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The medium-term sustainability of organisational change in the National Health Service: a comparative case study of clinically led organisational innovations Graham P. Martin,1 Simon Weaver,2 Graeme Currie,3 Rachael Finn,4 and Ruth McDonald5 1

University University 3 University 4 University 5 University 2

of of of of of

Leicester Leicester Warwick Sheffield Nottingham

© Queen’s Printer and Controller of HMSO 2013. This work was produced by Martin et al. under the terms of a commissioning contract issued by the Secretary of State for Health. Project 09/1001/40

Address for correspondence: Graham Martin University of Leicester Department of Health Sciences Adrian Building University Road Leicester LE1 7RH Email: [email protected] This report should be referenced as follows: Martin GP, Weaver S, Currie G, Finn R, McDonald R. The medium-term sustainability of organisational change in the National Health Service: a comparative case study of clinically led organisational innovations. Final report. NIHR Service Delivery and Organisation programme; 2013. Relationship statement: This document is an output from a research project that was funded by the NIHR Service Delivery and Organisation (SDO) programme based at the National Institute for Health Research Evaluations, Trials and Studies Coordinating Centre (NETSCC) at the University of Southampton. The management of the project and subsequent editorial review of the final report was undertaken by the NIHR Service Delivery and Organisation (SDO) programme. From January 2012, the NIHR SDO programme merged with the NIHR Health Services Research (NIHR HSR) programme to establish the new NIHR Health Services and Delivery Research (NIHR HS&DR) programme. Should you have any queries please contact [email protected]. Copyright information: This report may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NETSCC, HS&DR. National Institute for Health Research Evaluation, Trials and Studies Coordinating Centre University of Southampton Alpha House, Enterprise Road Southampton SO16 7NS

© Queen’s Printer and Controller of HMSO 2013. This work was produced by Martin et al under the terms of a commissioning contract issued by the Secretary of State for Health

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Disclaimer: This report presents independent research funded by the National Institute for Health Research (NIHR). The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health. If there are verbatim quotations included in this publication the views and opinions expressed by the interviewees are those of the interviewees and not necessarily those of the NHS, the NIHR or the Department of Health. Criteria for inclusion: Reports are published if (1) they have resulted from work for the SDO programme including those submitted post the merge to the HS&DR programme, and (2) they are of a sufficiently high scientific quality as assessed by the reviewers and editors. The research in this report was commissioned by the SDO programme as project number 09/1005/01. The contractual start date was in December 2010. The final report began editorial review in March 2012 and was accepted for publication in January 2013. The authors have been wholly responsible for all data collection, analysis and interpretation, and for writing up their work. The SDO editorial team have tried to ensure the accuracy of the authors’ report and would like to thank the reviewers for their constructive comments on the final report documentation. However, they do not accept liability for damages or losses arising from material published in this report.


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Contents Contents

4

List of tables

6

List of figures

6

Glossary of terms/abbreviations

7

Acknowledgements

8

Executive Summary

9

Background

9

Aims

9

Methods

9

Results

10

Conclusions

11

1

12

2

Introduction 1.1

Implementation, embedding and sustainability

12

1.2

The structure of this report

14

The literature on organisational innovation, implementation and sustainability 17 2.1 The limited research knowledge base on sustainability of organisational change 17 2.1.1

Key facilitators and barriers in sustaining organisational change

2.1.2 The emergent literature on sustainability and existing conceptual frameworks 2.2

3

Beyond facilitators and barriers

19 22 25

2.2.1

Policy and changing organisational structures

26

2.2.2

The NHS professional context

28

2.2.3

Leadership

31

2.2.4

Discourse and framing

33

2.3

A note on definitional precision

36

2.4

Conclusion

37

Setting and methods 3.1

38

Clinical genetics provision in the United Kingdom

38


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4

5

6

7

3.2

The ‘mainstreaming genetics’ pilot programme and its evaluation

40

3.3

This study

42

3.3.1

The sample

42

3.3.2

Data collection

44

3.3.3

Data analysis

46

After the pilot: the first steps towards sustainability

47

4.1

Case A

47

4.2

Case B

51

4.3

Case C

55

4.4

Case D

59

4.5

Key themes

63

Embedding sustainability for the medium term and beyond

65

5.1

Evidencing services’ value

65

5.2

Appealing to the right agenda in a shifting policy context

70

5.3

Networks of support

72

5.4

Leaders and champions

77

5.5

Temporary fixes, shifting contexts, new networks

79

5.6

Biding time and seizing the day

84

5.7

Implications for services

86

Discussion: key issues in sustainability

88

6.1

Sustainability in practice: key issues in medium-term sustainability

88

6.2

Policy and changing organisational structures

90

6.3

The NHS professional context

92

6.4

Leadership

97

6.5

Discourse and framing

102

Conclusion

111

References

116


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List of tables Table 1. Mapping key factors in sustainability identified in the literature onto conceptual categories relating to implementation put forward in Damschröder et al.’s ‘Consolidated Framework for Implementation Research’ ......................... 24 Table 2.

Key characteristics of the four selected case-study sites.. ............. 43

Table 3.

Interview participants by case study site. ................................... 46

List of figures Figure 1.

Ideal trajectory for innovation leadership. ................................... 33


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Glossary of terms/abbreviations DH

Department of Health

CLAHRC

Collaboration for Leadership in Applied Health Research and Care

GP

general practitioner

GPSI

general practitioner with a special interest

NHS

National Health Service

NICE

National Institute for Health and Clinical Excellence

PCT

Primary Care Trust

UK

United Kingdom


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Acknowledgements We are grateful above all to our research participants, especially those involved centrally in the clinical genetics service innovations studied, who have given up over the course of this study and the preceding evaluation several hours of their time, and introduced us to further participants. Graham Martin (Senior Lecturer in Social Science applied to Health, University of Leicester) led the study and the writing of the report, and carried out some of the fieldwork. He worked with SW on the data interpretation and analysis, independently reading transcripts, contributing to coding, and validating the analysis. Simon Weaver (Research Associate, University of Leicester) carried out the literature review, most of the fieldwork, and led the secondary analysis of the dataset from the earlier study, and the analysis of the new dataset collected in the course of this study. Graeme Currie (Professor of Public Management, University of Warwick) provided input into several areas of the analysis and writing up, particularly around leadership. Rachael Finn (Professor of Organisation Studies, University of Sheffield) provided input into several areas of the analysis and writing up, particularly around discourse and framing. Ruth McDonald (Professor of Healthcare Innovation and Learning, University of Nottingham) provided input into several areas of the analysis and writing up, particularly around professionalism.


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Executive Summary Background There is a growing literature on the process of introducing new ways of working in complex organisational systems such as health care services, but to date there has been very little examination of the sustainability of such change beyond efforts to implement and gain initial acceptance. Previous reviews have found minimal empirical study of this area, despite the obvious importance of sustainability of organisational change in an NHS in which clinically led innovation is seen as a crucial component of future viability. The existing evidence base on the ‘implementation’ of new ways of working provides some clues as to the challenges that are likely to be faced in sustaining innovation and the ways in which these can be overcome, but further empirical study is needed to understand the issues involved, the connections between these and their consequences for the prospects of sustainability of clinically led changes.

Aims This study starts to address this gap in our knowledge by examining in detail four innovative approaches to service provision, in the field of clinical genetics, whose initial implementation was previously studied by the authorial team. Though in some ways an idiosyncratic clinical field with a particular set of contextual characteristics, the nature of the clinically led changes invoked by these services and the organisational contexts in which they worked are also typical of a range of clinical areas which lack a high public profile and top-down, managerially backed approaches to change. The study follows these four services as they move beyond pilot funding and seek to sustain and embed themselves in their health economies. We ask: what helps and hinders the medium-term sustainability of organisational innovations in the National Health Service?

Methods Four case study sites, which had originally received national pilot funding and had then been successful in obtaining ongoing funding from local services to continue beyond their pilot period, were sampled purposively. These converged and differed in terms of key variables considered in the existing literature to be of potential importance in determining sustainability—notably professional leadership, sector of provision (primary, secondary or tertiary care) and degree to which the service was based on a © Queen’s Printer and Controller of HMSO 2013. This work was produced by Martin et al under the terms of a commissioning contract issued by the Secretary of State for Health

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nationally endorsed, evidence-based model. This enabled an explicitly comparative analytical approach, providing insights into the consequences of these contextual factors on the pathways towards sustainability. The study involved two principal phases: a secondary analysis of data previously collected on these four cases in an earlier evaluation of the pilot initiative, and further follow-up data collection (primarily using in-depth qualitative interviews) about their work towards ongoing sustainability. Data from both phases of fieldwork were analysed using an approach based on the constant-comparative method.

Results The study provided novel insights into a number of issues in the process of sustainability, some converging and some conflicting with existing knowledge in this area. Most notably: 







Sustainability of organisational change should not be seen as a binary state to be achieved once and for all; rather, in these four cases it constituted a continuum, such that ongoing work was needed to consolidate their positions within their local health economies. Several years down the line from their initial introduction, none of the four services could be said to have ‘achieved’ sustainability; rather, varying degrees of active work were still needed to maintain provision. A crucial component in making a case for sustainability was the ability to frame the utility of the service in flexible terms that appealed to a shifting range of influential stakeholders across professions, organisations and sectors. Although none of the services was able to draw on a ‘gold standard’ of evidence to make its case for sustainability, in different ways, and with varying degrees of success, each sought to mobilise a notion of ‘clinical quality’ that had some resonance with those in positions of influence. The building of an alliance of advocates, champions and ‘leaders’ across sectors at an early stage was highly important in the sustainability of these services. In a turbulent organisational environment where boundaries and criteria of value were in flux, services which were able to engage these stakeholders early on found that they had important allies whose sponsorship was essential in gaining acceptance and embedding services in the local health economy. In the more successful cases, there was considerable complementarity between networks of clinical relationships (e.g. referrals between services), networks of clinical advocacy (alliances with clinicians in related areas who endorsed the case for sustainability) and networks of managerial relationships (e.g. with commissioners). In a dynamic NHS environment, services which were not insulated from such changes by their organisational set-up needed to be alert and responsive to changes outwith their control. These could radically alter


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the expectations of those with responsibility for resource allocation and others in positions of power, and thus impact significantly on whether and how sustainability could best be achieved. Continued policy and organisational change contributed to the uncertainty of these services around their ongoing sustainability. There was a risk that large-scale changes to the NHS might result in a neglect of these services on the part of commissioners and managers, so that they stagnated, rather than remaining responsive to their changing environments. In addition to this final report, findings will be disseminated through peerreviewed journal publications, and through partnerships with at least three NIHR Collaborations for Leadership in Applied Health Research and Care, to ensure that insights are fed to clinicians, commissioners and managers in provider organisations in a form that is useful and accessible to them.

Conclusions This study adds to our nascent understanding of the process of sustainability, especially in complex organisational contexts such as the National Health Service. The study offers important lessons for those involved with, and those attempting to foster receptive environments for, clinically led changes in a policy and organisational environment that offers significant challenges—but also opportunities—for such efforts. It highlights the way in which sustainability, at least in an increasingly marketised organisational context in which service providers must continually provide evidence of their value according to often shifting criteria, is not a final state to be achieved, but rather an ongoing process, the dynamics of which are likely to vary significantly through time and across contexts.


