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1 Introduction
There is a growing recognition of the importance of evidence to support allocative policy decisions in health care. Indeed, the use of research evidence to underpin policy decisions is not new in western societies, but the assumption that increased utilisation of policy-relevant knowledge will enable more ‘rationality’ in policymaking, has grown stronger over the years, and thus indirectly the supposition of downgrading the impact of politics and political decision-makers (Learmonth and Harding, Reference Learmonth and Harding2006; Head, Reference Head2010; Kay, Reference Kay2011). In health care the use of systematic research has a particularly strong appeal, not least due to the influence of the powerful evidence-based movement (EBM) (Raine, Reference Raine1998). It is more often suggested that not only clinical decisions, but also health policy making in general will benefit from research evidence (Walshe and Rundall, Reference Walshe and Rundall2001). Hence, there are strong tendencies nowadays in the health policy arena to use research evidence in the search for ‘a technocratic fix’ for many, often complex, problems (Syrett, Reference Syrett2003).
Without doubt the health policy sector is characterised by complexity (Plsek and Greenhalgh, Reference Plsek and Greenhalgh2001), and the governance of health care is a constant challenge, due to the many stakeholders (Kuhlmann and Bureau, Reference Kuhlmann and Burau2008) representing various and competing types of rationales. Most prominent are the scientific rationale, which is dominated by positivistic science and upheld by professional groups, and the political, which relates to the distribution of values and the management of power represented by elected officials accountable to citizens (Lin, Reference Lin2003). While there are many studies on evidence-based practices in health care, there is a limited understanding about how political and scientific rationales collide in this process. A policy problem that is characterised by ambiguity and complexity, and where different rationalities collide, is the allocation of health care resources, within and – most notably – between service areas. Demographical changes, technological advances that lead to increasing costs and rising public expectations have made this a policy problem of growing concern in many countries. In a publicly funded system, limit setting in the form of prioritising or even rationing, appears in different guises, implicit and sometimes explicit, and is thus described by Hunter (Reference Hunter1997) as an ‘intensely political issue’.
In Sweden, which has a tax-funded and universal health care system, directly elected politicians are responsible for providing health care to the public in 21 independent regional health authorities. They decide on the tax rate and the overall finances, organisation and content in the health service. At the same time, the national government remains a significant actor within health care, with an ambition to use accessible policy instruments to assure efficient, knowledge-based and equal care. Even though traditional national policy instruments such as legislation and economic incentives are still in use in the governance of Swedish health care, other instruments based on stakeholder negotiations and input of expert knowledge have gained ground in the past two decades.
Currently there is an emergent pressure by the national government, on the regional health care politicians, to apply decisions that make the best use of available resources within limited budgets. The most prominent policy instrument in use in this context, representing ‘management by knowledge’ (Kalkan et al., 2015), or ‘informative governance’ (Fredriksson et al., Reference Fredriksson, Blomqvist and Winblad2014), is the National Guidelines (NGs). According to the Government, its overall goal is to attain more efficient care, reduce regional disparities, increase the use of best evidence, and should support both organisational and resource allocation decisions within the regionalised system. Currently, NGs exist within 18 service areas (of which 5 are preliminary). Although the NGs are sometimes perceived as a set of traditional clinical practice guidelines (CPGs) (Tistad et al., Reference Tistad, Palmcrantz, Wallin, Anna, Olsson, Tomson, Widén Holmqvist, Gifford and Eldh2016), they are far more complex as they draw on both a scientific and a political rationale. To get involved in activities that aim to encourage other physicians to conform to standards, or even to perform in ways that contain costs, is not in any way unique to Sweden, but is common among medical researches or academic professionals (cf. Freidson, Reference Freidson2001). As the foundation of the NGs is in professional expert knowledge, they clearly represent a scientific rationale (Grip et al., Reference Grip, Lindahl, Levin, Kärvinge, Eklund and Wallentin2011). Multidisciplinary working groups, including expert professionals and health economists, are assigned by the state agency to produce guidelines for specific service areas. The working groups are dominated by medical professionals and hence the scientific rationale is predominant.
However, what make them different from traditional CPGs are the recommendations in the form of a priority grading, rooted in politically decided ethical principles (Eckard et al., Reference Eckard, Nedlund, Janzon and Levin2017). Sweden is one of the few countries where ethical principles (human dignity, need-solidarity and cost-effectiveness) for setting priorities in health care have been issued by Parliament. The guidelines include recommendations on the most effective prevention and treatment within a service area. Relevant interventions are ranked 1–10 and the expected organisational and economic implications are presented. The NGs are intended for decision-makers throughout the entire health care system including regional politicians, administrators and clinical managers. Even though the content of their decisions differs, the intention with the guidelines is to improve the ability among all recipients to better handle prioritisations in the health service (Fredriksson et al., Reference Fredriksson, Blomqvist and Winblad2014; Kalkan et al., Reference Fredriksson, Blomqvist and Winblad2015). Hence, they also represent a political rationale for setting limits in health care.
