Technological Forecasting & Social Change 80 (2013) 673–686 Contents lists available at SciVerse ScienceDirect Technological Forecasting & Social Change A structuration approach to scenario praxis☆ Brad MacKay a,⁎, Paul Tambeau b a b University of Edinburgh, Edinburgh, UK KPMG LLP, Toronto, Canada a r t i c l e i n f o Article history: Received 13 October 2011 Received in revised form 8 June 2012 Accepted 9 June 2012 Available online 15 July 2012 Keywords: Giddens Healthcare Intuitive logics Praxis Scenario planning Structuration theory a b s t r a c t Scenario planning has become a widely used approach for making sense of complexity and uncertainty in turbulent organizational environments. While its early development is rooted primarily in the practitioner world, more recently scholars have been directing attention to its theoretical and methodological presuppositions as they seek to establish rigorous epistemological and ontological axioms that can further advance these methods. In this article we seek to contribute to this lively area of scholarly activity by demonstrating how structuration theory can inform scenario planning by offering a set of concepts that can be used to consistently and systematically analyse future uncertainties within a flexible sociological framework. Structuration theory posits that social systems are reflexively structured through actor–structure interactions over time. Crown Copyright © 2012 Published by Elsevier Inc. All rights reserved. 1. Introduction The application of scenario methods for making sense of complexity and critical uncertainties in organizational environments has become widespread in recent years [1]. While originally a strategic planning tool developed primarily by practitioners, more recently scholars have been directing attention to critical theoretical considerations underpinning the method by drawing on a rich array of conceptual frameworks [e.g. 2–16]. In this article, we contribute to this wider scholarly activity by demonstrating how structuration theory, as formulated by Giddens [17,18], can inform scenario planning theory and practice by providing a consistent set of ontological and epistemological axioms for analysing future uncertainties within a flexible sociological framework. Structuration theory offers insights into how social relations are reflexively structured across time and space within pluralistic and overlapping social systems by drawing on virtual rules and resources. By focusing on actors and the rules and resources they deploy to effect change, we argue that scenario methods can better make sense of the unpredictable twists and turns that arise from the reflexive relationship between human activity and structural properties within continuously evolving social systems. Structuration theory provides a useful framework for analysing how highly disparate social variables (in the context of social systems, this includes economic, political and technological considerations) interact dynamically in common terms [19]. Scenario planning can benefit from such an analytical approach because, from a sociological perspective, it is through such structuration processes that future possibilities reflected in scenarios are shaped and emerge over time. ☆ We would like to thank the three anonymous reviewers and the editorial team for their valuable insights and suggestions for this article. We are also very grateful to the participants interviewed for the scenarios, who were generous with their time and candid with their views. Finally, we would also like to acknowledge Professor Alan McKinlay, who unknowingly planted the seed for this project in a conversation many years ago when he speculated in a conversation with one of the authors about whether structuration theory could be adapted to inform scenario planning. This study was undertaken while both authors were at the University of Edinburgh School of Business. ⁎ Corresponding author. E-mail addresses: Brad.MacKay@ed.ac.uk (B. MacKay), paul_tambeau@yahoo.ca (P. Tambeau). 0040-1625/$ – see front matter. Crown Copyright © 2012 Published by Elsevier Inc. All rights reserved. doi:10.1016/j.techfore.2012.06.003 674 B. MacKay, P. Tambeau / Technological Forecasting & Social Change 80 (2013) 673–686 1.1. Research purpose In this article we report on our efforts to draw on structuration theory to construct three exploratory scenarios into the future of the public healthcare system in Ontario, Canada. We use this exploratory case not as an empirical study per se, but as an indicative exemplar of how a structuration framework can be usefully applied to scenario praxis. By praxis we take Gidden's [18] meaning, which is the interweaving of theory and practice. Ontario, with a population of 13.5 million inhabitants, is Canada's most populous province. As with the majority of state-funded healthcare systems around the world, there has been growing concern over the system's viability in the long-term. Such concerns precipitated the building of exploratory scenarios in the tradition of action-research, where our aims are both to explore the critical uncertainties inherent in the future of the healthcare system in Ontario, while simultaneously adapting structuration concepts for scenario planning perspicacity. We thus constructed the scenarios from the point of view of Ontario's Ministry of Health and Long-term Care. The purpose of this article, consequently, is to illustrate how a structuration framework for developing scenarios and analysing their theoretical and practical implications can be applied. 1.2. Research question and article structure The central research question that we seek to address in this article is: How might structuration theory provide a useful, theoretically informed framework for constructing scenarios? We therefore assume that the main tenants of structuration theory apply in a scenario planning context. The article begins with a critical overview of scenario methods. It proceeds on to outline the main tenants of structuration theory and its relevance for scenario planning. We then demonstrate an application of structuration theory to an exploratory scenario intervention exemplar. Finally, after discussing the possibilities, limitations and further refinements needed in such an approach, we conclude by arguing that structuration theory is a useful concept for further advancing scenario praxis. 1.3. Research contributions In this article, therefore, we intend to make three contributions. First, we contribute theoretically to the literature on scenario planning by demonstrating conceptually how structuration theory can enrich this vibrant area of management practice. Second, we advance scenario planning methodologically by illustrating how structuration concepts can be fruitfully applied to the building of scenarios. Finally, we contribute to praxis by operationalizing several theoretical concepts from structuration theory by applying the framework to an indicative exemplar involving the construction of exploratory scenarios for Ontario healthcare. 2. Conceptual overview In the following section we present a critical conceptual overview of both the scenario planning and structuration theory literatures. Our aim is to elicit insights into how structuration concepts can be drawn on to advance scenario planning praxis. 2.1. Scenario planning With its intellectual roots in systems thinking during World War II, Anglo-American scenario planning quickly moved beyond its military origins to become a widely used strategic planning process in public, private and non-for-profit organizations [20,21]. Originally developed at the RAND Corporation, a military oriented think-tank in the United States, it proliferated to businesses in the 1960s through researchers at the Stanford Research Institute and the Hudson Institute, the latter of which was founded by former RAND analyst Herman Kahn [22,23]. Through the Hudson Institute it was further refined in a number of different contexts, but most notably by planners at Royal Dutch/Shell, the Anglo-Dutch oil and gas giant, who has been one of the leading proponents of the approach since 1973 when strategic planners turned to scenario planning to help convince senior executives of the impending OPEC-oil crises, later crediting it with Royal Dutch/Shell's successful navigation of the oil shocks of the 1970s and 1980s [e.g. 3,24–29]. In this section we will focus on this approach, critically appraising its current standing. 