Legitimizing a world-class hospital: policy mobility and narratives in megaproject planning

ABSTRACT

Megaprojects are vehicles of change and spatial products of policies from near and far. In this paper, we demonstrate how insights from the policy mobility literature can contribute to a critical analysis of the legitimization of megaprojects. Through a study of the planning of a new ‘world-class' hospital in Stockholm, we show that ideas, experiences and practices from abroad played a decisive role in legitimizing this megaproject. Policies mobilized from elsewhere were strategically used to construct, modify and (re)present a legitimizing narrative centred on the aspiration of excellence and international competitiveness. This narrative emphasized the need to transform both the spatial structure and the organization of the studied welfare institution based on political and value-based rationalities. Initial international references and ideas were adopted in an unstructured and selective manner, but proved enduring throughout the extensive planning process and were eventually consolidated into a coherent concept, effectively excluding alternative development paths. The vague notion of ‘world-class' functioned as a ‘magic concept’ that strengthened this narrative, rendering the project difficult to criticize. In conclusion, the paper emphasizes the importance of considering the temporal dimension of planning processes alongside the relational geographies of policy-mobility in megaproject analyses.

KEYWORDS:

• Megaproject
• policy mobility
• legitimization
• narrative
• planning
• Stockholm

Introduction

Megaprojects are large, complex and transformational (Flyvbjerg 2014, 6). These sizable projects are gaining global prominence and are prevalent across various sectors, including urban development, mining, infrastructure, and mega events (Clegg et al. 2017; Söderlund, Sankaran, and Biesenthal 2017; Ullberg, Körling, and Strava 2023). Megaprojects usually cost a minimum of one billion US dollars (Flyvbjerg 2014, 6) and they hold promises of enhanced productivity and competitiveness, higher quality of infrastructure and services, new employment opportunities, and environmentally sustainable solutions, etc. Historically, however, the performances of megaprojects have been remarkable poor (Flyvbjerg 2014; Miller and Lessard 2008). Megaprojects consistently exceed their budgets and timelines, and they are often characterized by democratic deficits and misinformation concerning risks, costs, benefits and timetables (Flyvbjerg 2014).

Previous research has explored the decision-making processes behind megaprojects, including their underlying rationalities and logics (e.g. Clegg et al. 2017; Flyvbjerg 2017; Flyvbjerg, Bruzelius, and Rothengatter 2003; Giezen, Bertolini, and Salet 2015; Priemus, Flyvbjerg, and van Wee 2008; Ronnle 2017; Söderlund, Sankaran, and Biesenthal 2017). It has been demonstrated that megaprojects are technologically, politically, economically and aesthetically sublime (Flyvbjerg 2014). Hence, narratives about the greatness of megaprojects and feelings of excitement, rather than rational decision-making processes, are of great importance in explaining these sizable projects (Clegg et al. 2017). A few studies have further highlighted the role of international expertise and consultants in the creation and dissemination of narratives and ideas framing megaproject planning (e.g. Aoun and Teller 2016; Coaffee 2013; Rapoport and Hult 2017). Yet most megaproject analyses focus on the processes and relations within local project organizations. The global embeddedness of contemporary megaproject planning, and how international referencing is used to create narratives in support of specific projects, therefore, needs more attention.

In this article, we aim to contribute to the emergent research on the complex relational geographies of megaprojects and their glocal embeddedness in international policy mobility circuits (e.g. Aoun and Teller 2016; Brill and Conte 2020; Prince 2012; Silvestre and Jajamovich 2022). We do this by analysing how policy and ideas from abroad were used to legitimize the new university hospital Nya Karolinska Solna (NKS) in Stockholm, Sweden. Drawing on the literature on narratives in planning and policy mobility, this paper illustrates how international referencing was used to portray the decision basis of this megaproject as rational, even though the international experiences referenced were actually handled in an unstructured manner and selected on basis of political and values-driven rationalities. In this political process, the expression of a world-class aspiration was used as a powerful rhetorical tool that helped legitimize and de-politicize the megaproject.

The paper is structured as follows. In the initial section, we introduce the new university hospital Nya Karolinska Solna (NKS) in Stockholm. Thereafter, we introduce the larger research project that this paper originates from and present the methods and material that this paper builds upon. Subsequently, we introduce the literatures on how narratives are used to legitimize (megaproject) planning, the idea of ‘magic concepts’, and the role of policy mobility in these processes. Thereafter follows our document analysis, divided in three parts, that traces how international experiences and references were used to legitimize NKS from the initial project reports to the materialization of the project. The paper culminates with a conclusion that emphasizes that the extra-local spatiality of megaproject legitimization is highly political and that the assembling of international experiences in the initial phase of policy formulation may play an important role in how megaproject planning unfolds.

The megaproject Nya Karolinska Solna (NKS)

Megaprojects are transformational and ‘not just magnified versions of smaller projects’ (Flyvbjerg 2014, 6). Hence megaprojects might potentially change society in profound ways (Clegg et al. 2017). One interesting example of a megaproject in the welfare sector is the new university hospital Nya Karolinska Solna (NKS) in Stockholm, Sweden. NKS has all the traits of a megaproject in terms of scale, complexity and transformative efforts (Flyvbjerg 2014), given the high cost of the project, the sizable building complex constructed, the intricate planning and management that included multiple public and private stakeholders, and the aspiration to reshape the healthcare landscape in Stockholm, as well as potentially Sweden, which developed over time.

Indeed, NKS has been described as one of Sweden’s largest healthcare projects and it has faced criticism for being among the world's costliest new university hospitals. In 2020, the Stockholm Region estimated the total costs of building, equipping, and managing the hospital until 2040 to be around SEK 57 billion (equivalent to circa 5.5 billion USD) (SOU 2020:15, 332).