The primary objective of this paper is to broaden the understanding of how a policy instrument, embracing both a scientific and a political rationale and intended for priority setting at the regional level, the NGs, is used for strategic purposes. We investigate how Swedish health care politicians perceive and make use of this policy instrument when trying to uphold the requirements of health care, both as a political and as an action organisation.
In so doing, we will draw foremost on theories of how expert knowledge is used for strategic purposes in policy processes, as a framework in which to view our results. In the paper, we focus in particular on the National Guidelines for Cardiac Care (NGCC).
The remainder of this article is organised as follows. Next we present a theoretical discussion and framework for the analysis. Section 2 describes the methodology and data of the empirical study. Section 3 presents the results of the study, and Section 4 summarises the main results and provides conclusions.
1.1 Priority setting as a political undertaking
The Swedish National Guidelines is foremost to be seen as a policy instrument aiming at explicit priority setting in health care. The setting of priorities is a crucial part of decision-making in publicly funded health care systems, where resources must be allocated between different needs (Syrett, Reference Syrett2003; Saarni and Gylling, Reference Saarni and Gylling2004; Robinson et al., 2012). The setting of priorities can result in decisions to disinvest, to invest, or to re-allocate resources within or between service areas. Decisions to disinvest can take various forms, such as the total decommissioning of services, raised indication levels or lowered levels of ambition (Daniels et al., Reference Daniels, Williams, Robinson and Spence2013). Priority setting is a sensitive topic since it involves ethical dilemmas and choices between different services, and is assumed to be an unpopular policy among citizens. As politicians expect it to be difficult to gain credit for priority-setting decisions, especially when they include different forms of limit setting, they may prefer to distance themselves from such an undertaking (Ham and Coulter, Reference Ham and Coulter2000; Garpenby and Nedlund, 2016).
One approach to ‘de-politicise’ priority setting is to redefine health policy as a technical or scientific issue, which can be done by appointing expert bodies to advise or recommend what services should be publicly funded (Ham and Coulter, Reference Ham and Coulter2000; Syrett, Reference Syrett2003). The difficulty with a technocratic approach, as explained by Klein (Reference Klein1993), occurs because priority setting is always of an ‘inherently political nature’, and thus it is impossible to organise decision-making in a way that makes those decisions unquestionable. According to Klein, the setting of priorities is a political process that involves mobilising consent among the public as well as medical staff. Williams et al. (Reference Williams, Robinson and Dickinson2012: 97) argue that priority setting ‘is not just about making the “right” decision; it is about making the decision in the “right” way, taking into account the right sorts of values and opinions’. Public opinion is clearly of importance for politicians and to create an alliance with the medical profession might be a prerequisite to disclose limit-setting activities to a broader audience (Garpenby and Nedlund, 2016).
Strategies to create a climate of trust within the health care organisation, and thus make clinical leaders sympathetic to taking part in limit-setting activities, has proved important (Harrison and Mitton, 2004). Robinson et al. (2012) found that local bodies involved in resource allocation (English PCTs) were using evidence not only to produce ‘correct decision recommendations’ but also for its legitimising potential. Thus, evidence played an important role ‘in constructing a narrative that was palatable to a clinical audience’ (Robinson et al., 2012: 2392). Hence, the conclusion of this literature is that priority setting is a complex type of decision-making where the use of expert knowledge is strongly affected by distributive/political aspects. Furthermore, the role of scientific evidence need not be restricted to producing clear-cut decisions, and could have other functions as well.
1.2 The use of knowledge in policymaking
Our analysis of priority setting explores the condition for using a particular policy instrument, the NGs, under pressing circumstances when political decision-making has to address resource scarcity. We will draw foremost on theories of how expert knowledge is used for political purposes in policy processes. This is in contrast to the classic approach in this field, which directs its interest towards the instrumental use of knowledge, where the intention is to understand if and how scientific knowledge helps improve policy choices (the problem-solving role of knowledge) (Weiss, Reference Weiss1979). Pointing to the complexity of the policy process, scholars have questioned this narrow and often unrealistic model of knowledge utilisation. The argument here is that evidence cannot generally be translated into concrete policy advice, and that there are often aspects that have to be considered that are specific for the particular situation. Many authors have also emphasised that knowledge can be used in ways other than as technical information to improve decisions: for example, filling an enlightening role to alter the decision-maker’s understanding of concepts and general ideas of policy (see overviews in Amara et al., Reference Amara, Ouimet and Landry2004 and Boswell, Reference Boswell2009).