2.1.1. What are scenarios? Scenario planning can be described as alternative views about possible future worlds that highlight key strategic decision points in the present and direct attention towards how underlying causal structures might evolve. They do not try to predict the future, but to focus on critical uncertainties that can result in major discontinuities and strategic surprises. Unlike traditional probabilistic forecasting techniques that base their future projections on analysis of determinable past patterns derived from historical datasets using sophisticated statistical techniques, it is an approach that is designed to accommodate the complex and uncertain interactions of indeterminate forces that can result in discontinuous change. Indeed, Royal Dutch/Shell planners referred to their approach as intuitive logics for this reason. What is meant by this is the process of transforming observed facts into fresh perceptions [3,26–28]. This is achieved through an iterative process of alternating between intuitive exploration of knowledge and rational analysis [29]. Yet, with its proliferation as a strategic planning tool through the practitioner world, some have argued that scenario planning has become “debased by frequent use in many different contexts, rendering it slippery” [30 p 34]. The use and abuse of scenario planning has become a concern for several observers [14,30–32]. B. MacKay, P. Tambeau / Technological Forecasting & Social Change 80 (2013) 673–686 675 2.1.2. The ‘intuitive logics’ approach As a strategic planning process developed by practitioners, scenario planning methods vary, presenting a challenge for academic inquiry. The problem is summed up by Schoemaker when he suggests: “Its subjective and heuristic nature leaves many academics uncomfortable” [33 p 288]. However, some research suggests that a significant proportion of scenario planning methods are either based directly on, or are derivatives of the Royal Dutch/Shell approach [34]. This approach can be either inductive or deductive [3,35], but consists generally of variations of ten basic steps including: defining the focal issue and setting the parameters of the study including time horizons and what stakeholders should be involved, conducting extensive primary and secondary researches, identifying key drivers/trends, distinguishing between whether they are predetermined or uncertain, rolling out a sequence of events that provide the core logics of the scenario stories, writing a set of learning scenarios, testing combinations of scenarios for their internal consistency and plausibility, revising the scenarios to produce decision scenarios, selecting warning signals for the scenarios, and linking the scenarios to strategy [see 2,3,7,16,26–28,36 for further elaboration]. But as Mintzberg [31 p 250] has pointed out, “this is no simple business!” Few seem as adept as the sophisticated Royal Dutch/ Shell team in the 1970s and 1980s at this complex and subtle exercise. 2.1.3. Why use scenarios? Proponents of the scenario planning approach suggest that its efficacy has to do with its innate ability to challenge the assumptions of key decision-makers contained in the microcosms, or mental models of senior managers, which are reinforced by accumulated experience and knowledge [3,24–28]. As Schoemaker observes, “the intended benefit of scenarios is that they stretch as well as focus people's thinking” [2 p 200]. From this perspective, scenario planning is a discipline designed to reduce cognitive inertia, allowing for the “rediscovery” of the original entrepreneurial power of “creative foresight” in “contexts of accelerated change, greater complexity, and genuine uncertainty” [27 p 80]. Scenarios are thought to facilitate individual and institutional learning about a present pregnant with innovative possibilities for the future. They are thus viewed as the grist for ‘strategic conversations’ within organizations aimed at perceiving and adapting to emerging frontiers wrought by novelty inherent in rapidly changing environments [3,6,24,37–39]. 2.1.4. The problem with scenarios… Because scenario planning is a technique that has been developed primarily by practitioners [e.g. 24–28], academic scrutiny of the axioms underpinning the process has only recently begun to formulate a corpus of scholarly knowledge critically appraising its presuppositions and theorizing its methods. A few examples might include Schoemaker's [2] use of behavioral theory to elaborate on its conceptual foundations, van der Heijden [3] and Chermack and van der Merwe [9] drawing on learning theory to unpack its hermeneutic appeal, Goodwin and Wright [5] and Wright and Cairns [16] seeking to extend scenario planning with decision analysis, Burt's [11] refinement of scenario methods by integrating them with disruption theory and system analysis, and more recently Sarpong's [15] application of social practice theory to augment its theoretical and methodological underpinnings. Nevertheless, until recently the production of such knowledge has generally not kept pace with its proliferation as a management technique [5,6]. Consequently, scholars observe that it has been “elusive and fuzzy by academic standards” [2 p 194]. For instance, in Porter's [40 p 481] chapter on scenarios in his seminal book, Competitive Advantage, he states that scenarios are “not a forecast but one possible future structure”. Yet, as van der Heijden [29] points out, where do we begin to find such structures? It is in finding such structures at a macro level, and crucially, in identifying the activities of actors by which such structures change over time at a micro level [27] that a structuration approach may advance theoretically and practically such methods. It is to structuration theory that we turn to in the following section. 2.1.5. Section summary In summary, while a widely used strategic management tool, scholarly interest in its underlying methodological and theoretical axioms has only recently begun to gain momentum. Such momentum is being catalyzed, in part, by concerns that its widespread use in many cases lacks the methodological and theoretical axioms that give it the sort of rigor that other techniques, such as forecasting approaches, have. And while progress is undoubtedly being made, the opportunity to import sensibilities from the wider social sciences continues to exist. In the following section we turn to structuration theory as a possible framework for enriching scenario planning praxis. 2.2. Structuration theory Structuration theory has been defined by Giddens as “the structuring of social relations across time and space, in virtue of the duality of structure” [18 p 376]. In essence, it presents a “cluster of sensitizing concepts” explaining how humans interact in society. Core to this work is the “rejection of dualisms in social theory — micro versus macro theory, subject (people) versus object (structure), individual versus society, subjectivism versus objectivism, and similar dichotomies around which great debate rages” [41 pp 520–523]. As Giddens [18 p 2] explains: “The basic domain of study of the social sciences, according to the theory of structuration, is neither the experience of the individual actor, nor the existence of any form of societal totality, but social practices ordered across space and time. Human social activities, like some self-reproducing items in nature, are recursive. That is to say, they are not brought into being by social actors but continually recreated by them via the very means whereby they express themselves as actors.” 676 B. MacKay, P. Tambeau / Technological Forecasting & Social Change 80 (2013) 673–686 The central premise of structuration theory, then, is that human action exists within predefined social structures including cultural and economic systems that are governed by rules and resources. While these social structures predetermine agency, individual agency can also modify or sustain such structures. There is thus a reflexive relationship whereby action is constrained and enabled by structure, but through reflexive feedbdack, structures are also changed by agency, often through the unintended consequences of action. 2.2.1. The duality of structure The duality of structure sits at the core of structuration theory, yet it is also the most contentious element (See Table 1 for a summary of structuration concepts and their descriptions). Phipps [42 p 198] describes duality of structure as “knowledgeable people who reflect on what they do, and what others do, draw on virtual rules and resources for their behavior, routinized from previous behaviors; and by doing this, they reaffirm these rules and resources, and therefore reproduce social life.” Rules refer to an actor's view of how things should be done and/or how they have always been done. Resources refer to who has control over people (authoritative resources) and materials (allocative resources) [43]. Taken together, rules and resources constitute the transformative relations of structures, which can be ‘dominating’ depending on the power relations governing control of resources, ‘legitimizing’ as norms, standards and values become institutionalized, or ‘signifying’ as meanings are produced through discursive and interpretive practices [17,18]. They can also be transformed depending on how rules are transposed across contexts, the unpredictability of resource accumulation, and the interaction of a multiplicity of structures at different levels [44]. 