Swedish media has continuously covered the project since 2015, closely scrutinizing the decision-making process, the high costs of the project (Ennart and Mellgren 2016), as well as the involvement of management consultants and the introduction of a new healthcare model (Gustafsson and Röstlund 2019). However, the story of NKS began in the 1990s, when the old hospital Karolinska in Stockholm, constructed in the 1940s, needed renovation. The poor condition of the old hospital created a window of opportunity for policymakers and enabled the ideas of creating a new hospital to enter the political agenda (Grafström, Qvist, and Sundström 2021, 82f.; Meijling 2020, 208). Policymakers saw an opportunity to construct a world-class hospital in the Swedish capital, which would help Stockholm ‘reclaim a leading position in the world both in terms of research and clinical operations’ (SLL 2001).

In 2001, a proposal to construct a new hospital was presented to the regional council in Stockholm. In accordance with the formal rational decision-making model fundamental to the Swedish government system, an investigation period then started prior to the formal decision to build the hospital was taken by the regional council in 2008. The actual construction of the building complex started in 2010 and the hospital was inaugurated in May 2018 (Grafström, Qvist, and Sundström 2021). The NKS project has been a technologically advanced construction project aimed at creating a modern and flexible hospital complex. Today, the hospital is one of the largest university hospitals in Europe, with 1,4 million annual patient visits and more than 16 000 employees (Karolinska Universitetssjukhuset 2024).

Importantly, however, the decision-making process behind this megaproject has not been linear, but rather episodic (Grafström, Qvist, and Sundström 2021; cf. Miller and Lessard 2008). The starting-point for the project was not an analysis of care needs or healthcare planning (Meijling 2018, 21; Öhrming 2017), but based on the material condition of the old hospital and the development potentiality of its geographical location. As in most megaprojects, it is difficult to clearly distinguish between a decision-making phase and an implementation phase in the NKS project since decisive decisions have been made in parallel throughout the project. However, decisions made during different phases or periods in the project have had significant impact on the subsequent phases, i.e. early decisions such as directives for the early investigations have been formative in the project (Grafström, Qvist, and Sundström 2021; cf. Priemus 2008).

Politicians in the regional council have been key actors in the project but ‘policy entrepreneurs’, including medical and clinical researchers, professional medical advisors, high-level public officials and management consultants, have also been crucial in the formulation and formation of the project (Grafström, Qvist, and Sundström 2021; Johannesson and Qvist 2020), partly through the international study trips and search for global inspiration discussed below. In the Swedish welfare system, the directly elected regional authorities are responsible for providing healthcare, but the decentralized system has since the 1990s become increasingly market-oriented. The regional authority in Stockholm has been particularly keen to implement new public management ideas (Grafström, Qvist, and Sundström 2021; Meijling 2018). For example, it uses a demand and supply model in which healthcare is administrated and financed through the public authority but delivered through both public and private service providers (Dabhilkar and Svarts 2019). New management models were also key policy ideas that shaped the NKS-project and implied that the new hospital introduced a new healthcare model organized around thematic care instead of clinics (Grafström, Qvist, and Sundström 2021; Meijling 2018). Moreover, a public-private partnership (PPP) arrangement was used for the procurement and funding of this project even though healthcare in Sweden generally is publicly financed.

Previous research has shown that the construction of NKS not only aimed to create a modern hospital building. Over time, the project also sought to (a) reform the healthcare system in Stockholm, possibly extending to all of Sweden, and (b) establish a world-class life sciences cluster (Grafström, Qvist, and Sundström 2021). As such, the planning of NKS functioned as an experimental site for new ideas and policy reforms related to health management and this megaproject came to inhabit transformational aspirations on multiple scale levels (Grafström, Qvist, and Sundström 2021). In addition, the NKS-project was planned and developed simultaneously with a large-scale urban redevelopment project that aimed to transform the former logistics and transit area surrounding the hospital into an attractive urban district (Smas 2021). The relations between these projects were complex (Swanson 2012), but research has shown how the seemingly contradictory concepts of competitiveness and collaboration were an organizational ideal in Stockholm during this time (Kaiserfeld 2023). The City of Stockholm was expecting SEK 70 billion (equivalent to circa 6.7 billion USD) to be invested in this urban district with space for 50,000 new jobs and 6000 new homes on an area of 96 hectares (Stockholms stad 2023), making the hospital an important element in the city’s long-term urban development plan and vision to become a world-class city. As such, NKS was in several respects a ‘trait making’ and not ‘trait taking’ megaproject (Flyvbjerg 2014, 6).

NKS is an interesting case of how megaprojects may transform society through multiple policy reforms. Several studies have provided in-depth insights into the organization, ideas and actors involved in the decision-making process behind this megaproject (e.g. Grafström, Qvist, and Sundström 2021; Meijling 2018; Öhrming 2017). In this paper, we focus on how ideas from abroad were used to help legitimize this megaproject, and thus highlight how the policy mobility literature can help us better understand the mechanisms of megaproject planning.

Tracing extra-local narratives through document analysis

This paper is a result of the larger research project ‘The university hospital of the future – decisions on Nya Karolinska Solna’, which analysed the organization, ideas and actors involved in the decision-making process of this megaproject. This research project included researchers within the fields of political science, management and organizational studies, as well as human geography. It was based on qualitative analysis of an extensive set of empirical material, including interviews, documents and media reports. The main results of the project have been disseminated in Swedish in the book Megaprojektet Nya Karolinska Solna (Grafström, Qvist, and Sundström 2021) but also in nine independent reports.¹

In this paper, we focus on five bundles of important documents produced in the planning process of NKS, which all include international referencing. We used a material-semiotic approach to analyse how ideas and practices from abroad were presented and used in project reports to create a policy narrative aiming to legitimize the construction of the new university hospital. While most studies on policy mobility have followed an existing policy or model, and how it transforms during the process of travel and implementation, our research strategy is more similar to Brill and Conte’s (2020) approach of ‘following a project’. Through a document analysis, we direct attention to how international ideas, experiences and practices were documented, represented and used at different stages in the NKS planning process and how this served as foundation for decision-making in this megaproject.

