Organizational change in the National Health Service: lessons from the staff

Organizational change in the National Health Service: lessons from the staffJoe Marshall1* and Anne-Maria Olphert2

1 Faculty of Business Computing and Law, University of Derby, UK2 Leicester City PCT, Leicester, UK

� This paper is based on research on the impact organizational change (mergers) had upon staff and patient care in Primary Care Trusts (PCTs) within Leicester, Leicester-shire, and Rutland from 2006 to 2007.

� The latest round of health reform has been driven by the ‘Commissioning a Patient-Led NHS’ (CaPLNHS; DOH, 2005) plan to reduce the number of PCTs and for a saving of £250 million in administrative and management costs.

� A cross-sectional case study using a series of focus groups was undertaken to identify salient aspects of mergers and organizational change in a health sector context and explore staff perceptions (negative and positive) of the recent organizational wide changes. Based on the fi ndings, we propose an ‘Agenda for Action’ to recognize and minimize the potential negative effects upon staff and service delivery.

Copyright © 2008 John Wiley & Sons, Ltd.

Change in the National Health Service (NHS) is

never likely to be straightforward and

linear, not least because of the size and complexity

of the organization

the organization, and their performance and behavior at work. Within the health service there is good evidence (Michie et al., 2004) that factors such as workload and control over work infl uence stress levels and physical and psychological health. The focus of this research is to investigate employees’ reaction to the most recent restructuring and reform in Leicestershire and Rutland PCTs from 2006 to 2007.

Strat. Change 17: 251–267 (2008)Published online in Wiley InterScience(www.interscience.wiley.com) DOI: 10.1002/jsc.831 Strategic Change

* Correspondence to: Joe Marshall, Faculty of Business Computing and Law, University of Derby, Kedleston Road, Derby, DE22 1GB, UK.E-mail: [email protected].

Introduction

Change in the National Health Service (NHS) is never likely to be straightforward and linear, not least because of the size and complexity of the organization. Change also takes place in the context of many professional groupings and organizations. It is now nearly two decades since the publication of the last major studies on organizational change in the NHS. Pettigrew et al. (1992) and Cortvriend (2002) suggest that despite the number of mergers that have occurred in the history of the NHS, there is scant research or evaluation in this area.

Michie and West (2004) suggest that the way people are managed through change infl uences employees’ emotional and physical wellbeing, their attitudes toward work and

Copyright © 2008 John Wiley & Sons, Ltd. Strategic Change

252 Joe Marshall and Anne-Maria Olphert

Copyright © 2008 John Wiley & Sons, Ltd. Strategic Change DOI: 10.1002/jsc

Iles and Sutherland (2001) maintain that although generating evidence and developing theory in the fi eld of change management may be seen by busy managers as an additional (even insupportable) burden, managers and health care leaders have a responsibility to generate evidence about change processes and outcomes, to present it in a form that can be useful to others, and to contribute to the development of theory.

This paper aims to generate such evidence by a cross-sectional case study of a merger of a number of PCTs. The lead researcher is an NHS manager with a clinical background who experienced the merger fi rst-hand. Whilst recognizing the inherent issues as an ‘insider’, the research was undertaken and the evidence examined with a degree of scrutiny and criti-cal refl ection. A signifi cant, relevant, and prac-tical outcome of the collaborative nature of the study was the opportunity for those taking part to infl uence future change programs.

National context

Changes in the way services are delivered and in the way patients are treated have been hap-pening continuously in the NHS since it was

fi rst set up in 1948. It was not until the publi-cation of the NHS Plan in July 2000 (DOH, 2000), however, that this steady pace of change gave way to a full-scale modernization program designed to totally transform the NHS and the way it cares for patients.

England is split into 10 Strategic Health Authorities (SHAs) and each one is split into various types of trusts (Figure 1) that take responsibility for delivering and monitoring health services in the local area. The cycle of reorganization in primary care over the past decade has seen Primary Care Groups evolve into 303 PCTs in 2001 with a reduction to 158 PCTs in 2006.

Reform agenda

In the NHS, spending increased by 30% between 1996 and 2004 whilst the recorded increase in output was only 2% higher. The continued increases in public spending have now caused much greater pressure on public services to focus on productivity and waste reduction. A pivotal point was the publication of the Gershon report ( July 2004), which stated that the public sector should fi nd ways to achieve substantial cost savings. The report

Figure 1. NHS structure (NHS Choices, 2007)

Lessons from NHS reorganization 253


The continued increases in public spending have now

caused much greater pressure on public services

to focus on productivity and waste reduction.

‘Independent Review of Public Sector Effi -ciency’ announced a headline fi gure of £20 billion annual effi ciency gains for departments across the English public sector to be realized by 2007–08 (Gershon, 2004). These effi ciency gains were detailed for the various depart-ments with targets focused on both cash and non-cash savings.

