Accountin& Organizations and Socieq),Vol. 14, No. 3,pp.271-JOl, l9a9

Printed in Great Britain

DRAMATIS PERSONAE

Researcbers One, Ttoo and Tbree: Threesociologists of science who are researching intothe practical application of health economics.A Tape-recorder: A small portable recorder(perhaps a Sony TCM 9 ) which plays tapes of ahealth economist being interviewed bysociologists.A Video-recorder: A \rHS recorder with monitorwhich plays tapes of health economists teachingclinicians health economics at a special week-end course.Katbleen: A health economist working withinthe NHS.Don: A health economist working in a universityapplied research unit.Iden Wickings: The Director of the King's FundCASPE research unit.

Throughout the play the words of the fictionalResearchers (One, Two and Three) have beenmade up except in Act IV where they are drawn

o36r-36a2/a9 $3.00+.OOPergamon Press plc

from an interview transcript. The speeches ofallother characters (except the Tape-recorder inAct tV) are taken verbatim from transcripts andtexts collected by the authors in the course oftheir research in the sociology of health econ-omics.

ACT I: AN IDEA IS BORN IN A LONDON CAFE

It is about one year into the research proiect

on the extension of economic reasoning into thearea of health care. Two of the researchers areseated in a cafe in London discussing, over a cupof tea, how the profect is going. They have just

carried out an interview with a health economistwho works at the nearby King's Fund HospitalTrust. There is a tape-recorder on the table. Asthe researchers talk they play back parts of theinterview they have iust recorded.

Researcber One: WelI that seemed to go okay, it

CLINICAL BUDGETING: EXPERIMENTATION IN THE SOCIAL SCIENCES:A DRAMA IN FTVE ACTS*

T. PINCH, M. MULKAY and M. ASHMOREDepartment of Sociologt, Uniuersity of York

Abstract

Clinical budgeting systems are increasingly being introduced into the British National Health Service. This

paper examines in some detail the testing of one particular budgeting system. It discusses the aims,

execution and cvaluation of the test. The paper is written as a play partly for reasons of clarity and

entertainment but also and, more seriously. to rcflect recent concerns in the sociology of scientific

knowledge whereby attention is drawn to the parallels between analysts' and participants' attempts to

render a definitive view ofthe social world.

'The play is based on a widcr research proiect that is concerned with the difficulties and dilemmas that health economists

face in the practical application of their knowledgc, a full rcport of which will appear in Ashmore et al. (1989). we wouldlike to thank Iden rWickings for his time and for commenting on an earlier draft. The rescarch was funded by the ESRC (grantA3325OOO4) under its "Science Studies and Science Policy" initiative, phase one.

2 7 1

T. PINCH. M. MULKAY and M. ASHMORE

was friendly and relaxed and we got lots of anec-dotes and good quotes we can use.Researcber Tu)o: Yes, he certainly was talkative.I think it definitely helped that you knew him.How did you get to meet him?Researcber One: On the cricket field.Researcber Two: You're kidding.Researcber Oze: Not at all. When I was at HighTech University we had this departmentalcricket team and every summer we would go ona cricket tour to play Knowex University's Econ-omics Department. When I first met him he wasplaying for them. When I say "playing", that is abit of a joke actually; he was the worst cricketerI ever met, even worse then me. I alwaysremember my first sight of him. He was a legen-dary character and he wore this ridiculousfloppy sun hat. I was sitting on the boundarywaiting to bat and someone skied a catch to-wards him and sure enough he dropped it. Wellit turned out he was a great drinker and racon-teur. We've kept in touch ever since, but we'venever talked about his career in health econ-omics until now. What I found to be intriguingabout the interview is that while we were havingall that fun on the cricket field, the poor blokewas going through an existential crisis concern-ing his faith in economics. I had no idea.Researcber Two: Yes, that was interesting. Let'sIisten to that bit of the interview again, shall we?We've got plenty of time before we need to leavefor our train.Researcber One: Okay,I'll just rewind the tape. Itwas somewhere near the beginning as I recall.Let's try it here.Tape-recorder.'.. . we llere interviewed onOctober the First and paid from October theFirst. Essentially the University of York had gotsome money from the DHSS for two projects, butit had come through a bit late, later than ex-pected, possibly they hadn't got their act to-gether, I don't know. And they certainly weren'tgetting much in the way of applications, so thefact that I was around was appealing. And Icouldn't resist risk aversion, three years'money- good money - flat on the campus, so I cavedin and got married. Did teaching hospital costsfor thrcc years or so . . .

Researcber One (stopping tape): I think it wasafter this stuff about how he worked at York, butlet's listen on here for a while.Researcber Two: I can't believe how easy it wasto get a job in those days - the only applicant.The last job I tried for in a sociology departmenthad two hundred applicants.Tape-recorder:. . . a typical York project. That'sto say thought up on the train getting down toDHSS. No I'm being unkind of course. A rela'tively sketchy protocol though. Let's put it thatway. Not the sort of detail I found later in mycareer at St Doubtings . . . We produced a report,we analysed some numbers, but I felt lookingback on it now, the thing was on tick-over mostof the time - we played a lot of sport in York.There's a tape running, what am I doing?

Cricket? You didn't play mucb cricket intbose days?

Cricket not much, a lot of table tennis,dominoes. . .Researcber Tuto (stopping and aduancingtape): Do you ever stop talking about cricket?Let's get on to whe re he leaves York for Knowex.Tape-recorder: . . . the idea was that some of thework I was doing on teaching hospitals wouldbecome a D.Phil. And really what got my careergoing was an aspect of a formula that precededthe RAVP [Resource Allocation Working Party]formula for dishing out money... I got in-terested in that for no obvious reason. It was a bitperipheral to our work on teaching hospitals andI cranked out a paper on that which then eventu-ally got published inApp liecl Economics . . . Thatwas enough to get a job at the University ofKnowex. Straightforward lecturer in economicsin 1974. And I had four years' bashing awaythere, undergraduate tutorials but keeping upthe health thing. . .Researcher One (aduancing tape): A proper lec-turing job with only one publication and noPh.D. Incredible. In sociology, even in the1970s, you needed a Ph.D. and two books forwhat few jobs there were.Tape-recorder: I moved to St Doubtings in '78,

really becoming increasingly fed up with econ-omic theory. Not so much with health econ-omics. . . I still went along with a lot of Alan

CLINICAL BUDGETING: EXPERIMENTATION ) - 7 1

Williams'line in those days. I still thought that inthe practical fields one could do somerhingwirheconomics fairly well. But I was disillusionedwith mathematics and economic theory, whichis, it's essentially a game, whatever comes out iswhat you put in . . . I remember having a sort ofcrisis of con-fidence, worrying that I wasn't doingthe best for my students . . . I got so frustrated byit. It seemed so pointless to me. . . I actuallystarted reading a copy ofthe latest edition oftheAmerican Economic Reuiew and workingthrough the articles . . . You know that was acomplete waste of time: what have we disco-vered?

Why didn't you get your disillusionmentearlier?

I was extremely seduced by economics. . . Ifirst went to York, there I was, it was well taught,Williams and, I don't knowwhether you get to sitin on their lectures and so on, but Villiams andCulyer are very clear teachers. I think they'revery persuasive and I really, I swallowed thewhole story. You know, if only the world waslike Alan Williams, if only everyone analyzedtheir decisions in this way, wouldn't it be a bet-ter place? So I think there is a nice internal logicabout economics which helps, like a crosswordpuzzle - the different pieces fit together -whereas something like accountancy has a set ofrules, largely arbitrary ones. . .Researcber Ttuo (pausing tape): Poor oldaccountants, they get it in the neck every timefrom the economists. But this is good stuff. Wecan use this in our book, especially the bit aboutif only the world was like Alan Williams wants itto be.Tape-recorder: I began to ask myself . . . I had te-'r,rre at Knoqrex . do I really want to spend thercsr or my llfe poundlng away at this stuff, whenit's clearly not getting anybody anlqrhere. And Ithink that's when I really started to get fed up . . .I mean something I was using in lectures cameout in a very prestigious journal as a comment.There is just some obvious side point that I'dbeen using in lectures, it never occurred to meto publish it because it was so obvious. . . Andthat contributed to my disillusionment . . . Therewas a famous article . . . it was about bargaining

and where economics missed out on things, likeconcentrating on a simple fair trade model . . .[this] paper said that if you were going to tradeonce with somebody. . . you can trade goodcommodities or bad commodities. . . then onthe whole you would give the guy the duffcom-modity, because on the whole you assume that'swhat he is going to give you and your gains aremaximized if you give him the duffone . . . A pro-fessor of economics at Sussex wrote a paperpointing out that if there was an expectation ofcontinued trade between the parties, then onthe whole they would be nicer to each other.That's to say, you don't want to turn a customeroff with a dud the first time, so you give him agood one. Now my wife, who had just given upwork, said, 'You know, since I've been going tothat greengrocer around the corner regularly, Iget much better stuff than when I used to pop inoccasionally on my way back from school". Ithought now, if that is such an obvious bit ofcommon sense that my wife who is noeconomist but a perfectly sensible citizen, ifthat's something that can be spotted in that sortof way, then why are we publishing that sort ofthing in the QuarterlyJountal of Economics?Researcber One (stopping tape): Presumably toget a job as an economist! Anlway you've got toadmire him for having the courage of his convic-tions, giving up a university position to work asa health economist in an applied context. But,surprise, surprise, when he got there he foundthat there wasn't much that he could do eithcr.because it turned out that issues were settledmore by local political interests than by econ-omics. There was a good bit on this later on.(Ad-uancing tape.) Listen to this. He's talking abouta health economics study of mobile X-ray sc-reening which showed that the costs far out-weighed the benefits because of the low num-bers ofcancers and TB cases spotted.Tape-recorder: I mean looking for six of anythingper thousand [screened] iust doesn't seem like agood piece of public money.

So it's tbat kind of decision tbat you feelbealtb economics could belp witb?

I used to, I think certainly yes when Imoved . . . I hoped that the sort of research that

271 T. PINCH. M. MULKAYand M. ASHMORI

I was doing would help.But it didn't?Well it doesn't . . . it's only more recently that

I've come to the conclusion that it doesn't help;partly because of its failure to take on board thedifferent interest groups. . . and I'm annoyedwith myself for not seeing it earlier. I mean howcould I? I'm annoyed with my own naivety ifyoulike. How could I have ever believed that youwould walk right into a meeting of different in-terest groups and say, here are the costs ofdoingthis, and here are the benefits, and here are thecourses of action. and we've decided that bene-fits exceed costs by most in this one, so will youall please agree. I mean it seems to be mad look-ing back, that it's incredibly stupid of me ro everfall for that . . .

Are you saying tbat a perfect uorld, or a bet-ter uorld would inuolue being able to go rounda table, and sbouting them tbe figures, andcoming to an agreement on tbe basis of . . . ?

Not any more. I used to think that. Now, Ithink that there's no such thing as a better world.I mean there are iust different worlds in whichdifferent people manage to secure more of a ser-vice that they're interested in. And I fully under-stand now why those people defended the massminiature X-ray service. If they were reassuredby it, then okay, fair enough, that's a legitimarereason for trying to hang on to the service . . .Researcber Tuto: He seems to have become in-creasingly disillusioned with health economics.What's he doing now working at the King'sFund?Researcber One: They offer courses to cliniciansand health service managers. That's why Kath-leen was there.Researcber Tuo: I got a hell of a shock bumpinginto her in the lift. I iust didn't expect to meetanother ofour respondents there.Researcber One: You did very well to rememberher name. I recognised her from an HESG

IHealth Economists' Stud]. Groupl meeting butdidn't have a clue who she was. Rewind the tapea bit, there was a very funny story at the startabout consultancy. Before you arrived he got aphone call from the World Bank in lVashington.

They wanted to fly him or.er for a two-day con-

sultancy. (Researcber Tuo rerainds tbe tape.)Tape-recorder: . . . it is all piggy backed onto Grif-fiths - management, consultancy, advice . . .someone pays for a group of managers to comein and talk about their problem . . . a sort of mix-ture of consultancy, therapy, customized teach-ing.

