitimation (through formal adoption of rules into law.)
It is the evaluation of practice in operation, through the monitoring of performance and outcomes, targeted research and community and public perspectives, that provides recursive resources for the further structuration of policy, supporting the reproduction of favoured structures, and spurring the evolution of new rules to address less favoured practices (Figure 3).
Figure 3. Structuration of policy implementation
These complex interactions take place over time, adding a temporal dimensionality to their analysis. The production and reproduction of operational structures occurs on a daily basis as practitioners interact with their clients. Micro structuration can therefore be observed within a narrow temporal bracketing, where meso and macro influences could be considered as established and ‘fixed’. As the timespan of observation and analysis increases, the range of structurational factors also increases: the cycles of business planning and the implementation of developmental projects bring changes to local rules and influence the allocation and domination of resources.
The shifting objectives of the ACT project, and the instigation of the wider Transformation project in Countyshire, illustrate how meso structuration is similarly influenced through the emergence of new rules and the allocation of resources arising from the macro cycles of national governance and policy development (Figure 4).
Figure 4. Temporal dimensionality of public sector structuration
Considering these models in combination (Figures 3, 4 and 5 (below)) contributes a greater understanding of how the expectations expressed in policy, translated through appropriation at the meso level, and implementation within micro structures, may become distorted and emerge in ways that poorly reflect the intentions of the originating initiative. This might suggest that the minimisation of structural divergence, i.e. delivering policy expectations, can only be achieved through implementation utilising a top down approach, through national projects, proscribed rules and controlled resources. Prescription in implementation, however, does not guarantee that the intent of a given policy can be achieved. Rigid directives and bureaucratically controlled resources can constrain innovation, and may well prevent the full implications of policy decisions from emerging. Berman (Reference Berman1978) argues that:
Figure 5. Structuration of a policy initiative across and between the macro–meso–micro layers
it is impossible to predict accurately the consequences of policy choices in non standard decisions situations or to control the process leading from policy to outcome.
The analysis in this study suggests that, given the evolutionary, iterative nature of public sector structuration, while the full consequences of policy decisions cannot be specifically predicted, there are opportunities to better understand, and subsequently manage, the processes of policy implementation so that the structures which emerge more closely reflect the expected outcomes.
The expectations articulated in national policy tend to be conceptual models, presenting intended outcomes and outlining the behaviours that are thought to be required in order to deliver them. Some policy statements may be accompanied by detailed guidance, be supported by strategy documents or even implemented through nationally directed projects, but the majority of policy development is aimed at leading and directing local implementation (Berman, Reference Berman1978). Organisations are afforded various levels of agency to extrapolate the expectations of policy into the establishment of organisational structures: while some policies define requirements precisely, most leave the details to local managers, enabling them to impose new rules at a local level, and to adapt them in ways that align with their own internal cultures and characteristics (Freeman and Peck, Reference Freeman and Peck2008). This creates a range of challenges when developing or adapting information systems to support local practice, particularly when building on ‘standard’ systems from commercial suppliers. Tensions inevitably arise between the need for flexible, responsive tools, which can be tailored for local interpretations of policy and local use, and the limitations created by existing, standardised systems, which have often been developed in response to earlier policy initiatives.
Local interpretation and the emergence of structural divergence:
The Countyshire research supports earlier findings in identifying that the translation of public sector policy into operational practice is a complex process, fraught with challenge and subject to a range of both tangible and intangible factors (Matland, Reference Matland1995; Bergen and While, Reference Bergen and While2005; May and Winter, Reference May and Winter2007; Lipsky, Reference Lipsky2010). Berman (Reference Berman1978) focused on interactions between the macro and meso layers, considering the translation from policy to process, and the distortion that can arise from the levels of ambiguity in the policy and its interpretation. This approach, while contributing to the understanding of policy design, misses some of the critical variation generated by individual behaviour within the decision-making processes (Hicklin and Godwin Reference Hicklin and Godwin2009). Beneath the meso level lies a micro layer of detail: the interpretation and application of organisational policies and procedures into the day-to-day activities of practice.
The observations made during the Countyshire study suggest that structural divergence, the differences between the expected structures outlined in policy and those which emerge in practice, arises through a combination of factors at both the meso and the micro level.
At the meso level, these include:
• the level of signification ascribed to the policy from the meso perspective;
• the level of organisational agency afforded in the adoption, adaption or translation of policy intentions;
• the scale (and appropriateness) of resources allocated to support change;
• the organisational agency to appropriate and redirect those resources;
• the overall availability of resources to promote change in given timescales (including the knowledge and expertise to revise and develop relevant infrastructures and tools, both internally and externally);
• the ability to release front line staff from on-going activity to enable their engagement in implementation;
• the clarity of policy expectations and the level of detail in which they have been described;
• the prioritisation of the policy and its alignment (or conflict) with other policy initiatives.At the micro level, they include:
• alignment of the policy change with professional perspectives (signification);
• alignment of the procedural change with professional perspectives (legitimation);
• local cultures of practice and the extent to which they have become embedded;
• managerial leadership and commitment to change;
• the amount of resources (training, support, supervision) invested to achieve the change (domination);
• ‘fitness for purpose’ of new tools and technologies;
• the useability of new tools.
These factors interact to create multiple variations in interpretation and implementation for even the simplest policy initiatives. Enactment at the meso level generates structures specific to a given organisation (or group of organisations) which, in turn, contribute to the enactment of structure at the micro level, where the exercise of agency by each practitioner gives rise to a range of variances across the micro structures of day-to-day activity. The level of meso agency afforded by policy will influence the emergence of structural divergence, which may then be further developed by micro agency expressed at the point of implementation/delivery.