2.2.2. The problem with operationalizing structuration theory Structuration theory, however, has been criticized for its “abstract emptiness” [45] and applicability to empirical research [46]. This has led some scholars to ask whether the duality of structure can be applied to the day-to-day evaluation of human activity, or whether it should be viewed as a device to evaluate behavior over time [47]. Perhaps the most sustained critique of structuration theory has been that of Archer [48–51], who argues that Giddens' view of agency and structure as mutually constitutive results in a central conflation of agency with structure. The alternative to Giddens' theoretical opportunism, she argues, is to keep agency and structure as separate entities, mediated by a reflexive inner conversation that engages people's concerns with objective structural opportunities for action. In response to these critiques, Giddens [53 pp 294, 298] argues that viewed as a sensitizing device, the operationalization of structuration theory should be done in a selective way, where “the prime underlying orientation, both of the planning of the investigation and the interpretation of its results, would be towards examining the complexities of action/structure relations.” Criticisms notwithstanding, structuration theory may thus offer a flexible framework for examining stasis and change in the reflexive production and reproduction of institutionalized practices within society. 2.2.3. A diachronic model of structuration theory In its original formulation, the concepts comprising structuration theory were presented synchronically, as simultaneous ‘reciprocity’ between action and structure, thus presenting an epistemological problem with investigating change and its unintended consequences over time [18 p 29, 54 p 623]. To address this problem, scholars have developed a diachronic model (see Fig. 1) that allows for bracketing agency and structure within different time periods so that structuration can be analysed processually [e.g. 54,55]. As Barley and Tolbert [55] explain, individuals interpret social norms, internalize them, and enact these norms through their behavior (arrow a). This manifests in behavioral regularities, but in our adaptation of the diachronic model, an element of uncertainty always exists within actor interactions. At some point, actors attempt to change these norms (arrow b). Change will be constrained by those who seek to maintain the status quo. Hence, contextual changes will usually be necessary in order for shifts in Table 1 Structuration theory concepts [18]. Concepts Description Agents/agency/actors Dialectic of control Groups or individuals who have the capacity to make choices and act on the world. Agents intervening or refraining from intervening in the world to influence power balances as different actors seek to exert themselves. Monitoring one's own social actions within a social system and then shaping future activities based on feedback/ outcomes from the social system. Consequences that are not intended by the purposeful action of agents, whether positive or negative. Structure is both a medium and an outcome of social systems. It is produced and reproduced through the recursiveness of social practices. Rules and resources: The structuring properties that bind time and space in social systems. Rules: An actor's view of how things should be done and/or how they have always been done Resources: People and materials (including economic resources) The power relations governing control of resources. Institutionalization of norms, standards and values. Production of meanings through discursive and interpretive practices. Reflexivity Unintended consequences Duality of structure Structure Structures of domination: Structures of legitimation: Structures of signification: B. MacKay, P. Tambeau / Technological Forecasting & Social Change 80 (2013) 673–686 677 Realm of Structure A A Time 1: Behavioral regularities and uncertainties through which the duality of the structural and action realm is sustained and/or modified A Time 2: Time 3: Behavioral regularities and uncertainties Behavioral regularities and uncertainties B B B Realm of Action Source: Adapted from [54,55] Fig. 1. A diachronic model of structuration. institutionalized norms to be successful. Such contextual changes include “changes in technology, cross-cultural contacts, economic downturns, and similar events increase the odds that actors will realize that they can or must modify an institution” [55 p 102]. For instance, the impact that technology has had on structures, such as institutional arrangements, can be used to illustrate the model. As new technologies are introduced into the workplace, the behaviors and activities of office workers change as new norms, power relations and meanings emerge. As the activities and practices of individuals change, so too do the rules governing the social system, as well as the demand for and use of technology [56]. With some adaptation, this diachronic model is a useful development for exploring how structuration theory can inform scenario planning praxis given the long-term time horizons emblematic of scenario analysis. 2.2.4. Section summary This section began with an overview of scenario planning, arguing that while a widely used strategic planning process, it has traditionally been under-theorized relative to its wide-spread adoption. More recently it has become a dynamic area of scholarly activity that this paper seeks to build on. Drawing on structuration theory, we propose, offers the potential to advance scenario planning praxis by presenting a framework whereby social interactions can be understood through the production and reproduction of structures, which includes many of the societal forces investigated by scenarios including their future cultural, economic, legal, political and technological properties, but importantly, also the norms and values constraining and enabling the production and reproduction of human activity. It thereby helps to further deepen the analytical capabilities of the scenario planning process. In the following section we illustrate how structuration theory can be operationalized as an approach for scenario planning. 3. Operationalizing structuration theory for scenario planning The approach to building scenarios that we followed was based on the intuitive logics approach outlined in Section 2.1.2. The indicative case that we use to illustrate a structuration approach to scenario planning is the future of the publically funded healthcare system in Ontario, Canada. Historically, healthcare spending has grown faster than the economy, and with an aging population, this trend is expected to continue. At current growth rates, forecasts suggest that by 2030 Ontario's healthcare spending could consume 80% of the entire provincial budget [57]. To deal with these concerns there has been a growing push towards searching for ways to mitigate these cost increases through alternative modes of delivery including community care, home care and private sector provision. Such alternatives are predicated on adjustments to financing the pay-as-you-go system, meaning that social services such as healthcare are paid for annually by the tax receipts of the same year, and improvements in technologically facilitated delivery. Further complicating matters, however, is the fact that the Ontario healthcare system is, in essence, a social system whose accessibility and universality is considered a fundamental Canadian value. With such an array of complexities, the future of the Ontario healthcare system is replete with uncertainties. This is where the novel application of a structuration approach to scenario planning has a potentially useful role to play. 3.1. Data collection: selecting the actors and identifying structuration features The data collection for the scenario intervention involved both semi-structured interviews and desk-based documentary analysis. Semi-structured interviews were conducted with senior stakeholders in the Ontario healthcare system including: presidents of industry associations representing physicians, hospitals, pharmacists and the community sector; hospital CEOs, representing urban, rural and northern centers; officials within Ontario's Ministry of Health and Long-Term Care who are 678 B. MacKay, P. Tambeau / Technological Forecasting & Social Change 80 (2013) 673–686 responsible for long-range planning; a CEO of a Local Health Integration Network; a former Deputy Minister as well as Assistant Deputy Minister of Health and Long-Term Care in Ontario; and, a former Canadian Senator who is an opinion leader in healthcare. Interview participants were selected based on their representativeness as actors who, either individually or collectively, could “make a difference” by being able to “deploy a range of causal powers” [18 p 14]. Interviews lasted between one and two hours, were digitally recorded and transcribed verbatim. Conversations were semi-structured and participants were asked a range of questions focusing on their perceptions of the past, present and future of the structural features and practices constituting the healthcare system. This also included probing participants on the rules, be they norms and procedures and techniques, and resources, whether allocative or authoritative [18 pp 21, 258, 19 p 695]. Secondary data was also collected through desk-based archival research. Trade reports, policy documents, forecasts, and commentary were collected from dozens of sources to give a broad contextual overview of issues in Ontario's healthcare system such as demographics, inflation, population health statistics, patient expectations, medical practices and technological trends, as well as that of overlapping systems. 