Hou mucb bealtb economics enters into it?Not much. I do some sessions particularly on

economic type things, but they're more reallyhealth service finance. I do stuff on clinicalbudgeting, it is something that all the managerswant to know about. .. Well I don't get phonecalls from the World Bank all the time - just anaccident. One of the reasons I'm - I wouldn'tsay I was successfi-rl - one of the reasons I'mpopular is because I almost never say no . . . I'vedone a little bit of background work for LondonWeekend TV a couple of times for casZ - cash inhand. They wanted some big numbers. \il&at willAIDS cost in 1993 if we don't act now? Like a lotof economics 1'ou collect some numbefs on cost,unit cost and you collect some numbers on num-bers of units and you sit there and multiply themancl out comes your fee . . . With London Week-end TV it was particularly nice because one ofthe guys providing the numbers kept changinghis mind. So they were on the phone to him forages chatting and I was sitting there, at the otherend of the phone with this London V/eekend guysweating. And I was rust sort clf, he thought I wasworking out the numbers, I u.'as working out myf e e . . .Researcber One (laugbittgl; Wonderful. tsut lis-tening to the tape makes me feel depressed.Researcber Tulo: Because you nevcr get any con-sultancy?Researcber ()ne:'fhat's true, but no, I was beingserious for a moment. It's such a mess this healtheconomics study. These people are just outthere in the messy real wodd and it's a problemmaking sense of it all, trying to get a handle onthings. I mean how do we treat this last inter-view? Was it with someone who works "inside"or "clutside" the health service? Is he even ahealth economist at all as he seems to have givenup serious research in health economics?Researcber Tuto: Well most of the health

CLINICAL BT]DGETING: EXPEzuMENTATION

economists we have talked with have claimednot to be proper health economists. That seemsto be part of the character of health economics- it's either what you used to do or what some-one else is doing.Reseetrcber One: But then how are we going t<rconclude anything? In a way. his current view,which is that political interests are more import-ant than economics in understanding the NHS, iscloser to our own view, but if he has ceased t<l hcan economist at all, what weight can we give tohis views? It wasn't like this when I studiedphysicists. You never got physicists saying, "Wellactually I'm not really a physicist" or "I gave upphysics because it was no better than commonsense", or "I now see that physics is all aboutsocial and political factors". It was all so clearcut. You found your experimentalist who claimsto have observed a new phenomenon of thenatural world and then you found a second whodisagrees with the first and sees something com-pletel,v different. And then,vou would inten'iewboth of them, along with their supporters andother protagonists. Finally you showed therewere good arguments on both sides, hey presto!,in comes the social world to settle matters. Itwas such a neat and tidy thing to do - all in thecontext of a tight technical argument over asmall set of experiments as Pinch ( 1986) did inhis recent book. I really should have stayed withphysics. Now wc havc these health economistswho don't do experiments, and don't even claimto be health economists, and we waffle away fbrhours with them about the myriad problems clfthe National Health Service INHS] with a bit ontheir career, a bit on QALYs [Quality AdjustedLif'e Years], a bit on option appraisal, a bit onmeasurement, a bit on rationalit_v and so on. Younever know whether they really know whatthey're talking about or whether they're justtalking offthe tops of their heacls. How on earthafe we going to make sense of it all?Researcber Tuo: I really do think you are roman-ticizing a little about the sociology of the naturalsciences. Take another read of some of therecent stuff by Gilbert & Mulkay (1984),Ashmore (1988, 1989), Pinch & Pinch (1988)or Mulkay (1984, 1985) on his own. But that

aside, surely the health economists' u'orld is nomore and no less messy than ours as sociologistsclf science? Take the origins of this project. As Irecall. rn.e decided on health economics as atopic after yorr phoned a health economist friendat High Tech who told you about the HESG andsince 1'ou only had tn'o days in which to &'ritethe proposal, 1'ou thought "let's study thisbecause at least we have a convenicnt samplingframe". Typical back-of-the-cnvelope rype thingI seem to recall.Researcber One: }Vell let's forget about that andbe thankful the tape recorder isn't on!Researcber Tulo.'YoLl also ke ep saying that so andso isn't a proper sociologist clf science ancl th:ltyou yourself have changed your views on thesociology of science as you have movedbetvyeen diffcrent research locations. And lookat all the changes in emphasis we have had dur-ing the course of this project. $(/e don't do ex-periments and we seem to manage alright; s<rwhy is it any worsc for thc health economists?Researcber One: I see reflexivity is rearing itsugly head again. Rather than go into all thoseissues which are dealt with in Woolgar's ( 19U8)new collection, why don't you find me a niceclean-cut area of health economics. rather likescientific experiments, which I could feel com-fortable about studying.Researcber Tutct: How about clinical tludgeting?Researcber One: Oh )'oll mean the thing that allthese managers want to learn about and which istaupiht at the King's Fund'/ It's some sort offinancial decision-making system to enable clini-cians and managers to managc more ellicientlyisn't it?Researcber Tu'o: That's right and many healtheconomists we have talked to seemed to beenthusiastic about it. But, as usual, the peopleinvolved sometimes de n1' being healtheconomists.Researcber One: llut how is clinical budgetinglike science? Surely budgeting is what you and Ido when we come down to l-ondon and we havcto decide whether we can afford British Railsandwiches or a meal out on the research pro-ject.Researcber Tuo: I think the health economists

T. PINCH. M. MUtl(AY and M. ASHMORE

would say there was more to it than that. But onthe train down I read this interesting articleabout experiments on clinical budgeting. It wasin a health economics iournal with an editorialby Tony Culyer.

Researcber One: Tony Culyer, he's one of theleading lights in health economics at York, right?

Researcber Ttuo: Yes, that's the person. I have thejournal in my briefc^se. (Researcher Tuo fum-bles under tbe table for bis briefcase emd pulls

out a battered copy of tbe journalNuffreldlYork

Portfolios He opens it and. starts to read outloud.) "Despite the three recent maior organiza-tional changes in the National Health Service themost striking features that continue to charac-terise its management are the absence of uarietyin experimentation in alternative s'ays of get-ting things done . . . This folio reports on what isthe one outstanding exception to these deficien-cies: some real experiments in offering cliniciansbudgetary incentiues to be better managers.Their importance is scarcely to beunderestimated, given the uniqueness of suchordinary experiments in Britain. Iden Wickingsand James Coles make the ethical case for clini-cal budgeting in the NIIS and show how it linksup with new developments in the provision ofinlbrmation for management at all levels"(Culyer, 1985, p. 1). Well this seems to be allabout experimentation so why not have a look atir?

Resean'cber One: Pass it over. (Researcber Tuobands otter tbe journal ancl Researcber ()nestarts to read.) lt certainly does sound as if this iswhat I have been looking for. Wickings & Colessay that "There have now been many clinicalbudgeting experiments in Britain" (Wickings &Coles, 1985, p. 4 ). And this guy Wickings seemsto have been involved with most of them. It sayshere that there were some very recent experi-ments carried out by Wickings which were:highly influential in persuading the GriffithsInquiry into health service management to advo-cate the introduction of management and clini-cal budgeting. They report that "A more basicmethod of reaching. . . agreement lbetweenclinicians and managementl has recently been

tested in some clinical budgeting experiments.The method involved district managers andclinicians negotiating Planning Agreementswitb Clinical Teams (PACTs)". (ResearcberOne giggles as be recognizes tbe auful pun.) "lnearly 1985, an independent Evaluation Groupchaired by Professor Buller, the previous ChiefScientist at the DHSS concluded.'The evaluationgroup is not aware of any other system thanPACTs that offers similar interaction betweenmanagers and clinicians"' ($fickings & Coles,1985, p. 7). Blah, blah, blah. It seems that theseexperiments were a success. lt goes on to say,"The Evaluation Group is unanimously of theview that in principle this PACTs-centredbudgeting system has all the right ingredients forimprovecl resource management in the NI{S andit should be given the support needed to ensureits wider dissemination within the scrvice"(Vickings & Coles, 1985, p. 7). l'his is great. Iwill have to get hold of that report on these suc-cessful experiments. Perhaps there are some cri-tics someq.here s/e can track down. !(e mighteven have an experimental dispute as in physics.

Researcher Tu:o: Ate you happy nou'?

Researcher One: Well happiness is asking toomuch. But at last we are going to be atlle to de-construct some real science instead of all thescpseudo-scientific measures such as eAlys andthe like which no one takes seriously. (Lookirzgut uatcb.) Good grief! Look at the time. Comeon. We'll have to shift if we want to catch the5.30 train back to York

ResearcberTuto; Aren't you forgetting one thing?

Researcber One: What's that?

Researcber Tuo: 'We said we would work outhow much of the research budget we had left tospend before deciding whether we could afforda meal on the train.

Researcber One: That's right, but we've got notime to do it now. We're bound to have somemoney left in the kitty and there's no point inslumming it. I feel it's been such a productiveday. I even think we might strerch to a bottle ofwine on the train back. (Tbey bastily pay fortbeir cup of tea and leaue.)

CLINICAL BUDGETING: EXPERIMENTATION

ACT II: \OTHAT IS CLINICAI, BUDGETING?

Researcher Two is seated at his desk at theUniversity ofYork staring at a video monitor. It ispaused on a frame showing a health economistgesticulating ^t alarge table of figures drawn ona blackboard. Researcher One enters carrying anenvelope tile of papers under his arm.

Researcber One Morning. Mind if I ioin you for abit?Researcber Ttuo: Not at all. I've been working ona chapter of our book. It's on the topic of opticlnappraisal and I've been trying to read some of thefigures from an option appraisal l)on presentedat that clinicians' course vhich I videoed. It'sstarting to give me a headache and anything fora break.Researcber One: Health economics again I'mafraid.Rese arc ber Two : Clinical budgeting?Researcber One: That's right. I got hold of that(IASPE rcport, you know the one inwhich \Wick-

ings and his team present the results of theirexperiments. That document is dynamite. I can'treall_v believe what I'm reading, so I just want togo through a few of the points with you to makesure I've got it right. I've started to write it all upfor a talk I'm meant to be giving at Brunel flniver-sity. (Tbere is a knock at the clrtor. ResearcberTbree enters.)Researcber Three: Mind if I join you? I need abreak from administration.Researcber One: Sure. We were just about to gothrough some of mv material on clinical budget-ing. I'm glad you've popped b,v because I'm draft-ing something to present to a seminar at BrunelLlniversit,v and tl-ris is an ideal opportunit)'to tryit out on you both. There may be some healtheconomists in the audience and I want to makesure I've understood the basic idea of clinicalbudgeting. Can I read you the start ofthe paper?Researcber Three ( sitting doutn): I'll imagine I'man economist. Go ahead.Researcber One (taking a type-u,ritten mnnu-script from tbe file be reads out loud): "Clinicalbudgeting and its close relation, managementbudgeting are financial decision-making systems

which are intended to fiive users of health careresources, and in particular clinicians, a [areaterdegree of choice over how resources are allo-cated such that, overall, resources may be usedin a nrore efficient way" (Pinch et al., 1987, p.l 5 ) .Resean'cberTtur.r.'Sorry to interrupt you, but whatjustification is there for treating mal)a€iementand clinical budgeting as the same thing?Researcber C)ne: I'm glad you asked me that. Asfar as I can see the_v are essentially the same thingfrom the point of view of economics except thatthe emphasis in the two systems is slightly differ-ent. Overall they are both ways of planning abudget so as to make clinicians and managersmore aware of costs ancl thus more efficient. Inclinical budgeting the prime target is clinicians.There are powers of virement . . .Researcber T uto; Virement?'What on carth's that?Researcber ()ne: lt's the ability to transfer asurplus from one category to balance a deficitunder another head. If a saving is made, themoney can be spent on something else the clini-cians think is desirable. Clinical budgeting hasvirement as a direct incentive to clinicians. Man-agement budgeting, on the other hand, doesn'toffer clinicians the samc powers of virement.There arc alscl differcnces in the wa]'s the cost-ing is done. In management budgeting costsinclude clverhead cclsts such as rates or the costof running the boiler house. The costing inftlr-mation is generally less accurate.Researcber Tuo: They sound rather different tome and I'm not certain you are justif ied in lump-ing them together. Perhaps -vou should look atthe ways in which for some prlrposes they aretreated as the same and for othe r purposes as dif-fere nt.Researcber ()ne: l,ook, as usual you are trying tobe too sophisticated. I want ,vou to react as aneconomist might react. From tl-rc economist'spoint of view they are the samc thing. I envis-aged this might be a problem, so just to back meup, I found this article by Wickings intbe Healtband Social SeruiceJournal where he addressesprecisely this issue. (Researcber One takesanotber paper from bis file.) Let me quote youthe man himsell "Are management budgets dif-

T. PINCH, M. MULKAY and M. ASHMOR!

ferent from clinical budgets? Clinical budgetshave been under test in several countries for anumber of years. In the NHS the CASPE ResearchUnit now has three experiments in progress. . .The clinical budgets now in use have many fea-tures in common with management budgetsalthough there are a few differences" (Wickings,1983, p. 466). He then p;oes on to say whatexactly these differences are: "To summarise,the differences are small although they possiblycould be significant. None the less theapproaches are sufficiently similar for most of usto ignore the finer distinctions" (Wickings,1983, p. 467).ltake that as warrant to ignore thedi-fferences for the pu{poses of introducing clin-ical budgeting in my paper.Researcber Tuo: Yes, but as we know, Wittgen-stein said that all similaritl'and difference judge-ments are accomplished by us and similaritiesand differences don't reside out there.Researcber" One (exasperated); Of course,everything may seem either different or similar,but that is the kind of nuance which I iust don'twant to take up here.Researcber Tbree: lf I mav interrupt. It seems tome that both of you are right.Researcbers One and Tuo: That's really helpful.Researcber Tbree: Let me explain. It is clearly thecase that any two things can be seen to be eithersimilar or different. But whether you do "similar-ity work" or "difference work" depends on thepractical occasion at hand. Presumabl1.. for thepractical purpose of presenting a paper toeconomists, you should treat managementbudgeting and clinical budgeting as the samething. Similarly, f<lr the practical task of hisarticle, Wickings was warranted in treating thedifferences as being negligible. But it is also quitecorrect to point out as he did that for other pur-poses the differences could become quite cru-cial.Researcber One: WelL given the preference toseek agreement in conversatiolls, this is prob-ably a good p<.lint for me to return to reading mypaper. I only want you to judge whether healtheconomists would find my account plausible,that's all.Researcher Tuo: ln other words, you want us to

stop raising all the interesting issues. But as thatis what economists also seem to want you'reprobably on the right rack.Researcber One (reading): "In the context ofhospitals. where clinical budgeting is initiallybeing introduced, rather than Health Authoritiesmaking a yearly allocation of resources to func-tional budgets - so much to pharmacy, so muchto radiologv, and so on - budgets will be allo-cated to each major area of clinical activity. Thismeans that individual clinicians (and wardsisters) will have a greater part in deciding theresource allocation for the budgetary year. Clini-cians need to be provided with information onhow much di,fferent components of clinicalactivity cost (e.g. the costs of an X-ray, of a testdone in a pathology laboratory, and so on) andon how much of their budget they, have spent.This information is provided by new computersystems" (Pinch et al., 1987,p. l5 ).