Documents are instrumental in planning and policy making not only as knowledge containers and calculative artefacts (Rydin 2014), but also as devices and narratives defining and continuously modifying the issue at hand (e.g. the problem-solution nexus in megaprojects). Documents are representations of reality but they are also ‘working upon, modifying and transforming that reality’ (Asdal 2015, 74). As such, they are crucial in the formation of the ‘issue’ at stake, and document analysis can reveal how an issue is translated and transformed through the ‘modifying work that goes on in paperwork’ (Asdal 2015, 76).

The documents analysed in this paper are official and published by Stockholm County Council (SLL),² but different parts of the documents were written and produced by other actors. Four of the documents have been main references in the decision-making process of NKS and the reorganization of healthcare in the region: Investigation of a new university hospital (2002)³; Investigation of Stockholm’s healthcare structure (2004); and Proposal Concept Business content: Nya Karolinska Solna university hospital (2009); and Nya Karolinska Solna – goal and business orientation (2011). The fifth document analysed, Study trip to Cleveland Clinic, Memorial Sloan Kettering Cancers Center and New York-Presbyterian. 29/8-2/9 2010. Reflections from representatives from SACO, Vårdförbundet, Kommunal, SKTF samt NKS management (2010), gives specific insights into one of several study trips that was conducted during the planning of NKS, and is therefore of relevance for this paper. The selected documents are strategic documents instrumental in the structuring of the project and its decision-making procedure (Brorström, Grafström, and Hallström 2022) and include both early investigations produced before the formal decision to construct the hospital was made and reports developed thereafter. The full reports, including the numerous attachments, have been closely read (Asdal 2015), yet the analysis presented here focuses on the parts of the material in which international referencing is present.

Our involvement in the larger research project about the decision-making processes behind NKS have provided us with contextual knowledge of the project at large, which enables us to contextualize our close reading of certain sections of the main documents behind NKS.

Narratives and policy mobility in megaproject legitimization

The planning and implementation of both policy and megaprojects are complex processes that depend not only on technical and instrumental decision-making processes and management procedures driven by rational choices, but also on the elements of excitement, compelling narratives, and political strategies (Clegg et al. 2017; cf. Fischer and Forester 1993). Hence, both factual and non-factual information play critical roles in the legitimization processes of megaprojects, i.e the reasoning that answers questions of why something should be done and why it should be done in a particular way (Van Leeuwen 2007). It is therefore of importance to analyse what information is being used in the planning of a specific megaproject, how this information was generated, and how that information informs decision-making (de Bruijn and Leijten 2008; Ronnle 2017).

Megaprojects are not simple solutions to predefined problems; solutions and problems are intertwined and formulated throughout the decision-making process, which is often driven by narratives rather than strictly rational methods. Narratives produced in support of a specific megaproject benefit from these projects being technologically, politically, economically and aesthetically sublime (Flyvbjerg 2014). However, these narratives often incorporate elements from both instrumental and communicative rational decision-making approaches (Grafström, Qvist, and Sundström 2021; Ullberg, Körling, and Strava 2023). From an analytical perspective, it is thus important to make visible how different narratives and rationalizations are used to legitimize both processes and the problem-solution nexus, i.e. the issue (Asdal 2015). Emphasizing the narrative aspect should not be conflated with a communicative planning ideal. Instead, it should be seen as a critical perspective where the narrative becomes a lens by which to understand power dynamics and the intersections between communication, language and knowledge in planning (Grafström, Qvist, and Sundström 2021; cf. Fischer and Forester 1993; Innes and Booher 2015).

The word ‘world-class’ has gained popularity in policy circles and is often used in narratives about megaprojects to demonstrate their aspiration to be of global relevance. This concept is thus a signifier of what Roy and Ong (2011, 3) have termed ‘worlding practices’, or the ‘ongoing art of being global’. Cities, businesses, universities and hospitals across the globe increasingly aspire to be of global relevance. World-class is a very broad and vague term with a clear positive connotation that rapidly has gained global popularity, and which is difficult to be ‘against’. It can thus be considered a ‘magic concept’ (Pollitt and Hupe 2011). Magic concepts share four characteristics: (a) broadness, (b) normative attractiveness, (c) ability to create consensus, and (d) global marketability (Pollitt and Hupe 2011). Given their vague definition and the lack of opposition against them, magic concepts work to depoliticize certain policy knowledge and can help to create consensus around specific policies. As such, the dubbing of a project as world-class in strategic documents can hide disagreements and de-politicize its planning and implementation. Furthermore, by describing a project as world-class, attention is drawn to it in a spectacular manner, which helps to mobilize support for it and legitimizes it through supposedly rational arguments and narratives (cf. Fischer and Forester 1993; Van Leeuwen 2007). Yet it is also easy to ignore the (vague) content of world-class when the idea is translated into practice (Ramirez, Byrkjeflot, and Pinheiro 2016).

Although the world-class idea is vague, it is intimately connected with a number of underlying ideas and practices, where its core significance revolves around the importance of positioning oneself internationally based on a market-liberal logic (Ramirez, Byrkjeflot, and Pinheiro 2016). The world-class idea reflects the increase in international management consultants, which has created a demand for measurements and comparisons of places and activities internationally (cf. Aoun and Teller 2016; Coaffee 2013; Rapoport and Hult 2017).

