Dialectical thinking and the 'economic determinants' of performance: What Marxism can contribute to health services research in an age of complexity

Health services researchers are increasingly urged to contextualise problems in a “multi-layered reality” of inter-related micro-, meso- and macro-level factors. Yet what is in the remit of the macro, and how macro-factors relate to micro- and meso-factors, is unclear. This presentation argues that Marxism can contribute here, both methodologically through dialectical thinking and in terms of substantive insights regarding the dynamics of capitalism which shape health service environments.

A process evaluation informed by complexity science was undertaken of a two-year HS&DR funded study which sought to develop and test ways of helping Healthcare Professionals (HCPs) to improve patient experience. Severe staff and service pressures were encountered on the 6 wards involved, prompting the question of how and at what level (micro, meso or macro) the pressures should be theorised. Applying Marxist dialectics was found to enrich understanding of the macro-level, set by an on-going macroeconomic shift from embedded liberalism to neoliberalism and the constraints on public resources implied by the latter. Furthermore, while staff engagement and culture were identified as being significant micro- and meso-level factors in the study, the Marxist concept of alienation suggests these are shaped by HCPs’ (lack of) autonomy over their work process, increasingly affected by capitalist forms of production and exchange despite the NHS being a public service.

In summary, Marxist insights can enrich complexity-minded health services research. Marxism poses the question of the macro-economic climate, resource levels and governance arrangements that would provide a receptive context in the NHS for research and improvement work.