Commentary on methodology

It is important that in conducting research the researcher can exhibit ‘sensitivity to the ways in which the researcher and the research process have shaped the data collection’ (Mays and Pope, 2006). All research, whether consciously or not, has a philosophical underpinning and is shaped by the researcher’s view of the world. Whilst this bias cannot be avoided, it can be mitigated through critical reflection about the assumptions made within the research and the extent to which the researcher may have unconsciously shaped the research (Mason, 2002).

A starting point for critical reflection is the identification of the researcher’s epistemological and ontological position. Epistemology refers to the researcher’s understanding of what constitutes knowledge and how it can be acquired. These assumptions influence the type of research questions we ask, which methods are viewed as reliable, and how they are justified. Much qualitative research belongs to the ‘interpretativist sociological tradition’ which is concerned with finding out how the social world is understood and experienced, rather than seeking to discover a single ‘truth’ about the way the world is constructed (Mason, 2002). In terms of this research my epistemological approach is most accurately characterised as one of ‘subtle/critical realism’ (Hammersley, 1992). The approach of critical realism is that phenomena have an existence outside the interpretations of the social world, but that it is not possible to gain direct, unmediated access to this phenomena. Critical realism therefore denotes a belief that knowledge is socially produced. In conducting my fieldwork I was of the view that my data was socially produced, and therefore seen through the lens of interviewees’ own understanding of the world. However that is not to say that a reality, for example the ‘true’ nature of organisational relationships, does not exist beyond the various understandings of it which are apparent in the data. To hold that no reality exists beyond the account of individuals would be problematic in relation to research of an applied nature that seeks to gain insights of use to a body such as the NHS (Mays and Pope, 2006). Instead, the

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role of the researcher who takes a ‘critical realism’ view of the world is to attempt to weigh the different perspectives and accounts against each other when analysing data.

A further connected philosophical underpinning research is that of ontology. Ontology is concerned with questions about what entities exist, in other words, the way social life is organised. The researcher’s ontological approach controls what entities are thought to be the route to understanding the phenomena in question. A researcher could be interested, for example, in individual psyches, in words, in identities or perhaps in feelings (Mason, 2002, p15). In terms of this research I am interested in the interactions between organisations and the impact of the wider institutional structure upon these interactions. Within this approach, I am interviewing individuals, but I am interested in their responses as members of organisations.

Whilst qualitative research, by its nature, steers away from the notion of ‘correct’ findings, it remains important to ensure that research is ‘valid’, and to ascertain ‘the extent to which the account accurately represented the social phenomena to which it referred’ (Pope and Mays, 2008, p87). The use of multiple methods in the case study approach allows the triangulation of multiple data sources. Triangulation is recommended as a means of improving the validity of the study (see for example Yin, 1994). The triangulation of data in this research offers different perspectives of organisational behaviour as a route to comprehensiveness, for instance observation of meetings generates data about behaviour in competitive situations and interviews generate data about participants’ understanding of the incentives for competition and co-operation in their environment. It has been noted that triangulation should not be used as a method to reach an ‘overall truth’ (Silverman, 2000). In this case the data generated is being compared to reveal different aspects of the phenomena being observed.

A further technique to improve the validity of qualitative research is to provide a clear account of the methods used to gather data and how the analysis was conducted. This enables the reader to judge whether the methods used were sound and whether the data supports the interpretation made. I have attempted to achieve this by keeping a field diary recording key thoughts and learning during the fieldwork period, keeping audio recordings and transcriptions of the interviews, keeping a record of all documentation used and keeping a written record of all contacts made with case study organisations. In addition, within this chapter I have attempted to make clear the methods followed, and the reasons the field work was conducted as it was.

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Additionally, the validity of the research is increased by an awareness of how my identity as a researcher may have impacted on the research process.

