- Planning processes in the field of healthcare tend to be very complex. They are invariably made up of many steps and actions carried out by many participants drawn from many organizations. But if we choose our concepts carefully we can cut through this complexity and dissect the process into its component parts.
- This note distinguishes between administrative, technical and political processes as components of an overall planning process. And it shows, with examples, how options for the plan that emerges can be limited in the course of the process by using two mechanisms: creating commitment and pre-empting alternatives.
Administrative, technical and political processes
For a start, we can pick out those steps and actions that are prescribed by law or by standard operating procedures. Examples might be the issuing by a higher authority of a mandate or instruction requiring a plan to be submitted. It could be necessary to authorize spending money on hiring consultants. There might be statutory requirements to offer the public opportunities to see proposals and submit their opinions on them. Towards the end of the process there will be a formal decision to go ahead with implementing the plan.
I call such a sequence of steps and actions an administrative process. It provides a framework for the planning process as a whole.
Within that framework we can see taking place what I call a technical process and a political process. These are components of the overall planning process.
The technical process is to do with generating and using information. The category ‘information’ will of course include factual material, such as demographic data and data that describes current services and the people who make use of them, and projections of such data into the future. It will also, in my scheme of things, include the theories and principles (‘ought’ statements) that are applied to factual and projected factual material.
Technical steps and actions include collecting data, processing it and presenting it in various ways; carrying out surveys and analysing the findings; making projections, including alternative projections; formulating proposals; choosing criteria for evaluating alternatives and applying those criteria.
Just as the technical process involves working with information, the political process involves working with interests. As I define it, it is made up of steps and actions in the course of which the perceived interests of various groups and individuals are accommodated or overridden. Examples of such interests might be the consumer interest of the residents of a particular area in resisting the closure of a hospital emergency department, or the institutional interest of a hospital consultant in preserving his or her autonomy when it comes to deciding what treatment a patient should receive.
The dynamics of planning processes: commitment and pre-empting
As a planning process proceeds, the successive steps and actions that take place have the effect of narrowing down the options that are going to be available at the point when a decision has to be taken. We can see two mechanisms at work here: creating commitment and pre-empting alternatives.
Commitment is a psychological mechanism. People who have been working on producing a plan are liable to become increasingly committed to certain elements of it.
They take decisions about the kind of plan they want to see, and about working methods, i.e. how they are going to produce the plan. To then go back on these decisions, and write off some of the work that has been done, will generate stress and involve loss of face. Similarly, people make assumptions and become wedded to these: even if evidence turns up that shows that their assumptions were unrealistic or could have harmful consequences, they may disbelieve and deny that evidence: this well-known phenomenon is known as ‘cognitive dissonance’.
And the staff working on the plan will have their own motivations. They will have personal ambitions, such as advancing their careers, and typically will want to produce something distinctive and striking. Such ambitions too generate commitment.
Some people will have easier – ‘preferential’ – access to the planning process than others. For example, in the NHS senior managers and consultants may get together privately to find and agree a course of action that suits both groups. Once that agreement has been reached, and both sides are committed to it, it will be very difficult for junior doctors and members of allied health professions, let alone the public, to get it reviewed and altered.
Pre-empting, by contrast, is a practical rather than psychological mechanism. An example is the using up of time and staff resources when a deadline has to be met.
Once the deadline has been set, there is simply not the time and manpower to go back to square one and start again. If no alternatives have been investigated and considered, there is no time now to investigate them. Even if alternatives have been considered, these will usually have been reduced to a shortlist, and it won’t be possible to resurrect any that didn’t make it on to the shortlist. The opportunity of backtracking has been pre-empted.
Not only time but money may have been used up. Maybe the planning team had a budget for research, and agreed a contract with an outside research outfit for it to do this work. This contract will set out ‘terms of reference’ for the work, e.g. to explore and evaluate the implications of possible plans X and Y. Then as the planning team forges ahead it may become apparent that there’s a third possibility, option Z. But if the research budget has all been used up, and there is no money to explore and evaluate option Z, that option Z will be pre-empted, ruled out by default, long before a point of formal decision is reached.
Pre-empting may also take place by virtue of the situation on the ground changing. For example, a specialist hospital ward may be closed for repairs. It then happens that staff drift away, local people at first protest and then find ways of coping, the building gets starved of maintenance and begins to decay, so the option of restoring it to use becomes increasingly expensive and consequently difficult to justify (the ‘planning blight’ syndrome).
The effect of these dynamics – the generation of commitment and the pre-empting of alternatives – should not be underestimated. By closing off options they limit the scope for formal decisions. As a former very senior civil servant has put it:
The experience of anyone who has worked in Whitehall is that there is an early stage in any project when things are fluid; when, if you are in touch with those concerned and get hold of the facts it is fairly easy to influence decisions. But after a scheme has been worked on for weeks and months, and has hardened into a particular shape, and come up for formal decisions, then it is often very difficult to do anything except either approve it or throw it overboard.*
He might have added that there is invariably a huge penalty attached to throwing it overboard at that stage.
We have to be alert to the fact that managers who are familiar with these phenomena can deliberately take advantage of them. Thus they can limit the number of staff working on the plan and impose unrealistic deadlines, they can impose stringent budget limitations, they can reach deals with the more powerful interest groups, and they can change the situation on the ground. Indeed, they may have reached their present positions in their organizations precisely because they are skilled in using strategies like these.
So while such managers may be absolutely correct when they say that no formal decisions will be taken before the public are consulted, they may have a host of strategies and tactics under way to guarantee that they get the result they want.
To sum up.
By dissecting a planning process into the steps and actions of which it is comprised, we can distinguish administrative, technical and political components – sub-processes, so to speak. And by examining those steps and actions, in the context of the dynamics of each process, we can identify which of them create commitments and pre-empt formal decisions.
We can do this not only in retrospect but in the course of a process. Please note that by using this analytical framework, and insisting on transparency, those outside any charmed inner circle will stand a chance of heading off steps and actions that create commitment and pre-empt potential options.
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*Lord Bridges (Cabinet Secretary 1938-46, Permanent Secretary to the Treasury and Head of the Home Civil Service 1946-56), ‘Whitehall and Beyond’, The Listener, 25 June 1964. Cited in Peter Levin, ‘Opening up the Planning Process’, in Stephen Hatch (ed), Towards Participation in Local Services, Fabian Tract 419, 1973 and in Peter Levin, Making Social Policy, Open University Press 1997 (p.44).
© Peter Levin 2020. All rights reserved.