That all seems perfectly straightforward Ihope. "Clinical budgeting is held to be a way ofachieving a more "rational" and "efficient" dis-tribution of scarce resources such that ulti-rnatell' patient care will be improved. Underly-ing the new decision-making systems is the viewof social behaviour which is prevalent in econ-omics, and it is no accident that the leadingproponents of clinical budgetingwithin the U.K.have been health economists. According toeconomists, given scarce resources, individualsmake choices in which they trade-offthe costs ofsonte action against benefits such as to maximizethe benefits fr>r themselves or for some groupthey purport to represent. The problem forhealth economists is that in this case the alloca-tion of scarce resources cannot be mediated bythe usual mechanism of market prices. This isbecause it is held that health care should notdepend upon the abilitv to pay. Healtheconomists are thus forced to search for surro-gates for market prices. One way round the diffi-culty is to treat the consumption of resources bygroups other than patients - such as clinicians- as the mediators of market forces. This is, ineffect, the basis of the economic rationale f<rrclinical budgeting" (Pinch et al., 1987, pp. 16-r8) .

CLINICAL BUDGETING: EXPERIMENTATION 279

I then give a little quote from a health

economist supporting this underlying economic

rationale. I go on to say: "The argument is that

the system as a whole will operate most em-

ciently when benefit is being maximized by

clinicians - clinicians in this case act, as it were,

on behalf of their patients. As \i/ickings & Coleswrite, ". . . the clinicians can be given extra dis-

cretion and thus have an incentive to use their al-

located resources more efficiently in the in-

terests of their own clinical service and their pa-

tients. In this way optimizing the output of the

NHS, in terms of quality and quantity of the ser-vice provided" (Wickings & Coles, t985, p. 3).In short, the rationale undedying clinicalbudgeting is none other than the standard route

which economists offer for reaching Nirvana(that perfectly rational society in which thegreatest good to the greatest number is pro'

duced by individuals trading off costs and bene-fits and maximizing benefit)" (Pinch et a1.,7987,pp. 18-19). That's it sofar. Does that seem okay?ResearcberTuo: I'm sure you're right that healtheconomists do advocate clinical budgeting -

our interviews support that. But I still have wor-ries about you presenting a definitive version ofclinical budgeting as if it was all based uponeconomic principle. I was looking the other dayat the video of the talk on management budget-ing which Kathleen gave at the course for clini-cians. As I recall, she says hardly anything at allabout economic principle. Instead, she put it allin terms of the practical problems which man-

agement budgeting helps to solve.Researcher Tbree: ls that on the same tape youhave just been looking at?Researcher TwtlYes it's after this option apprai-sal stuff. Shall we have alook? (Aduancing tape.)Researcber One: I really want to get onto thetesting of clinical budgeting as soon as possible.That's the bit that interests me because it's mostlike physics.Researcber Tuto: This is the sort of thing I mean.Here is Don, who chaired the session, introduc-ing Kathleen.t

Video-recorder:. . . it's also relevant, of course,

because it's actually being imposed to a consid-

erable extent on the service. And so exactly

what is the sort of experience that have, there

have been so far? They are both highly relevant

questions and they'll be questions to which

Kathleen will be addressing herself this morni-

ing.Researcber Tuo (stopping and aduancing

tape): See what I mean? He seems to be em-

phasizing the practical side of knowing about

something that is going to come into force any-

way. Kathleen's introduction is also in terms of

her practical experience with management

budgeting. Listen to this:Video-recorder: Every district has to commence

implementation . . . and we went out to district

ancl worked with districts and helped them

implement management budgeting . . . So if your

district is starting on the path of implementingmanagement budgeting, these are the sorts of

area you might find yourself being involved in.

Researcber Ttuo (stopping and aduancing

tape): Then she uses all the rhetorical devices

we are familiar with from our "Colonizing the

Mind" paper (Mulkay et al., 1987). She dis-

associates management budgetingfrom cost cut-

ting and, of course, it's nothing to do with

accountancy.Video-recorder; This is uery uery important.

Management budgeting is not a costing system,

it's not a glorified cost accountanc,Y system, it's

about management. managing resources. . .

Researcber Tbree: That's a lovely example of a

three-part list with a contrast. In other words,

two things which management budgeting isn't

are presented, followed by a third thingwhich it

is. And look how each point is accompanied by a

downward arm movement to add emphasis. She

is using all the skills of political rhetoric which

Max Atkinson (Atkinson, 1984) documents.Reseq.rcber Tuo (aduancing tape): Later on she

claims management budgeting is all about help-

ing patients:Video-recorder: Also it's quite specifically

rAll the excerpts quoted here are taken from a talk given at a course for senior clinicians entitled "Effectivencss and Efficiency

in Patient Care" held at Bowness-on-Windermere, Cumbria, England, l7-18 March 19U6.

T. PINCH, M. MULKAY and M. ASHMOR-E

patient related, in other words you're looking atthe cost of patients, you're looking at the sort ofthings you can deliver to patients, it makes senseto the consultants, to the doctors, it also makessense to the nurses, because under managementbudgeting we actually have a system of wardbudgets and consultant budgets.Researcber One.' It seems as though it is designedto help just about everyone.Researcber Tuo (aduancing tape): And theimplications are only to be felt at the margins.Video-recorder: And a lot of - in my experience- a lot of consultants actually, are happy withwhat they're doing now and they just want, youknow, want to make sure they're not going to getsqueezed. But you know they just chug alongand maybe in a few years time they'll make somemore changes . . . I mean I'm sure that Don is say-ing what you know, that most of the changes areat the margins. A gleat body of your costs arefixed, it is quite dificult to change . . .Researcher Tbree: It seems to be rather like thedistinction between the "strong" and "weak"programmes of health economics which we out-lined in our paper "Colonizing the Mind" (Mul-

kay et al., 1987). Kathleen and Don when theytalk to clinicians present management budgetingas something which will help them do what theydo already a little better. It involves no radicalchange and affects things only at the margin. It isvery much in the vein of the weak programme.Researcber One: lt's what we might call a "user

friendly" system.Researcber Tuo: That's a good metaphor. Afterall, one of the main features of clinical budgetingis its use of computers which doctors fear willfeed yet more useless information into the NHS.Kathleen addresses this point specifically (re-uinding tape).Video-recorder:. . . it sounds horrible. I've iustbeen on a planning course at the King's Fund lastweek and we've sort of had all this wonderfulmanagement iargon thrown at us, you know andyou can open your mouth and out it comes. . .ResearcherTuo (stopping tape): Sorry that's thewrong place.ResearcberOne:That must have been the courseat the King's Fund which she was attending

when we met her a few weeks ago. I'm reallystarting to feel part of this network.Researcber Two (reuinding tape some more): Ithink this is the right place now.Video-recorder:. . . the point is, you must have abudget statement that is accessible to you. that isinteresting to you, that gives you the sort ofinformation you want.Researcber Tbree: Does she ever stop usingthree-part lists?Researcber Ttuo (aduancing tape): Her talk isfull of them. Here is another where she arguesthat what consultants want is more flexibility -

a flexibility which of course managementbudgeting provides them with.Vicleo-recorder:. . . and as consultants we wantthe ability to get our hands more on the budget,we want more flexibllity, we want to be able toactually change more within what we'redoing. . .Researcber Tuo: Tlris version of managementbudgeting seems to be a longway away from theattempt at radical change in clinicians'behaviour which you propose at the start of yourpaper. (Aduancing tape.) Here is just one laststatement from her as to what it is. This is prob-ably the weakest version of all.Vicleo-recorder: Management budgeting isn't apanacea; management budgeting isn't going tosolve your problems. What it is, it's a searchlighton the management problems. . .Researcber Tbree: I don't believe it, anotherthree-part list and contrast formulation.Researcber One: Yes,I'm sure he's selecting thedata so that we only listen to lists and contrasts.Researcber Zeao; Not at all, but I must admitwhen I went through the tape the other day Imarked the places on the counter which Ithought might interest us.Researcher Tbree: If I may summarize. There is aradical economic rationale or "strong pro-gramme" of clinical budgeting which we haveused at the start of the Brunel paper and thenthere is a "weak programme" of trying to helpclinicians with their problems and attending totheir misconceptions about these kinds ofbudgeting systems. And it is this latter versionwhich is presented by Kathleen in her talk.

CLINICAL BUDGETING: EXPERIMENTATION 2al

Researcber Tuo: Maybe she takes a rather differ-ent line in her presentation at that recent HESGsession on clinical budgeting.Researcber One: lreally feel we should move onto the CASPE study, we seem ro be getting side-tfacked.Researcber Tuo: No, this is important because ifKathleen pfesents management budgeting in adifferent way there we can start to documenthow management budgeting is a flexibleresource which actors present in different waysfor the particular occasion at hand.Researcber One: WelL her talk at the HESG is nota very easy thing to analyze because as you mayremember she spends most of her time counter-ing another health economist, Peter West, whoraised eighteen different obiections to clinicalbudgeting.Researcber Truo: Do you by any chance have acopy of the relevant documents with you?Researcber One (searcbing in tbefolder): This isPeter's paper called "Clinical Budgeting: ACritique". And Vivienne has iust finished thetranscript of Kathleen's response and the sub-sequent discussion. There may be a few wordsshe didn't get but as usual it's good enough towork from.Researcber Tuo: How does Peter present clini-cal budgeting?Researcber One: Well rather in the same way thatI presented it in my paper for Brunel. In fact itwas Peter who was the health economist Iquoted in the introduction to my paper. He said:"The central plank of clinical budgeting is that ifthe use of services was charged to a clinician'sbudget, hieher cost services would be reflectedin a faster depletion of the budget, forcing con-sultants and other doctors to choose between areduced level ofactivity and a reduced use ofre-sources for each case. This isprecisely the modelthat economists use in examining consumer be-haviour in the market place" (West, 1986, p. Z).Researcber Truo: But he's criticizing clinicalbudgeting there, so how do you know that hisversion is the definitive one?

Researcber One:Well, as I said before, he simplyputs forward the economic view underlying thewhole thing, so I would have thought that it waslargely uncontentious.Researcber Two: But the whole point is that youcan talk about it in the way that Kathleen didwithout ever having to mention this economicrationale.Researcber Tbree: Pethaps we can settle this byseeing how Kathleen responded to Peter's criti-cisms.Researcher One: Okay, but as I seem to re-member her response was pretty weak. Shedoesn't seem to take on board any of his econ-omic arguments. But we'fe wasting time. Theimportant thing is to move on to the testing ofclinical budgeting. We don't want to get boggeddown in these nuances of presentation.(Researcber One passes transcript ouer and saltstestily:) But if you are so keen, you have a look atit.Researcber Tuo (reading tbrouglt transcript):Well, here's something interesting for a kick off.She says: "I mean we're starting to get into prob-lems already because he seems to use clinicalbudgeting and management budgeting inter-changeably. I've gone back to Griffiths and Ithink that we're quite clear about what we'retalking about".2 Then she quotes Peter as sayingthat "the main objective of clinical budgeting isto increase efficiency". But according to her,"That is not the case. I mean if you go back againto your Griffiths then management budgeting isvery much about management and it's aboutaccountability. Increasing efficiency is not in myview the main view of clinical budgeting". Inother words, there is a genuine dispute over themeaning of clinical budgeting or managementbudgeting, call it what you will, at a very funda-mental level. In summarizing her comments onPeter she says: ". . . what he's saying essentially isnothing really much to do with managementbudgeting. . . he's missing the point about man-agement budgeting in Grffiths, which is aboutmanagement and accountability". By the same