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The Report 1 Introduction There is a growing evidence base on the challenges of introducing new ways of working into complex organisational environments such as the National Health Service (NHS). This evidence base covers the difficulties of achieving changes in professional bureaucracies infused with powerful institutional forces, and the interventions that can be developed in order to increase the likelihood that such changes are accepted by the diverse stakeholder groups who will determine success or failure. A considerable literature has developed on the subject of ‘implementation’, and the art and science of changing practice in a context where the limitations of traditional approaches to change are increasingly recognised. However, there is considerably less knowledge of what happens after the initial ‘push’ for implementation, adoption or (more likely) adaptation of an organisational innovation of this kind has ended. In the short-term, a new way of working may be developed, put into practice and made to work, but what happens after the immediate campaign to introduce organisational change—for example, a policy mandate, a campaign to convince stakeholders of the worth of change, or short-term pump-priming money— ceases? The study reported here builds on the existing literature on the uptake of new ways of working in the NHS, and on the emergent literature on the medium- and longer-term maintenance of these new ways of working, to produce new knowledge about what helps and hinders sustainability of such organisational innovations.

1.1 Implementation, embedding and sustainability The existing literatures on change management, diffusion of organisational innovations and public policy and management provide important lessons on the nature of the challenges relating to instituting, sustaining and spreading change in the NHS and other complex public-service organisations. Recent literature in these fields has diverged from traditional models of the uptake and diffusion of innovations to be found in accounts such as that of Everett Rogers.1 Increasingly, this literature emphasises instead that “the dissemination of innovations is not necessarily a linear process,” but one in which “rational, institutional and political forces” are implicated.2 There is an increasing recognition of the importance of the complex nature of the public-service environment,3 as well as of the fact that organisational innovations are rarely so simple that they can be implemented without implications for wider practices, care pathways and professional jurisdictions.4 The implementation of such organisational innovations in public-service professional bureaucracies such as the NHS is © Queen’s Printer and Controller of HMSO 2013. This work was produced by Martin et al under the terms of a commissioning contract issued by the Secretary of State for Health

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thus a much more “messy, dynamic, and fluid”5 process than the traditional way in which innovation diffusion is understood would suggest. This, of course, has significant implications for those seeking to introduce, replicate and also to sustain change in the NHS. New ways of providing services will not translate simply into practice, even if backed by a substantial evidence base. Rather, they are likely to require considerable negotiation and political action, encompassing mechanisms including alignment with wider pressures, individual and distributed leadership, and the use of professional networks to engage others with change. This is especially so where organisational innovations emerge from the ‘bottom up’, led by individual clinicians or managers with ‘good ideas’ rather than driven by policymakers or by powerful organisations such as the National Institute for Health and Clinical Excellence (NICE).6,7 Above all, the recent literature on implementation of complex changes to practice suggests that this is not really in fact a matter of ‘implementation’ at all, but of adaptation to local need and context rather than simple adoption of a potentially inappropriate innovation.4 These considerations are likely also to be relevant in work aimed at sustaining organisational innovations which have been successfully introduced. However, there may also be further, divergent factors involved in ongoing sustainability of change. Through time, initial favourable conditions become less important, and the question starts to become one of how far “this innovation has the capacity to continue to adapt to current and foreseeable system conditions.”8 To date, however, there has been little research on the question of the medium- and longer-term sustainability of organisational innovations. As Fitzgerald and Buchanan note, “in most studies of change, the focus has been with the ‘front end’, with initiation, resistance, and implementation,” with little attention to “the process of change over a longer time frame.”9 In their SDO-funded systematic review of innovation in service organisations, Greenhalgh et al. similarly found evidence to be “very sparse,” with a “near absence of studies focusing primarily on the sustainability of complex service innovations.”10 Thus there is a need for more research on how to mitigate the ‘improvement-evaporation effect’, as the NHS Institute has termed it,11 and in particular on the factors associated with successful sustainability and routinisation of organisational innovations.8,12 In particular, what strategies—including but not limited to those outlined above—are required in establishing change that is robust enough to survive and thrive in a competitive NHS environment subject to changing priorities and finite resources, without the support of ‘top-down push’ by policymakers in the form of guidelines, targets or managerial commands? This study seeks to provide answers to these questions by following four organisational innovations which, to varying degrees, can be characterised as being ‘bottom-up’ in character, from a previous study carried out by the authors. These innovations, each providing clinical-genetics services in a © Queen’s Printer and Controller of HMSO 2013. This work was produced by Martin et al under the terms of a commissioning contract issued by the Secretary of State for Health

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novel way which deviated from established practice in the field, were each initially successful in instituting new ways of working, obtaining follow-up funding after initial pilot money ceased. Having tracked them in the prior study through the process of establishing their innovative ways of working, this research follows them through the processes by which they obtained initial ongoing funding, and into their medium-term efforts at consolidating change and ensuring their ongoing viability. Using a combination of secondary analysis of data collected in the course of the earlier study and new primary qualitative data collection in these four theoretically sampled sites, the research seeks to address the understudied issue of the mediumterm sustainability of innovative organisational practice, and in particular the question of what helps and hinders the sustainability of clinically led micro- and meso-level organisational innovations in the NHS (those which take place at the level of the micro-level clinical team or meso-level clinical service, but which do not involve the reorganisation of entire care pathways or NHS organisations). We take our conceptual cues from the empirical and theoretical literature outlined above. While building on traditional notions of innovation adoption, diffusion and sustainability, recent authors have also drawn attention to the deficiencies of linear models of uptake in relation to complex public service organisations and professional bureaucracies such as the NHS.4,10,13 Instead, these authors emphasise the need to account for complications in the uptake and sustaining of organisational innovations by viewing these as processes of negotiation among multiple interested stakeholder groups,4 and by understanding sustainability in the contexts of organisation, system and history.14 Our own earlier study—which covered not just the establishment of the organisational innovations, but also their initial efforts, successful and unsuccessful, in making these sustainable—highlighted the utility of this approach in understanding implementation and the initial steps towards sustainability.7,15,16 This study enabled us to revisit these findings and begin to develop an understanding of sustainability in the longer term— and the way in which change through time and different organisational contexts demand different strategies, with varying levels of success— specifically in the light of the emergent literature on sustainability. By reanalysing our earlier data and collecting new data through this study, we consider the four cases’ strategies over the transition from introduction, through initial sustainability through local funding, to work around mediumand longer-term sustainability which started to secure their place as established components of their local health economies.

1.2 The structure of this report In chapter 2, we consider in more detail the existing literature on innovation, organisational change and sustainability in health care organisations. While finding that, as others have noted, there is a dearth of research on the sustaining of change beyond its initial introduction and © Queen’s Printer and Controller of HMSO 2013. This work was produced by Martin et al under the terms of a commissioning contract issued by the Secretary of State for Health

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integration into existing practices, we also highlight the conceptual frameworks available from the literature that might inform research into this question. However, we also acknowledge that the dynamic, non-linear, complex ways in which these factors interact with one another limits the utility of typologies of relevant factors—meaning that they should be treated as being of use more as sensitising concepts rather than as discrete issues for study in isolation. Finally, we highlight four particular fields of inquiry which, based on the existing literature, we consider to merit more detailed discussion, to which we return in later chapters following empirical data collection. Chapter 3 presents the setting in which our study takes place, and the methods of data collection and analysis we used in the study. We consider the particularity of the clinical field—clinical genetics—that provides our empirical context, but note also features of this field which make it a particularly interesting and potentially illuminating context for understanding the factors that help and hinder sustainability of clinically led innovation in an NHS characterised by hierarchical management, interprofessional conflict and market-based change. We discuss the ‘mainstreaming genetics’ initiative, which saw the introduction of new ‘boundary-spanning’ clinical genetics services that brought together genetics specialists with other professional and organisational groups. This initiative provided initial funding for a range of pilot services that introduced organisational changes of this kind. We detail our approach to sampling four of these pilots, included in our earlier study of this initiative, which converge and diverge in theoretically interesting ways with the potential to illuminate key aspects of the process of sustainability identified in the literature review. We describe the approach we undertook in our prior evaluation of the introduction of these services, which included two data collection points at the beginning and end of this process, and then account for our approach to re-analysing data from this work in terms of the sustainability of change. Finally, we describe the methods employed in collecting new data in these four sites, and our approach to analysis. The next two chapters present our empirical findings in detail. In chapter 4, we present our secondary analysis of the data from the original evaluation, describing on a case-by-case basis the means by which stakeholders in the four sites managed to obtain local funding to sustain their work following the cessation of pilot funding from the mainstreaming genetics initiative, and the wider social, political and organisational processes through which they began to embed themselves in routine service provision in their localities. The descriptive case-by-case analysis provided in chapter 4 also sets the stage for the more integrative analysis presented in chapter 5, in which we present findings from the primary research carried out for this study on medium-term sustainability further down the line after initial funding had been secured. Here we cover a number of issues thematically that emerge from our analysis as of particular importance in the divergent trajectories towards sustainability of the four cases, from their ability to © Queen’s Printer and Controller of HMSO 2013. This work was produced by Martin et al under the terms of a commissioning contract issued by the Secretary of State for Health

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evidence the value of change, through the differing ways in which they were able to draw on networks of support of key stakeholders in their health economies, to the ambiguous ways in which the changing health policy context looked set to impact on their further routinisation. What emerges in particular from this chapter is the key message that sustainability is better understood as an ongoing process rather than as a binary state to be achieved and then ticked off once and for all; in the current NHS context the cases studied continued to face a somewhat uncertain future, though some had had considerably more success than others in orchestrating networks of support, appealing to the right agenda and stakeholders, and adapting their work to make themselves less dispensable to their local health economies. In chapter 6, we summarise some of these key messages for sustainability, highlighting important lessons from the cases studied which illustrate the barriers and facilitators to sustainability, and how clinically led, ‘bottom-up’ service innovations can surmount and harness these. We then return to the four areas of particular interest presented in chapter 2, and relate in a more theoretically oriented way our empirical findings to these issues—while also deriving policy-relevant lessons. Finally, chapter 7 concludes this report, highlighting strengths and weaknesses of our study, and reiterating the key messages.


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2 The literature on organisational innovation, implementation and sustainability Recent years have seen a markedly increased interest in the art and science of effecting change in health service contexts. The study of implementing change in health care has been undertaken from a variety of perspectives, from approaches that conceptualise change primarily in terms of psychological barriers and facilitators at the level of the individual health care practitioner, to more sociologically informed and organisationally focused studies of the implementation of change in wider contexts. Conceptual frameworks have been developed, an empirical evidence base is being assembled, and an emergent discipline of ‘implementation science’ is forming. However, certain aspects of the change process remain understudied and theoretically underdeveloped. One of these is the sustainability of change beyond the initial phase of implementation, and the question of how improvements in the quality of health care provision are retained, cemented and embedded within the provision of health care. In this chapter, we review the limited literature on the process of sustaining change in the way in which health care services are provided. We connect the findings of this literature to the related literature on the initial implementation of change, noting points of confluence. We outline certain conceptual frameworks that have been developed to account for the process of implementing change, and note how these might productively guide the study of sustainability of change—while acknowledging that such typologies are also limited in the degree to which they can explain the dynamic, interactive ways in which changes are secured and cemented in practice. Then, we offer overviews of the wider literature on four selected issues which the existing literature suggests may be crucial in the process of sustaining change. Finally, we summarise the state of knowledge in this field and explain how this feeds into the research questions that guide our empirical study, which we describe in the next chapter.