The comparative and competitive component of the world-class concept points to the importance of a relational understanding of policy, which is emphasized by the ‘policy mobility’ literature (e.g. McCann and Ward 2012; Peck 2011; Temenos and McCann 2013). A relational understanding helps us grasp how places elsewhere shape policy and planning locally and we thus conceptualize the (re)production of policy and planning as ‘extra-local’ processes (Baker and Ruming 2015; Temenos and McCann 2012). Previous research shows that travelling policies are always translated and transformed along the way and adapted in different ways to the new place of policy formulation and implementation. Policy thus seldom travels as a complete package, but rather in pieces assembled from near and far (McCann and Ward 2013).

The empirical focus of the policy mobility literature has been on how travelling policy and policy knowledge shape national and urban policy documents and plans formulated by state actors (e.g. McCann and Ward 2013; Prince 2010; 2012; Temenos and McCann 2012). More recently, policy mobility within the private sector has also gained attention (Brill and Conte 2020). Less focus, however, has been on policy mobility in relation to welfare institutions, such as hospitals, which is problematic given the important role welfare institutions have in contemporary societies.

In contrast to the more traditional ‘policy transfer’ approach developed within political science, the policy mobility literature stresses that policies are formulated through social relations and that actors and artefacts, such as documents, move policy around for political purposes (Temenos and McCann 2013). Political objectives and strategies as well as emotional reasoning is thus of great importance in this process. As such, the dissemination of policy from one place to another is not primarily motivated by instrumental or technical arguments, even though it might be framed as such (McCann and Ward 2012), which emphasizes the importance of recognizing underlying value-based rationalities in the analysis (cf. Buunk and van der Weide 2015; Flyvbjerg 2004).

Study tours constitute one key mechanism for the dissemination of policy (Baker and McGuirk 2019; Cook and Ward 2011). The possibilities for digital interaction have rapidly increased during the last decades and information on ‘best-practice’ and new policy is highly accessible, yet ‘visiting other places continues to be regarded as a valuable learning technique’ in planning circuits (Cook and Ward 2011, 2531f). But policy tourism is not only about learning. Montero (2017, 346) has shown how study tours also work ‘as instruments of governance able to create and expand local coalitions that would push for particular policy solutions’.

Similarly, Kennedy (2016) reminds us that even though ideas from elsewhere are important, we still need to pay close attention to local politics and the importance of argumentation in local policy-making. At times, policy makers are indeed ‘mobilising different elements of international projects’ in order to legitimize ‘their own visions’ (Brill and Conte 2020, 92; see also Baker and McGuirk 2019). In addition, the link between the referred place and the proposed policy may be symbolic rather than closely related (Peck and Theodore 2010). As such, policy mobility is part of narrative policy making. Honeck (2018, 133) has showed that policy narratives ‘work with association as well as imagination and thus emphasize the non-factual’. These narratives also carry with them a transformative power, given that the authority of references to policy elsewhere is primarily given by the policy’s demonstrated ‘success in transforming a place, social group, organization or something else’ (Andersson and Cook 2019). Factual or not, imported policies can be used to (a) formulate problems that need to be solved locally, and (b) legitimize specific solutions to these problems based on policy elsewhere. Consequently, other possible problem formulations and solutions are often left out from local processes of policy making (Temenos and McCann 2012).

Below, we seek to demonstrate that research on megaprojects can benefit by expanding its analytical horizon to incorporate more extra-local policy processes. The policy mobility literature and the idea of ‘magic concepts’ offer useful insights on how the legitimization of megaprojects may take place through the creation of policy narratives that partly build upon references to practices abroad. In the case of NKS, we suggest that the concept of ‘world-class’ functioned as a magic concept and played an important role in creating a narrative on the new hospital’s need for excellence and transformation, which helped legitimize the coming into being of this megaproject. In addition, we argue that documents as material and semiotic artefacts are important governance instruments and crucial in mobilizing and assembling narratives that are used to formulate and implement policy. A better understanding of how megaprojects are legitimized through non-rational mechanisms is important since the number of megaprojects rapidly is increasing across the globe, in a broad range of businesses and sectors and through major events, even though previous research has demonstrated that they often come with severe negative consequences (Flyvbjerg 2014).

Episode 1: an unstructured and selective search for world-class

The early visions for a new university hospital in Stockholm were largely legitimized through selective international references. The first proposal to build a new hospital was put forward in 2001 by the financial commissioner in the Stockholm regional council. He had been inspired by study visits to new university hospitals in Spain and the US and envisioned that a new building would enable NKS to be internationally renowned (Johannesson and Qvist 2019, 16). In the proposal the financial commissioner states ‘A new university hospital would be an opportunity for KI/KS⁴ to reclaim a leading position in the world both in terms of research and clinical operations’ (SLL 2001). So, from the very beginning, the idea of NKS constituted an attempt of engagement in the ‘art of being global’ (cf. Baker and Ruming 2015; Roy and Ong 2011).

The first investigative report from 2002 that investigated the possibility of building a new hospital also argued that the new hospital ought to position itself internationally, in accordance with the aspiration of the financial commissioner and in line with the world-class idea (cf. Pollitt and Hupe 2011). The report emphasized that the new hospital should offer highly specialized healthcare in close connection to high quality research and education. Furthermore, the report stressed that the new hospital was expected to become ‘world leading’, ‘attractive’, ‘internationally competitive’, ‘successful’ and ‘modern’ (SLL 2002a). As such, the report presents a narrative about a future world-class hospital that is difficult to oppose, and which helps de-politicize the more concrete suggestions of how to develop this megaproject (cf. Pollitt and Hupe 2011).