Clearly, this kind of reasoning has made an impact on how observers of health policymaking, and scholars interested in ‘knowledge translation and exchange’ (KTE) strategies, have later come to reason (Lomas and Brown, Reference Lomas and Brown2009; Grimshaw et al., Reference Grimshaw, Eccles, Lavis, Hill and Squires2012). Although the short-term goal has been adjusted to achieve better capacity for ‘evidence-informed policymaking’, the ultimate goal for KTE strategists is still to link research to action, i.e. research should result in improved health status or a more effective health service (Lavis et al., Reference Lavis, Oxman, Lewin and Fretheim2009; Boyko et al., Reference Boyko, Lavis, Abelson, Dobbins and Carter2012). Hence an instrumental way of approaching the use of knowledge prevails in much of the literature dealing with evidence-based health policymaking, also when the use of knowledge is described as something context specific, where improved interaction or deliberative dialogues between producers and users of knowledge is put forward as the solution (Culyer and Lomas, Reference Culyer and Lomas2006; Boyko et al., Reference Boyko, Lavis, Abelson, Dobbins and Carter2012).
This is fundamentally different from the large body of literature that has emphasised the political or strategic use of knowledge. Here, knowledge is understood to be something that supports or legitimises a pre-determined position (cf. Boswell, Reference Boswell2009; Radaelli, Reference Radaelli1995; Schrefler, Reference Schrefler2010). Boswell (Reference Boswell2009), for example, takes her starting point in the assumption that the value of expert knowledge for policymakers does not have to be its contribution to problem-solving, or even have to fulfil an enlightening function. Instead, she argues that knowledge more often fulfils an important symbolic function for policymakers. Boswell distinguishes between two types of symbolic use. Firstly, a legitimising function, which means that an organisation tries to draw on knowledge to ‘(…) enhance its legitimacy and potentially bolster its claim to resources or jurisdiction over particular policy areas’ (Boswell, Reference Boswell2009: 7). Something that other authors have named political-strategic (Schrefler, Reference Schrefler2010) or tactical (Weiss, Reference Weiss1979) usage of knowledge (cf. Radaelli, Reference Radaelli1995). Secondly, a substantiating function of expert knowledge, which means using knowledge to lend authority to a specific argument or policy position. This use of knowledge can, for example, serve to legitimise decisions already made, or as ammunition in an adversarial context (cf. Schrefler, Reference Schrefler2010).
A central aspect of Boswell’s perspective is the reasoning on how different organisational and political conditions affect how knowledge is used. She argues that different organisation types encourage different uses of knowledge. While so-called action organisations derive their impact mainly from their concrete output, political organisations derive their legitimacy chiefly from formal structures and decisions. Action organisations can primarily be expected to use knowledge in an instrumental fashion, solving problems to increase output. Both organisations can be expected to use expert knowledge to validate their claims, but a political organisation is more likely to use expert knowledge as a source of legitimation. Furthermore, there are, according to Boswell, contextual conditions where symbolic use of expert knowledge can more frequently be expected. A central contextual factor concerns the nature of the political debate. Boswell further points to the importance of conflict for the political use of knowledge. In an organisation that experiences a sense of instability, and where it faces resistance from a rival organisation, knowledge is more likely to be used to substantiate policy positions.
Drawing on Boswell (Reference Boswell2008; Reference Boswell2009), what kind of knowledge use can we expect from policymakers in a publicly financed health care system, when having to act in an environment where resources are limited and where activities to balance different needs and demands occur? The process of priority setting is to a large extent a political process, involving negotiations and struggles about how to distribute resources. Although in some regards health policy in Sweden is not a contested area, since there is an agreement on the importance of high-quality medical services that are equally distributed to all citizens, issues concerning variations in medical practice across the country, and the need to set limits due to resource restrictions have created tensions that place the NGs in the midst of a highly contested policy area. The guidelines might contribute to increasing the legitimacy within the health care organisation and in its relation to the public (Ham and Coulter, Reference Ham and Coulter2000; Saarni and Gylling, Reference Saarni and Gylling2004; Robinson et al., 2012). NGs could even become part of a strategy for blame avoidance in priority setting where decision-makers refer to ‘the protocol’, be it rules, routines or guidelines based on expert knowledge (Syrett, Reference Syrett2003; Boswell, Reference Boswell2009; Hood, Reference Hood2011).
