By Rene Wiedner
In 2019 the UK government launched the long awaited National Health Service (NHS) England Long Term Plan. In part, the plan set out the spending priorities for the additional £20.5 billion of annual funding announced in 2018.
Resources are an important part of any change initiative, and given the pressure NHS services are under, including constrained funding, it is vital that any changes are implemented effectively.
Yet, as my study conducted with Michael Barrett, of the University of Cambridge, and Eivor Oborn, of Warwick Business School, of change initiative outcomes following the last major overhaul in the NHS reveals, failing to account for two key change factors can easily lead to disappointing results.
The Health and Social Care Act, eventually passed in 2012, heralded one of the biggest NHS shake-ups in its history.
At its heart was the empowerment of practitioners, notably GPs, to command resources with the creation of Clinical Commissioning Groups (CCGs) and the dismantling of Primary Care Trusts and Strategic Health Authorities. The idea being that attributes such as the possession of medical knowledge, proximity to patients and the direct influence over healthcare costs meant that GPs were better positioned than managers to understand patients’ care needs and to allocate or cut resources.
Seven years on and the impact of measures implemented under the act has provoked a rethink and further reorganisation of the NHS introduced in the 2019 Long Term Plan. For example, a 2015 review by health charity the King’s Fund, commenting on commissioning changes, highlighted issues with fragmentation of care provision and decision making, inadequate leadership and sustainability.
The new plan promotes the concept of integrated care systems, which is likely to lead to CCG mergers and once again change the scope and role of GPs in the commissioning process.
As part of my research into managing change, together with my colleagues, I was able to observe and analyse some of the challenges associated with changing the commissioning process — and navigating change generally — at close quarters.
From the outset there was a specific focus on the role of resources in shaping change. In particular, we wanted to investigate the relationship between the availability (or otherwise) and use of resources, such as clinical expertise, control of budgets, and managerial know-how and experience, and the change outcomes.
To do this we investigated how one regional health organisation sought to alter the way that contracts were managed in three specific practice areas: hospital services, community care and mental health care. The research included more than 700 hours of direct observation, some 50 semi-structured interviews with stakeholders (including specialist clinicians, managers, GPs and other staff at primary healthcare trusts), and a wide range of archival data from mid-2009 to the autumn of 2014.
Our findings provided some interesting insights into the relationship between the actions of change agents, resource allocation and change outcomes. But perhaps most importantly, the research identified the critical role that two specific factors played in determining those outcomes.
They were the level of interest and attention focused on a specific area; and the power dynamics at play. In the hospital services and community care settings these factors contributed to a failure to produce the positive change outcomes that might have been expected or hoped for.
How the level interest can harm a change project in the NHS
Hospital services were designated as a priority for change; partly because of the potential for cost savings, and partly because of GP interest. Thus attempts to change contracting in hospital services attracted a lot of resources and attention from practitioners.
Several work streams began to develop with regard to hospital care, with a large number of managers allocated to this activity (supporting the GPs as they began to take on a commissioning role), and with many GPs across the region asking to get involved.
However, despite being the focus of attention and attracting resources as a result, progress was slow. This was partly because the initiative was a victim of its own popularity. Simply put, it was difficult co-ordinating all the people and their various activities in a productive way.
It was apparent from our observations that there is an optimal number of change agents that can be directly involved in driving any change initiative, beyond which it becomes more difficult to implement action.
GPs were not short of ideas about how to change existing contractual arrangements, but found it difficult to collectively agree a course of action. Vested interests got in the way. Discussion became polarised as participants coalesced around favoured positions, instead of seeking compromise.
Although not designated as a priority, community care suffered from similar issues — poor co-ordination, co-operation and compromise. In this case, GPs had a high level of interest in community care as they interacted with these services on a daily basis. (There were about 70 GPs in the region that declared a “special interest” in a particular community-based service).
Why power plays an important role in attempts at change in healthcare
A second factor was the effect of power dynamics on the relationships between change agents and other stakeholders involved.
This was particularly relevant in hospital care where GPs appeared reluctant to actively monitor performance or challenge the hospital clinicians. GPs were unable to leverage their resources of medical knowledge and budgetary power when negotiating agreed outcomes with representatives of a large teaching hospital in the region.
To bring about system wide change, the GPs, as commissioners of healthcare, had to deal with everybody within that system — clinicians, managers, even local politicians potentially.
In a teaching hospital, as with other professional hierarchies, there are many high status practitioners who are perceived as experts. The commissioning GPs and managers, who by comparison were perceived as lower status and less expert, were reluctant to challenge these higher status individuals.
Additionally, high status individuals may have their power bolstered by protection from elsewhere — the local community, activists, and politicians, for example. In the NHS this is most evidently the case with publically contentious issues such as the closure of accident and emergency departments, or the location of hospitals.
The exercise of power is not always overt; it can be subtle, implicit in the interactions between the negotiating parties. Thus power imbalances are not necessarily manifested through observable conflict and disagreement in the negotiations.
Instead, they may arise through a mutual understanding and recognition of the professional hierarchy and resource-based power structures, which in turn has a dampening effect on discussion. It was clear, for example, that prior to their meetings with hospital clinicians, commissioning managers and GPs discussed the actions they planned to propose. However, during the meetings, GPs were not always willing to raise those issues.