The latest round of reform has been driven by the ‘Commissioning a Patient-Led NHS’ (CaPLNHS; DOH, 2005) plan that describes the reduction in PCTs and the need for a saving of £250 million in administrative and manage-ment costs in order to realize Gershon’s rec-ommendations. At the heart of the reforms is the notion that the NHS should change to provide a service where patients have a greater range of choices and where NHS organizations are better at understanding and responding to

patients’ needs. Advocates of reform argue that it will make the NHS more effi cient, effec-tive, and economical whilst producing more and better patient care.

Opponents of reform argue that organiza-tional restructuring, rather than create effi -ciencies, tends to divert time and effort from the challenges of improving healthcare deliv-ery and that the impact on front-line clinical staff or patients is often negligible. The process of reform within the health service is com-monly seen as circular (Walshe, 2003). An example of this are the PCTs created in 2002 that look remarkably similar in function and boundaries to the district health authorities created in the 1982 reorganization of the NHS, which were subsequently merged and reorganized.

Local context

Until October 2006, Leicester, Leicestershire, and Rutland (LLR) was made up of six PCTs when, as part of the (CaPLNHS; DOH, 2005) plan the six merged into two, one in the city and one in the county. Specialist Community Child Health Services (SCCHS) deliver care to children across the city and county and is sup-ported (hosted) by the City PCT on behalf of all the PCTs.

In November 2006 the formal consultation process and timetable (Table 1) for staff at

Table 1. Timetable for new city organizational changes and structures (October 2006)

Week commencing Actions

W/C 16.10.2006 Time line agreed by CEO and Directors.W/C 13.11.2006 Draft staffi ng structures created detailing job roles.

CEO to share draft structures with Staff Side Chair and Secretary.HR & Staff Side to benchmark salary grades for draft staffi ng structures.

W/C 20.11.2006 Draft staffi ng structures launched at Joint Staff Consultative Committee (JSCC).30-day consultation begins on day of JSCC.Group consultation meetings to be held with each staff group directly affected by the

new structures.1–1 meetings offered to all directly affected staff.

W/E 29.12.2006 Staffi ng structures fi nalized.W/E 5.1.2007 Decisions on ring fencing/pooling/slotting and voluntary redundancy fi nalized.W/C 15, 22, 29.1.2007 Interviews for posts in new structures as per pooling and ring fencing arrangements.W/C 5.2.2007 At-risk letters issued to staff that have been unsuccessful in obtaining posts in the new

structures. Redeployment of affected staff to commence from this date.1 April 2007 Redundancy notices issued to staff who have not been redeployed.



risk (as a result of the mergers) was publi-cized. This signaled a clear message to staff that redundancy and change were a reality to come. For PCT managers this reality has been job losses and displacement; two CEOs and 11 Directors within the City PCT were put ‘at risk’ and only three Directors kept their posts. Middle managers were offered secondments, redundancy, or alternative roles. The PCT utilized a fortnightly email to communicate the change program to all staff.

The opportunity to explore staff percep-tions of these changes was taken, based on the day-to-day observations of staff feeling and describing ‘uncertainty, fear, frustrations, dis-empowerment, stress’, etc. Post-merger analy-sis is supported by Marks and Mirvis (1992), who suggest that tracking the merger has several benefi ts: ensuring that the organiza-tional goals are still ‘on track’; appraising if the organization came out of the merger unscathed; and fi nally showing employees that the orga-nization does care for their welfare, survival, and active participation in the whole process. Not all change is negative, and therefore it is important to understand and identify if an assumption (representing bias) has been made.

Relevant literature

Mergers

Bellou (2007) argues that an organization’s ability to understand and control employee attitudes and behavior is critical if serious problems in strategy implementation and success are to be avoided within any merger. Carleton (1997) suggests that mergers and large organizational change rarely succeed in fulfi lling the aims, with 55–70% of mergers failing to meet their anticipated purpose. Assumed management cost savings, such as the predicted £250 million quoted by the DOH in the CaPLNHS document, are rarely realized (Dickinson et al., 2006). Whilst a large propor-tion of early literature and research is domi-nated by the economic approach where mergers are understood mainly as fi nancial

and strategic alliances, Weber (1996) found that 35% of mergers that fail in their fi rst three years of life are as a result of poor employee relations. According to Pritchett et al. (1997), the greatest lull in productivity following a merger happens during the fi rst few months, with organizations taking a period of one or two years to fully recover. It would follow then that to support staff and reduce the pos-sible negative effects of mergers will reduce the negative effects associated with them. Baskin et al. (2000) suggest there are three different kinds of mergers:

� Partition — managers assume that every-thing can continue as it has, with merged units operating side by side. This approach overlooks the tension that putting units together may cause, and serious confl ict results.

� Domination — one organization and its culture take over another. This approach results in debilitating resentment in the ‘defeated’.

� Synthesis — through careful planning, design, and execution, managers in the merging companies try to synthesize the best elements of each into a higher, super-ordinate harmony.