2.1 The limited research knowledge base on sustainability of organisational change In their seminal systematic review of the diffusion of innovations in service organisations of 2004, Greenhalgh et al. found a “near absence of studies focusing primarily on the sustainability of complex service innovations.”10 More recently, Fitzgerald and Buchanan have similarly noted that “in most studies of change, the focus has been with the ‘front end’, with initiation, © Queen’s Printer and Controller of HMSO 2013. This work was produced by Martin et al under the terms of a commissioning contract issued by the Secretary of State for Health

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resistance, and implementation”; relatively little attention has been devoted to “the process of change over a longer time frame.”9 Compared to the process of implementation, on which there is a now-burgeoning literature, theoretical attention to and empirical knowledge of the process of sustainability are limited.17 However, a number of studies provide some understanding of the process of achieving sustainability, and highlight key issues involved. Searching the literature for studies of organisational sustainability is complicated by the more prominent use of the term in relation to environmental sustainability and sustainable development. Reconciling sensitivity with specificity in choice of search terms and search strategies is consequently challenging. A comprehensive systematic review of the literature was beyond the scope of this primarily empirical study, so we chose combinations of search terms that seemed likely to access the most relevant literature on sustainability of organisational change. A number of combinations of key words was used to search the Scopus and Web of Knowledge databases. Some of the most obvious search terms produced an unwieldy number of sources, the vast majority of which were unrelated to this study. For example, sustain* AND health OR network produced tens of thousands of sources on various unrelated topics. Using sustain* AND NHS OR organisational change OR embedding OR boundar* OR leadership provided more manageable and relevant results. Once the sources were reduced by eliminating unrelated disciplines, 822 papers were left of which 88 were considered directly relevant to the study. Relevance was assessed through abstract review by Weaver. In addition to this formal literature searching strategy, we also reviewed abstracts of papers cited in two systematic reviews relating to the field,18,19 and incorporated the findings of relevant papers into our own review. It is, however, worth noting that the source documents this approach yielded were highly heterogeneous, covering the sustainability of projects, programmes, roles, guideline implementations and changing work processes in a variety of sectors, including both ‘bottom-up’ changes initiated from the front line, and ‘topdown’ changes led by policy or management. As outlined in chapter one, our interest in sustainability in the NHS context is narrower and more specifically designed: we are interested in the sustainability of projects that are ‘bottom-up’ in nature, professionally led and deriving from perceived need for improvements in frontline practice, rather than centrally decreed by policy makers or managers and then implemented through bureaucratic diktat. Nevertheless, despite their heterogeneity, the insights provided by this existing literature do offer a useful if rather non-specific knowledge base to guide our empirical enquiry. For ease of presentation and in keeping with the way in which findings are presented in many of the source articles cited, we offer an overview of the facilitators and barriers that have been found to affect sustainability. However, we are also conscious that such ‘checklists’ of factors are a somewhat limited and unsophisticated means of understanding © Queen’s Printer and Controller of HMSO 2013. This work was produced by Martin et al under the terms of a commissioning contract issued by the Secretary of State for Health

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sustainability (and other complex social phenomena) as they are realised in practice. As we describe later on, our own approach follows others who have adopted and advocated ‘contextual-processual’ ways of understanding organisational processes,14,20 which pay attention to the interaction between organisational structures, particular contextual environments and the actions of stakeholders in effecting change. As a means of mapping the current state of knowledge, however, and identifying ‘sensitising concepts’ that might inform the direction of the empirical research, this overview of barriers and facilitators provides a useful starting point, albeit one that lacks a specific focus on the contexts and processes with which we are concerned.

2.1.1 Key facilitators and barriers in sustaining organisational change For ease of presentation, and in keeping with the classifications used by others,18,21,22 we focus first on the level of the characteristics of the organisational innovation being sustained itself, then consider the organisational setting in which change is being sought, before moving out to role of the wider institutional environment in encouraging or inhibiting sustainability. At the level of the project, programme or other innovation being sustained, a number of factors, some obvious and some less expected, have been identified as important. Following introduction, trialing and withdrawal of initial funding, careful planning for the future has been found, as might be expected, to increase the chances of sustaining.23–27 Similarly, stability of staff (low staff turnover) and effective staff training are important for the sustainability prospects of many innovations,27–35 most notably those where effective ongoing provision rests on the direct or indirect involvement of wider practitioners beyond an immediate project team—for example, guideline implementation or a new care pathway.33,34 Evidence of efficacy of the innovation has been identified as an important correlate of sustainability in some settings,33,36,37 with rigorous evaluation associated with ongoing service provision. However, the degree to which evidence of effectiveness or cost-effectiveness is associated with sustainability is perhaps not as great as might be expected. This is perhaps due, in part, to often considerably divergent views on what constitutes ‘good-quality’ evidence across professional groups.38 In their recent systematic review, for example, Wiltsey-Stirman et al. found that ‘effectiveness or benefit’ was linked to sustainability in only nine out of 66 studies reviewed.18 In a review of over 100 projects initially funded by Australia’s federal government, Savaya et al. similarly find that “it cannot be assumed that proven success in achieving its goals ensures a program’s continuation beyond its initial funding.”39 August et al. find that failure to sustain a community-based prevention programme could be attributed not to ineffectiveness or lack of fidelity, but to wider organisational factors that inhibited the degree to which it was embedded in several settings.40


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These findings start to point to issues beyond the level of the innovation itself, towards the meso-level influence of organisational context. Indeed, this is the level at which much of the literature locates the key challenges and opportunities in securing ongoing sustainability. Organisational fit—the degree to which the change in practice being sustained is easily compatible with existing norms and practices—is noted as a crucial factor in a number of studies,22,24,26,33,41–43 reflecting traditional models of institutionalisation.44 In their regression analysis of factors associated with the sustainability of heart-related health promotion initiatives, O’Loughlin et al. found that “interventions that fit well with the host organization’s mission, objectives, and routines were more likely to remain viable than those that required adjustment within the organization.”42 Assuring organisational fit is not always, however, necessarily simply a process of ensuring that the innovation is made compatible with the context; rather, active work to manipulate the context can also improve fit. Stetler et al., for example, found work done to realign existing professional practices, to bring middlelevel managers on board, and to communicate their benefit, gave rise to a more embedded, sustained implementation of evidence-based practice guidelines.43 Furthermore, while organisational fit may enhance the chances of sustainability, it should not always be seen as a necessarily desirable characteristic for an innovation. Christensen et al. distinguish between ‘sustaining innovations’ and ‘disruptive innovations’, viewing the former as innovations which support existing practices and the latter as those which challenge them.45 Given the powerful vested interests that are likely to resist changes to existing practices, there may sometimes be a need to support disruptive innovations and advocate for more radical change, even if this can be challenging. A related theme at the meso level of organisational setting is the importance in many cases of adaptability of the innovation to ensure that organisational fit, and relevance to changing practices, remain.32,42,46,47 In some cases, fidelity to the original innovation model has been found to increase the likelihood of sustainability—and indeed, in some cases, for example evidence-based protocols where deviation is likely to result in poorer quality, sustainability arguably cannot be achieved without fidelity.18 However, where projects and programmes can be adjusted to increase integration with existing practices, reduce costs, or align better with local policies and norms, this can increase the degree to which they are sustained and embedded. Sometimes, adaptability may need to be ongoing, indicating a sharp departure from classical ‘before-and-after’ conceptions of group and organisational change such as those inspired by Kurt Lewin’s ‘unfreeze, change, refreeze’ model.48 Bridges et al., for example, found that the new care co-ordinating role they studied became “institutionalised while its boundaries and practices remain[ed] emergent and innovatory,”46 suggesting that an easy, linear distinction between introduction, development and sustaining of new roles may not always be applicable.


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Beyond organisational fit and adaptability, the literature also suggests that there is a need for more formal organisational integration of an innovation into the structures and processes of its setting.22,39,40,49–52 This implies not just that the change in practice is compatible with what already exists, but also that active work is done to institutionalise the change in official policy and formal protocol. “Self-contained programs are less likely to be sustained than are programs that are well integrated with existing systems.”39 Conversely, isolation within an organisational context can be antithetical to sustainability,13,43,53 with new practices failing to be integrated into usual work routines, care pathways and protocols, and thus progressively losing momentum through time. To some extent, this institutionalisation can be understood as being dependent primarily on managerial support.54 However, such is the complexity of most public-service organisational contexts that achieving both organisational fit and organisational integration require a broader arsenal of strategies. Effective leadership therefore tends to be crucial,7,32,36,50,55,56 often involving not just the leadership of high-level executives and influential professionals, but also the leadership of those directly involved in promoting the innovation, as well as leadership distributed among multiple other stakeholders who are able to build acceptance and work to improve fit across various organisational, professional and clinical boundaries.57 Relatedly, the importance of champions and opinion leaders in securing sustainability is highlighted in a number of studies.5,7,22,24,42,58,59 Influential individuals may, of course, work to advance or to block change,60 but evidence suggests that champions for change at various levels and in various groupings within organisations can be crucial in embedding change and securing sustainability. This need for a plurality and heterogeneity of champions is symptomatic, perhaps, of the wider, macro-level, institutional context in which sustainability in health care and other public service environments must take place. The multiple professional groups that constitute the health care field, and the ‘tribal’ relationships that often characterise their dispositions towards one another,3 mean that the ability to cross professional boundaries can be the difference between sustainability and withering.7,13,61 Few organisational innovations are so simple that they can be incorporated into existing organisational routines without affecting the practice of multiple professional groups;10,62,63 as such, a key task in removing resistance to change and achieving sustainability will be securing the acquiescence of those groups affected, negotiating carefully the changes to professional boundaries and territories that might be involved. Consequently, tying into networks that cross disciplinary, clinical, professional and organisational boundaries can be a crucial facilitator to sustainability.7,13,54,64,65 Bisset and Potvin, for example, highlight how those leading a nutritional programme built on connections between professional and organisational groups to tie into each group’s agenda and further multi-organisational support for the programme, so that it was sustained through time.64 Martin et al. and Ferlie et al. note the importance of inter-professional and intra-professional © Queen’s Printer and Controller of HMSO 2013. This work was produced by Martin et al under the terms of a commissioning contract issued by the Secretary of State for Health

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networks respectively for the sustaining and spread of some of the organisational innovations they study.7,13 Once again, though, the existence of such networks is not in itself necessarily positive for the prospects of sustainability, since networks can equally be mobilised to prevent organisational changes from being sustained. In her study of the discontinuation of a dental public health programme, Scheirer, for example, finds the decision to cease the programme could be explained more by “‘political’ influences from strong interpersonal communications rather than by formal decision-making processes.”65 Furthermore, the degree to which networks—and the other strategies to support sustainability of organisational change outlined above—are likely to be successful is structured to a large extent by the external environment in which organisations, professions and innovations are located.19,25 As Buchanan et al. comment, “in a turbulent external context, organization structures and working practices that remain static are regarded as legitimate targets for change. Sustainability has been widely regarded, therefore, not as a condition to be achieved, but as a problem to be solved.”19 The external environment—notably the policy context in which health care organisations operate—may have an important bearing on whether innovative changes are sustained, and on which are most likely to survive. For example, those networks which can be so important to the sustaining of change may be undermined by a prevailing wider context which does not value horizontal networking as a model of governance and means of managing organisational change: “the introduction of a rhetoric of a more collaborative approach to the management of public services has not been enough to destabilise the embedded managerialist framework.”66 More general organisational turbulence may also distract the attention of managers and clinicians away from service innovations, forcing them to devote their energies to more mundane activities.