To ensure that the new university hospital would be able to become internationally competitive, the first report requested ‘visionary thinking’ and sought inspiration abroad (SLL 2002a, 8). While developing the report, a number of study visits were made to Norway, England and the Netherlands. The investigators also arranged meetings with representatives from Danish university hospitals. The findings from these visits are listed in the background material attached to the investigation. It is stated that while the background material is not comprehensive, ‘the selection has been made to provide a basis as good as possible for an analysis of the current situation of healthcare, future challenges and development opportunities’ (SLL 2002b, 2). To seek inspiration abroad was thus, together with other information gathering, presented as an important step in a supposedly instrumental rational decision-making process.

In total, 14 university hospitals located in the different socio-political contexts mentioned above were discussed in the report. However, no motivation was given to why the countries and/or hospitals in the report were selected and the descriptions of them are highly unstructured. The amount and kind of information presented differs substantially between the hospitals, for some only overarching information is given while others are described in more detail. The descriptions included both perceived successes and problem areas of the various hospitals. It is apparent that the studied hospitals differed in terms of their functions and focus areas, as well as in their organization and governance structure. For example, these hospitals include units with and without emergency departments; old and newly built hospitals; hospitals with basic medical care and those focusing on advanced healthcare only; and hospitals with basic education and those that offered graduate studies only (SLL 2002b, 55–67).

In contrast to these tangible variations, the summary labelled ‘university healthcare in our surroundings’ (SLL 2002b, 67) is remarkably single-tracked. According to this summary, international experiences are pointing to a ‘number of distinct lines of development’ (SLL 2002b, 67), even though some of these features were identified only in one specific country. These development lines are thus presented as a coherent narrative about ‘international development of hospitals’, which give the impression of being factual (cf. Honeck 2018). These development lines can be summarized in eight points:

• Preclinical and clinical research is integrated.

• New hospitals are located close to medical faculty.

• University hospitals should focus on research and highly specialized healthcare, which implies that basic healthcare should not exist in these units.

• Centre formations replace clinic structures.

• Beds/care places are shared across the hospital (i.e. they are not tied to specific clinics).

• Control and follow-up systems are computerized.

• Public-private partnerships are being tested to meet neglected investment needs.

• Hospitals that are located close to one another are profiled.

In accordance with previous research on how policy moves and translates across space, it is evident that the first report on the new university hospital imported and highlighted selected parts of the various hospitals studied (cf. Peck and Theodore 2010). These selected parts were then put together and translated into a coherent, but very simplified, story about ‘international development of hospitals’, which lay the foundation for a narrative about how a world-class university hospital could be developed in Stockholm. This narrative also plants the seeds for a transformation of the organization of healthcare in the region, given that it states that university hospitals should not provide basic healthcare, which previously was the case in Stockholm. Local policymakers were thus putting together different elements from abroad and presenting them as an evidence-based list, even though the evidence was poor (cf. Brill and Conte 2020, 92). Put aside the public-private partnership, which the first report disregarded as a good solution for the new hospital, large shares of the suggestions on how the new hospital should be organized are found in this single-tracked narrative of how university hospitals abroad work. This implies that the constructed summary of the lessons learnt from abroad functioned as a decisive signpost in the planning process. Experiences from abroad came to create a narrative that legitimized the early visions of the new hospital in Stockholm, even though the actual analysis of international experiences was incomplete and thus non-factual (cf. Honeck 2018). This also implied that other visions and scenarios were effectively excluded (cf. Temenos and McCann 2012).

Many of the suggestions in the report present clear spatial rationalities for the location of the new hospital and other related institutions. For example, the report emphasizes the value of integration and proximity between healthcare and research (preclinical and clinical) and it was suggested that the new hospital should focus on medical research and highly specialized care, similar to Norwegian, British and Dutch examples. As a part of this strategy, the report suggested that ‘centers of excellence’ should be created, which was the case with Dutch hospitals. This in turn implied that the report advised that a large share of the basic healthcare at NKS should be moved to other care units in the region, as in one of the Norwegian examples. This is thus a first seed for transforming the healthcare structure in Stockholm. Moreover, the report emphasized that the new hospital should be localized close to the medical university Karolinska Institutet (KI), in order to strengthen both research and healthcare, again in line with Dutch and British examples. The report did not explicitly suggest that clinics should be replaced with centre formations, but it did emphasize that ‘healthcare chains in networks should be facilitated’ (SLL 2002a, 12).

In the second investigative report on the proposed new university hospital, from 2004, the investigators argued that large investments must be made in Swedish medical science to avoid Sweden from becoming ‘marginalized’ in the field (SLL 2004b, 60f). The report recurrently emphasized that the goal of the new hospital ought to be to create an international competitive hospital (SLL 2004c, 8), again in line with the first aspiration of the financial commissioner. This again shows the importance of the ‘world-class’ idea and how this megaproject planning relied on worlding practices (Baker and Ruming 2015; Ramirez, Byrkjeflot, and Pinheiro 2016). More specifically, the report argued that the hospital needs to be competitive in terms of attracting (international) researchers, referral patients and qualified hospital personnel (which was also a rationale used in the narrative for creating and developing the new urban district adjacent to the hospital) (SLL 2004a, 10; 2004b, 34; 2004c, 8; cf. Kaiserfeld 2023). In order to accomplish this, the report sought inspiration from abroad and summarized this information under the heading ‘International experiences’, much like the initial report (SLL 2004b, 36–40).

