Productive and unproductive organisational change: a view from within

The current round of clinical commissioning group mergers heralds yet another period of structural change that may not produce the intended outcomes. It is timely to remember the organisational changes to the predecessor primary care trusts in order to avoid the main mistakes made then.

As a previous PCT chair, I led the creation of Central Cheshire PCT in 2002 and the subsequent merger with Eastern Cheshire PCT into Central and Eastern Cheshire PCT in 2006. My diary note of 20 November 2006 sums up the difference between the two organisational changes:

The Primary Care Trust (PCT) Christmas party – a true story.

2005: The PCT has come together as an organisation that staff feel good about. The staff survey showed that the PCT was in the top five nationally. The Christmas party had two live bands, one included a staff member and the other the husband of the PCT chair. 180 people took part and there was a waiting list. Fantastic atmosphere.

2006: a protracted reorganisation and uncertainty (plus humiliation) for senior staff. Merger of four or two PCTs, unsettling, late decision. Financial stress. Finally new PCT formed from two PCTs with different histories and cultures. Staff unclear about their roles in the new structure. Christmas party sold only 10 tickets. Cancelled festivities. Proof of staff morale!?

Learnings

What does this thumbnail sketch tell us that might be useful to CCG mergers?

First, people matter. Organisational change involves more than structures and attention has to be paid to local contexts and the dynamic interaction between people and the organisation(s) in which they work.

People’s motivation to work in the health service is a valuable constant that needs to be nurtured if it is not to be adversely affected by shifting organisational configurations. Managers are facilitators of the clinical ambitions to deliver good care. Thus, creating a simple organisational vision that all staff recognise as a reflection of their philosophy is a necessity, and this can help to give meaning to the structural changes.

Second, perceptions matter. In the merger of CCPCT with ECPCT, the feeling in the former organisation was that they were “dragged down” because they merged with a PCT that carried a deficit. Staff in ECPCT felt they were “taken over” because the CEO, chair and most of the executive team came from CCPCT.

Organisational change involves more than structures and attention has to be paid to local contexts and the dynamic interaction between people and the organisation(s) in which they work

The resulting divide between Central and East carried over for a long time as we underestimated the challenge of tackling these cultural perceptions. It would be better to confront this type of tension right at the start and acknowledge opposing perspectives. This makes it easier to engage in open discussions about remedial actions so that a new shared direction can be formulated.

Third, size matters. We went from working with 30 GP practices to 56. The GPs (and other independent contractors) preferred to have personal relationships with PCTs and we had a rigorous programme of visiting each practice on a regular basis. However, after the merger the sheer numbers involved made it difficult to continue with this approach.

Various other methods were used such as dropping in to formal and informal meetings of GPs, practice manager and lead nurse meetings. In order to maintain good relationships and credibility, locally appropriate ways have to be found to ensure that GPs experience the interaction with CCGs as personal and authentic. An “open door, open email” policy is key to this approach.

Fourth, money matters. The constraints on growth and the subsequent budget pressures give CCGs limited room for manoeuvre. In this financially stringent context two things are needed: a critical use of scientific evidence, not just based on clinical trials and controlled studies, but also on qualitative research of patient/carer experiences and robust organisational studies; and courage to design a priority setting framework that allows transparent decision making and a strong defense for “unpopular” actions.

Productive organisational change is not primarily focused on structures, but on people. Understanding people’s motivations,  and values are the basis from which sense can be made of structural changes

The latter requires boards to internally debate issues vigorously, but externally present a unified voice. From my bitter experience, CECPCT’s financial difficulties led to pressure from the Centre and caused much anxiety amongst some NEDs.

Their behaviour became very defensive as exemplified in the words of one NED that “his individual responsibility for good governance was more important than corporateness” (diary note, 20 November 2009).

Individual board members abandoning their respect for the unitary nature of a trust board is something to be avoided. Contestation and disagreement within the board is necessary, but insistence on presenting a single perspective upwards and to the outside world is essential when faced with a difficult financial position and increased scrutiny.  

Fifth, time matters. The increasing pace of re(dis)organisation mitigates against embedding any gains from previous investments. In our experience, CCPCT had just started to deliver important benefits to services and local populations when board and managerial energies were usurped by the merger.

Staff and stakeholders struggled to make sense of the reasons for change only a few years after the creation of the first PCTs. While the timing of current top down decisions is largely out of the CCGs’ hands, effort is required to give meaning to the merger so that previous achievements can be recognised. This is an essential basis for gaining trust internally and externally and moving forward.

In conclusion, productive organisational change is not primarily focused on structures, but on people. Understanding people’s motivations, interests and values are the basis from which sense can be made of (imposed) structural changes.

Releasing the energy of individuals and organisations to pursue objectives that are important to them and the communities they serve is fundamental to successful delivery of good quality healthcare.

Ignoring the moral imperatives that drive people will lead to unproductive organisational change. Instead, CCGs need to step up to the plate and be courageous and principled leaders of their local health and well being economies.