The PCT merger using the Baskin et al. (2000) model can be described as a combination of partition and synthesis. This is due to the added complication of both new and existing Directors being slotted into a new structure, and previous unsuccessful Directors continu-ing in post until they are either made redun-dant or can secure new roles outside the organization.

Recent literature has begun to devote more attention to the psychological processes involved in mergers. Consequently, it is now well acknowledged that mergers may have many harmful effects on employee wellbeing and behavior, including high levels of stress, increased anxiety, increased staff turnover, lowered job satisfaction, and reduced organi-zational identifi cation (Lipponen et al., 2004; Dickinson et al., 2006).



Recent literature has begun to devote more

attention to the psychological processes involved in mergers.

Consequently, it is now well acknowledged that

mergers may have many harmful effects on

employee well-being and behavior

Even when change is viewed positively, staff experience stress, uncertainty, and loss (Shaw, 2002). Pritchett et al. (1997) found that the heightened state of uncertainty that is con-stantly created by mergers pervades the work climate and people get ‘jumpy’. Because they fear additional surprises, particularly regarding their own career safety, they instinctively move to protect themselves, with coping behaviors tending to be highly self-orientated and thus dysfunctional as far as the organiza-tional good is concerned.

Whilst much of the literature focuses strongly on the negative effects that mergers have — describing the stress, anxiety, uncer-tainty, etc. there is reference within the litera-ture to the fact that some people will view a merger as an opportunity to improve an exist-ing situation that is considered intolerable or dissatisfying (Appelbaum et al., 2000).

Evidence by Bediako (2002) found that given time, more benefi ts can be derived from restructuring and downsizing which would enhance staff’s quality of life and the organiza-tional climate. He suggests the quickest way to realize increased productivity and perfor-mance following downsizing lies in an organi-zation’s ability to manage the process effectively and give very careful consideration to the human dimension.

In order to reduce any uncertainty, Tapsell (1998) found that increasing amounts of

communication, even if the news is bad, was effective. This suggests that uncertainty is more ‘unsettling’ than bad news. Pritchett et al. (1997) found that uncertainties, fears, and inner tensions do distinct damage to indi-vidual productivity. Anxiety inhibits creativity, interferes with one’s ability to concentrate, acts as a drain of physical energy, and fre-quently lowers individuals’ frustration toler-ance. Within their research they found that employees became less willing to make deci-sions or take risks, with an air of tentativeness or a ‘wait and see’ attitude pre- and during mergers.

A large case study undertaken within an NHS hospital by Jones (2005) found that there are a number of ‘push’ and ‘pull’ factors infl u-encing staff decisions on whether to remain within an organization following a merger. These are crucial for managers to understand if they are to avoid undue loss of organiza-tional memory and talent, as senior and long-serving staff might choose to ‘jump ship’ as a result of the merger process.

Psychological contract

Coyle-Shapiro and Kessler (2000) suggest that the psychological contract is an attempt to understand and predict the consequences of changes occurring in the employment rela-tionship. In the context of PCT mergers, such theories can aid an understanding of staff’s perceptions of a potential breach or violation in what they expect from the organization.

Robinson and Morrison (1995) suggest that the implications of organizational restructur-ing and downsizing on employment relations have renewed interest in the psychological contract, and their research argues that when a breach of contract is perceived, violation naturally occurs. Cortvriend (2002) found that the psychological contract changed in line with individual experiences of change, with some people experiencing incongruence and perceiving that their expectations were unmet, hence resulting in exit from the organization during the merger. Interestingly, she suggests that as NHS employees are so used to constant



change and that as regular organizational transitions occur, this may be emerging as a component of a new psychological contract with the NHS.

One of the few pieces of research to link employee wellbeing and patient outcomes within the NHS comes from Michie and West (2004), who propose that within the health service there is good evidence that factors such as workload and control over work infl u-ence stress levels and psychological health. They conclude that people management infl u-ences employee health and wellbeing as well as individual, group, and organizational per-formance. They provide an evidence-based framework that describes links between key organizational infl uences and staff per-formance, health, and wellbeing. This frame-work can be used within the local PCT context by integrating management and psychological approaches with the aim of understanding and managing future change.

Organizational commitment

Organizational commitment is defi ned in terms of attitude as well as a set of intentions. An early and very infl uential view is that of Mowday et al. (1979; cited by McBain, 2005) for whom organizational commitment repre-sents an individual’s identifi cation with and involvement in an organization. For these authors, three factors underpin organizational commitment:

� A strong belief in, and acceptance of, the organization’s goal and values.

� A willingness to exert considerable effort on behalf of the organization.

� A strong desire to retain one’s membership in the organization.

It could be said that employees who exhibit organizational commitment within the PCT have accepted and understood the need for the mergers by generating increased levels of effort, aligning themselves to the organization and choosing not to leave but to embrace their

new roles. Factors two and three could there-fore be as a result of uncertainty and are more about a fear of change and possible redundancy.