-

;!;;ott"^ u.)m "Kathleen" and from Peter west are taken from a transcript of the HESG mecting, univcrsity of Bath, TJuly

za2 T. PINCH. M. MULKAY and M. ASHMOR-E

token you missed the point about clinicalbudgeting in the introduction to your paper forBrunel.Researcber ()ne: I can't take Kathleen seriously. Imean, who is this "Grffiths" she keeps harkingback to? Is he the Isaac Newton of health econ-omics or perhaps the Albert Einstein? No, he'sRoy Griffiths, a manager of a big supermarketchainl And no one at that recent HESG meetingwe attended took her seriously either. Look atthe transcript; Peter puts her down to devastat-ing effect (reading transcript): "Now Kathleensays it wasn't intended to increase efficiency, butit was intended to increase accountability andresponsibility. It seems to me that, I mean whatis it, why are you trying to increase accountabil-ity if not to increase efficiency? V/hy are you try-ing to make people more responsible? You'veoverspent 5,5000 - congratulations (laugb-ter)".Researcher Tbree: Notice the use the three-partjoke format, building up apuzzle in a list of three.It's no wonder he got masses of laughter.Researcber Tuo: lt seems to me that you'retaking Peter's side against Kathleen and you sim-ply can't do that because the "corfect" view iswhat is precisely at stake. They are both reputa-ble health economists who are very familiarwithclinical budgeting and to take one side would beto prejudge the issue.ResearcberThree: Perhapswe can go back to thisweak programme/strong programme idea. DidKathleen's version of clinical budgeting pre-sented to the HESG differ from that which shepresented to the clinicians?Researcber One.' As I've said, it's quite hard to tellbecause at the HESG she was very much on thedefensive in'response to Peter's attack. How-ever, I did notice one startling change. If yourecall when talking to the clinicians, she stressedthat management budgeting was designed onlyto bring about changes at the margin. But shesaid exactly the opposite at the HESG. Listen tothis: "I think another problem with managementbudgeting is just seeing it as being movements atthe margin . . . And again I think that misses thepoint as to what we're trying to do and what Grif-fiths is trying to do; he's trying to look at the

totality of resource allocation and managementof those resources. And I think that concentrat-ing at the margin iust isn't really what the core ofthe issue is. I feel it's a very narrow view".Researcher Tbree: That's interesting. Kathleencertainly seems to go for a stronger version ofmanagement budgeting when arguing withPeter West at the HESG.Researcber Tu)o: Which is exactly my point. Ifthere is no one definitive version of clinicalbudgeting, how can we present one at Brunel?Researcber One: Listen, we have been throughall this before. At Brunel I'll be talking to healtheconomists not clinicians, so the "strong pro-gramme" vefsion is the one that is appropriate.Researcber Tuo: I just find it odd that we associologists can feel happy about changing ourversions of what clinical budgeting is about tosuit different audiences.Researcber Tbree: But if the economists manageto do it, why sllouldn't we as sociologists also doit? But I think we're all getting tired and could dowith a coffee. I feel it's been a very productivesession.Researcber One: Well that's debatable. Perhaps Ican tell you about the CASPE tests of clinicalbudgeting over coffee. (Researcbers all get upand leaue officefor coffee bar.)

ACT III: THE PROBLEMS OFEXPERIMENTATION

The three researchers are seated around atable drinking coffee. Researcher One has adocument spread out on the table in front of himto which he refers as he talks.

Researcher One: Tt,e results are contained in thisreport entitled Experiments Using PACTs inSoutbend and Olclbam I1As. HAs are, of course,Health Authorities. It's written by.Iden Vick-ings, Timothy Childs,James Coles and and ClaireWheatcroft and is produced by the CASPEresearch unit of the King Edward's Hospital Fund- better known as the King's Fund.ResearcherTbree: I knowwhat the King's Fund isbut what does CASPE stand for?Researcber One: These health economists love

CI,INICAL BL]DGETING: EXPERIMENTATION 21t3

their acronyms. CASPE stands for ClinicalAccountability, Service Planning and Evaluation.It is a sub-unit of the King's Fund. It seems tohave been established by the Department ofHealth and Social Security [DFISS] as a separateunit to carry out targeted research such as thaton clinical budgeting.Researcber Tbree: And just to fill me in, whenwas the report produced?Researcber One: lt came out in December 1985.That is seven years after the research was fundedby the DHSS in 1978. The project actuallystarted in 1979.Researcber Tbree: Was it alarge amount of fund-ing?Researcber One: WelI it was enough for Wick-ings to head a research team consisting ofthreestaff with nine additional research team leaderslocated in the field at different NHS Districts.That, on anyone's reckoning, is a sizable opera-tion. The funding was, for instance, about tentimes larger than the grant we've got for ourresearch on health economics. Incidentalll', I seethat Kathleen is listed here as one ofthe researchteam leaders.Researcber Tuct: She seems to turn up every-where.Researcber Three: Are these experiments thefirst of their kind in the U.K.?Researcber One: Yes, but a clinical budgetingsystem has been in operation at Johns HopkinsUniversity Hospital in the States for the past 15years and several European countries are alsoexperimenting with clinical budgeting. How-ever, given the peculiarities of health care sys-tems in different countries, such experimentshaven't played much part in the Ll.K. debate.Researcber Tbree: I see. Is this Wickings' firstshot at this type of experiment?Researcber One:

'Wickings took part in two

eadier small-scale studies in this country. Thefirst was at Westminster Hospital and was theprototype for his curent work. Clinicians man-aged their own budgets and this led to some sav-ings being made. In his second study in Brenthealth district, rather than give the cliniciansbudgets, he only provided them with informa-tion on costs, and this proved to be less success-

ful. Although, as we shall shortly see, what suc-cess means in this game is far from obvious.Researcber Tbree: And just to make sure I've gotit absolutely clear, it is this study reported onhere which influenced the Grifftths Inquiry toadvocate what they called management budget-ing?Researcber One: Absolutely. The GriffithsInquirv team visited Wickings' experimentswhilst they were still in progress and they wereso impressed by what they saw that they recom-mended the implementation of managementbudgeting in their report. Norv twenty so-called"clemonstration districts" have been set up tofurther the implementation programme. Wick-ings has also continued to do his own follow-upstudies and, in particular, one at Guy's Hospital.Researcber Three: Given what we said earlierabout the strong and weak programmes of healtheconomics, how is Wickings' report couched? Isclinical budgeting presented merely as some-thing to help clinicians overcome their practicaldifficulties or is a rather stronger brew offered?Researcber One: Well let me answer that by tel-ling you my own reactions to reading the rep()rt.As you know when I first got hold of it I wasexcited because it looked like real science. As itstitle indicates, it seemed to be all about experi-ments. The original proposal made to the DHSSwas formulated to answer specific questions, thecentral three being (reading): "(i) Can the'Westminster/Brent

budgetary. svstem for consul-tants be established in very different districts?(ii) If so, what happens? (iii) V/hat general con-clusions can be drawn?" (Wickings et al., 1985,p. . i). It was claimed that (i) and (i i) could be re-solved by, it says here. "direct observation"(tVickings et al., l9tl5, p. 5). The report as awhole is hearry with this sort of scientificrhetoric. Technical terms are defined carefully,it is written up in the format of a scientific reportwith sections on "The Experiments in Outline"and "Results from the First Phase Experiments"and, as you can see here, it is full of graphs, tablesand figures. There was, however, one odditywhich I noticed. This is an early section of the re-port entitled "Evaluation".Researcber Tbree: Research evaluation is quite a

244 T. PINCH. M. MULKAY and M. ASHMORI

standard thing in applied social science projects,particulady in the States.Researcber One: That may be so, but I waspuzzled about why experiments needed exter-nal evaluation. Usually, the experimenter's in-terpretation of results is all that is requirecl.ResearcberTbree: Does it give any special reasonwhy additional evaluation was felt to be desir-able ?Researcber One: Well, part of the evaluation pro-cess involved getting the views of the partici-pants in the experiments, but the more interest-ing aspect was the setting up of a special Evalua-tion Group to monitor developments. It sayshere that "It was also proposed that the DHSSshould itself establish an evaluation group, fromwhich it will receive advice and a report" (Wick-ings et a1. ,1985, p. 5) .Researcber Two: ls that the same group headedby the Government Chief Scientist, Buller,which reported so favourably on the experi-ments and which was cited in that Wickings &Coles (1985) article in the Nuffield/YorkPortfolio - the article which got you starred onthis whole thing?Researcber ()ne: Yes, that's it. The group con-sisted of a number of senior health service mana-gefs, a professor of acc<tuntanc_v, a senior medic.a regional nursing officer and a regional medicalof,ficer.Researcber Tuo: ln short, all the interest groupslikely to be concerned with the introduction ofclinical budgeting.Researcber Tbree: Apart from patients.Researcber ()ne: Yes quite, but of course everyinterest group claims to speak for patients! Any-way, getting back to the Evaluation Group, attheir first meeting held in October 198O, rheydecided that there might be a conflict of interestbetween steering and evaluating the proiect. Itwas therefore agreed that their remit should beevaluation only. It says, "The Group's major roleis to evaluate the outcome of the CASPE project- that is to say make a judgment as to whetherthe value of the clinical service planning andbudgeting approach justifies the cosr likely to beinvolved in setting up the budgetary arrange-ments. It is hoped that when rhe proiect is

completed the Group will be in a position to re-commend to the Department whether the ap-proach should be commended fbr more generaluse in the service" (Wickings & Coles, 1985, p.6). That last point is highly significant because,of course, it is exactly that sort of recommencla-tion which the Griffiths inquiry team made. Butthe Evaluation Group had another role to play:"The Department recommended that i{ in thefinal analysis, the Evaluation Group consideredthe clinical budgeting research to be of value, itwould be essential to widel,v advertise theresults, thereby allowing other districts to adopta similar management style. The EvaluationGroup would therefore have an important roleto play in the dissemination of the researchresults. . ." (Vickings & Coles, 1985, p. 7). Notonly were they evaluating the research ancl mak-ing recommendations for future policl', but theywere also responsible for publicizing the find-ings. Provided, of course , thc findings were pclsi-tive. I never encountered anything quite like thiswith the physicists I studied. It is as if, in a par-ticular area of science, the scientists, their fun-ders and the science media were all rolled upinto one with the power to determine the fi-rtureclevelopment of that area.Researcber Ttuc.t: lt could be the case that inapplicd areas of science this is the wav thingswork. If )'ou think of tests of new technologiessuch as a new aeroplane, it is so complex andthere are so many interests at stake that there isbound to be some official evaluation process.Researcber One: Yes, that may be so. But what Idon't see is why the decision over whether ornot the thing works has t<-l be connected to itsexploitation" First, you want to know if you havea genuine effect; then, if there seem to be practi-cal applications, you can seek funds from indus-try or support from the government and, if youfeel you need it, you can always work up somepublicity. The priority, however, must be on theresearchers' right and ability to decide firstwhether the experiments work as claimed.Researcber Tuo: Distance really does lendenchantment doesn't it? The less involved youget with research on physics. the more your de-piction of how things work there relies on what

CI-INICAL BUDGETING: EXPER]MENTATION

you used to dismiss as old-fashioned views of thenatural sciences. Vork in the sociolog)' ofscience, such as Latour's (1987), for example,has challenged cvery one ofthese points. It jusfisn't the case that ideas are dcveloped in a "pure"context which are then taken up later fcrr pur-poses of "application". Political interests andmedia interests are often there right from thestart, even in physics. Look at the current fi.rssol'ef the seafch for r<tom,tempefatufe supercon-ductors. for instance.Researcber Oze: I suppose I've got to say reluc-tantly that you're right. But you mlrst agfee thatRobert Millikan never needed an "EvaluationGroup" to sit over him to decide whether hislneasurements of the charge of the electronwefe wofth pursuing.Researcber Tuo: And, probably just as u.ell too!Gerald Holton's (Holton, 1978) research on Mil-likan's notebooks shows how Millikan rejectedkrts of measurements with cleviant values thatdidn't fit his preconceptions of what the chargeshould be. If he had had an Evaluation Groupwatching his every move they might havenoticed that what was to become one of themost celebrated experiments in physics wasactually inconclusive! But joking aside, youshouldn't be comparing clinical budgetingexperiments with basic science expcriments. Abetter comparison is u'ith technologies whichare being tested in a public context. I don't knclwmuch about it, but from my reading of historiansof technology such as Edward Constant (Con-stant, 1980), it seems to be the case that nc\4,technologies are often tested in a very publicf61s11 - especiallywhcn the public might needto be persuaded to take up the technology. Thetrials of the first turbine-driven boat. the Tur-bina, were held in public. And if you are reallyinterested in pursuing the analogt', tIarry Collins(Coll ins, 198t3) has recentl) ' sent me a preprinton a couple of cases involving public testing: onewas of thc transportation of a nuclear-waste flaskby train; the CEGII stagecl a public crash t<t showhow safe it was. The other case Harry lookecl atwas the testing of an additive to kerosene to stopaircraft fires being so devastating. Again, a mockcrash was staged. Both are cases of tests where

there were technical experts and the mcclia pre-sent to evaluate the results.Researcber One: Ate you saying that these clini-cal budgeting experiments are more like thetesting of a technolog),' than scientificexperimentation?Researcber Tuo: Well, in a wa1.. \'ou can argue,fbr exan.rple, that health cconomics is a socialtechnologv. Clinical budgeting involves anattcrnpt to change human behaviour using theprinciples of economics ancl, as a system,includes material artifacts such as computersancl software packages. lndeecl, there is a lot ()fneu'work in the sociology of technologv whichargues that all technologies are irretrievably amixture clf social, material, economic and polit i-cal elements - a "seamless web" is how it isdescribed in the book by Bijker et al., ( l9S7).Researcber One: I like thc idea of health econ-omics as a technologv. It means that we can pre-sent this matcrial to the s()ck)logl'of technolclgl'people ahd get an adclitional audience fcrr ourresearch. But g<ling back to the EvaluationGroup fbr a moment, it does seem to be dift'erentfrom those very public tests you mentioned. Forone thing it was all kept undcr wr;rps bv theDHSS, who appointed the Group in the firstplace and, it was, of course, run by their ownchief scientist. The Evaluaticln Group in this caseseems to have actcd as a buftc'r bet*.een the cx-periment and the wicler puLrlic and policy con-tcxts. If vou recall i t u'as the recommendation ofthe Evaluation Group which rvas cited by Wick-ings & Coles ( 1985, p. 7) in their article ratherthan the results reported here (pointing to re-port on table).Researcber Tuo:'fhe Evaluation Group can thusbe seen as a neat way of giving an authoritativepublic interpretation of the cxperiments with-out having to address the messy and potentiallydefeasible proccss of thc rese arch itself. And, ofcourse, the fhct that the Group is formally inde-pendent from the experimenters gives it evenmore authority - which is why Wickings &Coles cite the report of the Evaluation Grouprather than their own findings. As I'm sure youare troth a!!'arer this is yet another instance of thewell-established finding of the sociology of