The international experiences highlighted in the second report, in general, closely resemble those presented in the first report. However, a distinction between the second report from the first one is the geographical reach of the international outlooks. The first one sought inspiration from European hospitals only, while the second one also included American university hospitals. In the second report, eight hospitals were studied: four in the US, one in Norway, one in the Netherlands and two in Germany. Based on the studied hospitals, the report constructs a binary between the US and Europe and argues that the ‘American university hospital healthcare is undergoing a very dynamic development’, while the ‘European healthcare is in financial crisis’ (SLL 2004c, 9). The report also explicitly states that the aim of the study trip to the US was to ‘study successful concepts for university hospitals’, while the trips in Europe ‘had a somehow broader aim with studies of the development of health care systems in the respective countries’ (SLL 2004c, 14). The narrative created in the report thus emphasizes that learning from American hospitals is a rational act and the suggested business orientation of NKS is legitimized on basis of international, in this case American, experiences. The introductory summary of the report exemplifies this construction:

[T]his report’s suggestions on a new university hospital building, with focus on specialised and highly specialised healthcare, and a close connection to multidisciplinary research, is in full concordance with the development of university hospital healthcare in the US (SLL 2004c, 9).

European experiences are also used in the second report to legitimize the suggestions on the orientation of the new hospital. For example, the report highlighted that the hospitals visited in Norway and the Netherlands – with the explicit stated goals of international competitiveness – were interesting role models given their efforts to create highly specialized healthcare, research and teaching (SLL 2004b, 38–39). The visited German hospitals are described as examples of a healthcare ‘in crises’. However, German experiences are also used to legitimize the suggestions on how the new university hospital in Stockholm should develop, given that the solutions presented to solve the German health crisis are much in line with the suggestions of the report (SLL 2004b, 39).

International role models and experiences are thus strategically and selectively used in the two first reports to create a narrative that presents certain developments as rational and thereby legitimizes the visions and goals of constructing a new university hospital. This clearly illustrates the ‘extra-local’ policymaking conducted by local policymakers during initial planning phase of NKS (Temenos and McCann 2012). This narrative is further constructed on a supposedly rational logic that emphasize proximity between research and healthcare as fundamental for innovation, excellence and the world-class idea (Smas 2020; 2021). By focusing on these specific features, the narrative efficiently excludes other possible development paths (Temenos and McCann 2012); for example, renovating the old hospital or building a new bigger hospital which did not only focusing on specialized care; locating the hospital to a more disadvantaged or peripheral part of the region, or continuing working with the clinical structure.

Episode 2: consolidating a coherent concept for a new hospital

In 2008, Stockholm regional council decided that a new university hospital was to be built and a new episode began where different ideas were consolidated through the creation of a coherent concept for the new hospital. At the same time, the management of the project was reorganized and separated from the ordinary administrative structure (Grafström, Qvist, and Sundström 2021), in accordance with common megaproject management practices (cf. Flyvbjerg 2014; Flyvbjerg, Bruzelius, and Rothengatter 2003). The new administrative unit created within the regional administration (i.e. not within the hospital administration) led the development of the new university hospital through two parallel processes: one focusing on the construction of the building and the other focusing on the content (Grafström, Qvist, and Sundström 2021). In 2009, a first coherent concept that described the organization and business orientation of the new hospital, i.e. the content, was presented. The international experiences that were brought to Sweden in the first two reports of the initial planning phase were prominent when the project went into this second development and construction phase. Moreover, new international references were also acquired by the new administrative unit to strengthen the narrative that legitimized the comprehensive concept proposed, which would transform the organization of healthcare not only within the new hospital but also in the whole region of Stockholm (Grafström, Qvist, and Sundström 2021).

The comprehensive concept was based upon six partial projects, one of them being ‘international reference objects’ (SLL 2009, 13–22). Within this particular project, politicians and public officials in the regional administration identified around 50 hospitals abroad as interesting reference objects for NKS. Of these, 18 were considered especially interesting. Politicians and public officials also made study visits to eight hospitals in the US, England, Germany and the Netherlands in preparing the concept report. By referencing to how university hospital healthcare is organized elsewhere, the concept established ‘the patient first’ as the motto for the new hospital in accordance with ‘leading American and European hospitals’ (SLL 2009, 31). This concept is based on ideas of new public management (Grafström, Qvist, and Sundström 2021; Meijling 2018). A patient-focused modus operandi had been identified already in the first reports, but at this stage, the idea was transformed into an explicit guideline for NKS. In the concept report, it was also emphasized that ‘the new university hospital needs to concentrate on the parts of the healthcare process that demand the exclusive resources and competences of the hospital, just like many other leading university hospitals’ (SLL 2009, 33). This suggests that the new hospital primarily should focus on highly specialized healthcare and research, while remaining healthcare is to be redistributed and relocated to other care units within the region. As such, it explicitly demanded a transformation of the relationship between the hospital and other care givers in the region. This is in accordance with the organization of healthcare in the selected international role models of the project, and in conformation with the recommendations of the first two reports. The concept report further proposed that the NKS should focus on a number of profile areas, like some of the international role models have done, in order to be able to live up to the status of ‘national’ hospital (SLL 2009, 34). This is, in turn, seen as a way to create international competitiveness, which was one of the organizational ideals in Stockholm at this time (cf. Kaiserfeld 2023).