Ebadan and Winstanley (1997; cited by Worrall and Cooper, 2002) suggest that a violation such as redundancy could reduce organizational commitment, morale, and moti-vation. Such violations cause employees to reduce their sense of obligation to employers and, at the same time, to increase their feelings of what they were owed by their employers. It is not clear from these writers, though, if it is actual redundancy or the fear of redundancy that reduces organizational commitment.

Positive emotions in the workplace can be fostered at the work group level.

This conceptual framework acknowledges there are several work-

related commitments that all infl uence the intention

to stay or leave and should be considered

Winchester and Bach (1995) found that due to high levels of responsibility, especially in times of organizational change, managers in the NHS often experience work-related stress, work long hours, feel isolated, and report lower levels of job satisfaction and commit-ment than non-managers. Baruch and Winklemann-Gleed (2002) carried out their research in a community health services NHS Trust and found that stress was negatively related to organizational commitment, with enthusiasm being strongly related to supervi-sor support and also to job control and support from colleagues. This would suggest that positive emotions in the workplace can be



fostered at the work group level. This concep-tual framework acknowledges there are several work-related commitments that all infl uence the intention to stay or leave and should be considered for future PCT change.

Limitations and gaps in the literature

Despite the fact that the literature, albeit mainly from the private sector, offers a wealth of knowledge in the areas of focus presented here, gaps and limitations still exist:

� There is very little evidence beyond the anecdotal of research concerned with views of staff that leave organizations which are undergoing major change.

� There is a plethora of evidence around the negative aspects of mergers, particularly with reference to a drop in productivity and performance and on the human side describ-ing the many harmful effects on employee wellbeing and behavior, including high levels of stress, increased anxiety, increased staff turnover, and lowered job satisfaction. What is not available is the evidence to sub-stantiate the claims around the possible effects of reduced costs, effi cient resource management, and so forth as there are no actual large-scale studies to show these effects in a merger situation for the NHS.

� Much of the research literature concerned with the psychological contract has used only one method, the survey. Whilst in some cases it has been used over a time period to track changes, it is nevertheless a ‘cold’ capture of information and does not fully inform the ongoing emotions experienced by healthcare staff. Surveys cannot inform what is needed to know about the psycho-logical contract, commitment, and so on, particularly in terms of organizational change, breach, and violation.

� Finally, there is only a small amount of evi-dence within the literature which describes the implications of organizational change (mergers) on management practice in the NHS.

Methodology

The purpose of the study was essentially to explore how PCT staff experience organiza-tional change. A qualitative research approach was chosen in an attempt to describe the social world (events, actions, norms, values) through the eyes of those experiencing it (Bryman, 1988). A cross-sectional case study, using questionnaires and focus groups, was undertaken to provide a ‘detailed description of a particular situation, organisation, individ-ual or event’ (Bryman and Bell, 2003: 48), the PCT as ‘the organisation’ and the PCT mergers as ‘the event’. The perceptions of staff cannot be fully understood and elicited through surveys and questionnaires; therefore, qualita-tive data yielded from focus groups has been used. A questionnaire was used at the begin-ning of the focus group to identify demo-graphic details of each respondent. Quantitative data (sickness and absence rates) were also used to better understand emerging themes. The acknowledgment that both qualitative and quantitative data can inform an overall qualitative strategy is important here.

The researchers in the study wanted to translate research evidence into practice. The problems of linking evidence with practice, including the source and nature of the evi-dence and the research method employed (Fitzgerald et al., 1999; Transfi eld et al., 2003), were in part addressed by a collaborative research design (Denis and Lomas, 2003). Involving participants in the process and out-comes of the research, we believe, contributes to dissemination and application.

A total of 17 participants took part in fi ve focus groups between April and May 2007, from a mixture of professional groups: Nursing, Administrative, and Therapy. The age range of participants was 31 to 55 years. Each focus group contained between three and four par-ticipants using a convenience sampling method (Remenyi et al., 1998). Each group contained staff at similar levels/grades within the organi-zation and in similar professions, such as therapy, nursing, and administrative staff. The same professional level and grade was chosen



for each focus group as it was believed that homogeneity within each group would induce higher levels of disclosure and honesty; for example, the participants in the focus group with administrative staff may have been inti-midated if the same group contained senior managers or clinicians. The organizational tenure of participants ranged from 1 to 29 years, with a mean of 17 years. It was not possible to engage a focus group of medical consultants at the time of this research due to clinical commitments.

A constructive dialog with members of the PCT team, including the research advisor, enabled a series of questions to be designed around the current and future changes referred to in the CaPLNHS document and to maximize the opportunity for discussion and debate within the fi ve focus groups. At the end of each focus group the participants were asked their views and suggestions on managing future organizational change. Gaining employees’ experience and expertise is an important source of knowledge in shaping processes of change (Dawson, 2003).

