I have followed recent discussions on health service integration with interest. It raises a wide range of different issues and there are just one or two that I would like to comment on. Some years ago now I did research for a PhD on disciplinary cases and the social and cultural factors affecting the management of poor care in nursing. (See for eg http://wes.sagepub.com/content/20/4/687.short  or http://wes.sagepub.com/content/20/2/223.short ) Then in 2011 I carried out research for a future book on the history of regulation in nursing. This amongst other things entailed reading enquiry reports on poor care dating right back to some of the enquiries into workhouse care in the 19th century. Taking this long view of enquiries, what struck me was the way in which each generation of policy wonks believed that the latest organisational or management fix would stop such problems from happening again. Essentially these problems were recruited to justify the latest policy rhetoric or fashion. Reading the enquiries into longstay care in the 1960s and early 70s one finds many commentators explaining that the 1973 reorganisation will solve  the problems of poor care (although the Normansfield Inquiry in 1978 showed that reorganisation had distracted attention from problems of poor care).

The rhetoric of integration is very much part of the debates running up to the 73 reorganisation and the debates that I have been reading here are very reminiscent of some of the debates of the early 70s. In 1977-8 I did some research into the politics of hospital closures with early community health councils and I saw the same justifications for closures being put forward as I now hear being proffered to justify reconfiguration of services. There was a belief then that better integration, better preventive and primary care would follow from the 73 reorganisation but I fear they did not. It proved nearly impossible to reallocate slices of a shrinking cake in a way that improved services . I thus have considerable doubts about some of the proposals for integration that have been put forward recently.

When looking at more recent enquiries and talking to managers and regulators during the course of my research I have noticed an increasing emphasis on culture change as the solution to health care problems. This is often coupled with the notion that the leadership can operate as some kind of magic organisational bullet. I remember when I was doing my Ph.D. reading a number of organisational studies which suggested that an emphasis on leadership and culture amongst managers occurred in inverse relationship to their opportunity to practically control their organisational environment. I don’t think it’s an accident that people are talking more and more about culture and leadership in an environment where they are asking more and more  for less and less from staff in   turbulent and fragmented  organisations operating in a deteriorating economic environment (see for example Roscigno et al  on organisational chaos ).

As someone with a social science background I think that much of the managerial literature on culture change is naive and mistaken. The anthropological understanding of organisational culture is more helpful. Anthropologists see culture as part of what the organisation is  rather than something an organisation has. Organisational culture is not something you can just change from the top by education and exhortation. An organisation’s culture is a reflection of the structure and function of that organisation not an add-on which can be manipulated at will. It can’t be changed without fundamental changes to structures of power, remuneration etc.  Thus most of the culture change that we see in healthcare involves the unintended consequences of organisational change  (There is a good deal of interesting literature on unintended consequences. I have found Sieber’s 1981 book Fatal Remedies: The Ironies of Social Intervention instructive and it should be required reading for all policy makers. Hood’s paper on public management reform is also good ). By contrast it has been my experience that many of the projects that deliberately try to engineer  new organisational cultures are short lived in their effects with much of their apparent initial success attributable to novelty effects or the ‘Hawthorne’ effect.

The final issue that has troubled me in some recent debates is the emphasis on changing professional culture and breaking down professional barriers. I think there is a real risk here of undermining professional identities in ways that are detrimental to care with yet more negative unintended consequences. What we need is better communication between professionals who have a secure professional identity and clear professional boundaries. What we don’t need are insecure professional identities and blurred occupational boundaries (See for example Rushmer and Pallis 2003 )

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3 Comments

  1. Thanks Hannah,

    Very useful. It seems to me that there are as many issues with integration as there are advantages. The fact that policy initiatives in this area stretch back so far but as yet we still have seen limited progress suggests that this has been something fundamentally wrong in our approach to date and that we havent understood the terrain or the process sufficiently well. I shall read you references with interest – they sound helpful.

    best wishes

  2. I think there are natural managers who get people to get things done optimally and holistically without programmes.Management as part of a career path is indicative of personal ambition which runs counter to working with people to get things done.In a career move,the results and failures of mangement are seen more as hazards or benefits to career prospects.This is a much lesser/paltry context to getting things done,and getting people to do things.

  3. Val Hudson says:

    I think you are absolutely right Hannah, and thanks for raising this important debate. You can’t just change culture by ‘dictate’ and ‘education.’ I too have a social science background but then went on to do a management qualification and taught organisational analysis at undergrad level. I think some of the management literature can be helpful, especially that of Charles Handy. The problem with the current set up is that you will never change culture in the current command and control structure, and patients and front line staff will always come at the bottom of the structure. Here the work of Sherry Arnstein is helpful, although she too uses a hierarchical structure to determine citizen power. I think the last Labour Government got it nearly right with the Every Child Matters ‘onion’ which had a theoretical underpinning and put the child at the centre. That like anything needed time to settle but we lost it in 2010. I don’t think we will get a cultural shift under this government. As cuts embed there is less likely than more likelihood of integration

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