The concept further suggested that the clinic structure of the old hospital should be replaced with a thematic organization, similar to the centre formations and theme areas found in many of the American hospitals referenced in the reports. This proposal is new and did not exist in the first two reports. However, the abolishment of clinics for the benefits of (thematic) centres constituted one of the international ‘lines of development’ identified in the first report, a proposal based on new public management ideas (Meijling 2018). Interesting to note is that the background description of the first investigative report accounted for strong criticism against centre formations and a patient-focused modus operandi, based on the experiences in Norway (SLL 2002b, 58). However, these concerns of patient-oriented care and centre formations (or thematic organization of healthcare) are not mentioned when these strategies are proposed in the new coherent concept for NKS. In contrast, the new administrative unit confirmed that the thematic structure of the healthcare at the new hospital is the ‘natural’ choice given the ‘medical and technical development described’ (SLL 2009, 34). Again, this demonstrates the highly selective sample of international lessons and the naturalization of certain ideas (Van Leeuwen 2007). This formulation clearly assists in creating a narrative that legitimizes the formation of NKS and the transformation of the healthcare organization in Stockholm while simultaneously excluding other alternatives and silencing criticism (Pollitt and Hupe 2011). Importantly, the international origin of certain ideas and practices in itself helps legitimize them (cf. Andersson and Cook 2019). As such, extra-local policy narratives work as strong rhetorical recommendations.

In the three documents discussed so far, international experiences were strategically used to legitimize the official narrative of how NKS can become a world-class hospital and seeds were simultaneously planted for the suggestion of a transformation of the healthcare organization in Stockholm. At the core of this narrative is international competitiveness and excellence through a small highly specialized hospital with a strong connection to medical research. International references were used to legitimize this vision and simultaneously excluded alternative ideas and perspectives. However, behind the official narrative of how international practices legitimize the orientation of the project on the basis of rational thinking, other actors diverge in how they perceive and value international experiences and the possibility to adopt them to the Swedish context. For example, differences of opinion are visible in the travel reports written after the study visits made to three American hospitals in 2010 by the new administrative unit responsible for NKS and representatives from four Swedish labour unions that participated in the field trip.

In the sub-report from the regional unit, lessons from the study trip are described in a positive way, supporting the narrative of local policymakers making use of international ‘expertise’ in line with instrumental rational decision-making processes. Five ‘very important lessons’ were also specified, which indicates that the new administrative unit wanted to make use of them in the continued planning process (SLL 2010, 13). The lessons learnt are partly recognizable from previous reports but with significantly less focus on spatial rationalities and more focus on a business management narrative:

• A well-developed IT support are present at the hospitals.

• The hospitals are part of larger networks of healthcare givers.

• The hospitals put the ‘patient first’.

• The hospitals have a thematic care structure.

• The hospitals have ‘very strong and very results-oriented cultures’.

The first two points correspond with ideas presented in the first two investigative reports, while the following two were present in the concept report. The explicit formulation about result-oriented cultures is new, even though the project from the beginning has emphasized the importance of excellence and international competitiveness. The sub-report from the region uses one and a half pages to reflect on the visit to one specific hospital, while reflections from the two other visits are absent. Hence, a structured reflection from the study trip as a whole is lacking, which again demonstrates the unstructured way of handling lessons learned from abroad amongst the local policymakers in charge of this megaproject.

The labour unions are more critical in their sub-reports from the study trip, and the lessons they brought home are partly different compared to the ones by the regional units. For example, representatives of physicians, nurses and other care personnel reported skepticism about the thematic care structure of the hospitals visited. In their sub-reports, they state that ‘none of the hospitals deviated from the medical specialist division’ (SLL, 9) and that the organization of one hospital ‘was difficult to oversee or even comprehensively describe’ (SLL 2010, 3). Furthermore, they expressed that ‘they did not get any clear sense that teamwork work prevailed’ and complained that no information was given on how thematic work was practically conducted, which they had seen as one of the aims of the study visits (SLL 2010, 9). These examples illustrate that the acquisition of ideas, models and experiences from abroad is coloured by the pre-understanding, normative agendas and value-rationalities of various actors involved (cf. Clegg et al. 2017; Flyvbjerg 1998). As such, the study tours worked as instruments of both learning and governance (cf. Montero 2017). The usage of international experiences in the rationalization of various decisions, within this project as well as more generally, is thus a highly politicized process (cf. Temenos and McCann 2012).

Materializing enduring narratives of excellence and transformation

In September 2010, the construction site of the new hospital was ceremoniously inaugurated, with a number of international guests attending, and thereby the realization of this prestigious megaproject took off. The year after, 2011, Stockholm Region presented a status report over the work of confirming the goals and business orientation of the new hospital, a report that aimed to make up a decision basis for future healthcare in the whole Stockholm Region. In this report, the world-class idea is explicitly articulated and the administrative unit writes that ‘the vision is that the new university hospital shall be of world-class, in the middle of one of the world’s foremost areas of life science’ (SLL 2011, 5). It is thus emphasized that both the hospital and the area in which the hospital is being built shall be put on the map and become internationally competitive. Furthermore, the report states that ‘the facility as such, with its general design, single rooms for all hospitalized patients, short distances, good logistic and immediate closeness to Karolinska Institutet (KI), create very good preconditions for a world-class university hospital’ (SLL 2011, 5). The proximity to KI is thus still at this stage an important idea in how the project shall be able to reach world-class status. The regional political ideas of cluster building and the need for physical proximity between life science actors are thus also prominent in defining the business orientation of the new hospital 10 years after the project was initiated (Kaiserfeld 2023; Smas 2020; 2021).