2.1.2 The emergent literature on sustainability and existing conceptual frameworks The previous subsection highlights a host of factors noted in the literature to advance or impede sustainability. Although, as already acknowledged, the literature on sustainability of organisational change is relatively limited, the wider study of implementation of change in health care has advanced considerably in recent years. As this field has matured, various authors have sought to consolidate the findings from the empirical study of implementation into conceptual frameworks that offer a comprehensive understanding of relevant factors, to inform both practice and further research. Given the close relationship between implementation and sustainability, we now briefly seek to relate the categories of domains we have identified in the literature to one such existing framework. We consider this to be a helpful exercise for two reasons: (i) it enables us to map the factors described above onto existing conceptual categories, ensuring that our findings are easily understood in terms of the language © Queen’s Printer and Controller of HMSO 2013. This work was produced by Martin et al under the terms of a commissioning contract issued by the Secretary of State for Health

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used by others; (ii) it allows us to identify other concepts which have not been highlighted in the literature on sustainability, but which, given their relevance to the study of implementation, might also be useful in informing our research design and the questions asked in the course of the study. This latter purpose is especially important given the current underdeveloped knowledge base in the field of sustainability of organisational change specifically. We use the Consolidated Framework for Implementation Research developed by Damschröder and colleagues,67 since this builds on, rationalises and consolidates the categories used in 19 previous conceptual frameworks relating to implementation. As such it offers as comprehensive a set of categories as it is currently possible to find, and provides a clear framework of concepts to inform further study. Table 1 indicates how the factors outlined above map onto the conceptual categories of the Consolidated Framework. Especially notable from this is that there is considerable congruence between the factors identified from the literature on sustainability and the conceptual categories grouped by Damschröder and colleagues under ‘inner setting’. Some of the other factors identified correspond to the concepts grouped under ‘intervention characteristics’, ‘outer setting’ and ‘process’, but none corresponds to the concepts grouped under ‘characteristics of individuals’.

Topic/Description in Consolidated Framework

Factor identified in literature review

I INTERVENTION CHARACTERISTICS A Intervention source B Evidence strength and quality

Evidence

C Relative advantage D Adaptability

Adaptability Fidelity

E Trialability F Complexity G Design quality and packaging H Cost II OUTER SETTING A Patient needs and resources B Cosmopolitanism © Queen’s Printer and Controller of HMSO 2013. This work was produced by Martin et al under the terms of a commissioning contract issued by the Secretary of State for Health

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C Peer pressure D External policy and incentives

External environment

III INNER SETTING A Structural characteristics

Organisational integration Isolation (lack of)

B Networks and communications

Networks

C Culture

Professional boundaries

D Implementation climate (including tension for change, compatibility, relative priority, organisational incentives and rewards, goals and feedback, learning climate)

Organisational fit

E Readiness for implementation (including leadership engagement, available resources and access to knowledge and information)

Staff turnover

Managerial support

Training

IV CHARACTERISTICS OF INDIVIDUALS A Knowledge and beliefs about the intervention B Self-efficacy C Individual state of change D Individual identification with organisation E Other personal attributes V PROCESS A Planning

Planning

B Engaging (including opinion leaders, formally appointed internal implementation leaders, champions, external change agents)

Leadership Champions

C Executing D Reflecting and evaluating Table 1. Mapping key factors in sustainability identified in the literature onto conceptual categories relating to implementation put forward in Damschröder et al.’s ‘Consolidated Framework for


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Implementation Research’

This latter feature of the mapping is likely a product of our literature searching strategy: our searches, and the reviews which we used to locate further relevant studies, focused on the innovation itself and its interaction with varying levels of context, not on the reception of new ways of doing things by individual practitioners. However, the other conceptual categories presented in the Consolidated Framework indicate areas of potential interest and significance to the sustainability of change that have not been considered in any detail in the literature we have reviewed, and which merit investigation in the course of the empirical work. We took these areas into account as we designed and carried out our empirical fieldwork and analysis, described in the next chapter.

2.2 Beyond facilitators and barriers With varying degrees of empirical validation, the factors described above have been shown to have an important bearing on the degree to which projects, programmes and other organisational changes can be sustained through time. However, they should not be understood as a list of ingredients that can be applied additively to secure sustainability, or as independent variables which in the right combination will give rise to sustained change. As in many other areas of the study of organisations, linear understandings of the processes of implementation and sustainability have come in for considerable critique. They are seen as lacking the explanatory power necessary to account properly for the complexity of social processes as these play out in real-life contexts, with all the interaction and interdependence between variables this implies. Empirically, this suggests an approach which is able to apprehend these interdependencies, and construct an account of sustainability that incorporates the ways in which different organisational contexts and multiple actors give rise to particular outcomes through time. “A processual perspective thus appears to offer a useful lens through which to examine sustainability, by focusing on the flow of events in a wider spatial, temporal, and political context.”68 We consider the implications of this for our approach to the study of sustainability in the next chapter. Theoretically, the crucial implication of this way of understanding sustainability is that some of the key ‘factors’ identified in the literature as being relevant to prospects of sustainability need to be ‘unpacked’. It is one thing to identify the importance of ‘leadership’ to sustainability, for example, as many of the studies cited above do. It is another thing to understand the dynamics of leadership as these operate in public service organisations such as the NHS, to apprehend its power, limitations and contingencies as it operates in a professional bureaucracy, and to derive from this understanding the potential utility and form of leadership in supporting sustainability. In seeking to unpack these issues in this way, we also return our literature


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more specifically to the context in which our study takes place, and the professionally led, ‘bottom-up’ nature of the projects on which we focus. With this in mind, we now consider in further detail the literature on four key sets of ‘factors’ relating to sustainability that merit further consideration, putting forward a richer and more context-specific account of these than has thus far been offered. These are ‘Policy and changing organisational structures’, ‘The NHS professional context’, ‘Leadership’ and ‘Discourse and framing’. Our reasons for choosing these issues are two-fold: firstly, both the literatures on implementation and sustainability and the wider literature on organisational change in healthcare and other organisations highlight these as significant mediators of change. Secondly, as will become apparent in chapters four and five of this report, these four issues, and the interactions between them, emerged as being of crucial importance in the empirical work that formed the main focus of this study. We pick up and discuss further the empirical implications of these issues in chapter 6; for now, we offer this overview of the literature on these areas to provide background on these issues, the way they have been understood in studies of change in the contemporary NHS, and their implications for sustainability ahead of the empirically framed discussions of chapter 6.

2.2.1 Policy and changing organisational structures It is something of a given that the NHS finds itself in constant organisational flux. Commentators deploy vivid terms such as ‘redisorganisation’ to describe the efforts of successive policy makers to restructure the service in pursuit of various policy aims.69,70 Since the inception of the internal market in health and social care in the early 1990s, governments have engaged in numerous reorganisations of the NHS with a view to improving its efficiency and effectiveness.71 The introduction of Primary Care Groups, and abolition of GP fundholding,72 after the election of a Labour government in 1997 was quickly followed by further reforms which marked a return to competition as one of the key modes of governance of the health care system.73 In particular, the government introduced a significantly more pluralistic market among the providers of certain elective treatments and in community services,74 and alongside this, split Primary Care Trusts into commissioner and provider arms to reduce the potential for conflicts of interest in commissioning decisions and secure a more ‘level playing field’ in the provision of primary care.75 Greater involvement of GPs in commissioning decisions was pursued through practice-based commissioning, and considerable effort was undertaken to empower and equip commissioners to drive changes to care provision based on evidence about quality and local need. Alongside this, however, centrally mandated direction remained a core component of health care governance, with national service frameworks, specific targets and central directives seeking to drive improvements through a more ‘top-down’ process of change.76


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At the time of writing the most recent round of proposed changes to the health service—the abolition of Strategic Health Authorities and Primary Care Trusts, and the introduction of Clinical Commissioning Groups to increase the involvement of GPs and other primary care clinicians in commissioning decisions77—is still ongoing, and so the exact consequences of this policy are yet to be seen. However, the latest policy shift can reasonably be understood as the latest iteration in a series of shifts towards a health care system in which competition plays a greater part70,78—but in which apparent efforts to devolve power to local agents remain tempered by ongoing central direction of key decisions.70,79 The result is an ambivalent environment for efforts to innovate and improve service provision. We consider the policy and organisational context facing genetics services specifically in the next chapter; for clinically led innovations more generally, there is both encouragement and obstruction for efforts to establish and sustain change in the current policy and organisational environment. On the one hand, specific initiatives have sought to reward innovation by health care providers, and encourage commissioners of care to use their role intelligently to work with providers to drive improvements in quality. Such approaches are designed to foster locally driven and clinically led improvements to care, incentivising change and ensuring that it is appropriate to patients’ needs. Additionally, various specific initiatives to encourage and reward innovation in care have been proposed or set up, from Innovation Hubs in the early 2000s, through the regional innovation prizes announced in High Quality Care for All in 2008,80 to the recent introduction of Health Innovation and Education Clusters.81 All in all, considerable effort has gone into creating an NHS in which “frontline staff [are empowered] to lead change that improves quality of care for patients.”80

On the other hand, however—and despite such efforts—there is considerable evidence that much NHS activity continues to be driven by centrally determined targets, guidelines and frameworks.71,75,76,79,82,83 Minimum standards in areas such as waiting times, and a policy focus on high-profile clinical areas such as cancer, drive managerial behaviour to a significant extent. Furthermore, there is evidence that the organisational turbulence associated with the successive structural changes to the NHS of recent decades itself represents a significant distraction for managers and clinicians, reducing the scope for leading change ‘from the bottom up’. While in general terms, it has been posited that uncertainty can be a driver of innovation,1 in the health care context this is not always the case.14 Competing organisational priorities and misaligned managerial and clinical foci are likely to reduce engagement with change and make sustainability more challenging.84 With the greater use of quasi-markets in the governance of the NHS, there is again scope for commissioning decisions to reward innovative service models that diverge from traditional modes of provision. However, past © Queen’s Printer and Controller of HMSO 2013. This work was produced by Martin et al under the terms of a commissioning contract issued by the Secretary of State for Health

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experience suggests that conservatism may prevail in commissioning decisions, furthered by knowledge asymmetries between primary carebased commissioners and secondary and tertiary care-based providers, only partially mitigated by greater clinical involvement in commissioning.85 Furthermore, the more fractured system that might arise from further marketisation may not favour the integrated, boundary-crossing services that the clinical-genetics innovations studied here are designed to provide: competition may present a challenge to such services, despite wider policy emphases on joined-up service provision and patient-centred care.86 In sum, then, the current NHS policy and organisational context offers both challenges and opportunities to the sustaining of clinically led service innovations such as those studied here. Government policy and shifts towards a more pluralistic approach to service provision seem to favour novel service delivery models, but the means by which this is to be achieved, through marketisation, presents threats to such services, as does the potentially entrenched conservatism of those in charge of resourceallocation decisions within the NHS. Our empirical work addresses directly the effects of this developing NHS policy scene on the innovations studied, capturing the impact of this dynamic setting on the way in which they have sought to achieve sustainability.