Furthermore, the role of politicians in the Swedish health care system is challenged by highly qualified employees with a strong position in the health care organisation, but also in society at large, giving the medical professionals an advantage in public discussion on priority setting. In addition, politicians at the regional level also have to match the expectations of the national level. Hence, in this context, expert knowledge will, to a large extent, be expected to fulfil the function of a political weapon in a struggle over power, while the substance of the knowledge becomes subordinated (Lundin and Öberg, Reference Lundin and Öberg2014).
We will dwell on the nature of knowledge use in the complex organisation of publicly funded and politically governed health care, as it prompts a series of questions:
1. If the NGs have both a scientific and a political rationale, how can political decision-makers in the regional health authorities make use of them in resource allocation situations? In what way does the nature of political debate surrounding resource allocation in health care affect the use of knowledge?
2. How is the use of NGs affected by a state of instability in the governance of health care, where ‘rival organisations’ (the political and the action organisation represented by professionals) exist? To what extent and in what way can the use of expert knowledge be characterised as a way to substantiate policy positions, that is, as a way to use it as a political weapon?
In line with Boswell (Reference Boswell2008; Reference Boswell2009), we use the term ‘expert knowledge’ in a broad sense to denote knowledge processed and presented by people considered to be experts in their field, in contrast to, e.g., laypeople or elected officials. As Boswell points out, the boundary between different types of knowledge will vary and depend on different contexts. The point here is that policymakers prefer to use this as ‘expert knowledge’ in a particular setting, although this knowledge could, as explained above in the case of NGs, draw on both a scientific and a political rationale. In fact, understanding how policymakers interpret expert knowledge and what role it could play is an important research task.
2 Method
The empirical material was gathered as part of a larger study on the implementation of the National Guidelines for Cardiac Care (NGCC) in Sweden. The interviews were carried out in 2011 with 11 strategically selected politicians, i.e., 2–3 participants from each of the four regional health authorities included in the study. The regional health authorities were Skåne, Sörmland, Västra Götaland and Västernorrland, representing diversity in pre-conditions for priority setting and characteristics with their different geographical locations, population size and area of responsibility.
The participants were chosen by purposeful sampling, which means that they were strategically selected to give in-depth information on the research questions at hand (Patton, Reference Patton1990). With the help of a contact person in each regional health authority, the participants were selected on the criteria that their role should give them specific insight into, and knowledge about, the implementation of the NGCC in their authority. The relevance of the selection of participants was confirmed in the interviews, where all participants presented relevant knowledge and experience on the NGCC and its use in the context of regional health care governance. The participants represented diversity in political affiliation but this was not referred to in any of the interviews. Regionally elected politicians are common in health care governance in Scandinavia, and the politicians sit not only on the directly elected political assemblies that decide on the overall budgets but also make up the standing committees for the commissioning of health services and for deciding on major investments (Hagen and Vrangbæk, Reference Hagen and Vrangbæk2009). In Sweden, regional politicians can be engaged by the health authorities on a part-time basis though some are working full-time with political matters. In this study, the participants were all dedicated full-time to their political duties and had high-level positions in their health authorities.
The interview guide was constructed with a combination of closed and open-ended questions, giving the participants an opportunity to add information that they considered relevant (Kvale, Reference Kvale2009). The participants were asked questions on the NGs in general, and in particular on the NGCC. Interviews were conducted at a location chosen by the informant and lasted approximately 30–75 minutes each. All interviews were recorded and transcribed verbatim. Informed consent for recording of the interviews was obtained before each interview. The participants were also informed about how the collected data would be analysed and presented, with particular emphasis on the fact that identification of individual informants would not be possible in the final presentation.
A thematic analysis was carried out to elucidate the essence of the data (Boyatzis, Reference Boyatzis1998). The data were analysed through the following steps: first, the interviews were read through to capture more general themes based on the research questions; second, these themes were developed in more depth; connecting different themes to each other and developing a deeper understanding; and third, these themes were analysed in relation to theories of knowledge use, mainly the work of Boswell (2008; Reference Boswell2009).
Ethics approval was provided by the Regional Ethical Review Board in Linköping in May 2011 (Dnr. 2011/126-31).
3 Results
We will present our results in two sections. First, we will show how political decision-makers use NGs for resource allocation, in situations where the scientific and political rationales collide. Thereafter, we will analyse how the use of NGs is affected by a state of instability in the governance of health care, where politicians have to relate to both the requirements of the political and the action organisation represented by strong professionals.