At the end of each focus group the participants were asked their views

and suggestions on managing future

organizational change

Marshall and Rossman (1999) argue that focus groups have a high apparent validity. Since the idea is easy to understand, the results are believable. Also, they are low in cost, one can get results relatively quickly, and they can increase the sample size of a report because several people at a time can participate. The use of participants from a wide variety of professional groups and experiences would support the view that a wide interpretation and understanding of recent changes has been sought. Although the research attempts to

understand the local view and perceptions of staff, it is suggested that the regularity of change within the national context can enable some generalizability.

Cormack (1996) suggests that the accuracy in the reproduction of subjects’ perspectives largely depends upon the researcher’s knowl-edge and familiarity of the social setting being studied. In this case the lead researcher as focus group mediator and ‘insider’ was ideally placed (a clinical background, ‘spoke the language’, credibility with staff). Group discussions were captured using a laptop and contemporaneous notes. The discourse from all focus groups was examined to identify themes and patterns (regular and repeated text) to show affi rmation of fi ndings and concurrence between respon-dents. The method relied on the closeness of the moderator/researcher to the situation, remaining critically aware and fully conversant with events, allowing an understanding of the collective sense-making by respondents (Wilkin-son, 1998; Bryman and Bell, 2003). Staff who took part in the research were asked to confi rm the accurate capture of discussions within the focus groups, one from focus group one and one from focus group fi ve. The focus group scripts were sent by email for them to peruse and reply with any comments.

The issue of consent is key to all studies within the NHS, not only the consent to par-ticipate in research studies but consent per se. The Research Ethics Committee deemed the project as not requiring research governance because patients and children were not involved in the study. Therefore, approval for the study was given under the heading of ‘Service Evaluation’.

The quality of the research was enhanced by ensuring its ‘trustworthiness’ (plausibility, credibility, authenticity) as Lincoln and Guba (1985) advocate for qualitative research; pro-cedural reliability (Flick, 1998); and member validation (Seale, 1999) as described earlier.

Findings reveal high anxiety

The analysis of the fi ve focus group discus-sions on the recent organizational changes



revealed a wide variety of emotions and per-ceptions. The process of analysis was complex and thorough and was tabulated around nine question categories and the key themes based on the literature, and sub-themes that emerged as follows.

Uncertainty related to the mergers

Two of the most common feelings expressed by respondents were ‘uncertainty’ and ‘vul-nerability’, and they were mentioned through-out the discussions. Much of the discussion seemed to be in relation to what respondents thought the future held rather than what they had just been through. This supports Terry and Jimmieson’s (2003) research that ‘the most frequent psychological state resulting from organisational change is uncertainty’.

Two of the most common feelings expressed by

respondents were ‘uncertainty’ and

‘vulnerability’, and they were mentioned throughout the

discussions

In contrast to the uncertainty felt by many, several references were made to the possibil-ity of improvement through the reconfi gura-tion of PCTs — and confi rmed by Appelbaum et al. (2000), who suggested that mergers are viewed by some as an opportunity to improve an existing situation that is considered intolerable or dissatisfying.

Administration and managerial staff reported feeling threatened by the changes. They were described as being at ‘risk’ within the PCT merger timetable, and there was regular reference to ‘vulnerability’ and ‘uncertainty’ amongst this group of staff. Clinicians such as nurses and therapists have what is described

as ‘non-feeling or denial’, possibly because of the ‘skills’ and ‘expertise’ they have.

Alternatively, nursing and therapy staff tended to describe the uncertainty in relation to the children they care for instead of for themselves, as one nurse declared:

I have concerns about affecting children’s community care

Constant change in the NHS

The NHS change literature clearly describes the cyclical and continual pattern of change described within the context and reform agenda sections. One of the most salient themes to emerge from discussions was in relation to the amount of change that staff felt the NHS had experienced. Nearly all questions yielded reference to ‘another change’ and ‘not another change’, for example:

. . . felt like we were going round in circles. Didn’t feel worried when told something else that’s going to change

Cortvriend (2002) suggested that despite the fact that people are no longer shocked by the announcement of changes in the organization, they nevertheless appear to remain affected by such declarations. Drucker (1981; cited by Wilson and Rosenfeld, 1990) noted that the capacity for individuals to handle change is limited. This varies from person to person, but even the most receptive individuals can easily reach the limits of their tolerance.

Discussions generally consisted of not being involved in the management of the change or the decisions leading to the change, but that this had come from much higher up the orga-nization. Several group members believed that decisions ultimately came from the govern-ment, which led to a lack of control locally. Despite discussion about governmental involvement, there seems to be a certain amount of resignation about this issue. It was as if people felt that this is the way it is and always will be and that NHS employees have little control over these decisions:



Several group members believed that decisions

ultimately came from the government, which led to a lack of control locally

Not learnt its lessons from previous organ-isational changes . . .

