Regionalization in elderly care: what makes up a healthcare region?

Introduction

Speaking on a Sunday morning news and political commentary programme in early March 2019, the Dutch Minister of Health announced the launch of a regional approach for combatting the increasing problem of staff shortages and inadequate quality in elderly care. Regions, the minister said, would stimulate collaboration among local organizations, practitioners and policymakers. Funds were subsequently made available to elderly care providers to support joint initiatives with neighbouring healthcare organizations focussing on the design and implementation of promising solutions to the problem of medical staff shortages. In addition to requiring organizations to collaborate to obtain these funds, officials from the Ministry of Health used active persuasion to encourage elderly care providers, for example in consultations. Besides these “soft” strategies, the Ministry had no other mandate to enforce regionalization in elderly care. The public (and authoritative) appeal for regional collaboration was surprising in the light of over a decade of market-driven policies in healthcare, which the minister now openly declared to be inadequate to the task of resolving contemporary problems in elderly care. The shift in focus from competition to regional collaboration, however, fits in with a broader (re)discovery of “regions” as places for care (Lorne et al., 2019; Ivanova et al., 2016; Jones et al., 2019; Oldenhof et al., 2015; Lorne et al., 2019).

Regions have become popular places for healthcare policymaking, although the trend is not a global one, with some countries seeing a growing level of consolidation and concentration of healthcare providers (Kapp, 2016). The renewed emphasis by policymakers on regionalization more or less implies that regions constitute singular and bounded geographical spaces that are well defined, tangible and “useable” for developing a policy strategy, and it assumes that regional actors feel a sense of regional engagement and a willingness to cooperate in regional care delivery. Regional geographical boundaries are in fact often taken for granted in the organization of healthcare and are seldom a topic of research enquiry. The delineation of regions as primordial and clearly bounded geographical areas is open to question, however, both empirically and conceptually. The socio-political literature on regions shows that they are not just “out there” but emerge from multiple (and often contested) geographical constituencies (Lorne et al., 2019; MacLeod and Jones, 2001). Rather than being clearly demarcated, regional boundaries may be fluid or overlap, with multiple (functional, administrative, cultural and professional) regions being contained within the same geographical area.

Increasingly, scholars have come to understand (healthcare) regions as “assemblages” comprising a diverse set of institutional actors tied to provisional allegiances (Ivanova et al., 2016). Rather than a given or based on formal agreements, relations between institutional actors within a regional assemblage are fragile and conflict-ridden. As a result, assembling a region is a continuous process that requires “work” (Lorne et al., 2019). We know little about why such formations are rife with conflict and require continuous maintenance. To fill in this recurrent hiatus in thinking about geographical space relationally, scholars must embrace a richer pallet of conceptual tools that will enable them to understand the “forces that restrict, constrain, contain and connect the mobility of relational things” (Jones, 2010, p. 249). In this paper, we take on this challenge. A total of two questions have guided our research: (1) What is a healthcare region? and (2) What mechanisms inform institutional actors' decisions to form, maintain or abandon collaborations with neighbouring organizations within an administrative region?

We draw on a large and ongoing action-oriented research programme in the Netherlands (2019–2021) in which healthcare providers, policymakers and researchers jointly develop and implement solutions to the entwined problems of a burgeoning elderly population and an increasing shortage of staff, particularly of elderly care physicians. In the pilot projects undertaken within this programme, healthcare providers operating within a care office region are encouraged to collaborate on devising and implementing “promising solutions”, such as integrated services, practitioners working for several healthcare providers in the region, shared instruments of triage and shared technological tools. In total, 14 of the 32 care office regions – the administrative area linked to the largest healthcare insurer within a constituency – are represented in the project. The project is innovative in encouraging healthcare providers to cooperate rather than to compete with healthcare organizations in their geographical proximity. As researchers, we study, evaluate and, through our research, contribute to the experiments, elucidating how they impact elderly care and traditional ways of organizing care (e.g. use of triage, integration of GP and nursing home care). By participating actively in healthcare providers' efforts to cooperate regionally, our team obtained an in-depth understanding of the dynamics through which practice and policy networks in elderly care are assembled and disassembled.