3.2. Data analysis Data analysis proceeded in two phases. First, all data was coded based on an iterative process of constant comparison, moving between structuration concepts and data [e.g. 17,18], and it was entered into a data-workbook anonymously and drawn on for the building and analysis of the scenarios. For instance, data was clustered based on whether it pertained to rules and resources (structures), individual practices (agency), and the relationships between the two. Such an evidence-base for scenarios, we suggest, is important for rooting future scenarios in present concerns and causal propensities emanating from the past. This is because the purpose of an intuitive logics approach to scenarios is to explore how such causal forces may interact indeterminately, thus shaping the future in unexpected ways [cf. 27,28]. Scenarios do not belong to history in the same way that, for instance, forecasts do, but any eventual scenario will nevertheless be influenced by it, if in unpredictable ways. In the second phase of the analysis, we drew again on our structuration analysis within the intuitive logics approach to scenario building. From our data-workbook we identified fourteen major drivers of change and we looked at their relative certainty and degree of impact that they would have in the future. Of relative certainty and high levels of impact, for instance, were population growth, annual growth in healthcare spending, the health characteristics of the population, improvements in life expectancies from advances in pharmaceuticals and patient's expectations for healthcare. After identifying such ‘predetermined’ causal forces, structuration theory was used for further refinement of the analyses. Demographic trends, to take one example, can be further distilled into demographic groups, such as the aging but relatively wealthy seniors, the working age population whose growth is slowing, but whose tax revenues are needed to support the system, and new immigrants who will comprise a rising share of population growth, and thus the tax receipts needed to finance different social services. The demographic implications of each group can then be analysed in terms of the structures of domination, legitimation and signification that can enable and constrain change. Of less certainty, but still containing the possibility of high impact were the future outcomes of federal-provincial-territorial renegotiations of the Canada Health Accord governing national standards of accessibility, funding and quality across the provinces and territories, the production and reproduction of medical practices, the role and relative influence (e.g. structures of domination) that patients will take in the management of the system, growth of private sector healthcare delivery (e.g. structures of signification), and the scope and dispersion of medical practices between hospitals, communities and private providers (e.g. structures of legitimation). In this phase of the analysis we adapted the diachronic model to reflect agent–structure interactions for building the scenarios. In identifying and analysing the key actors and the rules and resources they draw upon to enact or resist change, precipitated by contextual changes, structuration theory offers a framework for identifying the drivers of emerging futures in common terms within the scenario planning process [cf. 19]. By contextual changes we mean changes in the set of circumstances that form the backdrop, or milieu, of an event/situation. As Fig. 2 illustrates, we drew on the diachronic model to build the logic around the scenarios in a theoretically consistent way. In the diachronic model we began at point A1, which signifies the current environment. The first set of contextual changes was then introduced, which would disrupt social norms. Based on those contextual events, we identified the key actors who are most likely to enact or resist change (point B1 in the model). In this analysis, the rules and resources that the actors draw upon were evaluated to construct and assess the emerging scenarios. Point A2 signifies new norms, upon which additional contextual events were added. The assessment of actors and the rules and resources they draw upon were conducted again at point B2, eventually achieving a ‘new norm’ at point A3. This analysis was conducted through several iterations until our horizon year, 2025, was reached in each scenario. 3.3. Section summary In summary, a structuration approach to scenario planning directs attention towards actors, the rules and resources (structures) that they draw on, and the contextual changes that emerge from the disruption of social norms and their impact on the structural realm. Where rules and resources constitute the transformative relations of structures, as discussed in Section 5, the scenario logics were built by identifying and then bracketing out how different contextual changes, the source of which could be the reflexive activities of actors and their unintended consequences or structural adjustments based on agent–structure interactions, could result in changes in both the realm of action and the realm of structures. For instance, where scenarios began to emerge from our analysis was in the unpredictability of how rules and resources are recombined over time, how agency– structure interactions would result in unintended consequences resulting in different possible futures, and where certain structures/agents might resist changes. The unintended consequences of reflexive action–structural interactions constitute an B. MacKay, P. Tambeau / Technological Forecasting & Social Change 80 (2013) 673–686 679 Realm of Structure A1 Actors interpret, internalize and enact social norms B1 B2 Identify key actors and the rules and resources they draw upon in the scenario to enact or resist change Identify key actors and the rules and resources they draw upon in the scenario to enact or resist change Contextual Change: Major event or indeterminate interaction of key drivers in scenario disrupts social norms A2 Actors interpret, internalize and enact social norms Contextual Change: Major event or indeterminate interaction of key drivers in scenario disrupts social norms A3 Actors interpret, internalize and enact social norms Contextual Change: Major event or indeterminate interaction of key drivers in scenario disrupts social norms Realm of Action Source: Adapted from [54,55] Fig. 2. A diachronic model of structuration applied to scenario planning. underlying uncertainty within social systems, but can be systematically analysed within a structuration framework. Indeed, the recombination of rules and resources such as the influence of patients in the management of the system, the dispersion of resources from hospitals to community care or private sector provision within the healthcare system and how the structures then influence reflexively the production and reproduction of practices all have different implications for power relations within structures of domination, the institutionalization of novel norms, standards and values within structures of legitimation, and new meanings that may emerge through different interpretations in structures of signification. The criteria used to assess the internal consistency and plausibility of the scenarios thus become their congruence with structuration concepts and what eventualities are possible within agent–structure interactions. In the following section we illustrate the operationalization of a structuration approach in three scenarios that emerged from the scenario intervention. 4. Illustrating the structuration approach within exploratory scenarios In this section, we draw on our adaptation of the diachronic model to illustrate how the interactions between actors, rules and resources occur within a duality of structure to result in different scenarios for the future for healthcare in Ontario. 