Whilst the literature suggests that senior man-agement ‘expect that responsibility will be absorbed’, what has been found is that actually the changes and management themselves hinder the ability to take actions and respon-sibility:

There was a lack of clarity in roles, not sure what we were meant to be doing. I felt paralysed, resentment, anger, anxiety and de-valued.

There was one reference made by a nurse to feeling empowered on a day-to-day basis and there seems little to suggest how this was felt by one individual and not by others.

The research reveals an array of emotions from respondents who fi nd they face different roles with new demands. Pritchett et al. (1997) found that employees became less willing to make decisions or take risks, with an air of tentativeness or a ‘wait and see’ attitude pre- and during mergers. The reverse was found within this research, where respondents wanted to be left to make decisions and ‘get on with the business’ but felt unable to, there-fore it was not so much ‘less willing’ than ‘not allowed or able to’. One respondent described the positive impact of ‘having’ to manage workloads and capacity differently:

It has let us look at the discharge fl ow and improve it.

The reference to ‘let’ almost suggests that without the major change there was a

perception of being unable, disempowered, or even prevented from making changes.

Organizational commitment

Principally, emotions described during change were uncertainty, insecurity, and vulnerabil-ity. Somewhat of a paradox emerged, with some respondents within the same nursing group suggesting how valued people felt, and conversely expressing sentiments of feeling undervalued. Coyle-Shapiro and Kessler (2000) found that to be positively valued was seen as vital for a positive contribution by employees, with contribution and intention to stay clearly linked.

There is evidence to show that staff’s per-ceptions of change within the NHS are such that they expect change to occur. Some respondents within the administrative group described themselves as ‘institutionalised’, and were not really concerned that something else was going to change. Exploration of the statistical data reveals a link with lengths of time in service and the professional group they come from, with a clear link with longer service from those in the administrative group.

There is evidence to show that staff’s perceptions of change within the NHS

are such that they expect change to occur

Our research fi ndings do not support Meyer and Allen (1997), who suggest that highly spe-cialized staff stay within the organization due to limited opportunities of moving. It is sug-gested from these fi ndings (whilst only small in number) that the admin staff have a ten-dency to stay within the organization even though they have what can be termed ‘trans-ferable skills’, which would enable them to move around the public and private sector.



Respondents also spoke about leavers, a phenomenon described by O’Connor and Fiol (1997), where staff chose to leave mid-consul-tation process, also referred to as ‘bailing out’; three staff referred to knowing or being aware of colleagues leaving the organization — when prompted for what they felt may be the reasons, staff felt it was due to being unsuc-cessful at the slotting in and recruitment phase, unhappy with not securing the right job, or because of Agenda for Change (A4C) issues (pay scale changes). Jones (2005) described a number of ‘push’ and ‘pull’ factors infl uencing staff decisions on whether to remain within the organization; A4C can therefore be described as a ‘push’ factor for some employees.

On investigation of the PCT statistics and exit interviews from 2004 to 2007, the fi gures are actually showing a recent downward trend (Table 2).

Information on reasons for leaving is not very specifi c, and in many cases not declared so it is diffi cult to say if any people left because of the merger. What is already known is that the two Chief Executives, one PCT Chair and some of the Non-Executives were leavers although not necessarily through choice — mostly any reasons given were promotion, retirement, relocation, further education, or better work/life balance, the remainder were not known.

The loss of senior people is concerning, and it feels like we’re taking a step backwards

The return rate of exit questionnaires is very low, but of those returned the most common

comments about what could be improved in the Trust were management style/attitude and communication. A couple of leavers also com-mented that the uncertainty of fi xed-term posts contributed to their decision to leave.

Fisher and Ashkanasy (2000) and Michie and West (2004) found the recognition of emo-tions to organizational commitment is im-portant because of the expected impact on performance, satisfaction, wellbeing, stress, and health, and it is suggested that the variety of employee commitments are adversely affected by negative emotions at work and positively infl uenced by positive emotions. It would follow that if the perception is that sickness levels have risen then staff commit-ment has reduced and if sickness levels remain the same or are reduced then commitment is maintained or even increased. Several refer-ences were made to ‘staff worried about taking time off sick’, with the paradox of:

. . . all this change has had an impact on sickness — occupational health are involved at the moment

Several references were made about staff not feeling like they could take time off or that staff were doing ‘over and above’ the normal. Pritchett et al. (1997) found that ‘coping behaviours tend to be highly self-orientated’. Handy (1998; cited by Worrall and Cooper, 2002) refers to this as ‘presenteeism’, which suggests the fear of redundancy may go some way to explain why staff attempt to demon-strate their indispensability by visibly working long hours. Michie and West (2004) subse-quently found that high absenteeism is associ-ated with higher intentions to leave followed

Table 2. Leavers (gray shading indicates the merged PCT from October 2006 to March 2007)

Headcount Apr May June July Aug Sept Oct Nov Dec Jan Feb Mar Current Average

Total

2007/08 leavers 11 2 8 13 16 16 3 11 102006/07 Leavers 8 10 10 13 12 20 10 10 9 11 6 8 12 1282005/06 Leavers 14 9 12 19 15 24 16 12 9 14 3 18 14 1652004/05 Leavers 14 10 19 13 23 19 19 11 18 14 8 26 17 194



by resignation. In analyzing the sickness rates for the City PCT (Table 3) (for the period pre- and post-merger), a fairly consistent trend can be seen against previous years. This would support the perception by the respondents that felt staff ‘were not’ or ‘could not’ take time off sick.