2.2.2 The NHS professional context The NHS has traditionally been characterised as a professional bureaucracy,87 with medical professionals, as a result of their specialist knowledge, enjoying a high degree of autonomy over diagnosis and treatment decisions, evaluation of care and the nature and volume of medical tasks. This autonomy of individual doctors at the micro level has been reinforced by the ‘biomedical model’ which equates ill health with individual pathology. This legitimises the requirement both for doctors to apply clinical judgement in the treatment of individual patients and for medical expertise in the macro scale design of health services and systems.88 The 40 years after the Second World War have been described as the ‘Golden Age of Doctoring’.89 Since then, however, the medical profession has been subject to attempts to increase control and accountability, with the autonomy of medical professionals being increasingly challenged.89 This trend can be observed across the public sector more broadly and has been conceptualised as part of the rise of ‘new public management’,90 which involves the transfer of business principles, management techniques and market forms to the public sector. As part of this process, there has been a proliferation of management tools (such as guidelines, clinical audits, incentive payments, computerised knowledge management systems and so on) aimed at measuring care activities. Measurement and marketisation (considered above) both imply standardisation, since benchmarking and performance assessments need to take place using a common currency and © Queen’s Printer and Controller of HMSO 2013. This work was produced by Martin et al under the terms of a commissioning contract issued by the Secretary of State for Health

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contracts for care incorporate service definitions which (at least in theory) can be commissioned from a number of providers. As part of this process of what has been seen as the commodification of care, the trend has been towards co-optation of the biomedical model for managerial purposes.91 This enables control not just of market exchange mechanisms, but importantly, over the production of services. The latter has implications for medical autonomy, since it implies that care can be standardised and knowledge codified, in a way which reduces reliance on specialist knowledge. These developments have been underpinned by changes to financial relationships between those who commission health care services and those who provide them. As noted in the previous section, this has significant implications for the organisation of health care services, but it also influences the professional division of labour within the health service. As part of this process, the ‘payment by results’ system, which was initially confined to general and acute care providers but is being rolled out to other types of provider, involves reimbursement according to a standard tariff, based on national average costs.92 Whilst this enables money to follow patient flows, it also encourages providers to scrutinise costs and services in order to avoid loss-making activities. As part of the process of containing costs more generally, there have been initiatives globally to extend roles of non-medical professionals.93–96 A view of professionalisation as a process involving struggles about boundaries and jurisdictions97–99 might lead us to conclude that such initiatives are likely to create conflict between groups and resistance on the part of the medical profession. However, recent empirical studies suggest that such changes can be accommodated relatively amicably, particularly where doctors have formal control over other staff.100 Even where there are no such formal lines of accountability, the dominance of the medical profession (over other professions, as opposed to in absolute terms101) means that such changes may not necessarily provoke explicit resistance from medical professionals.102 Furthermore, the ability of doctors to delegate to nurses, whilst at the same time depicting them as delivering ‘protocol driven’ care (and thus constructing this as requiring less skill and judgement), enables medical professionals to reinforce their specialist knowledge and to present nurse inputs as complementary to, rather than competing with, their own activities.102 With regard to mechanisms such as protocols and guidelines for medical staff, various commentators describe doctors as reordering their ways of working in a way which combines self-surveillance and self-control with a defence of professional norms of self-regulation.103,104 This suggests that doctors are not passive recipients of such policies and alerts us to the need to understand the dynamic interplay of policy and practice in this area. More generally, whilst protocols specify processes and pathways to be followed, policy makers and those who commission services are increasingly preoccupied with outcomes and/or outputs. There has been increasing © Queen’s Printer and Controller of HMSO 2013. This work was produced by Martin et al under the terms of a commissioning contract issued by the Secretary of State for Health

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acceptance amongst medical professionals of the legitimacy of measuring and reporting outcomes (or proxies for these) especially where these are defined by clinicians as opposed to non-clinicians and reported at aggregate level.105 We might therefore expect to see the approaches to sustainability adopted in these projects embracing notions of effectiveness and efficiency, and furthermore acquiescing—or perhaps adopting or even appropriating— managerial tools aimed at measuring, monitoring and evaluating their success in realising these aims. With regard to the spread of managerialist techniques more generally, there has been a tendency to conceptualise the impact on professional practice in terms of a continuum ranging from compliance to resistance.106 This emphasis on conflict resonates with studies of changes imposed from above which ride roughshod over established clinical relationships and working practices.99,107 However, much less attention has been paid to change which is initiated or supported by clinicians in a ‘bottom up’ manner (as to a large extent in the case of the pilot projects which are the focus of our study) and/or which involves collaboration between clinicians and managers. This is despite the fact that there are occasional glimpses of such collaboration even in studies which report conflict and resistance.108 Additionally, the depiction of clinicians and managers as inhabiting separate worlds, and embodying contrasting sets of beliefs and practices, ignores the fact that many clinicians are involved in undertaking management roles.107 Llewellyn’s description of clinical directors who ‘embody and transmit both clinical and management ideas’ is a helpful reminder of this.109 That said, her use of the terms ‘professionals’ to denote clinicians in contrast to ‘managers’ may suggest tacit acceptance of the arguments made by clinicians about the inferiority of ‘managers’, and also overlooks the fact that managers are likely to think of themselves as professionals. Furthermore, with regard to the literature on attempts to codify knowledge and control medical professionals, there is a need for a more nuanced understanding of evidence-based medicine. In practice evidence-based medicine may combine the use of protocols with judgement rather than treating them as polar opposites.110 A framework informed by such an understanding might enable investigation of issues which are relatively unexplored, such as the existence of a shared understanding of service provision and the nature of trust, as opposed to distrust, between different types of doctors and other types of healthcare professionals.106 In all, then, the approaches to achieving sustainability adopted by the projects studied is likely to link into a number of prominent issues in the reformulation of professionalism in the contemporary NHS, including interprofessional relationships, clinician-management relationships and the deployment of managerial and measurement tools by clinicians in their strategies for sustainability. We address these issues in our empirical data collection and return to them in chapter 6.


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2.2.3 Leadership In addition to the literature addressed directly above,7,32,36,50,55,56 the wider literature also suggests that effective leadership will be vital to sustained change. Leadership represents a panacea that is popular among policy makers worldwide as a means of driving changes within healthcare and other public services settings;111 any evaluation of sustaining innovation must consider the effect of leadership.10 English health care can be viewed as a ‘fast mover’ in leadership reforms, particularly with respect to policy reforms designed to distribute leadership for transformational effect.7 Despite a policy emphasis upon (transformational and distributed) leadership as a means of achieving change and ensuring that it is embedded within a complex, multi-stakeholder system, there remains an absence of contextualised studies of leadership in practice within the health care setting,112 even more so with respect to sustaining innovation.10 Lessons from the wider literature can be brought together, we suggest, to put forward an ideal model of leadership, which might support the development and sustaining of innovation over time. We describe this model in this section. The intention here is not to set up a ‘straw man’, but merely to use the ideal model of leadership as a ‘heuristic device’ to identify limits and possibilities for leadership in the distinctive institutional context of health care, which frames the sustaining of innovation. Building on this, we identify how policy and professional organisation impacts leadership to sustain innovation, and how challenges might be overcome to better support innovation through leadership efforts. Then, in chapter 6, we test this model in empirical practice, drawing on our data to discern the extent to which it could be operationalised in the four empirical settings covered in this study. Two possible models of leadership are favoured by policy makers. The first model privileges transformational leadership.111,113,114 Transformational leadership encompasses charisma, inspiration, individualised consideration and intellectual stimulation, with the leader maintaining a continuous challenge to followers by espousing new ideas and approaches.115,116 In its academic conception, we highlight that it does not necessarily prevent distribution of leadership (see below), although in its translation into organisational practice, it has tended towards a ‘heroic’, individualistic approach, particularly in public services organisations.112,117 The second model is one of distributed leadership. Compared to individual leadership, with its long history in theory and practice, distributed leadership is a much more recent idea. It was first suggested by Gibb in 1954,118 but lay dormant until its rediscovery by Brown and Hosking in 1986.119 Since then, the descriptive and prescriptive literature on distributed leadership has blossomed. Distributed leadership results from “spontaneous collaboration, intuitive working relations, and institutionalised practices,”120 and represents a shared and emergent process, “dynamically constructed and shaped over time through the interaction of leaders, followers, and the © Queen’s Printer and Controller of HMSO 2013. This work was produced by Martin et al under the terms of a commissioning contract issued by the Secretary of State for Health

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situation.”121 Conceptions of distributed leadership emphasise the widespread nature of agency for leadership, highlighting interdependencies of leadership actors throughout complex organisations. There are a number of different conceptualisations of leadership, but most of these variants are underpinned by the view that there is some degree of organisation for distributed leadership driven by formal leaders. For most commentators, distributed leadership does not mean the absence of a leadership hierarchy: rather, the enactment of distributed leadership requires ‘top-down’ activity. Some commentators, though, see distributed leadership as a relatively ‘bottom-up’ phenomenon, characterising distributed leadership as having “nobody in charge”122 or involving “collaborative leadership.”123 In the contrast between these conceptions of distributed leadership, a key question—especially in terms of the realisation of leadership in practice in initiating and consolidating change— appears to be the relationship between top-down, more mandated leadership on the one hand, and the emergence of leadership in a more bottom-up way, and its individualised and distributed components. Commenting upon how individualistic and distributed components of leadership are fused in public services organisations, Currie et al. have suggested there is a temporal dimension to the development of distributed leadership in line with organisational change.124 There exists, they suggest, a necessary concentration of leadership with an individual in the early stage of organisational change, which leads to a more distributed leadership configuration as change progresses. Drawing on this, we might view patterns of leadership in sustainability as exhibiting a two-stage leadership process. At the inception of the change process, leadership tends towards the individualistic, with transformational leaders or champions identified by the organisation to drive the change vision forward. As change gathers pace, the implementation of service change then starts to require that leadership be more distributed, to engender a commitment to transformational change and to harness the creativity and energy required to identify and take local-level actions in pursuit of service change. In essence, a discernible leadership trajectory should be evident over time, which moves from individualistic to distributed leadership. Rather than being mandated from above, such a distributed configuration of leadership is likely to emerge from below or within the change process, as local-level actors engage with the service change and seize opportunities for change. Such a leadership trajectory might be expected to emerge in an ‘adaptive’ manner, where a formal leader empowers others in the organisation to enact leadership influence, and at the same time supports others’ capability to take up this leadership mantle.125 For those policy makers and management practitioners seeking to drive service changes, the prototypical model for leadership, which we will use as a heuristic device for analysis of our comparative empirical cases, is set out in figure 1. Here we present an ‘ideal’ trajectory for leadership influence, with individualistic leadership supplanted over time by distributed leadership, with the latter more © Queen’s Printer and Controller of HMSO 2013. This work was produced by Martin et al under the terms of a commissioning contract issued by the Secretary of State for Health

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emergent in nature, as service change progresses. We describe the degree to which this model reflects practice in our four case study sites in chapter 6.

Individualistic Leadership

Distributed Leadership

Emergent programme of reform

Formal programme of reform

Figure 1. Ideal trajectory for innovation leadership.

2.2.4 Discourse and framing A more diffuse, yet arguably still crucial, dimension to the process of achieving sustainability is the way in which innovations are presented and framed to key constituencies, so that new practices and relationships are accepted by wider stakeholders. As noted above, objective evidence of effectiveness has been found to account for successful sustainability only to a limited degree,18,39,40 whereas leadership, championing, and the capacity to build alliances and a network of support for the pilots among key constituencies have been shown as important factors for success in a number of studies. The importance of leadership and other social activities among stakeholders points to the central role of discursive effort in securing sustainability of innovations. Such efforts involve, among other things, network-building activity by pilot leads seeking to sustain their innovations, through attempts to embed and maintain new ways of working, as a challenge to traditional hierarchies and boundaries associated with medical professionalism.126 We therefore conceptualise these efforts as representing ‘institutional work’, whereby professional agents have to work to actively maintain their positions and advance their interests in a number of ways. Professionals are continually engaged in creating, maintaining and disrupting institutions in line with their interests in a dynamic system of shifting boundaries and jurisdictions, and a number of purposive and creative activities are required on a day-to-day basis to accomplish this.127,128 In examining our empirical cases, we seek to identify the activities and strategies utilised by pilot leads to build such networks for embedding and sustaining their innovative services, working arrangements and professional relationships. © Queen’s Printer and Controller of HMSO 2013. This work was produced by Martin et al under the terms of a commissioning contract issued by the Secretary of State for Health

