National IT strategy in the turbulent English NHS: A structuration study of meso-level phenomena.

The National Health Service (NHS) structure has been remarkably volatile throughout progressive and incremental strategic national health information technology (NHIT) initiatives over a thirty-year period from 1992. The NHS structure can be conceptualised as three levels: a macro-level policy executive; micro-level provider organisations in primary, acute and community care; and an intermediate meso-layer with a mediating function between the policy and provider levels (effectively between government and the front line of the health service). While the macro- and micro-levels have enjoyed relative stability over the years, it is the meso-layer that has been most affected by restructuring. This layer comprises regional and local health authorities; advisory bodies at national and local levels; national and local monitoring and regulatory bodies; and bodies representing professional, service user, and commercial interests.

Against this complex and dynamic backdrop, NHS IT programmes appear to have had a troubled history, evidenced by numerous cross-sectional evaluations highlighting the challenges and suboptimal outcomes. Informed by Strong Structuration Theory (SST) and using document analysis and semi-structured interviews, this longitudinal study examines the evolving relationship between the structural context and the cumulative series of IT strategies. The analysis reveals that, within the field of practice for national health IT, goal alignment between levels and end-user engagement have been suboptimal. Driven by changing political, economic, and technological factors, turbulence disrupts formal and informal network relationships, and the agency of organisational actors. The meso-level has been especially unstable, compromising its ongoing contribution to national IT initiatives. This study has contributed to the literature through its extended longitudinal view of national IT initiatives, identifying responsibilities, interdependences, and progressive scope expansion; the adoption of a top-down approach to the exploration of national programmes; the detailed functional decomposition of the meso-level; and the development and application of the SST-informed conceptual model.