High absenteeism is associated with higher

intentions to leave followed by resignation

The period from 1 October 2006 when the PCTs merged (shaded in gray) reveals a consis-tent rate for 3 months with a rise in January 2007 and a signifi cant drop in March and April 2007.

Summary

The main fi ndings from the focus group dis-cussions relate to four themes: Uncertainty, Cyclical Change, Commitment, and Leavers/Sickness. Many respondents focused on the ‘constant change’ with no time given to adjust-ment, stability, evaluation, and the lack of stra-tegic direction that seems to emanate from central government and thus weakens local delivery. Reference to feeling valued played a prominent feature in the discussions, and what appears to offer another paradox between ‘presenteeism’ and exit, loss, and sickness.

Reference to feeling valued played a prominent

feature in the discussions, and what appears to offer another paradox between

‘presenteeism’ and exit, loss, and sickness

This varied from staff wanting to be seen to be doing and those that chose to ‘exit’ and leave the organization.

Agenda for action

The research fi ndings enable a degree of com-parability against those theories and research reviewed earlier in the paper. The aim is to see if there are similarities and/or differences in the local context of organizational change and the perspective in the literature.

The literature suggests there is a consider-able drop in productivity around the 0–3 month stage following a major organizational change such as the merger we have seen in the local PCTs. There are confl icting views on the simplicity of the mergers and much of the literature does focus on the economic effects rather than the human side.

What is clear from the literature that has been developed around the human side is the uncertainty, increased anxiety, increased staff

Table 3. Sickness rates (gray shading indicates the merged PCT from October 2006 to April 2007)

Sick Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec Avg

2005 wte 48.14 41.20 38.47 42.26 54.97 48.33 41.93 36.09 29.92 44.84 44.77 41.37 42.692006 wte 45.27 48.38 50.20 39.84 31.64 35.83 40.40 41.85 35.56 41.39 45.35 44.33 41.672007 wte 51.26 49.15 37.05 38.48 53.96 53.38 51.66 41.91 34.29 38.43 41.67 0.00 44.662007 %

lost5.65 5.46 4.15 4.31 6.01 5.89 5.51 4.48 3.63 4.03 4.26 0.00 4.85

DOH annual target

3.91 3.91 3.91 3.91 3.91 3.91 3.91 3.91 3.91 3.91 3.91 3.91 3.91



turnover, and lowered job satisfaction that such change provokes in individuals. In explor-ing the literature there was very little evidence of the positive effects such a change can have on staff, with brief reference to ‘some will view a merger as an opportunity to improve an existing situation that is considered intoler-able or dissatisfying’. The literature supports the detailed tracking of the post-merger phase and gives several reasons for the benefi ts of conducting research, discussions, and inter-views, such as ‘to show staff that the organi-sation’s leadership really care about their active participation’. This study hopefully contributes to this.

The literature provides several models that can help to understand what staff are feeling, and why productivity, performance, behav-iors, and/or change are affected both in a pos-itive and a negative way, and provides insights for future change in the NHS.

Whilst the Psychological Contract is by no means a new concept (dating to the 1960s), it has only recently been applied to the health-care setting and this provides valuable insight into how staff feel when let down by the change in the employment relationship that they had come to accept as the ‘norm’. This is referred to as a ‘violation’ and incorporates the idea of how staff feel valued, or not (as has been seen within the research and literature).

To understand ‘absenteeism’ and ‘presen-teeism’ in respect to organizational change, several authors have drawn upon the concept of Organizational Commitment. This area looks at perceived obligations that staff have of the organization and the behaviors that can be expected from them as a result of what is seen as unfulfi lled obligations.

The research fi ndings revealed several recur-ring themes that staff discussed in the focus groups, and these were:

� Uncertainty.� Lack of strategic management, which led to

cyclical change.� Behaviors associated with Organizational

Commitment and the Psychological Con-

tract, namely presenteeism, sickness, and those choosing to leave the organization as in ‘bailing out’.

� The effects of Organizational Change, namely added responsibilities due to delay-ering, staff unwilling to make decisions, how staff feel devalued and why, and the ‘roller coaster of emotions’ that staff feel from the changes and new roles.