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In viewing network-building activities as institutional work, we build on the insights of Lawrence and Suddaby,127 who emphasise the distinctly normative nature of such work, whereby professionals are concerned with influencing the values and belief systems of others such that working arrangements become accepted, embedded and routinised as ‘the way things are’. Similarly, Scott emphasises the way in which professionals are concerned with influencing the cultural-cognitive frameworks of others, or ways of thinking, in line with their interests.128 This activity is inherently political, in that its success is tied up with the resources and power of the actors concerned within the professional hierarchy, their capacity to influence the norms and behaviour of others, and the inevitable fact that within the system of professions other professional stakeholders can view such changes as a threat to their professional dominance, and are likely to be pursuing their own interests and defending jurisdictional boundaries in potentially contradictory ways.62 Thus, to gain normative acceptance for the innovations studied here, leaders must necessarily engage with the interests and agendas of others and attempt to align with these to sustain their work. Our examination of the case study sites that follows in the empirical chapters highlights one particular strategy or form of institutional work as central to efforts for sustaining innovations: framing, or presenting reality in a particular way. In order to be sustained, services may need to reframe or reinvent themselves to appeal to agendas and priorities of wider stakeholders. Scott argues that “the primary weapon of professions are ideas,”128 emphasising the role of professionals in creating knowledge systems and defining reality in particular ways. Professionals, then, are actively engaged in diffusing and maintaining institutional arrangements, by serving as advocates, ‘spreading the word’ through creation of coalitions and alliances with others, and remaining continually mindful of the need to adapt and translate their messages to fit the expectations of specific recipients and varying local circumstances through adaptation in the messages they carry. We thus investigate in our empirical cases the ways in which those involved with the pilot projects were actively engaged in such framing activity as a means of ensuring ongoing support and maintenance of the innovation. As highlighted earlier in the chapter (section 2.1.1), the capacity to achieve organisational fit with existing norms and practices is important,22,24,26,33,41–43 but such fit is not solely a product of the innovation itself. Rather, the ability to work discursively and adapt to accomplish alignment is a key factor in determining sustainability. We emphasise the way in which this fit and adaptation is accomplished through normalisation processes at the micro level, via framing activities carried out by pilot leads that include the presentation of new services in ways that align them with the priorities of those key constituencies who have the greatest influence over sustainability. Our cases highlight the importance of adaptation through framing among pilots, to account for both different stakeholder agendas and as a response © Queen’s Printer and Controller of HMSO 2013. This work was produced by Martin et al under the terms of a commissioning contract issued by the Secretary of State for Health

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to shifting wider priorities and changing contexts over time. As we see in chapters 3-5, in the field of clinical genetics in particular, exactly what constitutes ‘value’ and ‘effectiveness’ in clinical genetics is ambiguous due to the preventive nature of services, and challenges involved in generating clear evidence of worth in a short time period. In such a context, success in achieving sustainability rests, as we shall see, to an extent upon the capacity to align pilots, at least in terms of how they were presented, with the priorities of commissioners, and others with power to influence decisions regarding the allocation of resources for services. This involves political sensitivity to the priorities of others within the wider context, and creativity in framing and presenting cases favourably in particular lights using a variety of resources. A key factor is therefore the changing context over time in terms of the shifting local priorities and agendas, and the capacity of leads to identify and appeal to these. This framing activity represents a particular form of institutional work for gaining support or co-option of key stakeholders, through constructing the nature of the services in line with their interests and priorities. To conceptualise these different visions created through framing activity, we draw upon the notion of discourse. Organisational discourses can be construed as sets of meanings and practices, mobilised through language, to construct a particular version of reality or events.129 Significant is the fact that multiple versions are possible, and that this discursive activity is fundamentally interest-based or political, i.e. the versions created are persuasive and intended to pursue particular professional interests whilst silencing others. Discourses are persuasive insofar as each “promotes particular attitudes and discourages others”.130 As such, discourse represents performative and purposeful social action, intended to do particular things by making the world meaningful in particular ways. Research has increasingly emphasised the ways in which such discursive action can serve both local and wider institutional ends,131 and professional interests in the context of health care in particular.132–134 Thus the process of securing sustainability of organisational innovations can be understood as one that involves creativity and strategic instrumentality in the framing of services by use of discursive resources. Particular versions of pilots are invoked to pursue sustainability, which emphasise their value, plausibility and legitimacy with reference to wider discourse of commissioning priorities. Importantly, discursive work of pilot leads takes place within an existing context, whereby certain discourses of value are embodied within local policy agendas and decision making around funding by commissioners (see sections 2.2.1 and 2.2.2 above). Crucial then is the constraining influence of context on the choices pilot leads have in framing their new services in particular ways, with the need to both appeal to wider sets of priorities of those with the power to ensure sustainability, but also the capacity of leads to be able to identify and speak with legitimacy within these discourses. There are also further structural constraints on discursive action, such that some actors are more able to appeal to, or ‘speak within’ © Queen’s Printer and Controller of HMSO 2013. This work was produced by Martin et al under the terms of a commissioning contract issued by the Secretary of State for Health

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particular discourses and to particular audiences than others, as a result of their professional membership and associated legitimacy. All these issues are considered further in light of our empirical findings in chapter 6.

2.3 A note on definitional precision It may have been noted that thus far in this report, we have allowed the concept of sustainability to ‘speak for itself’, providing no precise definition or clear summary of how we operationalise it in this study. Others have sought to delimit sustainability more strictly, specifying temporal parameters and sometimes defining it in terms of fidelity to an original intervention (so that where an innovation continues to develop or mutate through time, it may not necessarily be considered to have been sustained). For reasons that may be apparent from our overview of the literature above, we demur from such approaches. ‘Implementation fidelity’ may be a valuable trait in some areas of change—for example, the implementation of evidence-based practice guidelines or care bundles—but in this field, where changes are more amorphous and subject to further (legitimate) development and mutation, it presents an overly exclusive way of understanding sustainability. In selecting our case study sites, therefore, we did not seek to assess the extent to which they had maintained the exact service delivery model or organisational form which they had introduced at the start of the pilot period. As we discuss in more detail in the next chapter, we selected sites where ongoing funding from one source or another had been obtained to sustain the new models beyond their piloting. We therefore deliberately deploy a minimalistic definition of ‘sustainability’ in order to account for the dynamic nature of change and embedding. We should also add that we do not consider ‘ongoing funding’ to be a necessary condition of sustainability, but in the field in which our study was carried out, this seemed to be the most feasible way of operationalising our understanding of sustainability to enable empirical study. Similarly, we have not explicitly stated what we consider to be ‘medium term’ as a specific measurement of time (months and years). Rather, we use this term to summarise the period that is of interest to us, a phase which, as we have detailed above, has been neglected in the literature to date: the period some time after the introduction and adaptation of a new service model, when initial intensive activity aimed at ensuring it takes hold in practice (and perhaps initial funding) has passed. Exactly when this ‘medium term’ begins will vary depending on the nature of the innovation and again, defies definitional precision. In this case, as we see in chapter 3, we have treated it as covering the period after initial pilot funding had ceased, as services sought to steady themselves with new sources of funding and consolidate their position in local health economies without the backing of this pilot status.


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2.4 Conclusion In this chapter we have provided an overview of the literature on sustainability of organisational change and related fields. We have highlighted four areas of the current literature in particular that seem to be of especial significance for understanding sustainability in an organisational context like the NHS. Aligning ourselves with approaches that seek to understand the interaction of such ‘factors’ in giving rise to change or maintenance, we suggest that the way these play out can only be understood through empirical study that acknowledges the rich interplay between contexts, service changes and social processes. In the next chapter we describe our approach to carrying out such a study.


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3 Setting and methods We turn now to consider the clinical area in which this study took place, and the methods used to investigate the question of medium-term sustainability of organisational innovations. In this chapter we first present a brief overview of the recent history of clinical genetics provision in the UK, providing a background to the clinical context in which this study took place. We note that although there are many particular features of the field of clinical genetics and the way it is organised, in certain respects it is exemplary of a number of areas of clinical provision in the NHS which have been exposed to ‘modernising’ pushes aimed at workforce reorganisation, greater joined-up working between sectors, and more patient-centred care. Following on from this, we provide a description of the approach taken in the earlier evaluation on which this study builds, which analysed a major government-funded initiative of pilots aiming to further reform the way clinical genetics services were provided in the NHS. We highlight some of the key findings that arose from this study, and the questions that it posed in terms of the ongoing sustainability of the services funded through the initiative. We then move on to the current study, discussing first the rationale for the selection of four case study sites, a subsample of the 11 sites included in the original evaluation, before considering finally the methods we planned to use (and the realisation of this through our data collection) and our approach to data analysis, including secondary analysis of data from the original evaluation and analysis of data collected anew in this study.

3.1 Clinical genetics provision in the United Kingdom In common with many other fields of NHS provision (see sections 2.2.1 and 2.2.2 above), clinical genetics has been subject to considerable organisational upheaval in recent years. In addition to wider pressures affecting the NHS as a whole—changing patient demographics, rising patient and public expectations, new innovations in treatment, the rise of managerialism and marketisation, and challenges to a professionally dominated model of service provision and governance—a development of particular importance in this field has been advances in the mapping of the Human Genome, and concomitant discoveries of particular individual mutations or gene patterns that give rise to a significantly raised risk of certain diseases. Such developments had an important impact on the traditional model of clinical genetics provision in the NHS, with the discoveries permitting much enhanced capabilities to predict and manage risk. These diverged considerably from traditional approaches based on family history mapping, which took place both in tertiary care genetics © Queen’s Printer and Controller of HMSO 2013. This work was produced by Martin et al under the terms of a commissioning contract issued by the Secretary of State for Health

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centres and on a more ad hoc basis in other specialities where family history was recognised as a risk factor. Consequently, from the early 1990s, there was a considerable rise in demand for the services provided by tertiary care clinical genetics centres, and the start of efforts to reconfigure services to delegate to a larger degree less specialised tasks to practitioners outside these centres, ensure that these tasks were overseen through appropriate clinical governance mechanisms, and equip the workforce within and beyond genetics centres with skills at an appropriate level for dealing with patients’ enquiries. The subspeciality of cancer genetics (in which two of the cases studied in detail in this study are located) provides a good example of the changes that have taken place across clinical genetics over the last two decades. Family history of certain cancers has been well established as a risk factor for the development of those diseases for some time, and consequently family history clinics had been a common, if unevenly developed, feature of cancer care in many hospitals for several decades, led by oncologists and cancer care nurses. However, only a few, rare cancers were known to be caused by Mendelian genetic disorders, i.e. those where a specific mutation in an identified single gene was responsible, and it was only in these cases that clinical-genetics services tended to be involved.135 In the early 1990s, a number of Mendelian syndromes were discovered that related to small subsets of more common cancers, notably breast, ovarian and colon cancer. This led to a growth in clinics located in clinical genetics centres for patients at risk of inherited cancer, and by the late 1990s, cancer genetics was the major reason for referral to these centres—though coverage was highly variable.136 The government responded by setting up a working group on cancergenetics services. The Harper report,137 as its recommendations were known, called for a reorganisation of cancer genetics provision following a managed clinical networks model, with primary care responsible for identification of potentially at-risk patients (representing a more proactive approach to ascertainment than the reactive risk assessment of symptomatic cancer patients in hospitals that had previously predominated), cancer units responsible for risk assessment and screening of those referred by primary care, and specialist genetics services, in tandem with specialist cancer centres, offering services for high-risk patients and disseminating expertise across the area. The Harper report, then, was about networked knowledge management, service rationalization and matching expertise to need. These recommendations were accepted by the government of the time but not funded, and consequently, in the few years following publication, the degree to which provision in England corresponded to the model varied markedly.136 In cancer genetics and other subspecialities, then, the developments in basic science of the 1990s had raised the issue of service reorganisation, but limited progress had been made in creating a system that was fit for © Queen’s Printer and Controller of HMSO 2013. This work was produced by Martin et al under the terms of a commissioning contract issued by the Secretary of State for Health