How a change project succeeded in the NHS
With mental healthcare, however, the impact of both the level of interest and power dynamics was very different.
For a start, mental health was not seen as a strategic priority and did not attract substantial additional financial resources. Out of several hundred GPs, fewer then 10 declared a special interest in mental healthcare across the region. Thus, when it came to changing contracting arrangements, there was very little interest from GPs to get involved in any of the mental healthcare work streams.
With a small number of participants, co-ordination costs were fairly low. It was relatively easy to agree an initial position to put to the mental health clinicians, and to subsequently negotiate and implement decisions. What limited resources were available could be used without lengthy negotiations.
The people tasked with making the contract changes made some important decisions about process. Rather than relying on metrics, commissioning managers asked mental health specialists to attend meetings and report directly on service provision. They also brought in GPs to ask their advice about improving the overall process.
For the clinicians’ part, initially senior psychiatrists did not participate. However, when it became apparent that there was the potential to influence the distribution of funding and raise the profile of mental health services, more senior clinicians attended.
The mental health clinicians were not perceived as high status and powerful within the professional hierarchy in the same way as their surgical colleagues in the hospital setting, for example. At the same time it was clear that, unlike the politically charged situation with the hospital, the GPs had the practical power to control the budget. Thus, in terms of power, the two sides were relatively evenly balanced.
The mental health contract management process transformed from an administrative practice with limited clinical involvement to a successful clinically led commissioning group. In doing so it succeeded in implementing alterations to services described as a “radical transformation”.
How to implement change intiatives in the NHS
Most change does not happen in isolation but as part of a system. Resources are allocated across the system, according to priorities that are designated or that emerge through the actions of change agents.
Prioritised areas tend to attract more resources. However, prioritising a project, as with the hospital services, does not necessarily increase the likelihood of a positive change outcome. In fact it may well have unintended and unanticipated consequences.
With change initiatives, more is not always better. Attracting resources can hinder a positive outcome. Whereas a lack of attention and interest may lead to low co-ordination costs and create the conditions necessary for rapid and potentially radical change.
In this case mental health practice was low profile and attempts to make changes went largely under the radar. As a result, negotiations took place without the scrutiny and pressure of expectations attached to the hospital services setting. The lack of attention contributed to a degree of freedom, a resourcing space within which all stakeholders could negotiate and action change.
These conditions may emerge naturally in some areas due to the allocation of resources. But if not, it may be necessary to take action to minimise co-ordination costs such as limiting participation to strategically important voices, and tightly controlling the numbers involved in negotiating and managing change.
Otherwise discussions may rapidly descend into chaos and confusion, making it very difficult to implement anything. It may also be possible, for example, to create a separate work stream or task force without widely publicising these efforts, helping change initiatives gain momentum early on.
Freedom from attention does not mean no monitoring at all. Managers still need to track low profile change initiatives. Partly for good governance reasons and partly to ensure that any transferable insights that emerge and can be applied positively elsewhere are picked up.
Addressing the power dynamics issue is more difficult, given the breadth of interactions change agents may need to engage in. The level of attention, and allocation of resources, has an effect on power dynamics. Prioritised areas are likely to attract resources and, therefore, attention and act as a magnet for stakeholders. If change is widely perceived as on the way, backed by resources, participants in any change process are more likely to engage their most powerful representatives.
In mental healthcare there were no great expectations concerning change. Nor initially, much interest in potential outcomes. Few people were involved; a couple of GPs and a couple of clinicians. Both the lack of expectations and small number of people involved helped to expedite agreed change.
Interestingly, on the commissioning side the manager involved had limited experience in mental health. They came to the discussion unencumbered by vested interests or pre-existing positions, and open to a negotiated outcome.
One reason for introducing clinically-led commissioning was a feeling that managers lacked the clinical expertise to make the best decisions. Yet, in practice, imbalances in specialist knowledge and power between practitioners proved a barrier to agreement.
Whereas when managers with limited specialist knowledge are on both sides, an element of the power problem is removed from the outset. There was even evidence from the practitioners interviewed suggesting that when managers are the principal negotiators driving a change initiative, bringing in clinicians as they see fit, they get things resolved quicker.
There is also evidence from other research showing how change can be negotiated and implemented by individuals further down the professional hierarchy. In one study, for example, nurses negotiated small changes that became sufficiently well-established over time to the extent that senior clinicians were unable to object to the new changes. This suggests that any change initiatives should, to some extent, aim to eliminate potential imbalances in power hierarchies.
In the NHS, as with many other large organisations, a common approach to change is to throw resources at it in the belief that this maximises the prospects of success. However, as our research shows, while resources are undoubtedly useful, managers must also ensure that those resources do not become an obstacle to change.
Managers need to create conditions that will promote positive change outcomes. In particular, the effect that attention and power have, and seek to create a space within which change agents can operate with minimal scrutiny, low co-ordination costs and the ability to challenge, unencumbered by power hierarchies.
Rene Wiedner is Assistant Professor of Organisation and Human Resource Management and lectures on Leading the Knowledge-Based Organisation on the suite of MSc Business courses. He also teaches Critical Issues in Management on the Undergraduate progamme.
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Originally published at https://www.wbs.ac.uk on May 1, 2019.