4.1. A diachronic structuration scenario analysis Three scenarios emerged from our analysis into how Ontario's healthcare system could evolve by 2025. In the first ‘Greying Reality’ scenario, a world is portrayed where an aging population dominates how the system is managed and funded. With the aid of technology, this growing demand forces healthcare to be provided in the home. In the second ‘Power to the Patient’ scenario, a similar picture is painted where most healthcare is delivered in the community. However, it presents a world where patients are the most powerful actors and drive many of the structural changes to the system. The third scenario, ‘A Private Affair’, illustrates a health system where the private sector is permitted to compete with the public sector in delivering care, while still being funded by the government. The logic of each of these scenarios is rooted in different possibilities about how actor–structure reciprocity might emerge over time. 4.1.1. Greying Reality The first ‘Greying Reality’ scenario begins when three contextual changes occur due to actor–structure interactions both within the healthcare system, and also within overlapping systems. In 2014 the provinces renegotiate the Health Accord with the federal government. The federal government has already committed to offering annual funding increases of 6% to the provinces. In return, it is expected that the provinces will agree to improvements in wait times as well as home and community care. While these additional funds will be helpful, provinces will still have to dedicate a larger proportion of resources to fund the system (see Fig. 3). By 2015 there are approximately 500,000 new seniors in Ontario which begin to put increased pressure on capacity. Also, it is anticipated that the government is successful in having every Ontarian included in the electronic medical record. These structural changes enable the government and patients to push for a greater focus on home and community care. Action, therefore, leads to 680 B. MacKay, P. Tambeau / Technological Forecasting & Social Change 80 (2013) 673–686 Realm of Structure A1 B1 A2 B2 Present-2014 • Continued push to community and home care • E-Health expansion • LHINs reformed to enhance effectiveness • Physicians, nurses and hospitals cautiously embrace change • Patients grow more powerful with access to information and continued expectations of care • Government grows more concerned about costs 2015-2020 • Community and home sector growing substantially • Family Health Team model is the norm • Technology helps keep patients home • Hospitals begin to reduce scope • Government begins to take heavy hand in system reform • As a result of new tax, public begins to expect major changes • Hospitals influential in their changing role • Physicians and nurses cautiously embrace change 2015 Contextual Changes: • 2014:Health Accord Renewed • All Ontarians have electronic medical record (EMR) • 500,000 more seniors in the system 2020 Contextual Changes: • Government implements 3% Health Tax • 1,000,000 more seniors in system A3 2020-2025 Horizon Year • A world emerges where an aging population dominates how the system is managed and funded. • With the aid of technology, this growing demand forces health care to be provided in the home. Realm of Action Fig. 3. A diachronic model of structuration for ‘Greying Reality’. structural changes, which then structure further actions as action and structures are mediated by actor reflexivity as they reflect and act on changes to structures of domination, legitimation and signification. In this scenario the greatest changes to the system are introduced in response to structural changes in 2020. At this point in time, an additional one million seniors (compared to 2010) begin requiring, and demanding care. Healthcare spending as a proportion of total government spending grows so large that a 3% health tax and greater co-payments is introduced. This additional revenue helps to maintain the system, but the public's expectations of the system's performance grows, and with it, their import in structures of domination. While the scenario does not anticipate that significant collectivities of actors such as physicians, hospitals and nurses will put forward major resistance to change, their role in system reform cannot be overlooked particularly given their influence in structures of legitimation (e.g. with the production or resistance of new norms etc.) and signification (e.g. interpreting and communicating the meaning inherent in such changes to, for instance, the public). Physicians would be particularly influential in terms of their influence over structures of legitimation and signification in voicing opposition to changes that, in their view, may reduce the quality of care that patients receive. For example, while many physicians are embracing technology today, they may stop short in believing that devices could make decisions in diagnostics and treatments — which is contemplated in this scenario. They would also have to accept changes in scopes of practice such that Physician Assistants, which have yet to be introduced in Ontario, as well as Nurse Practitioners assuming greater roles in primary and emergency care. Hospitals are an important source of influence in terms of both their allocative and authoritative powers within structures of domination given that they control a significant number of people and materials. They would therefore have to be willing to transform into mainly assisted living communities while focusing exclusively on emergency rooms and intensive care units. They are also influential in designing and transferring resources to boutique centers in the community. Nurses would also have the power to influence, particularly, structures of signification given that they are a trusted audience by patients and are more involved on the front-line. Their stake in salaries, seniority and pensions which are tied with hospitals would also be a hurdle to overcome as they shift towards home and community bases. However, the shift towards the community would require more nurses which would give them, as a group, greater influence with decision makers. 4.1.2. Power to the Patient There are many similarities in the analysis between the Power to the Patient and Greying Reality scenarios. The key difference in this scenario is the source of power within structures of domination, legitimation and signification that the public leverages to enact changes in the system. In this second scenario, the creation of a patient's coalition in 2015 would give patients a greater voice in system reform, increasing their influence in structures of signification in particular, especially in the 2016 and 2021 provincial general elections. An unintended consequence of this increasing power in structures of signification is enhancing the role of the provincial government in structures of domination, as an electoral mandate would in effect give the government an enhanced status in structures of domination through increased power over allocative and authoritative resources. While their support of home and community care along with a greater stake in how the system is financed is still relevant (i.e. allocative resources), the size of the group with 1.5 million members would be significant. This would give them greater control over people (i.e. authoritative resources) in terms of grassroots members who could be vocal in change with local decision-makers. The B. MacKay, P. Tambeau / Technological Forecasting & Social Change 80 (2013) 673–686 681 Realm of Structure A1 B1 Present-2014 • Continued push to community and home care • E-Health expansion • LHINs reformed to enhance effectiveness • Patients grow increasingly frustrated with system 2015 Contextual Changes: • Patients Coalition Created • 2014:Health Accord Renewed • All Ontarians have electronic medical record (EMR) • 500,000 more seniors in the system • Patients Coalition becomes powerful voice • Physicians, nurses and hospitals cautiously embrace change • Government grows more concerned about costs A2 2015-2020 • Community and home sector growing substantially • Family Health Team model is the norm • Technology helps keep patients home • Hospitals begin to reduce scope 2020 Contextual Changes: • Referendum endorses income-tested co-payments • 1,000,000 more seniors in system B2 • Government begins to take heavy hand in system reform • Patients Coalition uses enhanced power to drive change • Hospitals somewhat influential in changing role • Physicians and nurses cautiously embrace change A3 2020-2025 Horizon Year • A world emerges where most health care is delivered in the community. • Patients are the most powerful actors and drive many of the structural changes to the system. Realm of Action Fig. 4. A diachronic model of structuration for ‘Power to the Patient’. public's increased access to information which is contemplated in this scenario would also give them greater control over resources (i.e. both allocative and authoritative) and thus enable them to challenge the conventional rules that other actors rely on. A referendum in 2020 where Ontarians choose income-tested co-payments (in effect, an action by government to increase their power in structures of legitimation) is also a major structural event that legitimizes further changes in the system (see Fig. 4). The analysis from ‘Greying Reality’ related to physicians, hospitals and nurses applies to this scenario, although an increase in both government and public power over structures of domination diminishes the influence of hospitals, nurses and physicians in structures of signification. An unintended consequence of this agent–structure reciprocity is that the influence of hospitals, nurses and physicians in structures of legitimation increases as they take actions to resist the increased influence of patients, which would effectively reduce their sphere of power. 