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purpose given the radical implications of developments in genetics for patient management. The rapid increase in knowledge about both singlegene Mendelian disorders and associations between multiple gene variations and risk of disease meant that a more fundamental shift in the way the NHS dealt with clinical genetics was seen to be required, so that genetic health services could form a component of patient care at every level, including risk management of asymptomatic patients and decision making in primary care. In 2003, however, the government announced significant changes to the organisation of genetics services, along with extra funding to ensure that genetic knowledge was at the heart of the entire NHS. The white paper Our Inheritance, Our Future represented the government’s response to an unfolding “revolution in health care,” as the prime minister put it in his foreword to the document.138 This white paper heralded new investment in clinical-genetics research, and in the staff and equipment of specialist services. More significantly in terms of the interaction of clinical genetics with the rest of the NHS, though, it also announced funding for a programme of pilots aimed at “spreading knowledge” and “building genetics into mainstream services”.138 With the potentially exponential expansion in knowledge about the role of patients’ genetic make-up in determining their health—not only specific gene mutations but also wider genetic makeup, and its interaction with environmental factors—it was important to ensure that those outside genetics centres were able to apply knowledge for the benefit of patients. With this in mind, the aim of the pilot funding announced in the white paper was to “spur the take-up of genetics by other specialties by supporting new initiatives in genetics based care—in the hospital sector, primary care and in screening programmes.”138

3.2 The ‘mainstreaming genetics’ pilot programme and its evaluation The programme of pilots encompassed four streams: five projects set up to identify and treat people with a relatively common genetic disorder known as familial hypercholesterolaemia; 10 service development projects aimed at integrating genetics knowledge with other clinical specialities; 10 general practitioner with a special interest (GPSI) in genetics projects, involving GPs taking one or two days a week to acquire genetics knowledge and then work to spread awareness through primary care, provide leadership on genetics issues and provide clinical services; and seven cancer genetics projects, co-funded by the charity Macmillan Cancer Support, which were to implement a model of cancer-genetics service provision encompassing primary, secondary and tertiary care in their local areas (similar to that envisaged in the Harper Report, but only patchily implemented). Invitations to bid for the £8 million of pilot funding were issued in early 2004, and money was allocated to the familial hypercholesterolaemia, service development and four cancer genetics sites in the second half of 2004. The © Queen’s Printer and Controller of HMSO 2013. This work was produced by Martin et al under the terms of a commissioning contract issued by the Secretary of State for Health

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GPSI sites and the other three cancer genetics projects followed early in 2005. While responding to the specifics of the clinical genetics field, then, the aims of the innovations introduced by these pilots also reflected wider concerns in the ‘modernisation’ of health care.139 By joining up care across several sectors, they sought to organise the service around the patient and reduce the gaps between clinical and organisational silos that might impede patient-centred care.15 By introducing new practices and novel roles (such as GPSIs in genetics, and new nurse specialist roles in settings outside tertiary centres) they sought to generate a more ‘rational’ division of labour reflecting the various skill sets required for different aspects of clinical genetics work, from lifestyle advice based on family history through to specialist genetics input for complex and rare disorders, while maintaining appropriate oversight, accountability and clinical governance arrangements.99 In all, the pilot funding sought to displace a traditional professional logic of service organisation with a more managerial one,140 that might effect a more appropriate balance of resources between sectors reflecting changing patient demands, a more efficient way of providing services, and more responsive, patient-centred genetics care at every level of the NHS. Thus the pilots programme reflected many facets of wider reforms to the NHS in train at the time,141 as outlined in section 2.2.1 above. Each pilot funded following the 2003 white paper was required to include plans for evaluating its work, and alongside these internal evaluations, the DH also funded an external, programme-level evaluation of the pilots, to address the organizational issues arising from their efforts to achieve service reconfiguration. This qualitative, process-oriented evaluation was led by one of the co-authors (Currie), with another two working as researchers on it (Martin and Finn), and focused on these organisational dimensions of change, in terms of both the issues specific to the field of clinical genetics, and the more generic shifts in provision that arose from the ‘modernising’ thrust of the reforms. Findings from this evaluation highlighted various issues, such as the inter-and intra-professional conflict that impeded the degree to which changes in organisation could be made,99,140 the shifting criteria of success and failure that services needed to meet,6 the factors that facilitated compromises between actors from different organisations and professions that could result in new service configurations,16 and the role of processes such as distributed leadership across supportive networks of clinicians and managers where greater change was achieved.7 The evaluation included 11 case study sites, purposively sampled from across the cancer genetics, service development and GPSI in genetics work streams. By the end of the project, which included longitudinal study over four years from 2004 to 2008, it was becoming apparent that relatively few of the newly instigated services looked set to continue beyond their pilot funding period: in many cases, they were reverting to the model of © Queen’s Printer and Controller of HMSO 2013. This work was produced by Martin et al under the terms of a commissioning contract issued by the Secretary of State for Health

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provision operated prior to the service innovation, often due to the organisational and professional complications that had ensued from the changes introduced. Of the 11 cases studied in the evaluation, however, four stood out as having been somewhat successful in maintaining the reconfigurations they had introduced, albeit by varying means. In a final round of interviews with project leads in late 2007 and early 2008, they recounted the approaches they had taken to attempting to ensure their services remained in place beyond the pilot period, seeking local money (from commissioners or through intra-organisational budget reorganisations) and buy-in from relevant stakeholders to sustain the service reconfigurations. However, what was apparent at this point—just after funding for most of the innovations had ceased—was that many of these arrangements seemed provisional in nature, resting on short-term agreements or partial, compromised fixes between the stakeholders involved. Thus while sustainability had, on the face of it, been achieved, this seemed for the moment to represent only a short-term accomplishment. Furthermore, it was not clear from the analytical approach adopted in this study how this sustainability, even if only interim, had been achieved. So, for the purpose of their final reports to their funders, these services had obtained ongoing funding, but how had this happened? And to what extent could they be said to have embedded their practices in local health care systems? And how far would they remain sustainable in the medium-term?

3.3 This study This study, then, involved further research in this subsample of four of the 11 sites, which were themselves purposively sampled for the earlier evaluation. All four were initially successful in sustaining their work beyond their pilot periods, but differed in their clinical focus, health-service sector and inter-professional division of labour. By conducting secondary analysis of the original dataset, and then revisiting these sites 24-36 months after the original fieldwork was completed, this study sought to generate a rich, longitudinal dataset to allow a greater understanding of the short- and medium-term sustainability of these services, taking account of contextual and process differences between the theoretically sampled sites,142 and understanding contemporary challenges and resolutions in their historical, path-dependent contexts.143

3.3.1 The sample Employing a comparative case study approach that covered a breadth of different NHS contexts and stakeholders involved in these reconfigured clinical genetics services, we aimed to produce generalisable knowledge about the process of sustainability with practical and theoretical application across and beyond the health service. While, as noted above, the field of clinical genetics has certain distinguishing features which marks it out from other areas of service provision, the overall clinical context of the four case © Queen’s Printer and Controller of HMSO 2013. This work was produced by Martin et al under the terms of a commissioning contract issued by the Secretary of State for Health

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study sites nevertheless reflected in many ways the challenges of operating in other clinical areas which lack the political and popular interest of highprofile priority areas (e.g. cancer treatment or A&E waiting times), and which cannot therefore rely on centrally driven change management efforts. The issues faced in sustaining these new genetics services, then, were similar to those faced in other relatively marginal areas of NHS provision, and in an NHS confronted with severe restraints on budget, the challenges facing such areas in achieving sustainability seemed likely to become more, not less, acute. Furthermore, the cross-sector nature of genetics provision made it an especially suitable site for research of this kind, and our choice of cases took in sites from primary, secondary and tertiary care, sites with leaders from multiple professional groups, and sites in which locally developed and more centrally driven innovations are being sustained. As can be seen in table 2, our sample offered variations and similarities across a number of key variables of interest that prior theory, and the empirical literature covered in chapter 2, suggested would be of significance.

Primary carebased organisational innovation

Hospitalbased organisational innovation

Organisational innovation based on evidence-based model

Locally designed organisational innovation

Case A

Case B



Clinical speciality: cancer genetics



General primary care genetics



Led by a nurse



Led by a GPSI in genetics



Commissioned by PCT



Commissioned by PCT initially, funding currently halted

Case C (tertiary care)

Case D (secondary care)



Clinical speciality: cancer genetics



Other clinical speciality*





Led by a consultant clinical geneticist

Jointly led by genetics and mainstream consultants





Commissioned by a consortium of PCTs

Funded through integration into mainstream service

Table 2. Key characteristics of the four selected case-study sites. *To preserve anonymity, the clinical speciality of this site is not disclosed (since it was one of only a few). It is a lower-profile clinical area than cancer.

The sample, then, includes consistencies and divergences in several characteristics that are likely to be important in the paths of the sampled cases towards sustainability: clinical speciality; degree to which the original innovation derived from an evidence-based model; professional affiliation of © Queen’s Printer and Controller of HMSO 2013. This work was produced by Martin et al under the terms of a commissioning contract issued by the Secretary of State for Health

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lead; sector in which organisational innovation located; mode by which initial post-pilot sustainability achieved. Of particular theoretical interest among these characteristics are the sector of the health service in which the innovation is being sustained (primary care versus secondary/tertiary hospital-based settings),6 and the degree to which the innovation draws on some form of evidence base or is based on a locally designed approach to the reorganisation of care.10 As we saw in chapter 2, both of these are likely to have an important impact on the nature of and path to sustainability. The former will have significant implications for how sustainability might be achieved (in terms of strategies and choice of funding), while the latter has particular implications for credibility of the organisational innovation with different groups of stakeholders. These variables are therefore given particular prominence in our sampling strategy. Table 2 gives details of the features of the four sites, and how they embody the characteristics noted for this research, it emerged from discussions with the sites that they differed in their subsequent paths into post-pilot sustainability. While three continued to enjoy ongoing funding, Case B had its funding from one source dropped, and was seeking at the time that this application was made to replace this with alternative funding. Given its place in our purposive sample—and given also the fact that the GPSI in genetics projects seemed from our original evaluation to be especially vulnerable to termination of funding6,97—we retained this site in our study, looking to understand how the apparently promising funding situation at the end of the pilot period had deteriorated so that medium-term sustainability here was not achieved.

3.3.2 Data collection The original evaluation utilised a range of qualitative methods, in particular in-depth interviews with key stakeholders involved in the pilot projects, alongside observation of relevant meetings and analysis of documents. In the new data collection for this study, we planned to repeat these methods. Interview schedules covered a number of areas, informed by the original study, our secondary analysis of data collected in the four cases in the original study (see below), and key issues in the literature discussed in chapter 2 (and especially those covered in our ‘mapping’ of important issues, presented in table 1). Interviews with those closely involved with the services (for example leads and core staff) generally took a broadly narrative, chronological approach, in which participants talked through the journeys of their projects towards sustainability, highlighting key junctures, relevant stakeholders, persuasive arguments, alignments with other priorities and so on which had been instrumental in these journeys. Interviews with more peripheral stakeholders focused on their involvement in this process, and their role in facilitating or impeding sustainability. Participants in this study included those previously interviewed in the course of the earlier evaluation, plus others identified on a ‘snowball sampling’ basis (i.e. identified through existing participants) as having influence on medium-term sustainability (for example business managers, © Queen’s Printer and Controller of HMSO 2013. This work was produced by Martin et al under the terms of a commissioning contract issued by the Secretary of State for Health

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commissioners, PCT executives etc.). In total 44 interviews were conducted (see table 3), including follow-up interviews with service leads at the end of the fieldwork period to pursue areas of interest raised by other interviewees. It will be noted that Case D has a relatively small number of participants: this was due in part to the nature of the service (see table 2 and later chapters: this service was much more ‘self-contained’ in the way it approached sustainability, and was reliant on a much narrower set of stakeholders in sustaining itself), but also due to non-responses from other participants we approached, some of whom considered their involvement to have been too minimal to warrant participation in an interview. We planned to carry out observational work, mirroring the observation of pilots’ project and steering group meetings that had been carried out in the original evaluation, but found that as services that were no longer pilots, none of the cases now held such meetings with any regularity. In the event, therefore, we observed only one meeting (in Case D). Finally, we also collected documentary evidence about the four services, including reports, publicity materials and press coverage, and collated this with materials collected during the earlier evaluation to analyse in terms of the strategies deployed for sustainability. This source of data was used primarily to inform the in-depth interviews.