T. PINCH. M. MULKAY and M. ASHMOR-E

science that distance lends enchantment to sci-entific certainty. The further you are away fromthe messy details of laboratory work, the morecertain the results appear to be. The EvaluationGroup in this case was able to transform themessy reality of experimental activity into a firmpolicy edict.Researcber Tbree: Cleafly we will have to studythis Group further. But first I for one want tolearn more about the experiments themselves;wefe they really that messy?Researcber One: lt was more than just a mess, itwas a disaster. The most interesting thing aboutthe report is that as I read it I became increas-ingly puzzled as to how the research could everbe seen as a success.Researcber Tbree: lt ran into difficulties then?Researcber One: You can say that again. Butbefore getting on to what those difficulties con-sisted o( let me tell you a little bit ab<lut howthey planned to test the clinical budgeting sys-tem.Researcber Tbree (looking at report): I can seethat it's full of these cursed acronyms. W'hat onearth are CATs and DNITs?Researcber One: CATs. or Clinicallv Accountable'Ieams, are the new formations in u'hich clini-cians are supposed to u,ork. CA'Is have plannedbudgets which have previously been negotiatedwith the DMTs, the District Management Tearns.The planning agreelnents with the DMTs q.'ereknown as PACTs, which are Planning Agree-ments with Clinical Teams. All pretty straightfor-ward isn't it? PACTs are the main feature of thistype of clinical budgeting. A PACT is establishedeach year which would set the budget for thatyear and outline the various clinical develop-ments that were planned. As part of the project,CATs would be provided with extensive infor-mation as to what their various costs were. Itsays here that the CATs "were to be affordedmajor opportunities to redeploy resourceswithin their budgetary limits" (Wickings e/ a/.,1985, p. l7). This is the basic economicrationale designed to change clinicians'behaviour which I outlined earlier. If the clini-cian has the responsibility for the budget he orshe wil l spend the money in a more economi-

cally efficient way. There is much debateamongst health economists over the most effec-tive form of incentive for clinicians, and in thisform of clinical budgeting virement is the mainincentive.Researcber Two: T}lis is the "strong programme"of clinical budgeting?Researcber One: Exactly. They then selectedthree particular districts of the NHS - Oldham,Southend and East Birmingham - in which t<rrun the experiments. Similar districts wereselected as controls.Researcber Tbree: 'fhat seems fairly clear. Sowhat does the report say?Researcber One: Well, after setting out the aimsof the research the report profiles the threedifferent districts and outlines how the researchwas implemented in each of them. Great atten-tion is given to what is called the "Organisational

Environment". The reason for this is spelt outlater where it srdys, "During the five year periodof the research a large number of fundamentalchanges occurred in the orientation of the NHS.In combination with the more usual factors suchas staff changes and selective industrial actionthey provided an environment within which theresearch took place and against which theresults should be evaluated" (Wickings e/ a/.,1985, p. 18) .Researcber Tbree: lt sounds as ifthey are hintingat problems to come.Researcber One: That's right. And the first prob-lcm is a pretty damning one. Look, this is thechapter in which the results are given. They areprefaced by the statement that there will be noresults from East Birmingham at all! This wasapparently because the project had to be aban-doned in that district before any discussionswith clinicians were held.

Researcher Tuto: That looks to me like a prettystraightforward fai l u re.Researcber One: But the question is what countsas success or failure? Since the project at Bir-mingham never got started it could be treated asnot properly a part of the experiment at all andtherefore neither a failurc nor a success.Researcber Ttuo: That sounds llke gross adhocery to me.

CLINICAL BI.lD(iETING: EXPEzuMENTATION

Researcber Tbree: Surely some sort of reason isadvanced as to why that part of the experimentwas abandoned?Researcber One: lt says here, "There is almost noreference to th€ proiect in East Birminghambecause (a) a separate report for the EvaluationGroup has already been prepared and (b) the ex-periment was abandoned. . . . The abandonmentwas a decision taken by CASPE Research becausethe unit Director judged that the East Birming-ham DMT was insufficiently committed toimplementation within a reasonable time-scale.It should be noted, however, that the second ofthe recent NHS reorganisations was in progressat the time and this placed great difficulties uponthe Districts concerned" (Wickings et al., L9tl5,p .52 ) .Researcber Tuto: That sounds to me like a classicway of handling a negative result. It is a pointwhich sociological studies of the naturalsciences have repeatedly revealed. Since everyexperiment involves a whole host of back-ground assumptions - ceteris paribus typeclauses - the significance of any experimentalresult is in principle questionable. It can alwaysbe argued that some factor from the environ,ment or some background theory was responsi-ble for the negative result.Researcber On ei Ri$it, that's the classic Duhem-

Quine thesis. It's like what we used to do in ourstudies of physics when we showed how scien-tists actively negotiate what counts as back-ground and what counts as foreground duringthe course of an experimental controversy. Anexperimenter claiming some new phenomenonof the natural world may face hostile critics whoargue that some uncontrolled background effectis really responsible for the results. A goodexperimenter tries to rule out such potentialgrounds for criticism by producing as "closed"an experiment as possible. A successful critic isone who manages to open up the experiment tothe environment.Researcber Tuo: But in the clinical budgetingcase it is the experimenters themselves who areciting environmental factors - such as the NHSreorganization - to explain why a negativeresult is not actually a disconfirmation of the

phenomenon.Researcber Tbree: Aren't you two building a loton what is after all only one small aspect of thefeport?Researcber One: Oll., but it goes beyond just theBirmingham case. The results chapter as a wholeis fi.rll of similar moves to accommodate negativeresults. For instance, the authors continuallydraw attention to the adverse environment theyfaced during the course of the experiment. It re-fers here to the "worst of all environments inwhich ro test" (Wickings et al., 1985, p. 53) andit goes on to a list a number of organizationalchanges which took place at the time. But whatI found to be so arrrazing about the report - andthis is the real gen - was the section on thequantitative data. That is the real test of all thiseconomic theorizing. If clinical budgeting w-asto have any effect then it should show up bychanges in the resources used by clinicians. Butas I read through the lists of all the quantitativemeasures examined I found that there was not asingle number which could be said to show un-ambiguously that clinical budgeting was havingan effect. The best that could be said was that thedata werc inconclusivc.Resectrcher Tuct: That ,s pretty amazing giventhat the whole point of clinical budgeting is tobring about changes in how clinicians usefesoufces.Researcber Tbree: I would like to know a little bitmore about these quantitative measures.Researcber One: Okay. The first thing theylooked at were changes in non-staff clinicallyrelated items such as drugs, X-ral. consumablesand the purchase of medical equipment. Theycompared the costs in the experimental districtswith the region as a whole. They found it a dif-ficult exercise to do and were apparently unableto come to any cleaf conclusions (reading): ". . .perhaps the only firm conclusion that can bedrawn is that it is impossible to make any suchconclusions from this type of data" (Wickings e/al., 19a5,p.86). They then looked for changes inresource use brought about by the specificPACT agreements. There are pages and pages offigures but again their conclusion was, "In sum-mary the figures do not conclusively

T. PINCH. M. MIILKAY and M. ASHMORI

demonstrate either a better or worse use ofresources" (Wickings et al., 1985, p. 9l). Nofirm conclusions could be drawn from data onpatient management related costs or on casemixes either.ResearcberTuo: I don't believe this. There musthave been some positive results to report. Surelythe Griffiths team can't have got it totallywrong.Researcber One: Well, there is one positiveresult. Let me read you this: "Although the analy-sis eadier in this chapter suggests that little hap-pened which apparently changed the overallperformance of the districts, when measured interms of overall throughput or relative expendi-ture on particular headings, it is fair to point outthat the PACT discussions between cliniciansand members of the l)istrict Management Teamwere found to be worthwhile on a number ofcounts and that during these meetings a numberof important planning issues were raised" (Wick-ings et al., 1985, p. 11O). Basically they got onbetterl (Laugbter.)Researcber Tuo: That's really ironic. Their onesuccess is in an area which seems to have little todo with economics. But this is all very puzzling;how on earth could these experiments beregarded in any way a^s a success?Researcher One: Thatwas exactl,v what I was try-ing to understand by the time I got to the sectionon "Lessons Learnt". lndeed, it seems that the au-thors of the report themselves realized that theyfaced something of a proble m. They wrote at thestart of this section: "It sounds perverse, and mayindeed be so, to regard the experimentsreported here as encouraging rather than disap-pointing" (Wickings et al., 1985, p. lll). Therefollows a list of the "encouraging" points. I mustadmit I chuckled reading this list. It goes as fol-lows: "(i) The management teams in both Old-ham and Southend have continued to invest instaffto support the system. (ii) Much technolog-ical development occurred which has sincebeen adopted by the Management Budgetingdemonstration districts." Those, by the way, arethe ones set up after the Griffiths report. "(iii)Some (although the minority) of consultantsliked and used the available systems and a num-ber of beneficial changes were made." These are

the changes such as the talking together which Ireferred to earlier. (Laugbter from ResearcbersTuo and Tbree.) "( iv) The ward sisters in South-end enjoyed being budget holders." (Morelaugbterfrom Researcher Tuto. ) | 'rhought you'dlikc that one. Here is another important finding:"(v) MrJim Blyth, of the Griffiths Inquirv team,was sufficiently impressed to advocate what hecalled "Management lludgeting" after his visit toSouthend and the systems have substantialsimilarities." You see they are alike after all! Nowcomes the finding to which the_v attach the mostimportance : "(vi) Perhaps of more significance,the national Evaluation Group were sllpportivein their interim report (April 1985)." If you re-call, that is thc positive report u.hich Wickings &Coles quote in their article. F'inall_v they say:"(vii) Although therc are onlv limited signs of"success" therc have been even f-ewer sugges-tions that the overall thfust was !i'rong" (!flick-ings & Cole, 1985, pp. 133-134).Researcber Tuo (clisbelieuing): Is that it?Researcber One: Yes that's it. After five ,vears ofcxperimentation that is q,'hat thc_v found.Researcber In,o: V'ell, one thing I've learnt fromthis projcct is that in cclmparison the para-psvchok)€i)' experiments looked at by' Collins &Pinch ( 1982 ) sce m like Nobel Prize candidates!Researcber One: ltctld you it was drnamite. Themost intcrcsting thing about this list, apart frontits meagre natllre in contrast with the originalobfectives, is that most of the positive reasonsgiven are on the lines of saving it is a succcssbecause other people like it, or even, in the caseof the Evaluation Group, because other peoplethink that it's a sllccess! That reallv does scem toput the cart before the horse. If thcre is ncl evi-dence that the thing works in the first place. youcoulcl argue that the more peoplc that come tobelieve in it, the bigger is the failure.Researcber Tbree: What was the exact statementwhich the Evaluation Group made in support?Researcher Or?ej Well, there is a l<tt of hedgingaround describing the experimcnts and so forth.but thc ke,v part is the last paragraph where itsays, "Despite the major difficulties encounteredin the research districts. the Evaluation Grclup isunanimously of the viex' that in principle this