4.1.3. A Private Affair The third scenario offers the most radical departure from 2011's reality, which means that a number of actors will deploy a significant amount of resources at their disposal to resist change (see Fig. 5). The introduction of the electronic medical record, the renegotiation of the Canada-wide Health Accord between the federal government, ten provincial governments and the governments of three territories in 2014 ensuring equitable and publicly available healthcare provision across the country, and the existence of 500,000 new seniors in the Ontario healthcare system remain important structural events that will pushes delivery of care out into the community. The additional fact that healthcare would represent 50% of all government spending is significant because it will start to severely limit allocative resources available for other programs, creating tension between overlapping systems and the agent–structural reciprocity that comprises them. However, in this scenario major changes would begin to occur by 2020. The Greying Reality and Power to the Patient scenarios both contemplate additional allocative resources with increasing revenues through taxes or fees by 2020. An unintended consequence of such increased taxation revenues from the public is that the relative power of hospitals, nurses and physicians within structures of legitimation, signification and to a lesser extent domination are maintained. This is not the case in this scenario. By 2020 the key structural events include the additional one million (compared to 2010) seniors who would require care, and healthcare would represent 63% of all government spending. This would cause the government, and the public at large, to become increasingly concerned about the sustainability of the system and their willingness to resource it. This would be particularly the case with the working-age population, increasingly burdened by tax increases, but an increasingly important demographic group in terms of both structures of domination and legitimization. Given this unease, this scenario suggests that the public elects a new government during the 2021 general election with an electoral mandate of major transformations. The government would then act, calling a referendum to provide the public with a direct voice on how the system is managed and funded. Leading up to the referendum, the broader healthcare community would become heavily involved, exercising their power in structures of signification as they sought to interpret the proposed reforms and communicate meaningfully the unintended consequences of them. They would be vocal in drawing upon the societal norms and conventions of a universal, public healthcare system. They would also use their allocative and authoritative resources to fund and organize campaigns. Following such a referendum, by forcing changes through legislation, the government would exert its power in structures of domination to alter 682 B. MacKay, P. Tambeau / Technological Forecasting & Social Change 80 (2013) 673–686 Realm of Structure A1 B1 Present-2014 • Continued push to community and home care • E-Health expansion • LHINs reformed to enhance effectiveness • Patients grow increasingly frustrated with system 2015 Contextual Changes: • Health care = 50% of provincial budget • 2014:Health Accord Renewed • All Ontarians have electronic medical record (EMR) • 500,000 more seniors in the system • Physicians, nurses and hospitals cautiously embrace change • Patients grow more powerful with access to information and continued expectations of care • Government grows more concerned about costs. A2 2015-2020 • Community and home sector growing substantially • Family Health Team model is the norm • Technology helps keep patients home • Hospitals largely stay the same. B2 • Public elects new gov to fix health care • New gov calls referendum • Health care community becomes extremely vocal in referendum A3 2020-2025 Horizon Year • A world emerges where the private sector is permitted to compete with the public sector in delivering care. • The government continues to work with the private sector to fund the system. 2020 Contextual Changes: • Health care = 63% of provincial budget • 1,000,000 more seniors in system. Realm of Action Fig. 5. A diachronic model of structuration for ‘A Private Affair’. the rules and resources within the system, effectively diminishing the power of hospitals, nurses and physicians to exert power in structures of legitimation to resist change. Forcing efficiency through changes to the OHIP (Ontario Health Insurance Plan) formulary and procurement mechanisms would also be significant. The federal government would also be relevant in this scenario given that changes in the Canada Health Act, which is national legislation, may be required. The actions of the government would be legitimized by the choice that the public made through the referendum, but as the changes are enacted and the consequences (both intended and unintended) of the depth and breadth of the changes become clear, elements of the public would begin to support the positions of the wider healthcare community, bolstering their power within structures of signification and legitimation. Once private sector provision, however, is enabled through structural changes to the system, they become powerful actors, and many physicians begin to defect from the public sector to the private sector motivated by a profit incentive. They thus become influential in their ability to provide services at a lower cost than the public sector, partly because they are not as encumbered by the public interest motive, but a profit motive. An unintended consequence of this scenario, then, is that as private sector actors begin delivering services, the structures would be modified further. This, on the one hand, reflexively creates more demand for still greater private sector provision as these actors seek to expand their businesses, but on the other hand, it erodes support with elements of the disaffected public who have difficulty having their needs met as they find their relative power within a mixed system reduced. 4.2. Section summary This section has drawn on structuration theory to demonstrate how it can be usefully applied to scenario planning. The diachronic model that we have adapted allows for the bracketing out of periods of time into the future so that agent–structural interactions can be analysed. The three scenario exemplars that we use to illustrate the structuration approach reflect three different sequences of agent–structural reciprocities, but constructed through the application of a consistent set of concepts informed by structuration theory. In the following section we reflect on the potential contributions and limitations of such a structuration approach. 5. Discussion The research question that this article has sought to address is how structuration theory might provide a useful, theoretically informed framework for constructing scenarios? Given the widespread application of structuration concepts in the study of management, we premised our study on the assumption that it might also be usefully drawn on to extend scenario praxis methodologically and theoretically. We have, therefore, sought to address our research question by applying concepts from structuration theory and a diachronic model of structuration to an exemplar of three exploratory scenarios. While in its original formulation structuration theory was meant to appeal more to ontology than to epistemology, its application to scenario planning renders a theoretical framework of logically coherent concepts [58]. Such concepts allow, for instance, the structural features of social systems driving future scenarios to be analysed in common, consistent terms [19]. It also suggests that the source of uncertainty in the future is not the structural features (whether they be economic, political or technological factors, all of which are, in themselves, determinable), or agents (whose behavioral predispositions are analysable individually), but the complexity of agency–structure interactions resulting in discontinuities and unintended consequences. B. MacKay, P. Tambeau / Technological Forecasting & Social Change 80 (2013) 673–686 683 Structuration theory, as essentially a processual theory concerned with how patterns in social systems change and exist over time, applied diachronically rather than synchronically as we have done here [cf. 54,55], helps to overcome some of the analytical challenges within scenario methods of identifying agents, structures and the indeterminacies arising from their interactions [e.g. 29,40], which can result in unexpected futures emerging within social systems. A structuration approach to scenario