The NHS and the cult of change: evaluating integrated care in East London
By Nathan Davies, on 5 October 2017
“We trained hard—but it seemed that every time we were beginning to form up into teams we were reorganised. I was to learn later in life that we tend to meet any new situation by reorganising, and what a wonderful method it can be for creating the illusion of progress while actually producing confusion, inefficiency, and demoralisation.” (Petronius Arbiter 27-66 AD)
As a member of the Improvement Science team (ISL) for the past few months I’ve been evaluating the delivery of integrated care in East London. Integrated care refers to care that is person-centred and co-ordinated across health and social care, so providers, commissioners and local authorities need to work together to deliver the different elements of care that a person needs. In 2013 WEL (Waltham Forest and East London) was launched as one of the 14 Pioneer Programmes of Integrated Care bringing together commissioners, providers and local authorities covering the area served by Barts Health NHS Trust.
When I started this job last May, the ISL team had already carried out a two-year evaluation of WEL, which highlighted a disconnect between strategic thinking and service design on the one hand, and the delivery of integrated care on the other hand. This is hardly surprising. We know as many as 70 percent of change programmes do not achieve their intended outcomes. A lack of commitment (patience?) to see a programme through to the end and high turnover of management might be part of the problem.
Very soon I realised that WEL no longer enjoyed much attention. There were new programmes, new acronyms, new objectives, and with them different pressures, different actors, and different priorities: TST (Transforming Services Together), STP (Sustainability and Transformation Partnerships), ACS (Accountability care Systems)… Petronius Arbiter’s quote came to mind, “it seemed that every time we were beginning to form up into teams we were reorganised…” (The fact that this quote might have been misattributed doesn’t make it less painfully relevant).
Where do we look to see organisation change?
Within a very crowded policy context, I faced a dilemma: how could I build on the findings of the previous phase of the WEL evaluation if WEL was no longer a priority? It felt important to look at the impact that all this change at the strategic level is actually having on frontline work, to unpick the gap that my predecessor identified between strategic thinking and operational delivery. It is at the frontline level, after all, that change is meaningful, when it happens. But how does it happen?
The literature on organisational management is quite clear on the matter: change is often evolutionary rather than the result of radical restructuring (Hodgson, G, 2008). Organisation-level change is hardly ever linear and often has an emergent element (Dawson 1996). It tends to happen by ‘drift’ rather than by design. By looking at organisational routines we might then have a chance at unpacking the grammar of organisation change, so to speak. Routines are recurrent, collective, and interactive behaviour patterns, which help coordinate work (Becker 2004). This new phase of the WEL evaluation will then focus on frontline professionals’ routines in the three WEL boroughs and look at how health and social services staff work together to deliver more coordinated care. The aim is to shed some light on patterns of resistance to change and sustainability of change towards integrated care and understand the impact of organisational development on the ground.
I am a researcher-in-residence, which in practical terms means that I’m embedded in the organisations I’m evaluating. I work closely with stakeholders across three boroughs with the aim to coproduce learning that is relevant and timely, and so increase the chances that evidence might inform programme developments. This role raises a number of challenges, including maintaining objectivity, but it also gives me regular access to management and frontline professionals, as well as key operational meetings. This gives me a vantage point to understand better their organisational routines, how these professionals work with colleagues across different organisations, and what challenges they face on a day-to-day basis.
Based on my initial scoping work, it is clear that the rhetoric on integrated care is powerful, but so are the blockers on the ground, namely a lack of staff and resources (particularly within social services) and an increased fragmentation of services, after the separation of commissioner and provider functions.
For all the rhetoric, is care really more integrated or actually more fragmented? I hope that my work in the next few months can contribute to finding some answers.
Becker MC (2004) Organizational routines: a review of the literature. Industrial and Corporate Change 13:643-77.
Dawson, S. J. N. D. (1996) Analysing Organisations. Hampshire: Macmillan
Hodgson, Geoffrey M. (2008). ‘An Institutional and Evolutionary Perspective on Health Economics’, Cambridge Journal of Economics, 32(2): 235-56.