CI-INICAL BUDGETINC: EXPERIMENTATION

PACTs centred budgeting system has all the

right ingredients for improved resource man-

agement in the NHS, and it should be given the

support needed to ensltre its widef dissemina-

tion within the service" (quoted in Wickings e/

al . , r9a5,p.7) .Researcber Tuo: That sounds very positive tome. The "in principle" caveat is a nice way of put-ting it. Of course, in principle, the system is theright one even if it doesn't work in practice. It isthe classic wa_y to save the phenomenon. If yourexperiment has been refuted you say that itwasn't actually a proper test and theretbre thenegative evidence doesn't count for anything.This puts a nice slant on an afgument I fecentlyrcad in a paper by MacKenzie (MacKenzie,1988) on the testing of ballistic missile technol-ogy. MacKenzie points out that tests of strategicballistic missiles offthe coast of the United Statescan be challenged b_v saying that the resultsobtained there may not be applicable when theweapons are used in a real nuclear war. Thisargument was, for instance, made for a time bythe U.S. manned-bomber lobby. Yor.r challengethe positive results by pointing to a differencebetween the context of testing and the contextof use. For those who wish to generalize fiom thetests. the context of test and and context of useare held to be similar. But for the critics the dif-ferences are significantResearcber One: Back to similarit,v and differ-ence judgements again?Researcber Tuo: Exactly. The connectionbetween testing and use can be said to be a mat-ter of social negotiation. Our own case exhibitsthe same phenomenon but in a different way.Here we have a negative rather than positive testresult being discounted because it is claimedthat the context of testing was in somewayspecial because of major reorganizations of theNHS which took place during the test. In thiscase too it is claimed that the context of the testdoes not match the context of use. The Evalua-tion Group argue that under normal conditionsofuse there is every reason to believe that clini-cal budgeting will work properly. In short, thesimilarity and difference between context of useand context of test is again seen to be a flexible

resource for argument.Researcber Tbree: I think that what the two ofyou are saying is interesting but I am worriedabout one thing. In order to make this kind ofargument at all, you have had to set up a defini-tive vcrsion of clinical budgeting - the versionwhich says that it is an attempt to change econ-omic behaviour and that whether or not it suc-ceeds in doing so can be discovered by "direct

observation" in these experiments. You thendeconstruct the Evaluation Group's "success"claim by contrasting it u'ith a "failure" versionwhich you derive from this report. But isn'tthere another way of looking at it? Suppose thereis more than one version of clinical budgetingavailable. I seem to remember that one of younot so long ago was arguing this very case. Sup-pose we take the version of clinical budgctingwhich Kathleen presented to the clinicianswhich suggests that it is a modest attempt tooffer practical help and that success is to bedefined in terms of getting the thing working tohowever limited an extent. You wouldn't. ofcourse! expect such marginal benefits to showup in the quantitative data. In terms of this ver-sion, rather than being a failure you can start tosee how the experiments might bc seen as a suc-cess, especiallv given the hclstile environment atthe time. 'I'he fact that people such as ward sis-ters liked the svstem - which you sneered at inthat rather sexist way earlier - is actually asgood a measure of success as anything else. Thefact that it is taken up by practitioners is surely inthe end the best criterion ofsuccess?Researcber One: I see 'ffhat you are saying, butmy point is that it was the participants them-selves, that is, Wickings et al. (1985 ) who madethe appeal to scientific rhetoric. And they them-selves acknowledged that the experiments wereless than successful; remember Wickings said,quote, "It sounds perverse.. . to regard theexperiments reported here as encouragingrather than disappointing."Researcber Tbree: Wel| we will clearly have totalk to Wickings himself to get his vicw. It coulclbe the case that these different rhetorics are con-tinually drawn upon for different purposes. Evenarguing that clinical budgeting is a technology

T. PINCH. M. MULKAY and M. ASHMORE

seems to involve one particular version.ResearcherTuo: I'm glad the stuffon technologywas useful even if it did onlv highlight howwe asanalysts are using different versions of healtheconomics. But I've got to get back to my videoanalysis. It's time for some real research.Researcber One: You're forgetting. We've got toarrange some more interviews.'We need to talkwith Wickings and also somebody who was amember of this Evaluation Group.Researcber Tbree (getting up to go): Well, I'llleave you both to do that. And if you find time,perhaps you could read through these two chap-ters of our book on health economics which I'vejust finished. (Handing oaer typescripf.) I've gotto get back to some administration - another ()f

these damn surveys evaluating the departmenthas arrived.

ACT IV: NTICKINGS' WORLD

The location is a large office resplendent withEdwardian furniture at the King's Fund Trust inLondon. Iden Wickings is seated behind a largedesk. Researchers One and Two are seated ineasy chairs in front of the desk. On the desk is asmall tape-recorder.J

Tape-recorder (off scene): I'd really like to pro-test, all these parts played below should actualll'be played by me, after all I recorded the wholething.Researcber One (ignoring tape-recorder): Iwonder if you could just say a little bit about thehistory of your involvement with clinicalbudgeting.Wickings: Okay, we've done a series of proiects.The Westminster one was the first that I know ofin which we did an experiment.. . and it cer-tainly seemed to demonstrate some change. Wecould go into it i f you're interested. . IThen atBrent]we tried to achieve the same changes justusing costin€i data - I don't know how familiaryou are with thc distinctions and such like -we

reported the cost to peer groups with various

hypotheses about the high cost group... andsaw nothing for three years, despite everybodysaying how valuable and important the informa-tion was. And so we then went into Southendand Oldham and another district. . .Researcher Tuo: East Birmingham?Wickings: East Birmingham. And there we weretrying to see whether one could get the sameresults using only the variable costs and exclud-ing staffing and capital costs. .. . I get a bit irri-tated, people say, you know, "You've been doingthis for ten years and u.hat have you shown?" llutin fact each time we've been trying a differentapproach and we believe that we've graduallylearnt the conditions under which it's likely tobe successftll. \W.e would no longer recommendit for universal adoption, certainl,v until somesuccessful projects have run for a while, whichhasn't happencd yct. . . .Researcber Ttuo: Is there a distinction betweenclinical budgeting and management budgeting?Vickings: Well there is yes, but it's a bit arcane,I mean I don't know how much detail _you s'antto go into, but nanagement budgeting - u'hichis noq.' called resource management - is con-cerned q'ith thc techniquc of distributing coststo manafaers so that thev can control them . ..The differences are not all that clear. IIn manage-ment budgeting] thev also believed verv muchin charging out overheads. We did not in the pro-jects that we've been engaged in, because q'e feltthat it was important to emphasize those thingsthe clinician could influence himself, youk n o w . . . .Researcber One: I read the Nulfield Portfolio,there is an introduction from Tony Cull.er andhe describes these clinical budgeting trials, orwhatever, as experiments, I mean did you see ityourself as an experiment in that sense?Wickings: Yes, I mean; yes w(r tried, in so far aswe could, to set it up so that you would getgenuine learning, so I suppose, I don't like thephrase "experimenting", but yes, I don't mind, Isuppose . . . we wclrked - sorry I'm sort of stam-mering really - we certainly saw it as beinginnovative. and therefore worthwhile if you

rAn intervicw with Idcn Wickings was conducted on 2 February 1987.

CLINICAL BUDGETING: EXPERIMENTATION ) o l

were going to learn from it, of trying to establishsome reasonable sorts of controls, you know andsuch like, it makes it more complicated and suchlike. And because of the difficulty of learningfrom these things and forming balanced judge-ments, there were various ways you ought toevaluate the proiect.Researcber One: I noticed there was an Evalua-tion Group set up . . .Wickings: That's right and they think it's the bestthing since fish-fingers more or less, they werevery supportive. But you see that's an examplethat one of the difficulties we felt . . . was of defin-ing what success is.Researcber Zeao: Returning to the point aboutthe experiment nature of it. I mean I got theimpression when I read the beginning of this re-port (Wickings et a|.,1985) these were being setup as kind of like fesls of the idea, and somethingriding on these particular events . . .Wickings: I think that's probably right, I meanthere's a limited number of occasions on whichyou'll get governmental money to try thingso u t . . .Researcber Tuo ( laugbizg)r Sure.Wickings (laugbing): Precisely. Particularly ifthey're expensive as in many senses this was. Istill think actually that it's a piddling little invest-ment comparedwith the importance of trying tcrbe able to get a negotiated set ofexpectations ofwhat each expect of the other, from generalmanagers and clinicians, but obviouslyvou haveto be very discreet. \We thought it would beeasier than it was. There were terrible di,fficul-ties due to the repeated reorganizations of thehealth service. I mean that genuinely, it meantthat people were coming and going and thatpeople were without staffand so on and so forth.Researcber One: Tbis affected the Birminghampart of the study didn't it?Wickings: It affected all of them. Birminghamwas part of it, but it also affected Southend. Atone stage, only the district administrator hadbeen working in Southendoutof any of the man-agers for longer than a year ... and to expectthem to be introducing new ways of workingimmediately during that period was verl' dif-ficult. And there were three successive changes

in Oldham, but I mean that's what the world'slike I'm afraid, but it makes it very dificult; Ioften wished I was injecting rats in cages.Researcber One: Could you make an argumentthat in a sense for a successful clinical budgetingsystem to work, you must be able to deal withthose sor t of . . .Wickings: Yes, you're right .. . the period thatyou don't want people to go is when you're set-ting them up. You know, we never got to any sortof stage . . . And I think we're going to find thesame troubles with the resource managementsystem; that it's very difficult to set it up. I think,going back to the point I was making, a lotdepends on whether you have managers of thecapacity to cope with it, who want to go ond o i n g i t . . .Re searc ber One: Y our various economic criteria.there wasn't actually much change as I under-stand it in . . .Wickings: Well, I don't regard those as a success!I don't think they demonstrated very much,except that in the circumstances in which wetried it. it didn't work.Researcber C)ne: Yeah, and you put something, Iquote from the report: "It sounds perverse toregarcl the experiments as encouraging ratherthan disappointing."Wickings: Yes.Researcber One: So you regard the experiment,that those ones are largely a failure then?Wickings: Well, I don't like these words "failure"and "success". You know how these things workdon't you?Researcber One:Yes.Wickings: What I meant, the things I felt that wecould really be encouragecl by, were that it wasnever rejected, firstly. We can try and start in anew system, and if you've worked with doctorsvery much - have you worked with clinicians inhospitals?Researcber One.' No.Wickings: \Well, they're an extremely powerfuland rightly I think arrogant lot by and large, veryindependent, idiosyncratic, they're not managedbv anybody you see, they're like professors. And,that to get them to accept changes ofthis sort isalways dfficult. Now, by and large, the medical

292 T. PINCH. M. MULKAY and M. ASHMORE

staff were either apathetic, or supportive, there

wefe one or two fierce opponents, but they

were unusual ... Where I felt the encourage-ment came was that if the managers had beenable to do tbeirbit,I think that the evidence wasstill encouraging - but obviously you can't betoo unkind about people who've been very kindand worked for you over several years, I meanit's very good of them to have done itatall. . . For

example, East Birmingham - the medical staffthere, I hadn't, we had no problem with them atall, they were very keen. But I mean I stoppedworking there because the bloodl'DMT IDistrictManagement Team] weren't putting any effortinto it and you can't go on pouring moneY intothese things unless people are putting someeffort into it. I mean they were all different, you

see one of the troubles, one was trying to do somany things at one time . . . we were testing outsomething to see whether it could be a nationalmodel - that was the idea. And our conclusionson that were, that you don't stand a hope in hell,of doing it, if you haven't got at least some goodmodels demonstrated by test pilots, that was theanalogy we used.Researcber One: Can I just go back to somethingin the report, the interim evaluation reportwhich is attached to that appendix. lWould yousay it's faidy positive?Wickings: Yes, I mean I was, I was pleased. Ithink very correctly (laugbter),I mean we feltthat it was our job to present the results of ourevaluation, and we couldn't ourselves claim thatthere was much evidence. Nonetheless, it's stillour view that the potential of the system has notbeen invalidated at all and that's what fortu-nately this Evaluation Group - they were quitetough with us at times - but they helped to saythat there wasn't a better way forward in theirview; that there is always going to be resourceshortage, you have to find ways of handling that.That does in some way or another require somedealings between clinicians and managers andalthough you haven't done it very well yet, that'sthe way forward, to do something like that.Researcber Tulo: So in effect it wouldn't havemattered ubat the actual results were in theexperimental districts?