planning thus adds to the existing scenario literature [e.g. 2–16] by bringing a new dimension that offers a common set of ontological and epistemological axioms that, when operationalized, can guide practices. The diachronic model, for instance, as the scenario analysis above demonstrates, permits the bracketing of different time periods into the future and sensitizes the practitioner/researcher to structuration concepts that illuminate such aspects as how structural features might constrain and enable the activities of actors, how these activities might then shape structural features, and how those structural features will then reflexively influence further agent–structural dynamics. A structuration approach to scenario planning, therefore, arguably integrates ontological and epistemological considerations into a mutually-reinforcing dynamic that enhances the conceptual rigor and logical consistency of both the building and interrogating of scenarios. In Table 2 we break down the scenario planning process used in the exploratory scenarios constructed here with the different concepts from a structuration framework to illustrate at what points elements of structuration theory can be used within scenario methodologies. Table 2 Integrating structuration theory with the scenario method. Scenario step Structuration theory Exemplar 1. Defining the focal issue, setting The actors who have the potential to ‘make a difference’ • Growing concern over the healthcare system's viability in the future; parameters of the study including with the rules and resources constituting structures over • The Ontario Health Care System to 2025; time horizons what stakeholders to time. • Senior stakeholders in the Ontario health care system include. including. Interviews and secondary data collection. Collecting 2. Conducting extensive primary and Perceptions of the past, present and future of the data on the rules, be they norms and procedures and secondary research structural properties and practices constituting the techniques, and resources, whether allocative or health care system. authoritative, of the system. 3. Identifying key drivers/trends Actors and structures of domination, legitimation and Major drivers of change with ‘high impact’ for the future. signification. Predetermined: e.g. population growth, annual growth 4. Distinguishing between whether they Rules and resources, structures of domination, in health care spending, the health characteristics of the are predetermined or uncertain legitimation, signification, relative influence of actors population, improvements in life expectancies, patient's and structures within interactions over time. expectations. Uncertainties: production and reproduction of medical practices, the role of patients managing the system, growth of private sector health care delivery and the scope and dispersion of medical practices. 5. Rolling out a sequence of events that Diachronic model bracketing time between the present • Beginning with the current environment, contextual changes are introduced disrupting social norms. provide the core logics of the scenario and future horizon year to analyse actor–structure • Identifying key actors who are most likely to enact or interactions. stories resist change. • ‘Elderly Realities’ scenario, growing demand forces 6. Writing a set of learning scenarios Narratives around the main actors (including health care to be provided in the home. motivations and predispositions), interactions with • ‘Empowered Patients’ scenario, patients are the most structures and dialectics of control. powerful actors and drive many of the structural changes. • ‘Private Involvement’ scenario, the private sector is permitted to compete with the public sector in delivering care. • Do scenarios reflect the actors able to ‘make a 7. Testing combinations of scenarios for Ensuring that scenarios are consistent with difference? structuration concepts (structures as enablers and their internal consistency/ constrainers) and the diachronic model. The unintended • Are structures of domination, legitimation and signiplausibility/surprise fication considered? consequences of action. • Have the scenarios considered dialectics of control? • Have scenarios analysed the role of reflexivity and unintended consequences? 8. Revising the scenarios to produce Further refining the scenarios based on the outputs from N/A decision scenarios step 7. 9. Selecting warning signals for the Actor–structural interactions, changes in structures of • Changes in legislation; scenarios domination, legitimation and signification. • Changes in financing; • Actor activities and relative influence (e.g. government, healthcare community, public). 10. Linking the scenarios to strategy Strategic issues emerge from different patterns of actor– • Strategic issues in the Ontario healthcare system will include the increasing influence of an aging populastructure interactions and the contextual changes these tion, how and who will fund the system, hospital affect over time depending on the perspective they are design based on the dispersion and transformation of viewed from. medical practices, use of technology, the influence and management of the private sector etc. 684 B. MacKay, P. Tambeau / Technological Forecasting & Social Change 80 (2013) 673–686 The scenario process that we have followed is illustrative and, depending on the scenario planning context, may require different combinations or sequences of structuration concepts to be used at different stages. Where our scenario process has been inductive, allowing the scenarios to emerge from the data, for instance, deductive approaches that begin with the framework of the scenarios and then fit the data with the stories to ‘back-cast’ their logics would use these concepts in different configurations. It is this flexibility to draw on a constellation of structuration concepts that allow for their adaptation to a variety of scenario methods. In addition, a structuration approach does not need to be viewed as an alternative perspective on scenario planning theory and practice, but as a framework capable of also accommodating recent refinements such as the incorporation of, for example, disruption theory and systems analysis [e.g. 11] or decision analysis [e.g. 16] in its broader structuration lexicon. As a network of concepts formulated to be used selectively rather than en bloc [58], structuration theory thus permits theoretical adaptability within different contexts. While such a framework eschews the theoretical and methodological purisms of alternative approaches put forward by its critics [e.g. 48–52], such flexibility prevents methodological determinism, whereby there is a risk that rigid application of methods predetermines the outcome of the analysis. Indeed, Giddens argues that structuration theory should be adapted based on the research question being studied. In this study we have elected to use scenario planning to consider alternative futures for Ontario's healthcare system. Such a research question, or ‘focal issue’ in scenario terminology [cf. 3], which focuses on societal changes, lends itself well to drawing on structuration concepts that explore the role of agency, structure and power within a changing societal context over time. Structuration theory is not the only way of understanding the world, but it is a way. It integrates dualisms including individuals and institutions, the micro and the macro, objectivity and subjectivity, into its accounting of social phenomena without giving primacy to one over the other. Such dualisms inherent in wider social theory also pose challenges for scenario planning, which deals with the world of facts and the world of perceptions, certainties and uncertainties, systems and actors, the micro and the macro [27,28]. Structuration theory, however, goes further and places human activity in its cultural and historical contexts, and implies that future possibilities arise from an unpredictable recursive relationship between agency and structure, thereby providing an explanatory logic. These dualisms, and the cultural and historical contexts that they are embedded in, are no less salient in our exploratory study of the facts and perceptions surrounding the Ontario healthcare system with its multiplicity of structural features at a macro level and plurality of actors at a micro level. A simple process of ‘bracketing out’ time periods does not necessitate drawing on a structuration logic, of course, but by bracketing out the rules and resources constituting structures and systems, and the strategic conduct of actors/social collectivities so that their reciprocal production and reproduction can be analysed dynamically, it provides a window through which to view the contingent nature of social phenomena. Intuitive logics approaches to scenario planning focus on how predetermined elements – things that have happened or are likely to happen, but the consequences have yet to unfold – and critical uncertainties – those elements whose consequences are uncertain – interact over time to produce qualitatively different futures [cf. 3,16,27,28]. Where some scholars caution that this approach is often ‘subjective and heuristic’ in nature [33 p 288], a structuration approach addresses this issue through the provision of a framework that facilitates systematic analysis of the interplay between such elements driving the future (e.g. in terms of differences in behavior, individual and collective interests and the power of different actors to mobilize resources, and the various rules and resources that constitute structure and give systems their character), thereby setting the parameters of possibility (i.e. the range of uncertain futures reflected in the scenarios) and interpreting the findings (i.e. such as the implications of events/interactions at subsequent points in time that form the causal logic leading to a given scenario). In the following sub-section we engage in some reflexive critical reflection of the limitations of our study and the avenues of further research that a structuration approach opens up for scenario planning praxis. 