We begin this paper by providing a conceptual framework for (healthcare) regions and discuss recent work on socio-spatial formations and valuation practices, a concept that we used to understand the mechanisms shaping institutional actors' work within the networks studied. We then describe our research methods and go on to present our results, arguing that healthcare regions, rather than clearly bounded topological entities, can be better understood as an assemblage comprising a variety of dissimilar actors tied to uneasy allegiances and in a constant state of flux. An analysis of the regimes of valuation embedded in the healthcare sector helps to explain the dynamics through which such socio-spatial formations are assembled and disassembled.

What is a healthcare region? A conceptual framework

The focus on regions as a valuable site for organizing care has seen a recent upsurge in the medical sociological literature (e.g. Lorne et al., 2019). Whereas scholars in this discipline have proposed few theories as to what a healthcare region entails conceptually, a vast body of work on “new regionalism” has emerged in social geography discussing the conceptual understanding of a region and of regionalization (Agnew, 2013; Allen and Cochrane, 2007; Amin, 2004). We first turn to this body of work for conceptual tools that allow us to grasp what a healthcare region comprises and then move on to the concept of valuation regimes to shed light on the different evaluative principles that underpin processes of regionalization.

In the late 90s, the interest in new regionalism was understood as a reaction to a “failing” centralized state in a globalizing world (Keating, 1998), with regions being seen as a more appropriate bureaucratic level to manage societal challenges and accelerate economic prosperity. New regionalism cemented the idea of regions as more or less delineated geographical areas managed by clearly identifiable politico-administrative institutions (Macleod and Jones, 2007, p. 1,180). This conceptualization has also prevailed in health and healthcare research, for instance in quantitative investigations into the effects of place, or the specific conditions of a place, on the health of its denizens (Hazen and Anthamatten, 2012). Such conceptualizations of place have increasingly come under attack, as they falsely assume a bounded topological area with bureaucratic institutions operating on different scalar levels (Cummins et al., 2007). Instead, a relational perspective has been suggested to conceptualize regions and regionalization processes (Allen and Cochrane, 2007; Amin, 2004), shifting the analytical focus to the (symbolic) relations between diverse institutional actors that constitute a particular region (MacLeod and Jones, 2001).

Recent work conceptualizes regions as assemblages of diverse sets of institutional actors (Allen and Cochrane, 2007; Lorne et al., 2019). This line of work emphasizes the fluidity and heterogeneity of the institutional networks that make up regions and argues against the conceptualization of regions as clearly bounded geographical spaces. Assemblages should be understood as loosely knitted, temporal and entwined relational networks among heterogeneous institutional actors, such as local, regional and central state entities, interest groups and private and public organizations (Allen and Cochrane, 2007; Amin, 2004). These spatial-temporal networks are often “problem driven forms of coordination through partnerships and policy exchange” (Gualini, 2006, p. 889), meant, for example, to further economic development within a geographical area (Allen and Cochrane, 2007) or in the provision of healthcare. A region, then, can be conceived as a web of relations tied to a provisional allegiance, constantly changing and drawing in institutional actors that operate in various domains and in different geographical constellations.

(Dis)assembling healthcare region: regimes of valuation

Perceiving a region as an assemblage allows us to scrutinize the ongoing practices of assembling (new) actors, resources and policies and disassembling others to arrange healthcare systems and services into new and meaningful but potentially also conflict-ridden practices of regional care (Lorne et al., 2019). Assemblages are laden with conflictual dynamics; hence, various actors must work to keep the formation together. Lorne et al. (2019), for instance, show that in the context of initiatives to enhance regional collaboration among healthcare providers, austerity triggers a centrifugal dynamic in which healthcare managers prioritize the survival of their own organization above regional collaboration (2019, p. 9). As a result, work is required to sooth the tensions and to keep the formation together. How assemblages come into being and which dynamics galvanize the assembling and disassembling of socio-spatial formations often remain unclear. As Jones (2010) points out, this is a recurrent hiatus in thinking about geographical space relationally, and to fill it in, scholars must embrace a richer pallet of conceptual tools that enable them to understand the “forces that restrict, constrain, contain and connect the mobility of relational things” (2010, p. 249).