There was also a strong sense of resignation as people have become accustomed to con-stant changes occurring in the NHS. Respon-dents often voiced their doubts about the strategic planning behind the organizational changes. These fi ndings suggest that large-scale changes in the NHS enacted nationally may not always be made with suffi cient fore-thought or sensitivity to local context, and that change may take place for the sake of change.

Respondents often voiced their doubts about the

strategic planning behind the organizational

changes

Responses in relation to the Psychological Contract suggest that more attention needs to be paid to this in NHS organizations. Partici-pants remain loyal to the ethos of the NHS, to their patients, and to their employing organiza-tion. Incremental or sudden erosion of the con-tract does appear to lead to exit, although more research is required in this area as fi ndings were somewhat ambiguous, with the statistics not supporting the perception of an increased number of leavers. This does not detract from the fact that two CEOs and 11 Directors were put at risk and only three Directors retained their jobs, with the rest leaving the organization in one way or another.



Organizational change is seen here to be unsettling and causes considerable

disturbances to staff members and their patterns of working

Organizational change is seen here to be unsettling and causes considerable distur-bances to staff members and their patterns of working, and these effects are further multi-plied by introducing reorganizations into areas where the effects of previous changes are still felt, as has been identifi ed from Agenda for Change (A4C) issues.

Practical moves

One signifi cant aim of this study was the desire to generate evidence for an ‘agenda for action’ for future organizational change that recog-nizes and minimizes the negative effects upon staff and service delivery. To benefi t the dis-semination and application of the research, the focus groups were given the opportunity to consider ‘how change programs in the future could be improved’. An extract of this is summarized in the appendix. Without offer-ing a neat solution to the complexities of change, the ‘agenda for action’ provides valu-able insights into the experience and meaning of change of those taking part and helps in shaping the processes of future change for the organization. The study fi ndings, the agenda for action, and recommendations will be pre-sented to the Provider directorate team.

Appendix

Focus group issues and actions — extract from ‘Communication and Change’

ISSUE ACTION

‘Inform\people . . . what communicate’ Communicate the changes effi ciently, effectively and in a timely manner. A vacuum of information breeds scare and stories and fuels uncertainty and anxiety.

‘Think of workforce as people and not numbers’ Communication can be more relevant to staff groups rather than ‘en-masse’. Make it relevant to individual staff groups for example, managers, administration and clinical.

‘Communicate, more consultation’ Utilise various staff venues; don’t always expect clinical staff to travel away from their work environments to admin bases. Provide opportunities for employees to ask questions about the changes and how they will affect them. The line manager can often be the crucial link in this case.

‘To have clear vision with clear score-able outcomes’ Produce vision and statements in various formats: newsletters, workshops, emails, intranet website, local newspapers. Explain why you believe the change is necessary. Human beings have consistently negative reactions to unexplained events. This effect is so strong that it is better to give an explanation that people dislike than no explanation at all — so long as the explanation is credible.

‘The language is confusing and alienating’ Utilise the skills of the communications manager and dept. to understand how various communication techniques and language can be used.

‘PCT could learn a lot, they are distant, remote’ Organise stakeholder events so that staff can see senior managers.

‘Email correspondence is all there had been’ Discussions with Organisational Development manager suggest various workshops and forums can be utilised for future change and projects.



‘Email is devolving responsibility for getting people aware and feeding information’

Communications manager has suggested that many more formats and media can be used.

‘It never relates to how it affects you as an individual’

Need to make it real for the staff group concerned. Offer training to individuals to help them develop the resiliency skills to be able to regain a sense of personal control in a climate of change.

‘Took a long time, could be a quicker process. Decisions need to be made quicker’

If staff can see timescales, with actions and outcomes then progress will feel quicker.

‘It feels like an organisation that doesn’t learn’ The dissemination of post merger analysis (such as this work) may show as suggested within the literature that the organisation is trying to learn.

‘They pay lip service to the idea that we are valued’ There is clearly a link between feeling valued and obligations unmet, or feeling unfairly treated. It is therefore in the organisation’s interest to ensure staff feel valued and this can be done through a variety of initiatives such as those described above.

‘Need to do more feedback, refl ection, and listening to the patients’

Patient and public involvement is now central to the NHS changes. Seek views in many ways; stakeholder events, invite patients to redesign forums, ask patients their views when setting up new services, changing services.

Biographical notes

Joe Marshall’s teaching and research has focused on organizational change for a number of years at the University of Derby. He was the leader of the MBA program at Derbyshire Busi-ness School. His current research is on Systems Thinking and Organizational Change in the Service Sector.

Anne-Maria Olphert has worked in the UK Health Service for many years in a number of clinical roles. For the last six years she has held management positions in Community and Acute healthcare settings and is now Associate Director of Children’s Community Health Services at Leicester City PCT. Her research interests are in organizational change and the nature of collaborative research designs involv-ing practitioners as researchers and translating evidence into practice.

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Organizational change in the National Health Service: lessons from the staff

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