5.1. Critical reflections, limitations and future research There are several critical reflections and limitations of our study worth noting. First, as a body of ‘sensitizing concepts’ we have elected to focus on agents and structures within structuration theory from the perspective of Ontario's Ministry of Health and Long-term Care. Of course, some scholars might point out that what constitutes ‘agency’ for one actor may well constitute ‘structure’ for another. Such an implied criticism revives older distinctions between ‘objectivist’ and ‘subjectivist’ social theories, which a structuration approach attempts to reconcile. A structuration approach suggests that human activity is influenced by wider socio-structural contexts and vice versa. They are, therefore, not completely separate entities, but one constitutes the other. Moreover, reifying actors and structures as and within fixed stabilities, as some sociological perspectives can be inferred to do [cf. 62], negate the possibility that structuration is a continuously changing process. Second, we have sought to illustrate how a structuration approach can inform scenario methods through an exploratory study of the future of Ontario's healthcare system. A thought exercise of the sort presented here might seem self-serving to some, and of course we acknowledge that our methods will have had effects, producing part of the worlds that we purport to be studying [cf. 63]. However, our purpose has been to illustrate how a structuration framework might be operationalized usefully and drawn on to extend scenario planning praxis, and while mindful of our own professional biases, we have approached this project in the spirit of intellectual enterprise rather than market opportunity. Third, we have not sought to incorporate refinements of structuration theory into our analysis. The work of, for instance, Stones [58], who has introduced a quadripartite cycle that breaks the duality of structure down into internal structures (of the agent), active agency (the dynamics of internal structures), external structures (such as the conditions of action), and outcomes (be they events and/or structures), could be quite usefully used in further research and practice when analysing the forces driving the future. DeSanctis and Poole [59] have also adapted structuration theory to capture the complexity of social interactions and structural emergence within the context of group decision support systems. Their analytical strategy B. MacKay, P. Tambeau / Technological Forecasting & Social Change 80 (2013) 673–686 685 may also offer further insights into how key interaction processes can be studied in scenario methodologies. In addition, considering how actors use and reproduce such practices as scenario planning themselves, as DeSanctis and Poole do with technologies in an IT context, offers an intriguing future research direction. In our exemplar we have used structuration theory and the diachronic model to build three scenarios. Concepts from structuration theory, including structures of domination, legitimation, and signification, as well as the rules and resources (both allocative and authoritative) that constitute structure, and concepts of agency (be the government, the healthcare community or the public) have been drawn on, but without recourse to any strict protocol. Such an analysis differs from, for instance, Giddens' strategic conduct analysis, which focuses on analysing the contextually-specific activities, knowledge and motivations predisposing actors towards certain choices within a dialectic of control [18]. Incorporating a strategic conduct analysis into a wider structuration approach to scenario planning could unlock insights into the agentive predispositions of actors in a specific context. 5.2. Contributions Our article, consequently, makes three contributions to the literature. First, we contribute to the emerging scholarly program of study into scenario planning [e.g. 2–16] by demonstrating that with some adaptation, structuration theory can further enrich conceptually this area of management practice by directing attention to the role of agents, rules, and resources that constitute structural changes between the structural realm and the realm of action. Second, we advance methodologically scenario planning by drawing on structuration concepts and the diachronic model of structuration [cf. 54,55] to illustrate how structuration theory can be fruitfully applied to the construction of scenarios. It therefore builds on the work of both practitioners [e.g. 26–28] and scholars [e.g. 2–16] who have been progressing incrementally the intuitive logics approach to scenario planning. Finally, through the action-research [e.g. 60,61] application of structuration concepts to an exploratory scenario planning exemplar, we contribute to praxis by operationalizing several theoretical concepts from structuration theory [e.g. 17–19] for the study of the future. While structuration theory enjoys a long and distinguished lineage in the wider social sciences [e.g. 19,54–56,59], as far as we are aware, it has not been used in a scenario planning context. 5.3. Section summary In this section we argue that structuration theory provides a network of concepts that can be used to consistently and systematically build theoretically infused scenarios. Such an approach, however, should not be used unreflectively. While we were looking at uncertainties on a societal level, in fast moving industries the appeal of a structuration approach may be limited. Alternatively, if structuration concepts are considered a repertoire of sensitizing devices to be used critically and selectively, it offers a flexible and transferable approach for conducting scenario planning in common terms. 6. Conclusions We began this article by asking how structuration theory might be usefully applied to scenario planning praxis. To answer this question we have demonstrated through an exploratory scenario planning exemplar into the future of Ontario's healthcare system how building and analysing scenarios within the duality of structure collapses dichotomies, such as the micro–macro, object-subject and agent–structure dualisms, and directs attention to the reflexive relationship that exists between the realm of action and the realm of structure, including the virtual rules and resources that are drawn on to precipitate structural change. Structuration theory, we conclude, is a useful framework for extending scenario planning praxis in sociological terms. 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His main areas of consultancy and research interest are in the areas of emergence in strategy formation and implementation processes, non-linear dynamics of managerial-firm–environmental interactions and their implications for wealth creation, and the application of scenario thinking in decision-making contexts characterized by complexity and uncertainty. He works with companies in diverse industries including automotive, the cultural industries, financial services, general manufacturing, government, military and oil and gas. His research has been published in a number of leading scholarly journals and books. He holds a BA from Dalhousie University in Canada, and an M.Litt (MSc) and PhD from the University of St Andrews in Scotland. Email: Brad.MacKay@ed.ac.uk. Paul Tambeau is a senior consultant with KPMG's health care advisory practice. Before joining KPMG, he was a senior associate with MacPhie & Company where he provided strategic advice to senior-level clients in the health care and government sectors in the areas of strategic planning, market research and project management. Prior to his consulting career, Paul was an advisor to a Cabinet Minster on health care issues and was VP Finance of a multi-million dollar organization. He holds a BA from Wilfrid Laurier University in Canada, and an MBA from the University of Edinburgh Business School in Scotland. Email: ptambeau@kpmg.ca.