The work of (re)assembling socio-spatial formations depends, among other things, on the strategies, interests and actions of actors, for instance whether they value collaboration or prioritize competition. Such decisions are underpinned by certain evaluative principles, cultural logics or sets of norms on which actors draw to critique or legitimize existing arrangements and justify their decisions (Boltanski and Thévenot, 1999, 2006). Managers, for example, often base their strategic decision-making within organizational contexts on a market principle that values self-interest and competition (Kornberger, 2017). It should come as no surprise that such actions often hamper collaboration between organizations. However, as numerous scholars in the field of Science and Technology Studies (STS) have pointed out, the act of valuing is not based solely on ideational cultural logics from which human actors draw their strategic actions and justify and critique arrangements (Kornberger, 2017; Rushforth et al., 2019; Zuideren-Jerak and van Egmond, 2015). What is rendered valuable is, among other things, produced by concrete practices that are embedded in the organizational infrastructure. In the STS literature, these arrangements are often referred to as “valuation devices” (Callon et al., 2007). Rankings and reviews are pertinent examples; they have pervasive performative effects, trigger certain types of strategic actions and produce ideas of what is valuable (Kornberger, 2017; Rushforth et al., 2019; Zuideren-Jerak and van Egmond, 2015).

These two strands of valuation literature have opposing views on how to study valuation practices. One body of work focuses on the concrete valuation devices and construes organizational culture as a product of these arrangements (Kornberger, 2017; Rushforth et al., 2019). The other strand analyses the cultural logics within organizations and sees valuation devices as an outflow of these evaluative principles (Fourcade, 2011). We draw on the concept of “regimes of valuation” to resolve this conundrum (Fochler et al., 2016). The concept refers to systems of cultural evaluative principles and enmeshed organizational infrastructures, such as valuation devices, organizational routines, discourses and governance and accountability structures that value and galvanize particular strands of strategic action within organizations. Within academia, for instance, the (e)valuation of academic excellence is grounded in a whole organizational apparatus that includes such valuation techniques as citation scores, grants and funding, the number and performance of PhD students, tenure tracks and other organizational routines and the subjectivity of an entrepreneurial self (Fochler et al., 2016; Stark, 2011; Rushforth et al., 2019). It is this amalgamation of instruments, identities and values that makes up the regime of valuation.

Institutional domains may have multiple regimes of valuation that, at times, contradict one another and trigger conflicting practices of assembling and disassembling networks. Scholars have distinguished between fields in which one evaluative principle is dominant (hierarchies) and fields in which multiple principles coexist in a non-hierarchical relation (heterarchies) (Stark, 2009). This distinction helps to conceptualize the relationship between different regimes of valuation and directs the analysis towards understanding how these regimes interact and to what effect. Writing about valuation practices in academia, Fochler et al. (2016) argue that although there are multiple regimes of valuation through which scholars value their work and act strategically, one regime of valuation, which is of competition and productivity, is dominant within the field. The normative power of such a regime is in fact determined by the degree to which it is institutionalized within a particular field (Fochler et al., 2016, p. 180). The regime of competition and productivity within academia, for instance, is powerful because it is grounded in a whole infrastructure of citation indexes, grants, hiring procedures, tenure tracks and university rankings. In analysing the strategic decisions actors make in valuing particular chains of action, scholars should consider the whole organizational apparatus in which these evaluative principles are rooted. In this paper, we show that the assembling and disassembling of socio-spatial formations is shaped by multiple regimes of valuation, and that calls for closer regional collaboration are not necessarily effective when a dominant regime of valuation emphasizes competition over collaboration.