Prior to my career as an academic researcher, I worked as an NHS Manager and have experience of working in both planning roles and in service management roles. As the research progressed I found this to be important in various ways. Firstly, I felt that my previous ‘insider’ knowledge of the NHS was helpful in enabling me to navigate within organisations to gain access to interviewees. Secondly, my background as a manager had relevance in the interviews themselves. Interviews are essentially social occasions, and the data generated at interview is the result of an interaction between the interviewer and the interviewee. Based on my preconceptions about staff groups within the NHS, I felt that my first hand prior experience of NHS services as a manager would be an asset in some interviews and a hindrance in others. In the interviews with NHS operational managers in particular I revealed my previous work experience as I thought it would build a rapport with my interviewees. On some occasions I feel it may have encouraged interviewees to be more frank with me as I was ‘one of them’. Conversely, I was less keen to reveal this work history in interviews with clinicians. During interviews with clinicians it was often the case that they felt there were different incentives in place between managers and clinicians, and I was concerned my work history would place me in the management camp in their minds and led to a less open response. However it may be that my assumptions in this situation were erroneous.

Thirdly, a further possible consequence of my previous work history on the collection of interview data, particularly in the interviews with managers, was the risk of an assumption on my part (and also on the interviewees’ part if they knew my background) that I had an insider’s knowledge of the functioning of NHS organisations, for example a pre-existing knowledge of the commissioning cycle, or the functioning of NHS budgets and so forth. Indeed whilst I may have a degree of pre-existing knowledge, it does not necessarily follow that these processes within the case study organisations were the same as the ones I had previously experienced. I realised during the interviews that these assumptions risked reducing the depth of explanation in the data, and guarded against revealing my background unless I judged in the interview that it would be necessary in order to establish rapport.

157 4.16 Conclusion

This chapter has discussed how the research design allowed the research to address the research questions. It has outlined the potential limitations of the case study design and the way it was executed, and has indicated how these limitations were mitigated wherever possible. The next three chapters of this thesis will discuss the data that was collected in relation to the research aims and objectives.

158 Chapter 5

Provision of diabetes services in the case study area 5.1 Introduction

This chapter describes the way services for adults with Type II diabetes were provided in the case study area. The nature of services for patients with Type II diabetes, as described in Chapter 1 (Introduction), necessitates the involvement of a number of organisations and health care professionals in the provision of services, who are required to work together to plan and provide comprehensive services for patients. The aim of this chapter is to describe the organisations and health care professionals involved in the planning and provision of services for adults with Type II diabetes in the case study area, and the way in which services were organised during the field work period.

The majority of this chapter focuses on a description of the organisations and professionals involved in the provision of services for adults with Type II diabetes in the case study area, their roles within local diabetes pathways, and the best practice models which were being used by commissioners to shape the provision of services during the case study period. As described in Chapter 3 (Research Methods), the field work spanned over two years (June 2011 – October 2013) and the provision of diabetes services changed significantly within this period. This chapter clarifies the change in provision during this time.

Whilst the focus of this thesis is to explore the impact that incentives for competition and co-operation are having on the behaviour of organisations and health care professionals, a subsidiary objective of the research is to examine how patients in the case study area experienced the co-ordination of services between organisations and professionals. The second section of this chapter therefore draws on data from interviews with a small number of diabetic patients in the case study area to describe how patients were experiencing the provision of care from a variety of organisations.

The chapter describes the organisation of services for patients with diabetes across primary, community, and secondary care and various providers as ‘pathways’. ‘Pathways’ describe the ‘expected route of care for a patient within a specified setting’ (O'Brien and Hardy, 2003). Whilst there is of course no single pathway through services, within the case study area there were several pathways which had been established by commissioners which aimed to encompass all the services an adult patient with Type II diabetes within the population might need to access. It is worth noting that this chapter, and the thesis as a whole, takes a

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deliberately ‘organisation-centric’ view of services and pathways. There is, of course, a very wide range of services which people with diabetes might need to access for reasons connected or unconnected with their diabetes. People suffering from diabetes are at risk of a number of other complications. Some of these, such as a greatly increased risk of suffering from damage to the eyes (diabetic retinopathy) have their own dedicated services. Others, such as the increased risk of kidney damage, are managed within mainstream services (National Institute for Health and Care Excellence, 2015). People with diabetes may also of course need to access health services for reasons unconnected to their diabetes (such as a broken leg for example), but for which their diabetes becomes a relevant concern during treatment. Whilst the patient pathway, and patient experience of their journey through all the services they encounter is very important, what is of interest here are those services identified by commissioners as specifically for people with diabetes.