3.1 The use of NGs as a policy instrument for priority setting
In all four sites, the participants spoke positively about the incoming national guidelines (NGCC) and the fact that central government, through the state agency (NBHW), had taken on the assignment of developing a series of evidence based guidelines. In one important respect, the NGs were perceived as a policy instrument that well serves the purpose of legitimising the political control over publicly funded health care. Their dual natures, where political and scientific rationales meet, are in line with the political debate on access to health services of equivalent standard across the country.
We did a study of cardiac care in Sweden a couple of years ago and then you could see how differently you were treated at the different hospitals, and that was because there were little Popes who sat there and decided, and I think it is a safeguard as I said before, that we now have a real regulation framework. (P6)
Hence, it is hardly unexpected that the politicians expressed an appreciation of the concept as such, as they focus on how well it serves the purpose of legitimising the national political objective of similar quality of care for everybody. The use of knowledge was expressed as the core of attaining high-quality health care since:
(…) it is vital to follow up that we have high quality, then I think we have to have National Guidelines (…) (P9)
Another participant declared his view in this manner: ‘Yes, the advantages are that you have the opportunity to offer equal care throughout Sweden. That you have agreed on, what it is, what there is evidence of’ (P7).
Yet another participant stated:
Yes, I think it is very, very good. (…) I think that it is absolutely the most important tool we have to get away from the inequality that exists in health care. (…) I think the ambition concerning this is very positive. (P11)
The Swedish regionalised health service is politically governed and with limited resources, and thus constantly occupied with finding ways to solve ‘distributive conflicts’. One participant stated that: ‘(…) you think it’s good to know that there are guidelines, but then comes the next problem: can we afford to run our health care as the guidelines stipulate? Do we have the resources?’ (P6). These traits are typical of a political organisation and one could expect that the politicians, in the case of allocation of resources, saw the NGs as a source of legitimation to increase control of their jurisdiction, alternatively as a way of substantiating arguments and positions. As mentioned before, the NGs have a strong political rationale but, as will be seen, not necessarily coinciding with the rationale the regional politicians display. On the contrary, the participants describe several underlying problems with the application of the guidelines; foremost, it is difficult for the regional decision-makers to maintain their independence in relation to central government, as well as the dilemma of advantages given to service areas covered by NGs.
A major theme among the participants was the problem they experienced in getting the guidelines to support a local process of prioritisation, and thus facilitate the ability of politicians to take full responsibility for the overall budget and its distribution between different service areas. This was also felt to be a key part of their role as representatives of a political organisation. Several of the participants underlined that they had difficulties in using NGs as unambiguous facts, as they had to position themselves in relation to the facts pertaining to many guidelines.
As the NGCC represents only one service area, cardiac care, it was seen to complicate things. The collision between different rationales, and the need to balance between the requirements of a political and an action organisation, stands out in the priority setting process of the regional health authorities. One participant explained: ‘Yes, it becomes more difficult for us at regional level to make independent decisions, and if we think that this service area should be prioritised and then comes the National Guidelines in a different area, that perhaps we don’t feel is very important, then we must, relatively quickly find a system that we can adapt to it’ (P7). In this way, several of the politicians described a situation where each set of guidelines tended to be an isolated silo, resulting in a narrow process that risked excluding contextual factors and other service areas.
The fact that new guidelines were launched frequently was a concern for the participants, as expressed here: ‘(…) if we now take the cardio guidelines or indeed guidelines for stroke, which have now been updated every third, fourth year or something like that over a number of years, and of course there is a lot of focus on that area, there are often new guidelines for cost increase demands and such, well then we do this’ (P10). Another participant put it like this ‘(…) if you look at this, it is like there has been pressure in the budget process in a different way than there was before’ (P3).
It was suggested that this would put politicians in a difficult position where they were not free to set priorities based on their own preferences. There was a growing problem with balancing the budget when new demands, underpinned by NGs, became pressing and frequent. Even though the NGs was supposed to result in both expenses and savings, the general perception among the participants was that new guidelines had a tendency to lead to larger expenses than before. One participant commented on this issue: ‘Well, the disadvantages that might exist are those that the politicians sometimes discuss, no one really said it out loud much but this is what they are afraid of, that they are costly, it is so, I don’t think it’s so rare that people would think that way’ (P3).
One disadvantage that was mentioned by several of the participants was that just because the NGs were becoming more elaborate did not mean that things became cheaper, and this was recurring across all NGs. Even if things were to become cheaper, one politician pointed out, this would still not mean that the budget holders would get ‘any refund’ from the clinical management. Hence the NGs did not lend the politicians legitimacy to adhere to the difficult task of reallocating resources between service areas.