A simple theoretical model of interaction between the layers may be applicable to a single instance of structuration observed through a given practice lens, but needs to be expanded into a far more complex model in order to encompass the variances emerging at the operational front line, micro structures which are shaped by the exercise of both meso and micro agency in the translation of policy into the activities of practice (Figure 5).
In Countyshire, an initial consistency in local practice was achieved through the establishment of a shared knowledge base, which articulated the meso expectations of the implementing organisation as they were expressed and then reinforced through guidance, training, peer interactions and support/feedback from the project implementation teams. The structures that emerged in day-to-day activity reflected the translation of national expectations into the local expectations of the organisation. In the longer term, the strutural divergence (and potentially convergence) of these structures will be both afforded and constrained by a series of recurrent and recursive meso and micro interactions, including inspection and regulation, performance and outcome monitoring at both the local and national level, peer review, research and public/community feedback. Over time these interactions may reinforce, creating strong cycles of routinisation, or revise the expectations expressed at both the macro and meso level, influencing structural stability and, in turn, potentially leading to the creation/introduction of new initiatives.
Aligning macro and meso expectations: rules of signification
Observation of Countyshire's response to the transformation policies, compared to earlier initiatives, suggest that the factors of signification associated with a policy initiative at the macro level can be influential in the exercise of organisational agency concerning its consequent signification at the meso and micro level, and similarly influential in affording or constraining the structural divergence that emerges from the policy's implementation (Figure 6).
Figure 6. Organisational agency: signification as a contributory factor in translating macro (policy) initiative into micro (practice) activity
The expectations laid out in Transforming Social Care (Department of Health, 2008) were high profile, perceived as having high significance from both practice and performance perspectives, and were required to be reported on, through outcome and performance measures, with very clear and challenging deadlines for compliance. The emphasis placed on the rules of signification within the organisation generated a greater allocation of resource, along with increased engagement and specific interactions at all levels to support the process of change. This level of investment helped reduce structural divergence, although, as the research illustrates, the range of other factors involved resulted in the enactment of structures which did not fully reflect the original expectations of policy.
Clearly, other factors, such as the legitimation underpinning the policy (i.e. the extent to which its requirements may be enshrined in law and regulation) and the amount of macro and/or meso resources allocated to support its implementation will also contribute to decisions determining the intent to initiate change, but the findings suggest that it is the factors of signification (and how they may or may not be sustained over time) that influence the alignment between macro and meso expectations of structure. When the signification of policy also aligns with the interpretive schemas of professional practice, there is a greater likelihood that those expectations will be enacted by practitioners, enabling new structures to emerge as intended. The implementation of any given policy, and the level of structural divergence that emerges from it, will also be shaped by the domination of resources, not just in the allocation of funding and the establishment of project/implementation teams, but through the changing of the modalities that deliver and shape the authoritative resources which define practitioner agency and afford (or constrain) day-to-day practice, the information systems and tools that practitioners are expected to use.
Conclusion
From a structuration perspective, human practice enacts structures through recurrent interaction with the technology at hand, so that, while the technologies of care may embody organisational rules and constraints, it is only through use of that technology that structures emerge. While use may capture the imprint of those structures within systems, it is the interaction with this imprint that recreates the structures as the system content is accessed and used. Challenges lie in ensuring that the relevant structures emerge and are maintained by that interaction, rather than being restrained by the limits of a rigid technology.
The project in Countyshire illustrates the complexity of factors involved in meeting that challenge. They include the defining rules of policy at the macro level, the meso level decisions about the revision of business processes and associated modalities for the allocation of resources, and the enactment of those changes through the micro structures of operational practice. Within this complexity, information tools and services serve as repositories of rules, act as allocative resources in the storage and transmission of data, and support communication and discourse over space and time. The structures that emerge from the use of these services, situated within and shaped by the tacit knowledge, both professional and cultural, of experienced practitioners, form the day-to-day technologies of care.
The power provided by effective access to, and authoritative use of information has great potential, both as an enabler of individual agency in the new paradigms of personalisation, and in supporting the fundamental structural changes that current policy promotes. But without an understanding of how new structures emerge through local enactment and interpretation, there is a equal potential for technology to inhibit and distort the implementation of change.
Care must be taken in the interpretation of these models and steps taken to avoid undue determinism. Orlikowski (Reference Orlikowski1992) notes that while expected relationships may hold empirically for certain organisations in certain historical and socio-economic conditions, the ever-present ability of actors to alter the cycle of development, appropriation, institutionalisation, and reproduction of technology may undermine any causal expectations. The ongoing interaction of technology with organisations must be understood dialectically, as involving reciprocal causation, where the specific institutional context and the actions of knowledgeable, reflexive humans always mediate the relationship. Nevertheless, the way that these factors combine and interact invites further exploration, and offers opportunities for future work looking at the implementation of policy and the development of associated technologies in other organisations and sectors.
The observations of the research suggest that the key to the successful development of these technologies will lie in taking a step away from traditional approaches, where ICT is seen as separate and distinct activities, and moving into more holistic delivery of change, with the information services and resources recognised as a fundamental component. That step should include moving from the rigid, product focused approaches of formal project management towards more iterative, evolutionary and interactive design that can deliver the expectations of policy, support the structures emerging from their enactment in practice and enable improvement in the technologies of care.
