Organizing implementation in healthcare: Balancing orders of worth

Abstract

In this paper we direct attention to unavoidable conflicts between disparate value systems co-existing within organizations. Drawing on John Law's concept of ordering and Boltanski and Thévenot's orders of worth, we understand incompatibilities inherent in implementation and governance as competing orders. In extracting and articulating competing orders from our abductive analysis of semi-structured interviews with primary care managers (n = 32) in a Swedish county council, we hope to enable actors to utilise and address them as they engage in implementation work. The potential of such an approach is exemplified by analysing a regional case of health promotion implementation pursued in 2019, in a Swedish county council. Early approaches to implementation and governance have entailed linear models emphasizing program fidelity. Critics have broadened this view by calling for optimization of multiple values and more room for professional judgment. We seek to add to this development by attending to how healthcare practices often entail different and at times conflicting configurations of patients, professionals and priorities. The county council in our case study attempted to steer primary care providers towards health promotion work. To capture the realities of the organization that primary care managers described, we propose that three competing orders can be discerned in primary care: the order of immediate care, focusing on professional judgments of the most pressing needs of patients; the order of accessible care, in which patients themselves define what needs should be cared for; and the order of future health emphasizing prevention of health in the future population. Each order enacts a specific prioritization between patients and a vision of what is or should be primary in primary care. Organizing implementation, we suggest, requires a balancing of orders of worth.

Keywords: Health promotion; Implementation; Orders of worth; Post-NPM; Primary care; Prioritization; Sweden; Trust-based governance.