Research methods

The research presented in this paper is part of an ongoing action orientated research. Between November 2018 and July 2020, we conducted a total of 273 semi-structured interviews with managers of nursing homes, elderly care physicians, specialist nurses, welfare workers researchers and policymakers. Respondents participated in various projects aimed at initiating “promising solutions” for the ongoing shortage of medical staff. During the interviews, respondents were asked to reflect on their organization's collaborations, on the organization itself and the quality of elderly care it provided, on initiatives to alleviate the shortage of medical staff and on organizational bottlenecks in current elderly care. Most interviews lasted between 45 and 60 min and were conducted in person. All interviews were audio-recorded with the consent of the interviewees and were transcribed verbatim.

Besides these interviews, we drew data from various ethnographic observations. We attended meetings of regional working groups charged with developing and discussing the various pilots. A variety of different actors participated in these working groups, from healthcare managers and consultants to physicians and nurses. The first pilot in our research project, which ran from January to March 2019, involved four nursing homes experimenting with a nurses' triage model. Over the course of this pilot, two of our researchers shadowed nurses and clinical practitioners (physicians and nurse practitioners) and managers who worked with the triage model. They also participated in the regional project group, providing feedback on their research findings and helping to refine the pilot. The second pilot, which ran from September 2019 to January 2020, reallocated the tasks of an elderly care physician and a general practitioner working in a nursing home in small rural community. In total, two researchers shadowed both professionals in the nursing home over the course of pilot. In total, we conducted over 1,000 h of observations for the whole project.

We analysed our data using an abductive approach (Timmermans and Tavory, 2012). Our research produced “surprising empirical findings” (p. 169) that we analysed against the backdrop of different social theories discussed in the theoretical section above. The first was the dissimilarity between the formal, administrative understanding of a region as a clearly geographically bounded entity, espoused in project plans and policy documents and the actual fuzzy, unbounded spatial formations of collaborating organizations on the ground. Additionally, we found that the process of building partnerships between different actors in the field of elderly care was anything but neat and simple. The partnerships were often fragile and rife with conflict, with participating actors having to juggle differing interests and values, some of which collided, or at times opposing the move towards further collaboration with partner organizations. In the analytic process, we coded our data and “revisited” the phenomena under study, weighing and fitting different theoretical explanations to the aforementioned surprising findings (Timmermans and Tavory, 2012). Additionally, we “defamiliarized” our data by comparing the neat and orderly idiom of regions in policy discourse with the messy, complex and fluctuating web of connections between the actors in our study (Timmermans and Tavory, 2012). We then proceeded to debunk and refine our emerging concepts, comparing our explanations with ill-fitting data and deviant cases. After intensive coding, we identified two “core categories” (Corbin and Strauss, 1990): the composition of socio-spatial formations, referring to the geographical spread of the various practice and policy networks in which our interlocutors operated and the underlying mechanisms of assembling and disassembling these practice and policy networks, referring to the forces that contributed to the formation, maintenance and disintegration of these networks.

Findings

In the remainder of the paper, we explore the composition of “healthcare regions” empirically and analyse the dynamics of assembling and disassembling practice and policy networks. First, we argue that healthcare regions are not clearly bounded topological entities but should rather be conceptualized as multi-layered webs of relations tied to a provisional allegiance. Some of these webs are formalized in institutionalized networks, and others are informal collaborations in which heterogenous actors, such as healthcare managers, medical professionals, policymakers and consultants, cooperate. This web of relations is constitutively dynamic. Some actors might disconnect from the assemblage while others might join the processes that apply even to the more formalized networks. As a result, the region is always in flux and its geographical reach changes over time. Second, multiple regimes of valuation exist within the healthcare field and shape the dynamics in which of socio-spatial formations are assembled and disassembled.