3.2 To use NGs to balance the requirements of the political and the action organisations
As the regional health care politicians find themselves positioned in the midst of a conflicting situation, where they constantly have to balance the requirements of a political organisation with that of an action organisation, they did view the NGs as an important policy instrument for reaching the medical profession. As elected officials at the regional level they have the ultimate responsibility for the allocation of resources, and to get in a position to strengthen the opportunities for rearranging the flow of resources (by setting priorities, rationing and reallocating), they have to approach the doctors. Since their initial situation was not strong, they hoped that NGs would help them legitimise their role vis-à-vis the most prominent representatives of the action organisation. One participant mentioned that health care is one of the most difficult areas in society to work with and that, as a politician, it is your responsibility to make sure that it works properly. According to this participant, the guidelines clearly indicated that ‘this is how it’s going to be’.
A view held by one other participant illustrates the difficulties facing the representatives of the political organisation when they have to confront those of the action organisation: ‘(…) the reason that you are a doctor, for example, is primarily that you want to try to cure and then… in contrast… the role of the politician, or when you must decide on allocation of resources, so it is also a balance against all other expenses’ (P5). Many of the politicians recognised the difficult position of the clinical management but would have preferred to have the political role acknowledged as well. One participant said that: ‘I feel that there is a bit of a misunderstanding… that those who are the angriest critics of politics maybe don’t always have a real understanding of under what pre-conditions politicians need to make decisions’ (P11).
The politicians referred to the relationship between politicians and clinical management as imbalanced. They described the need to find common ground in the discussions on service development and resource allocation. In this context, the importance of using NGs to legitimise their role was highlighted, since the relationship between politicians and clinical management was described as generally tense. This is bluntly illustrated by the following quotes: ‘(…) the profession quite often feels that politicians are real morons who have not understood anything, and from that perspective you feel from time to time that some people who work in health care are a bit blasé and think – now don’t you come here and decide this and that because we know best’ (P11). Another participant described the role of the doctors within the regional health authority with regard to the allocation of resources as follows: ‘If you try to do something within a regional health authority or region without speaking to the doctors, then I think you have a problem’ (P7).
However, the politicians also felt that the guidelines had strengthened their role, as they provide them with an opportunity to familiarise themselves with the core of health care, i.e. how medical decisions are underpinned. On this issue, one of the participants explained: ‘We get knowledge that we have not previously had, that has been restricted to the profession’ (P4). Some of the participants expressed a sense of renewed power and described the guidelines as a confidence booster for political decision-makers, enabling the politicians to ‘stand up’ against the clinical management and the professionals, as expressed by one participant: ‘I thought it [NGCC) was revolutionary when it came, you know. (…) Yes, I thought it was amazing, thought it was, it was a safeguard in some way, suddenly you could say to people “yes, but you see they do it the same way throughout Sweden, this is the latest there is”’ (P6). Several of the participants referred to the sense of knowing that they now feel, in contrast to before the NGs were published. In this way, knowledge was used to substantiate the policy positions of the politicians by giving them more credibility and strengthening them in relation to the medical profession.
Obviously the politicians noted that the prime representatives of the action organisation, i.e. the medical professionals, use the NGs and their scientific rationale for the particular purpose of defending and advancing their particular service area. Many of the participants described a situation where a service area covered by NGs had an advantage in the budget discussions. This was expressed in the following way by one participant: ‘(…) but there is of course also a risk that it directs the focus on a few, albeit major, areas within health care, and focus for clinical management, administrators and politicians and other areas are caught in the middle because they do not get the attention that the areas that have National Guidelines get’ (P10).
However, the NGs, and in this case in particular the NGCC, were also seen as a way forward, creating common ground for politicians and medical professionals to meet and deliberate on a specific set of guidelines, or a joint strategy aiming to get a grip on the allocation of resources. The term ‘relate to’ was frequently used by the participants, in the sense of knowing more and also in the sense of having facts available in the dialogue with clinical management when discussing new investments: ‘(…) they do have something, politicians have something to relate to (…)’ (P3). Against this background the elaboration of the guidelines was considered an important process as it would pave the way for politicians to use them with a legitimising purpose. The involvement of experts selected by the NBHW was considered a key reason for the possibility of using the NGCC in this way. One participant stated: ‘I think it is important, it is of course an important support for politicians to have these recommendations that one has developed over the years (…)’ (P1).
