Finnish ophthalmology services have been criticized for being suboptimal and in this regard, the authors analyze a development project set up to reform these services. The project descended into crisis 18 months after its launch, when its actors mapped out two different ways in which they perceived the problems related to ophthalmology and came up with different solutions to these problems. This paper pays special attention to the events following the crisis, when an external policy entrepreneur was recruited to lead the project. This policy entrepreneur did not adhere to either of the realities mapped out in the earlier stages of the project, but created interpretation of the problems at hand and their solutions. This paper focuses on the process in which the policy entrepreneur strove to convince other actors of the validity perceived interpretations. According to the analyse, the implementation of the new policy alternative consisted not only of a technically and politically feasible solution, but it also involved skillful policy making and right timing.
TopBackground
The ageing of the Finnish population creates a great pressure for change in the operational environment of ophthalmology services as ophthalmological diseases increase dramatically with age. At the systems level, the pressure for change mainly comes from the substantial technological developments in the field of ophthalmology. The technology used to treat the front of the eye has been developed to enable easier and faster operations, and we are now able to treat conditions at the back of the eye that were considered incurable. Other considerable changes at the systems level are the ongoing revisions to the Finnish Health Care Act and the municipal and service structures, and the consequences these reforms will have on ophthalmology services. These changes will have effects especially on integrating primary and specialized care, and will lead to the redefinition of the boundaries between different municipalities and joint municipalities. A third cause for change at the systems level is the chronic shortage of ophthalmologists in the public sector. This shortage can be seen as a result of a health care system outdated by decades, as well as the increased business opportunities in the private sector that derive from technological development (Kokkinen et al., 2009).
In order to relieve the pressures described above, especially the shortage of professionals, a development project was launched in the summer of 2007 in the catchment area of the Tampere University Hospital. The project was launched by the top management of the Pirkanmaa Hospital District, while the other four Hospital Districts within the catchment area took part in it. During the first 18 months of the project, two alternative ways to interpret the problems related to ophthalmology emerged together with different solution alternatives. The view of those advocating the first interpretation was focused solely on the problems and solutions within the University Hospital, whereas the problems and solutions related to the second interpretation related to wider operational environments within regional ophthalmology (see Kokkinen & Lehto, 2009). When these two alternative interpretations collided in late 2008, the project came close to being canceled. The project was, however, continued and it was reorganized in late 2008 and early 2009. At this point an external policy entrepreneur was hired to lead the project. The management of the Pirkanmaa Hospital District recruited a top name of Finnish ophthalmology for the position. This person was perceived as capable of analyzing not only the operation within the University Hospital, but also regional ophthalmology services in a wider sense.
This policy entrepreneur recruited from outside of the organization brought into the project not only her specialist knowledge but also her own ethical choices and the ways in which she evaluates and furthers her policies. From our point of view reforming health care involves a lot more than just the technical process. Acting in harmony with common values and influencing them are also vital, as is recognizing and justifying personal commitments (cf., Roberts et al., 2004). In other words, leaders often strive to execute changes that they believe will improve the system or society, and use both their policy making skills and the values they draw in to further these changes (Coles, 2000; Majone, 1989).
The right timing is often a key factor in executing changes (Kingdon, 1984). The situation in which the policy entrepreneur joined the project was a challenging one, but at the same time it opened a window of opportunity for the interference of an external actor. When reality appears to be complicated and involves contradictory interpretations, many people are inclined to accept simplified interpretations (Simon, 1957). In such a situation, a leader must be able to express his/her own interpretations and execute his/her suggestions for change. He/she is expected to dare to question and challenge the interpretations of other actors – including his/her superiors – even though this is seldom an easy task (Wildavsky, 1979).
This paper discusses the policy-making involved in the development project from the perspectives provided by the theoretical frame of reference chosen for the task. We analyze the third interpretation of reality, presented by the policy entrepreneur as a middle ground between the two interpretations presented earlier in the project. Moreover, we focus on the process in which she strove to convince the different actors that hers was the viable interpretation.