Conclusion

Our paper challenges the prevailing understanding of (healthcare) regions as clearly bounded topological areas, a view common in policy circles and healthcare research (Hazen and Anthamatten, 2012). We asked, what is a healthcare region? Drawing on socio-geographical insights, we regard a healthcare region as a complex, dynamic and multi-layered assemblage of heterogeneous – public and private, administrative and professional, national, regional and local – institutional actors (Allen and Cochrane, 2007; Amin, 2004)). We build on recent studies focussing on the spatial dimension of healthcare restructuring (Lorne et al., 2019) and emphasize the multi-layeredness, dynamism and unbounded nature of healthcare regions. The actors in our study participated in a variety of policy and practice networks that were entangled in complex ways and together formed the “regional assemblage” in which regional care initiatives were established. This assemblage was dynamic, with the composition of the constituent networks – even the mandated ones – changing over time and therefore challenging the general understanding of such networks as being rather rigid, with prescribed roles and fixed membership (Waring et al., 2017). Spatially, this healthcare assemblage was boundless and unstable. It comprised a multitude of networks with a diverse topological reach that changed as institutional actors joined or left. As a consequence, there is no unequivocal reading of what the healthcare region is; instead, it must be conceptualized as an entangled web of networks that is compositionally dynamic.

Regionalization fits in with a larger trend in which governance through networks is seen as a potentially productive approach for addressing “wicked problems” (Ferlie et al., 2013). Recent scholarship emphasizes the discrepancy between the managerial and technocratic view of networks as entities that can be mandated and imposed and a more sociological understanding of networks as emerging from the sustained and meaningful interaction of actors (Waring et al., 2017). We recognize this tension in our research. The policymakers and care offices we studied had a rather technocratic understanding of networks as entities that could be mandated and imposed on the field. As authorities, they set the parameters for regionalization as interorganizational collaborations meant to emerge within a given constituency. At times, this conflicted with the relevant organizations' established networks; some (like Sea-Care) had established partnerships with organizations in a different constituency, and this affected their commitment to the new, mandated networks. At the same time, these new, mandated networks jeopardized established partnerships when managers started to question which strategic partnerships would be viable in the long run. This echoes other research showing that the establishment of mandated networks is often complicated by pre-established interorganizational relations (Waring et al., 2017), and that such networks often threaten pre-established practice networks (Addicott et al., 2006). In this light, policymakers would benefit from having a more fluid understanding of what constitutes a region and from acquiring a more sociological perspective on networks. They might wish to refrain from a priori delineation of the geographical area and organizations but instead leave regionalization to the field and allow it to emerge from established relations within a healthcare assemblage.

It has been suggested that governance in networks can overcome the fragmentation brought about by the marketization of healthcare (Ferlie et al., 2013). Networks would foster relations of trust, openness, cooperation, shared decision-making and resource sharing, even if underlying market structures exist (Kickert et al., 1997). Other scholars, however, argue that network relations are often far from harmonious. They are shaped by structural power dissymmetries between groups and relations can be conflictual, for instance due to inconsistencies in health policies that push and pull actors within the network in opposite ways (Waring et al., 2017; Addicott et al., 2006). We asked the following: what mechanisms inform institutional actors' decisions to form, maintain or abandon collaborations with neighbouring organizations within an administrative region? Our paper offers a framework for understanding the conflictual dynamics within policy networks. Rather than seeing strained relations within networks as the product of different sets of values (Klijn and Teisman, 2003), we argue that tensions may arise from conflictual valuation regimes within the healthcare sector. One practical implication of our analysis is that calls for regionalization in healthcare will be ineffective unless the underlying governance and accountability structures are addressed. Current governance and accountability structures of elderly care in the Netherlands are tied to a market evaluative principle, meaning that managers value strategies that are primarily in the interest of their own organization. Without changing these underlying structures, the objectives of regionalization are unlikely to be realized. New modes of accountability that work from a networked perspective must be developed to make regionalization work.