It should however be noted that this status report was produced by a new programming office within the hospital administration, to which the responsibility for programming and concretizing the concept into a new organization and management model had been transferred (Grafström, Qvist, and Sundström 2021). In the concretization of the concept, international management consultants were highly influential (cf. Aoun and Teller 2016). The new programming office suggested that the healthcare at the new hospital shall be organized around six specified themes, and that both the emergency departments and the hospital as a whole shall be focused on highly specialized healthcare. The ideas of highly specialized and thematically organized healthcare that were brought to the project from international experiences in the early planning phase, and assembled into the project through the concept, were thus consolidated and specified through the work of international management consultants. When the first activities and functions started to move into the new hospital in 2016, it became clear that the international study visits and references analysed in this paper had real consequence for the design and business orientation of the hospital. In fact, six out of eight ‘distinct lines of international development’ (SLL 2002b, 67) identified in the very first investigation were implemented in this project (see list above).

This clearly demonstrates that ideas discussed in the first investigative report had a large impact on the project. The move from the old hospital to the new one became the starting point for the hospital’s transformation from clinics to a thematically organized healthcare. It was also now the strengthened collaboration between research, education and care should be realized, and the new IT-system was activated. In the beginning, this process was surrounded by challenges, for example, it proved to be difficult to integrate research, education and care, even though these functions were located in physical proximity to each other. A state report appointed to review structural changes in Swedish healthcare, including the example of the NKS, even concluded that ‘research and education have been negatively affected’ by the realization of the new university hospital (SOU 2020:15, 323).

In 2020, the new university hospital carried out its work based on ‘the patient first’ idea and its healthcare was organized in seven medical themes and four functions. The hospital focused on highly specialized healthcare and sought to integrate healthcare, research and medical education. As such, patients not in need of highly specialized care that the former hospital treated were now transferred and relocated to other care facilities in the region. Many of the ideas that were brought in from elsewhere during the planning process were thus implemented and the vision of a world-class hospital was still alive. On the hospital’s webpage, it was stated that for example operating rooms, the patient medical record system and the competence of the personnel were world-class standards. The search for international recognition is highly present and when the hospital in 2020 was nominated the tenth most preeminent hospital globally, according to the journal Newsweek, the Director of the hospital declared that ‘it is a big achievement for us as a university hospital that colleagues around the world see us as amongst the very best’ (Karolinska Universitetssjukhuset 2020). It is thus evident that the worlding practices evident in the narratives constructed during the early phase of the planning process endured throughout the extensive process of planning and realization of this megaproject (cf. Baker and Ruming 2015; Roy and Ong 2011).

Conclusions

In this paper, we demonstrate that ideas, experiences and practices from elsewhere have been essential in the legitimization of the NKS megaproject. In this project, as is often the case in megaprojects, solutions and problems were entwined, and they did not adhere to a simple instrumental rational decision-making process. Instead, the NKS megaproject became a vehicle for a set of policy reform packages and a solution to multiple problems (Grafström, Qvist, and Sundström 2021). The project was thus not initiated and formulated on the basis of a clearly articulated problem from within the healthcare sector of Stockholm, or actual care needs of the (growing and ageing) population it served (cf. Meijling 2018; Öhrming 2017). In a similar manner, the search for inspiration from abroad was open and international references were sought for on the basis of a vaguely defined desire for ‘world-class’, excellence and international competitiveness (i.e. driven by a market-liberal logic).

Through a document analysis, we demonstrate that international referencing was inserted in the planning processes to simultaneously help define and situate the problem (i.e. lack of excellence and international competitiveness) and to propose and present solutions (i.e. building a new hospital and reorganizing the health care system). International referencing was thus strategically and rhetorically used to create a narrative that centred on the need for constructing a new ‘world-class’ hospital aspiring for excellence, which would also play an important role in transforming the healthcare system in Stockholm. This narrative was presented as rational, partly motivated by the usage of international experiences and practices, even though it was largely built upon political and normative rationalities. As such, the clear international framing gave legitimacy to this megaproject and its transformative ambitions (cf. Andersson and Cook 2019; Montero 2017).

However, in contrast to the framing of a rational planning and decision-making process, our analysis shows that the international experiences were collected and presented in an unstructured and selective way. We also show that international practices and ideas presented in the early investigative reports ended up having a significant impact on the actual materialization of NKS, even though ideas continuously were modified during the planning process (e.g. Miller and Lessard 2008; Priemus 2008). The list of international experiences presented in the early investigation later became assembled and modified into a coherent concept that steered the decision-making process of this megaproject. In fact, more or less all of the ‘international developments’ selectively listed in the very first investigation were actually implemented and materialized. The narrative used to legitimize the hospital throughout the spatial–temporal planning process of this megaproject thus efficiently excluded other development paths. The usage of the magic concept world-class further obscured disagreements and made the project difficult to question and criticize (cf. Pollitt and Hupe 2011).

In conclusion, this paper emphasizes the importance of analysing the narratives used to legitimize megaprojects and the value of paying attention to their glocal embeddedness in international policy mobility circuits. We have shown how policy mobilized from elsewhere is strategically used in the construction, modification, and (re)presentation of legitimizing narratives throughout the duration of the extensive planning process. In accordance with this, we emphasize the importance of considering the temporal dimension in conjunction with the relational geographies of policy-mobility in megaproject research.

Acknowledgements

We would like to thank the two anonymous reviewers for their helpful comments on previous drafts of this paper. We are also grateful to our colleagues in the research project ‘Framtidens universitetssjukhus’ at Stockholm Centre for Organizational Research and the Department of Political Science at Stockholm University for their invaluable feedback throughout the entire research process.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This work was supported by Stockholms Läns Landsting.

Notes

1 See https://www.su.se/forskning/forskningsprojekt/framtidens-universitetssjukhus-beslut-om-nya-karolinska-solna.

2 In 2019 Stockholm County Council was transformed into Region Stockholm.

3 The document titles and quotes from these documents have been translated to English by the authors.

4 KI/KS stands for Karolinska Institutet/Karolinska Sjukhuset, which are the names of the university and hospital respectively.