The high profile of the NGCC makes it a facilitator in the local context. One participant described it in the following manner: ‘I think, in that one has had the profession involved in the process, means that you also get an acceptance’ (P5). Moreover, all participants considered it to be a document with high credibility by many of the most important stakeholders within this policy field. This should be viewed in contrast to the participant’s previous experiences of clinical management, raising objections when decisions are made by political actors. On this issue, the same participant stated that: ‘(…) the guidelines have been an opportunity for a… a, can we call it a platform, where you can meet and discuss these difficult issues’ (P6). Interestingly, this points to a more dialogue-oriented and deliberative function of knowledge, in the negotiations between politicians and the medical profession.
4 Discussion and conclusions
That health care is characterised by complexity is a truism. Viewed as an action organisation, where clinical professionals who are representing various types of knowledge address different needs to satisfy individuals with different expectations, it certainly deserves this epithet. In this study we add another element, that health care likewise should be viewed as a political organisation where resources have to be distributed within and across service areas, according to some criteria, and in our case under the control of directly elected politicians. Positioned at the regional level, and under pressure from both central government and prominent representatives of an action organisation, our politicians were responsible for the highly contested policymaking of setting priorities. In this article the intention was to display what happens at the regional level when politicians are confronted with a new policy instrument, introduced by central government, which contains both political and scientific rationales. The use of knowledge, especially research evidence, is often viewed in an instrumental fashion, for problem-solving at the clinical level in health care (Boyko et al., Reference Boyko, Lavis, Abelson, Dobbins and Carter2012). Undoubtedly there is a vast amount of literature on guideline implementation, especially CPGs, with this focus (Grol and Grimshaw, Reference Grol and Grimshaw2003). The work of Boswell and others, identifying the possibility of knowledge used for strategic purposes, provided us with the framework for analysing how political decision-makers, under difficult circumstances, make use of this new policy instrument, the NGs.
Our findings illustrate the dilemma of political decision-makers and how they prefer to use expert knowledge, but also what obstacles they face. The NGs are not mainly – although sometimes suggested (Tistad et al., Reference Tistad, Palmcrantz, Wallin, Anna, Olsson, Tomson, Widén Holmqvist, Gifford and Eldh2016) – an instrument for clinical practice, but an instrument directed towards the allocation of resources: in fact intended to support explicit priority setting. As previously mentioned, priority setting is a sensitive topic, with regard to public opinion, and also tends to affect the interplay between political and clinical decision-makers (Williams et al., Reference Williams, Robinson and Dickinson2012). Mostly there tend to be collisions on what criteria and values, applied by whom, should determine resource use. The introduction of NGs by the Swedish government can be said to illustrate how expert bodies can be used to provide a ‘technical solution’ to a problem that is eventually of a political nature (Klein, Reference Klein1993). The involvement of the professional elite in undertakings where the ultimate intention might be the control of rank-and-file doctors was earlier described by e.g. Freidson (Reference Freidson2001). As in the case of the NGs, they are primarily members of the medical profession who produce evidence on which other actors have to make their choices and, as Kuhlmann and Burau (Reference Kuhlmann and Burau2008) notice, new governance practice using professional knowledge, including methods of defining, measuring and evaluating knowledge, could in fact strengthen the power of professionalism.
Efforts to control clinical practice and the implications for the medical profession have been the subject of discussion among scholars for decades, and there are different views on how the actual impact of e.g. extensive use of guidelines, looks (Numerato et al., Reference Numerato, Salvatore and Fattore2012). Of key concern in this study, however, has been finding out how regional politicians interpret a new policy instrument, with a strong input from the medical profession. What this instrument actually represents for political decision-makers. At first glance it might be attractive, as an opportunity to disguise the conflict of values that is always present when allocating resources. However, as seen in this study, politicians face new problems when the NGs were pushed onto them, not least as this is a potent instrument in the hands of clinical actors who can use it to bolster their claims. It is possible to see how the politicians must react – or counter react – to manage the claims of an action organisation. Following Boswell (Reference Boswell2008; Reference Boswell2009), we can observe how specific organisational and political conditions affect the use of knowledge. At the regional level the Swedish health care organisation is highly dualistic, with a formal steering level of elected representatives (with high legitimacy due to a high voter turnout), who have to negotiate with the level producing health services with high professional legitimacy (the medical profession). Foremost, there is a constant balancing between the requirements of the action and the political organisation. The politicians are stuck with this task!
Evidently the politicians speak well of the NGs in general terms and in particular the scientific rationale, with regard to how it – superficially – could help to achieve better and a more equal care. In this way the politicians use it in a legitimising fashion, as here the simple message of a political and a scientific rationale coincide. In this respect, one could say that the NGs, as a policy instrument, fit well into the current political debate.