Wickings: Yes it would, yes I think it would, Imean if there had been absolute confusion. Imean goodness knows what they would havesaid. But they didn't say - which was an expec-tation when we did our research originally -

"this should now be implemented nationally"(bangs desk). There was nothing like that. Andwhat they really sanctioned was continued workto try and get it to work. And the resource man-agement initiative is the same. . . and they're try-ing six districts with again different patterns,because it's bloody difficult.Researcber One: That came through the GriffithsReport? The resource management?Wickings: Yes, that's right?Researcher One: Because that's one of the suc-cesses,Jim Blyth with the Griffiths commission.Wickings: Well, Jim Blyth went down to seeSouthend . . . butyou see again, I thinkhe under-estimated the complexity of it, because the Grif-fiths report said they had set these up to be im-plemented in six months. Well two years laterthey were just at the same stage we had been. It'smuch more complex than people seem tounderstand . . .Researcber One: Why do you think people haveunderestimated the complexity of introducingthis?Wickings: It's partly the boredom factor. I mean,the health service is greedy for new ideas. And anew idea comes along and everybody says, "tre-mendous!" And for a while it's terribly fashion-able, "this is it!" and so on ancl everybodyassumes it's going to be working whisky-a-gogoin no time . . . And then the actual business of set-ting that up and running it and bringing about so-cial change in a very complex organization,everybody's found that - not just us, I mean youlook at the literature about the introduction ofsocial change in industry - to take a good manyyears to bring about a very complex change is asnothing. And from the outside, I mean I couldhave said to British Leyland: all they've got to dois have fewer people and produce more cars, andthey'd be wonderful! That's what people think,but as you know when you try and do thatuitbin the organization, it's very difficult.Researcber One: It's interesting the role of the

CLINICAL BUDGETING: EXPERIMENTATION 7C)1

researcher in this sort of dichotomy, because ina sense we fesearchers afe always trying to stfesshow complicated it is and it's difficult to get hardand fast findings. Well in a sense the policypeople say, "well that's no user no, we want tomake these new policies". Did you find yourselfcaught in that sort of dichotomy?Wickings: Well we were undcr a sort of pressureto produce results. I mean there wasn't an,v verygreat support for what you might call thedelights of academic learning. They wantedresults. But I can certainly understand it. I thinkwe all of course tend to see the things we're en-gaged in as more complex than others will see itunless they're involved in it. I don't know, I feelthat the fact we were trying to change the modelwe were testing each time and that we were try-ing to bring about a very significant change incomplex organizations at a time when the chiefofficers were regulady changing .. . I felt oneshouldn't be discouraged by what one had seen,because there hadn't been any evidence to per-suade one that it was wrong; that is was difficult,yes.Researcber Two: But isn't it quite likely thatgiven all this kind of turbulence, all these organi-zation l changes being forced upon the healthservice, that people working within it and maybeespecially consultants, would see the clinicalbudgeting effort, the PACTs experiments, as iustanother one of those? You know. another one inthe train of . . .Wickings: Yes. That's right. There's lots ofpeople thinking that at the moment.Researcber Tuct: I mean aren't they in a senseright, that it's just another one of those?Wickings: Vell yes, of course, it's just anotherone of those. It's not a sort of Holy Grail or any-thing like that. The health service has not beentransformed by it. I mean it is now routinelyaccepted by most clinicians that they are goingto have to workwithin a budget at some stage . . .If you talk to the managers up and down the dis-trict they also feel that, that if the cash limitedstate funded system is going to be managed at all,it must be able to make choices: a bit more onthis and less on that and some sort of budgetingsystem is necessary for that. And I think, myself,

that we were largely accountable for thatchange. The fact we haven't, I'm afraid, been ableto show it all working whiskl'-a-gogo is a pity, Iwish we could, I'd be Sir Iden \Wickings or some -

thing now. ( Laugbter. ) But that's how real life is,isn't it?

At this point coffee is brought in and the taperecorder is switched off. Vickings asks theresearchers whether this is the sort of thing theywant from him because he has found the line ofquestioning rather unexpected. After reassur-ance from the researchers that the interview is

working very well, Wickings goes on to outlinethe different forms of management budgetingand resource management which have beendeveloped post-Griffiths. The interview re-SUMCS:

Researcber One: }{ow do you judge success orfailure in these resource management projects?Wickings: I think that's very difficult . .. Thesorts of things that I would regard as being evi-dence of success, are that the people locallyclaim that they're able to be better social actorsnow than thet' ll'ere trefrrre and can producesome evidence to support that. Now, it would bevery nice to be able to say that you know the,mclrtality rates have dropped or something, butthe likelihood of that being shown is so slightand one iust has to accept that that's not there.What I would call constructive redeployment offunds is some evidence of it being useful I think,particulady if people say, "wc can now do thisand we could do that and we couldn't have donethis without that system." And the sort ofpictureI have in my mind's eye, of success, would bethere being a set ofoverall plans . . . a set ofplansfor each specialty in which the managers and theclinicians both feel they're working to achievethe same things. And success will be that thevboth knowwhat successful is like, you know andthat seems to me to be an important sort of socialgoal ofthese efforts.Researcber One: lt's interesting, in that CASPEreport, some of the criteria for judging the suc-

294 T. PINCH. M. MUII(AYand M. ASHMOR-E

cess early on were listed as being economic, Imean they're like economic measures and yourmost recent one is very much; you said "socialactors" . . . my eyes sort of lit up . . .Wickings: I think . . . (Laugbs.) Yeah, there isn'ta monocular viewof the world is there? I mean if

you have got one, you're more a fool I think andone should ifpossible try and get a sort ofvecto-rial approach of various views. At least I thinkthat. But I mean I quite often have economistson, working in CASPE . . . I think economists are- I've iust reviewed a book by Gavin Moonev -I think economists have a very mechanistic viewof life; a view that people are logical. And theexpectations they have are based upon variouslogical hypotheses about reactions to differentincentives and so on and so forth. Now, I don'tthink obviously they do have to accepr thar, infact people are far less logical than that and makethe most bizarre choices and often hold con-tradictory views.'fi/hen you actually work withthem you find that they're in some cognitive dis-sonance way having diffrculty with trying toreconcile the greatly conflicting views . . . I meaneconomics is a very helpful way to analyze trans-actions between people, I'm very persuaded byit. I'm quite glad I didn't do afirst degree in econ-omics mind you, because people who work withme who did that, they often seem to me to beirritated that people don't actually seem to workthe way that they bloody well should, you know... I'm not sure whether the changes are grossenough to be seen in these big studies and that'sone of the problems about it. And that's why itmay be that you need to do more studies aboutwhat's happening at the micro level within theorganizations and see i{ if you believe that's . . .Researcber Ttao: You'll need sociologists forthat. (Laugbs,)Wickings: Yes there's no choice in that.Researcber Tuo: Okay. Suppose it was institutedas a national policy throughout, throughout theN H S . . .Wickings: Which I actually think it will, oddlyenough, despite all the difficulties, I think it will,because I think it's logical (laugbs); rhat soundsillogical.Researcber Two: Rigltt okay, well if it was . . .

Wickings: But not before 1995 | would say so.Researcber Ttao; Okay, so it's a very long term . . .Wickings: I think it will gradually come yes.Sorry, I keep intcrrupting.Researcber Tuo: Yes, you do it quite success-fully, I've forgotten what I was going say.(Lauglts.) This always happens.Wickings: Yes, clinical budgeting.Researcber Tuct: Yes thank you, yes, that's *'hatwe were talking about. Yes, so how would youenvisage the dillbrence in the health service,from a patient's point of view? I mean wouldthere be fewer waiting lists for instance?Wickings: I passionately believe that we oughtto be giving our patients a better deal than u'enow are. Often they're getting a very good deal,but there are many times they're not and wedon't seem to have the mechanisms to handlethat. And I know I'm talking long term and I'mtalking on the assumption that one has got some-thing, something like a national system, so I'mmaking huge gigantic leaps you realize rhat. Burif you imagine that most districts had somethinglike this and that the information was shared. notonly would _vou be able to have people like mesay. "Vell this is what I would expect us to see.'Why

are we only seeing that?" As new consul-tants appeafed, you'd be able to spell out whatyou thought they were going to do . . .Researcber ()ne: You said during the coffeebreak that you found our questions quite extra-ordinary. Why, by the way-iWickings: I don't know really. I hadn't reallyexpected that the discussion would go this sortof way. And also I'm wondering if you're goingaround a whole series of projects like this, howyou're going to draw common things togetherfrom them. I find that interesting. Will we be ablein the end to see something written?Researcber One: Oh,I hope so.Researcber Tuto: We've already written threepapefs.Researcber One: Some of our stuff, we've alreadypresented it to the Health Economists' StudyGroup.Wickings: Yes, unfortunately, I'm not a memberof the HESG because I'm not a health economistv o u s e e . . .

(]I-INICAL BTIDGETING: EXPERIMENTATION

ACT V: AN EVALUATION MEETING

The research on clinical budgeting has at longIast come to an end. Researcher One has man-aged to interview a member of the DHSS Evalua-tion Group - the first member of the group hehad approached had refused to talk on therecord. The paper for Brunel University has als<rbeen delivered. The three researchers are nowsitting in Researcher One's office at the lJniver-sity of York. They are talking over what theyhave achieved in the research.

Researcber Tuct: My feeling is the Wickingsinten'iew went quite well. FIe gave us a lot of histime and seemed to talk freely. He definitelypro-duced a "weak programme" version of clinicalbudgeting. He said that he didn't like us referringto his research projects as "experiments" and hepointed out that it was very hard to sav what suc-cess or failure meant - he preferred to talkabout it as a "learning process". The role of thePACTs agreements seems to have been to pro-vide a "negotiating framev'ork" to get moreexplicit discussion between clinicians and man-agers of their future plans. The direct route tochange on economic grounds advocated in hisarticle intlre Nuffielcl/York Portfolio - changemeasurable by "direct observation" in "experi-1nsnf5" - s/as replaced by a rather different con-ception. This is not to say that !(/ickings impliedthat PACTs were totally ineffective, but ratherthat what impact they had was not produced bydoctors, managers and nurses simply acting asindividual economic calculators. At one point Ieven heard him hinting that the undedyingproblems of the NHS were sociological ratherthan economic.Researcber One: Yes, I thought he was going tooffer us both jobs when he said that! Greatl Ithought, at last a bit of consultancy. Seriouslythough, the experimental rhetoric did ratherseem to vanish when we got talking. In the endhis research turned out not be be "science" inthe sense of physics, but neither did it seem apiece of "quick and dirty" policy research.Remember how he himself referred to what hewas doing. He said he had been "doing this for

ten years", "trying a different approach [eachtime I to try and see"; he described it as "a learn-ing process", "to try and see the conditionsunder which it's likely to be successful". Thescience-like aspects were reduced to "trying toestablish some reasonable sorts of controls" thus"making it more complicated", and he talkedmuch more about evaluating it in terms of "ba-lanced judgements" and "things we could reallybe encouraged by".Researcber Three: The languap;e of hypothesis-testing and experimentation, of cut and driedsuccess and failure, certainly doesn't seem to dosuch research justice. Maybe dealing with the"real wodd" requires the sort of research whereyou learn slowly over a long period of time bytrial and error.Researcher Tuo: Quite possibly. But the scien-tific rhetoric which was dominant in the CASPEreport made its appearance in the interviewnevertheless; though admittcdly usually in res-ponse to our formulations. But he quicklyadopted the alternative way of talking andindeed seemed rather unsure of himself whenwe asked him outright whether he regarded theth ing as an cxpcr iment .Researcber One: I know, but it only makes medepressed. I started offthis project thinkingwe'dat last found some real science - "forget your

QALYs", I thought, "it ma,v not be physics, but atleast they have experiments" - and it turns outthat it dissolves into something which as far as Ican see is not too dissimilar to sociology.Researcber Tuo: Lnd it's all the better for thattoo. I can't see why you're depressed at findingthat out. I'm more reassured. And physics is notso different either - at least according to mod-ern sociology of science.Researcber Tbree: And if you weren't so obsessedwith physics you would see that the sort of "par-ticipant centred" sensitive research which Wick-ings has evolved is probably the best that youcan do in a policy context. You've got to admir€him for having stuck with it for so long.Researcber ()ne: lf you insist. But then we stillhave the problem that he isn't a proper healtheconomist. Anlvay, moving on, at least I gotsome real dirt from the member of the Evalua-

296 T. PINCH. M. MULKAY and M. ASHMORE

tion Group I interviewed.'It turns out that theGroup was under direct pressure from thegovernment. I don't think either of you haveseen the transcript yet. Perhaps I could readsome of the relevant pieces to you?Researcber Tuo: You managed to use the taperecorder this time did you?Researcber One: Sott of. I felt there might beproblems after the first person we approachedsaid he didn't want to talk on the record at all.This time I managed to record half an interview.He let me use the recorder alright, but then wewere interrupted by a phone call and - I'membarrassed to say this - when I started the re-corder againl pushed the wrong button. I'm re-ally incompetent I'm afraid.ResearcherTuto: That's why you never made it asa physicist.Researcber One: lrealizedwhat had happened assoon as I had finished and I hastily wrore upsome notes on the train back. Ary.way (sbufflingthrough reams of paper on bis desk) here is thetranscript and my n{\tes (proclucing seueralsbeets of tatty typescript). I started by askinghim why thev pickcd him for the EvaluationGroup. He said he didn't have a clue. tught at thestart he stressed the importance of the Evalua-tion Group being independent from Wickings'team. He said, "The idea was that we would beindependent of the groups that were actuallyinvolved in the process. So we weren't reallypart of the promotion activity. We were inde-pendent of it." That's interesting because lateron, as we'll see, he gives reasons as to why in factthey weren't actually independent. He then de-scribed the way the Group worked. They wentout to visit the districts either alone or in pairsand tried to talk to everyone including the dis-affected people who didn't think the thing wasworking. He was really quite proud that the,v hadtried to find the disaffected people. Now here isthe best bit, he's talking about the production ofthe report: "Then we got to a point where they'decided, they suddenly decided in my view toohurriedly that we were to report, a sudden deci-sion that we were to report. And I know why that

was taken because by that stage the Department,the government, had decided that they reallys'anted to move ahead on this and they thoughtall this pithering around, this slow developmentwas really a waste of time and energy. $/e had tomake a big push and they wanted to knowquickly what the lessons were from what we haddone. They were also very dissatisfied with us asan Evaluation Group, obviously, that we werealso pithering around."Researcber Tuct: So there was direct govern-mental pressurc on the Evaluation Group. Atwhat level did the pressure come?Researcber One: That's what I asked him nextand he said, "Somebody high up the sysrem." Healso said that after that they decided to do awaywith Evaluation Groups altogether. An1'wa1' hesaid later that he felt most uncomfortable aboutthe whole way of working and that it was thisgovernment chief scientist, Buller, the head ofthe Evaluation (iroup who was orchestratingthings.Researcber Tuct: That's wonderful, a very clearexample ofdirect cxternal pressure on research,the sort of evidence which it is verl' difficult toget in sociologl'ofscience. A hard and fast caseof political pressures directly impacting on howscientific t'acts are constructed.Researcber One: Yes, I thought you v'ould likethat.Researcber Tbree: Much as I dislike the prescntgovcrnment. I feel slightly uneasy at ,tr. *'21.,vout\\'o are willing to accept this bit of intervicwdata so uncritically. After all it is only one versionand if we talked with Buller he might very v'ellgive a different account of what wcnt on.Researcber One: Come off it, that's taking thisstuff on versions too far. It is iust a fancy way oftalking to avoid biting the real political bullet. Itmay be a version, but it is the one I would be pre-pared to put my mone\.on.Researcber Tuo:Yes, and what about your argu-ment about the need to produce an appropriatcversion fbr thc occasion at hand? Surcly thc rele-vant occasion in terms of <tur research has got tobe the opportunit)' to deal with the politics of

'The intervien'with thc evaluator took placc on I I March 1988.

