Models of care for older people with chronic disease: a case study using Alford’s theory of structural interests

Author: Angela Littleford

Littleford, Angela, 2020 Models of care for older people with chronic disease: a case study using Alford’s theory of structural interests, Flinders University, College of Nursing and Health Sciences

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The population is ageing, and with ageing comes increased rates of chronic disease. Given the increased demand on the health system resulting from these two factors, there is an urgent need to install new models of care that better meet the needs of older people. This thesis has employed grounded theory as a method to understand how health leaders conceptualise the barriers and enablers to the implementation of new models of care. I argue that models of care are an expression of health policy and are used as an exemplar of health reform when they are established statewide.

Data was gathered from interviews with 30 health leaders in Australia, in the years, 2009-2010, with the majority working in New South Wales. As per the grounded theory method, relevant literature has been used as data to support the emergent theory.

Alford (Alford, 1972, 1975) proposed a theory about structural interest groups to explain why health reform is difficult to achieve. His three structural interest groups consist of ‘Professional Monopolists’, ‘Corporate Rationalists’, and ‘Equal Health Advocates’. ‘Professional Monopolists’ are made up of doctors, and their training institutions and professional associations. ‘Corporate Rationalists’ are the funders of healthcare, namely government. ‘Equal Health Advocates’ are the community who seek accessible, efficient, effective, safe, consistent, and high-quality healthcare.

Alford postulated that ‘Professional Monopolists’ held structural power because the healthcare system was designed in a manner that naturally protects their interests. That said, ‘Corporate Rationalists’ and ‘Equal Health Advocates’ can form temporary coalitions to challenge the ‘Professional Monopolists’ to achieve reform. However, these coalitions have generally been short-lived, have required extraordinary effort, and have resulted in compromise. Other authors have demonstrated the relevance of Alford’s theory in the United Kingdom (Harrison, 1999; North & Peckham, 2001), South Korea (Cho, 2000), and Australia (Duckett, 1984).

Alford’s theory was chosen from a number of potential theorists because it had the strongest resonance with the themes that emerged from the respondents, and hence, was consistent with allowing theory to emerge from the ground up. Alternative theorists, including Pawson, Bacchi, Tuohy, and Braithwaite were all considered before selecting Alford.

The data demonstrated evidence supporting the existence of, and interactions between, all three structural interest groups in Australia. The data also provided examples of ‘Professional Monopolists’ blocking efforts associated with health reform; most notably in blocking ‘Health Care Homes’. In this thesis, two case studies are used to demonstrate when coalitions of structural interests were formed to achieve reform (statewide establishment of ‘Hospital in the Home’), or to stymie reform (Nurse Practitioners). Drawing on the case studies, I argue that there was evidence of a fourth structural interest group, who I call the ‘Professional Advocates’, who were doctors who led change based on evidence-based medicine and best practice. I postulate their unique ability to work with, and persuade, the dominant interest group, the ‘Professional Monopolists’, as one of the keys to achieving reform that meet the needs of older people with chronic conditions.

Keywords: health reform, older people, chronic disease, models of care

Subject: Health Sciences thesis

Thesis type: Doctor of Philosophy
Completed: 2020
School: College of Nursing and Health Sciences
Supervisor: Professor Eileen Willis