As elected officials at the regional level, our participants had the ultimate responsibility for the allocation of resources and, to get into a position to strengthen their opportunities for controlling the flow of resources (by setting priorities, rationing and reallocating), they had to approach the medical profession. Since their initial position in this respect was weak, their effort to relate to NGs was thought to serve the purpose of improving their control of an important jurisdiction. One of our participants mentioned that health care is one of the most difficult areas in society to work with and that, as a politician, it is your responsibility to make sure that it works properly. This illustrates how the pressing demands of the action organisation constantly affect the reality of political decision-makers. Hence NGs could be used for substantiating purposes – as a way to handle a conflict over the jurisdiction of health care decision-making. By referring to NGs, the elected officials were able to signal to the professionals ‘we are knowledge’ and ‘we can use your type of knowledge’. Evidence also suggests that the NGCC was used to control new investments by questioning demands from clinical actors.
Clearly the NGs did not give politicians a concrete answer on how to make direct policy choices. In that sense they are not instrumental. Still, the NGs as a policy instrument gave politicians an ability to improve their problem-solving capacity, e.g. how to argue against professional demands on new investments. Although this might not be what is commonly referred to as instrumental use (Amara et al., Reference Amara, Ouimet and Landry2004), our article illustrates that there might not always be as clear-cut a boundary as is sometimes suggested between the use of knowledge for problem solving and other types of usage. It depends on whose perspectives are in focus, and what policy problem is regarded as being a particular problem for whom. Here focus was on how politicians make use of the policy instrument (NGs), but it does not exclude the possibility that NGs can prove useful in a more ‘traditional’ instrumental sense, e.g., in providing better health care to patients at a clinical level, although that was not within the scope of this study.
When it comes to making significant adjustments in the total health care menu, the NGs proved to be a blunter instrument. Undoubtedly NGs could provide politicians with facts and a recommended ranking order, but this seems to have put them in an awkward position. In one respect they did like ‘facts’, as using a scientific rationale to solve controversial policy issues could be attractive, i.e. by relating to a ‘standard’ (Hood, Reference Hood2011), or, in the words of one participant, that NGs send a message that ‘this is how it’s going to be’. It seems likely, however, that our politicians realised that ‘facts’ per se could not provide a sufficient basis for legitimising their governing of health care vis-à-vis the public. Thus, while NGs provided them with ‘facts’, following the political rationale of central government that priority setting should be based on similar ‘facts’, their own political rationale seems to have been to set priorities by applying ‘values’ under substantial discretion. It can be interpreted that their dilemma became more pronounced when confronted with many NGs where ‘facts’ pointed in different directions. The policy instrument did not provide a solution as to how to weigh different ‘facts’. They express a wish to improve the dialogue with the medical profession, but it is far from clear what they expect to come out of this. To use NGs to make reallocations between service areas is something completely different as compared to using individual guidelines in discussions with representatives of one particular speciality.
In focus in this study are the guidelines for cardiac care (NGCC), although the participants referred to other guidelines and the NGs as a total concept. Could the NGCC be different from other guidelines in its family, and thus be used differently than other national guidelines? Clearly the NGCC represents a high status speciality in the medical field, which usually gets lots of attention in media and elsewhere, and is also a speciality that produces lots of scientific data in order to prove excellence. Therefore, establishing a good relation with this speciality might be something that our politicians found particularly important, in order to achieve a legitimising function. On the other hand it could also be regarded as a speciality that was important yet difficult for the politicians to control, as it risked consuming lots of resources. All of this could have had an effect on how the politicians acted and used the guidelines.
Although the Swedish case, accounted for in this study, represents a specific context, it can contribute to the wider discussion on the use of expert knowledge in political decision-making. We think that our study contributes to the literature on knowledge use. The dualistic organisational context seems to, in our case, make knowledge important as a political weapon in negotiations. However, the negotiations are not primarily between different organisations, as is assumed in Boswell’s theory, but within a complex organisation. Furthermore, the strengthening of the politicians’ position in these negotiations (which seems to be a result of the NGCC instrument) can also create conditions for a more constructive dialogue between two more equal parts. This seems to be an aspect that is less discussed in the literature. In a public and politically governed health service, the nature of knowledge use becomes particularly visible. There are a limited number of studies on this theme and this article offers an important contribution to the research on the use of knowledge in health care priority setting (Robinson et al., 2012; Rooshenas et al., 2015). There is, however, a need to study this field further and also to explore the role of expert knowledge and experts in relation to the various stakeholders in the health policy arena.