CLINICAL BUDGETING: EXPERJMENTATION

the NHS and to criticize Thatcher's policies. Wecan't hide behind som€ sort of bogus neutralityby saying it's all just a matter of versions.Researcber Tbree: Well,I don't think we can re-solve that issue here. Perhaps the final chapter ofour bookllealtb andEfficiency might be amoreappropriate place for that. But getting back toyour respondent - the evaluator - did he disa-gree with the conclusion the Evaluation Groupproduced?Researcber One: Well, that's the problem. tsy andlarge he did agree.Researcher Three: So you could argue that in thiscase the government's intervention simplyspeeded up the inevitable.Researcber C)ne: You could argue that, but I'mnot going to. This evaluator has a rather frustrat-ing attitude towards the success or failure of theclinical budgeting experiments. Like Vickingshe spent most of his timc outlining what waswrong and the horrendous problems they faced,but despite all that, he concludes that they'restill the only way forward. Here, listen to this: "Imean they know one or two things from it, forexample, the system won't work without a highdegree of commitment from management thatthey will change their managerial style to make itwork. I mean I felt that there were far too manypeople who felt that this experiment !\.'as a sortof substitute for taking a tough management line ,somehow clinical budgeting was going to solvethe problem for you; it wasn't."Researcber Two (interntpting).' That's aninteresting argument. He seems to be saying thatthe experiment itself got in the way andadversely affected managers'practices - a kindof Heisenberg disturbance of the system withthe measuring instrument.Researcber One: I'm pleased to hear that you canuse a bit of physics too. The point is, he goes onto be pretty scathing about the experience ofPACTs: ". . . the clinicians I mean, some of them,they were more sceptical because they thoughtit was all a trick to get money out of them . . .They were right in their suspicion, which I thinkwas one of the things that was really bad and themanagement weren't strong enough to run thesystem . . ." But then having said all that he still

came out in favour of it: "Well I think we wentthrough all the difficulties you see. And then onesaid, "Okay, well what are we saying? Are we say-ing it's all so difficult we should give up? Or arethe difficulties there because it's fundamentallymisconceived, or despite the difficulties weshould soldier on?" It was at that point that wedid come to the overall view that it wasn't mis-conceived. I mean it does have the right ingre-dients, and the question then is, is it worthstruggling to make sure these ingredients arepresent and used in the right way? . . . Generallyone has to struggle with it. I mean they had threegoes and three failures but there was no reasonto stop iust yet".Researcber Tuo: Wbat is the role of the test.then, if you go on struggling with it after thething has failed?Researcber One:.Well, of course. I asked him thatbut he iust went back to a priori grounds as towhy it was so good: "It has the elements in it thatyou think a good management system shouldhave. The PACT - this is the central feature -

the PACT is the focus of negotiation" and so on.Researcher Tbree: So his view of it is rather likeWickings'- it is all about providing a manage-ment stfuctufe or a context within whichpeople can'negotiate.Researcber One: That's right. Unfortunately Ican't be one hundred per cent Sure because thetape stopped then. But I did manage to recordthe bit where he had doubts about the indepen-dent status of the Evaluation Group: "In a way Ifelt the Evaluation Group got too close to IdenWickings . . . We were almost pushed into a roleof helping him design his system better by feed-ing back to him the criticisms that were given . . .And I can see that in the interests ofhealth ser-vice management that might be a good idea, butfrom the point of view of doing strict evaluation,I think we should have been more detached thanwe actually were. I think we got - I won't saycaptured because we are not easy people to cap-ture . .. "'W'hen I suggested that maybe he was"sucked" into it he replied: "Well, we got pushedinto a slightly different role .. . We got pushedinto a role of helping the experiments to work,rather than evaluating them as they stood ...

'I. PINCH. M. MUI-KAY and M. ASHMORE

Well, that's fair enough, but I don't think it'squite what an Evaluation Group should be doing.But. on the other hand, I think it was better hav-

inp; us there than what they have done since.Which is to say without evaluation . . ."ResearcherTbree: So even the evaluators seem to

have ended up assisting the process of applica-tion - a kind of "weak programme of evalua-tion", which contrasts strongll'with your earlierquotation from this evaluator where he talkedabout the merits of independent evaluation.Researcber One: That's right. So many of theintcrviews oscillate around this double rhetoric.where one moment everything is scientificallyhunky dory, rigorous and independent and thenext it is all couchecl in vaguc phrases like "bet-ter having us there than not" or "helping theexperiments to work" and so on. For instance,earlier in the interview the evaluator criticizedother health service studies for not havingproper evaluation and at that point he offeredquitc a different version of scientific method. Ihad asked for his reaction to the point that at theCERN particlc accelerators they don't needevaluators and he replied, "Ilut the.v're doingexperiments, aren't they'/ . . . It's more like, say,well we're going to experiment, with artificialinsemination and we're just going to do it. Okal'and then that's it. Vell, and then the people whoare involved can, if you care to ask them, theymay' give you their experiences of it, but I meanthere is no attempt by any independent body toevaluate the experiment. It seems to me that isquite bad . . . That's the sort of thing that is hap-pening in the health service all the time. Peopleare going offin this direction and going offin thatdirection, if they have a nice experience theytalk about it, if thq/ have a nasty experience theytalk about it, but it is totally unsystematic."Researcber Tuo (ironically): Unllke his experi-ence of evaluating the clinical budgeting experi-ments!Researcber Tbree: Thete always seems to be acontrast made with some hypothetical groupwho are doing things worse in terms of some

model of scientific method - in this case peoplehaving "nice experiences" and "nasty experi-ences" which they merely "talk about", counter-posed with systematic independent evaluation.This appears to be the way it alwavs works: con-trasting pairs of opposed versions of scientificmethod are deployed, either to deconstruct anoverly systematic version, as Wickings did toeconomics in his interview, by saying it is to<-lmechanistic, inflexible and simplistic anddoesn't take account of real social actors orwhatever; or more usually to deconstruct soft re-search by saying it isn't hard, rigorous, testedwith independent evaluation, or whatever. Any-wav, I'm curious to know how you got on atBrunel. That must have been dfficult: an audi-ence of gencral sociologists, sociologists ofsciencc and all sorts of economists - and all atonce.tResearcber One: lwas trying to forget about that.That was another depressing experience. I gavcthe paper which dealt with all that stuff aboutclinical budgeting being a social technology -you know. an attempt to change human be-haviour with the use of economics - and l"'hichtreated the CASPE experiments as a test of thissocial tccl.rnologr'. Then I v'ent on to decon-struct the tests in the waY I've talked aboutbefore, bv a little analysis of the CASPE reportwhich showed what a disaster they had actuall)'been. I read out the list of the so-called "points ofencouragement" resulting from the tests andthere were just howls of laughter from the audi-ence, especially when I came to the bit about theward sisters enjoying being budget holders. Butthen I got pulled apart in an odd kind of waf inthe question session, or rather pulled in severaldirections at the same time. No one seemedentirellr happy with what I had done. In the firstplace, a sociologist interested in macrosociologysaid that it was clear that the whole thing wasreally to do with the role of the state andThatcher's policy to squeeze the NHS and m1.study didn't tell us enough about this wider con-text in which the experiments were taking

s()nc <tf us (Pinch) delivered a paper entitlcd "Clinical Budgeting in thc NHS: The Testing of a Social Tcchnologlr' to theCentre for Research int() Innovation, Culturc and Technolog,v (CRICT), Bruncl LIniYersity, 9 March 1988.

CLINICAL BUDGETING: EXPERIMtsNTATION

place. Then there was a sociologist of sciencewho argued against this macrosociologist butwho was also dismissive of my paper because hesaid everyone knew economics wasn't a properscience and so what? Then one of theeconomists, who seemed to be something of atheorist, got uptight with the sociologists for say-ing that economics was iust a matter of socialcontingency; he felt there was more to propefeconomics than that, and in a way I was in sym-pathy with this view because of course I wantedto show that there was something worth decon-structing in the first place. Finally, there was thishealth economist and he said that of course clini-cal budgeting experiments were nothing to dowith economics, but then he said he had justbeen given a contract by the DHSS to evaluatethe latest resollrce management experiments!( Speaking in an increasingly garbled.fasbion. )So there I was trying first of all to argue againstthe macrosociologist by pointing out to her thatthe wider social context such as Thatcherismonly took on meaning in people's everyday prac-tices, such as their experiences with these ex-periments, so of course I sided with thesociologist of science who supported me on this,but then found myself arguing against him bysaying that economics was the social sciencemost in need of deconstructi<tn and henceended up agreeing with the uptiti.ht economictheorist; then I proceeded to argue against thehealth economist who claimed clinical budget-ing wasn't health economics at all by saying thatit mllst be health economics because everyoneworking in health economics including himselfalways said that real health economics was whatother people did, ha ha - and an)'\fi/ay why washe evaluating the resource management experi-ments if they weren't health economics? By theway, I said I would send him the final version ofour study in case it was of any use to him in hisevaluation.Researcber Ttao: Poor guylResearcber Tbree: Anyway, you survived. Itsounds to me as if you did the usual bits ofjuggling which people have to do ro survive inthe social world: for each successive practicaloccasion constructing and deconstructing ag-

reements and alliances by constructing and de-constructing versions of sociology and econ-omics as you go along. Of course, normally itisn't such hard work because you don't get allthese different groups with all their di-fferent ver-sions together in one place.Researcber One: Except, perhaps, in the healthservice.Researcber Two: It seems to me that we ought toget clear just what it is that is inadequate aboutthe Brunel version of clinical budgeting.Researcber ()n e.' There 's no problem there. \ffhat

was wfong was that I took only one version ofclinical budgeting - the strong programme ver-5len - and deconstructed it by recovering theweak version.Researcber Two: That's not quite how I see it. Ithink what you did was to privilege the strongversion of success, as formulated in Wickings'scientific rhetoric, by using tbat to deconstructthe weak version of success - the warcl sistcrsenjoying their budgets and so on. By doing so,you effectively offered your own evaluation ofthe results of the experiments: they were afailure and not, as the Evaluation Group and theward sisters and Wickings in his sociologicalmood all thought, a (qualified) success. In short,far from using the weak-programme version ofclinical budgeting to deconstruct. the strong-programme version, as )'ou claimcd just no\,l, Ithink y'ou did the exact oppositc: you decon-structed the weak version s,'ith the stronfa ver-sion.Researcber One:You might be right. In any case,we clearly need to think hard about how \tr'e aregoing to write this stuff up for the book. But I'mworried that if we give equal prominence toboth yersions - d la BBC - we'll end up notreally saying anything.Researcber Three: Alternatively, like the healtheconomists, we could choose to present the ver-sion which is most suitable for the practicaloccasion at hand.Researcber One:'Whatever that might be!Researcber Two: ln that case we've got to makeup our minds what the practical occasion is. Imean, are we doing real science, or "quick anddirty" policy research, or sensitive participant-

300 T. PINCH, M. MULKAY and M. ASHMORE

centred reseafch?Researcber One: We don't want to spend yearson this so we can't be doing that last one. Andwe're not getting paid enough and have alreadytaken too much time to be doing a "quick anddirty", and we're too incompetent to be doing

science. Let's hope that by the time we'vefinished out book Healtb and Efficienqt we findout what we are doing.Researcber Tbree: Right. So let's think about thiscarefullv. . .

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