Case

Total interviews

Follow-up i/ws with lead/s

Interviewee roles

A

14

2

Nurse specialist (service lead), PCT senior and middle managers, commissioners, clinical geneticist, genetic counsellor, GPs, care trust director

B

9

1

GPSI (service lead), clinical geneticists, PCT senior and middle managers, medical directors

C

12

2

Clinical geneticist (service lead), nurse specialists, genetic counsellor, business managers, commissioners, consultants in associated clinical areas

D

5

2

Clinical geneticist (joint service lead), consultant in associated clinical area (joint service lead), nurse specialist

Other

4

n/a

Civil servant, Macmillan representative, service users involved in the pilots programme


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Table 3. Interview participants by case study site.

3.3.3 Data analysis Although, in keeping with many qualitative approaches, analysis was ongoing and iterative, and took place alongside data collection, two reasonably distinct stages to this process could be identified. In the first stage, we analysed data collected on the four cases over the period of the original evaluation, from 2004 to 2008. The purpose of this was to reanalyse these data in terms of the approach to sustainability, which had not been a principal focus in the original evaluation. Using an approach based on the constant comparative method,144 but drawing on ‘sensitising concepts’ identified from the literature, one of us (Weaver) developed an analysis of the key themes that had influenced sustainability in the four sites. He read and reread transcripts, coded these in terms of both issues identified in the literature and other factors that appeared relevant from the source data. Another of us (Martin) also read and reread these transcripts, and discussed emergent interpretations with Weaver, refining and developing the analytical framework that emerged from this process. This secondary analysis—which involved the reanalysis of some 42 interview transcripts as well as observational notes and documentary materials—both informed the collection of new data in the course of empirical fieldwork for this project, and provided us with an understanding of how the initial sustainability beyond their pilot period of the four projects had been achieved. Chapter 4 reports the findings from this analysis on a case-bycase basis, offering a richer understanding of the background to the four cases themselves, providing a further understanding of the context-specific dynamics of sustainability in each site, and paving the way for a more integrative analysis of their medium-term sustainability in chapter 5. The second stage of analysis, which took place in tandem with data collection, focused on the newly collected data. Again, it involved an approach that began with coding based on the constant comparative method, and was then substantiated by issues from the literature, the earlier evaluation and the first stage of analysis. Here, the whole team was drawn into the analytical process, which was led again by Weaver and Martin. Summaries of key emerging themes were circulated to the whole team with illustrative excerpts of data, and the team then contributed to defining further avenues for interrogation of the data. This gave rise to the analysis reported in chapter 5. Here, the organisation of the findings is thematic rather than case-by-case, bringing out both the key themes developed through this analysis and also the connections between them. Findings from both chapter 4 and chapter 5 are brought together for further discussion in chapter 6, which summarises the key issues and returns to the specific areas of enquiry highlighted as of interest in chapter 2.


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4 After the pilot: the first steps towards sustainability This chapter develops a case-by-case discussion of sustainability in the short term: that is, the efforts involved in obtaining ongoing funding from local sources immediately following the withdrawal of pilot funding, and in making the first steps towards consolidation and embedding in the local health economies of the cases. In each case, particular issues are important, but there are some commonalities across cases. Key themes are highlighted in each, before a number of common themes are identified in the final section of the chapter.

4.1 Case A In Case A (the primary care cancer genetics service) five particular areas of activity, led by pilot staff and others around them, impacted significantly on the sustainability of the service. These cover the role of public and patient involvement as a means of ensuring appropriateness of the service and fit with wider PCT strategies, the use of publicity to generate direct selfreferrals from worried members of the public, networking activities within the hosting PCT to enlist the support of key advocates and champions, and the support of other key stakeholders. Patient and public involvement was important for presenting the case for the maintenance of the service, ensuring fit with perceived public demand for the service and also assisting alignment of the service with the hosting PCT’s wider strategies. In the pilot phase the service had made use of the PCT’s patient engagement officer, and two service users in particular were drawn on to contribute actively to various publicity events in the pilot and immediate post-pilot phase. These service users were seen by the leads of the service and other key advocates as very important promoters of the service because the message they presented to the public as patients was a powerful one, and thus had a greater impact than nurse- or clinician-led presentations. The project’s internal evaluation lead explained this in the following terms: "I think patients tend to be a bit more interested if, rather than just having clinicians there on a stand, if you’ve got someone that’s actually been through the service to tell you more about it they’re a bit more forthcoming. So I think they’ve really, really helped us a lot with that and because they’ve been going out and about and doing all the talking and telling people about the service, which from my perspective I think if we were to do that © Queen’s Printer and Controller of HMSO 2013. This work was produced by Martin et al under the terms of a commissioning contract issued by the Secretary of State for Health

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on our own we wouldn’t have probably got as much of a response.” Service users also worked closely with the service in lobbying for ongoing funding as it moved out of the pilot phase, accompanying service leads to face-to-face meetings with PCT managers to help to make the case for sustainability: as the project manager of the pilot funding programme commented, “the service users in [Case A] are phenomenal advocates and promoters of the service.” Beyond direct service user involvement in the project, engaging the public and publicising the service represented a key component in work towards sustainability in this site, where the primary audience was, during the pilot phase, concerned members of the public themselves (rather than referring health care professionals, as in the other three sites). Consequently, of the four cases, Case A made the widest use of the media. This strategy developed because of the need to gain patients through self-referral in the early stages of the project, but it also served to put the service on the map in the local area, and thus make the case for sustainability more audible. Coupled with this, publicity work was also directed to GPs and other primary care professionals, resulting in referrals from these practitioners and starting to create a network of support which, as we shall see in chapter 5, became increasingly important. Work to engage the public in the service and generate interest and self-referrals was extensive: “When we first kicked-off, we went to every group of people that ever existed in [Case A area], we went to housing associations, trying to get to deprived areas. We tried to get into the BME communities, which wasn’t particularly successful, and that needs re-looking at. We went to Rotary Clubs, we went to all the support groups that were available in [the area], we spent a lot of time going out there in the community and actually advertising the service.” (Internal evaluation lead, Case A) In marketing itself towards the public and self-referrals, the service also undertook a considerable amount of wider cancer awareness and health promotion work. From the start, the service was viewed by its leads, and by key figures within the PCT, as fitting into a wider strategy around cancer prevention, rather than being solely about triaging potential cases of inherited cancer. As such, the work of the service—in raising public awareness as well as in narrow clinical activity—was recognised from the start in the PCT’s own framework for assessing the performance and recognising the value of the services it commissioned and provided, which sought to give recognition to wider aspects of the value of provision than narrow performance management measures: “[The PCT executive] would need to scrutinise applications for these type of services and do the usual things that executives do, does this fit strategically, where would be the direction we’re © Queen’s Printer and Controller of HMSO 2013. This work was produced by Martin et al under the terms of a commissioning contract issued by the Secretary of State for Health

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going down, does this provide the anticipated benefits over multidimensional benefits, so it’s not just clinical, it would be does it enable the PCT to move towards when we need to be moving towards. [...] If we start from a purely user perspective or service user perspective or a consumer perspective, then it certainly meets a lot of their requirements.” (PCT director, Case A) “[The PCT deputy chief executive] has been very, very keen about it from the start, which I was quite surprised at, because one of the worries we had when we started this was that the PCT were not going to feel the impact of this service. [...] We never capture that the vast majority of patients who have gone through and been told ‘You are fine, you are clear, you don’t have any of that’, if you focus on those that have had the disease, which is actually a minority. So that’s where it is useful the evaluation that [lead nurse] is doing of everybody, it just takes away that focus, that hard focus on cancer and looks at what I think is by far more beneficial, is the reassurance the service offers for the population as a whole.” (GP, Case A) Gaining awareness among the public and alignment with key PCT policies were, then, crucial components in the service’s work towards initial sustainability. Alongside this, significant work went into gaining traction with other key audiences. GPs were an important constituency, not just because of their role as referrers, but also because of their influence, via the PCT’s Professional Executive Committee, on the post-pilot funding decision. By the end of the pilot period, over three quarters of general practices in Case A’s PCT area had referred to the service, signalling increasing awareness of and confidence in the service. From the perspective of GPs, the service offered a helpful supplement to their practice, taking away the onus from GPs to ensure that they were managing patients appropriately: “Patients may go and see GPs and say ‘I am worried because my brother has had something, my sister has had something or whatever, am I at an increased risk?’ and maybe due to a lack of knowledge they might be being told something that might not be terribly appropriate or they might be being referred when that’s not appropriate and so causing concern and wasting a referral really, clogging up the genetic system from seeing somebody that perhaps they didn’t need to see. So that’s why this appealed.” (General practitioner, Case A) The clinical appeal of the service to GPs and other professionals in primary care helped to supplement self-referrals with referrals from primary care practitioners, but it was also crucial in ensuring support from these groups for the continuation of the service. Service leads also worked actively to build networks of support among other groups within and beyond the PCT, again obtaining support from influential stakeholders, and also with a view © Queen’s Printer and Controller of HMSO 2013. This work was produced by Martin et al under the terms of a commissioning contract issued by the Secretary of State for Health

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to spreading the service beyond the immediate boundaries of the PCT once its immediate future was assured: “I do a lot of networking, trying to get other people sort of involved and trying to hopefully engage other PCTs once this pilot is finished to try and roll the service out. And I, because of my previous role I know some of the GPs in other areas and some of the surgeons in other areas which might be useful.” (Lead nurse, Case A) Beyond GPs and primary care nurses, engaging secondary and tertiary care clinicians was also important. Secondary care surgeons and tertiary care geneticists would, traditionally, have been referred many of the patients with suspected family history of cancer prior to the existence of the new service. Acceptance of the value of the service by clinicians in secondary and tertiary care was therefore crucial, so that they would redirect patients inappropriately referred to them to the new Case A service: “It was well overdue. A, you can give the people more time and B, they have been formally trained in doing a fairly objective assessment of cancer risk. [...]So I think having the time at the outset and the mechanisms for actually getting a proper initial assessment do mean you get a much more real assessment at the outset and so that the person is giving a meaningful risk that they can then make their decisions on. [...] Now we tend to divert and direct if we can.” (Breast surgeon, Case A) “It’s a model that we put forward anyway, not necessarily doing it within primary care but certainly within secondary care having – we’ve trained a number of breast care nurses to do risk assessment. They would do the initial risk assessment and triaging in secondary care and then would refer in to the tertiary service and so it’s a model we put forward anyway . [...] We were seeing an awful lot of moderate risk families who didn’t need to be seen because from a genetics point of view we couldn’t do any testing and we couldn’t offer them anything else.” (Clinical geneticist, Case A) In making these contacts and ensuring that key stakeholders assented to the existence of the service—and were prepared to uphold the proper care pathway and divert direct referrals from GPs to the new service—the existing networks of the service staff were crucial. The lead nurse on the service had extensive existing relationships which proved useful in gaining this assent: “I know all the breast surgeons within [local hospital] which serves [nearby PCT areas]. So I think from the point of view of rolling the service out I already have those established relationships.” (Lead nurse, Case A)


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More broadly, a crucial advantage for the service in Case A in achieving its initial sustainability post-pilot was the heterogeneity of the networks enjoyed by its key champions. As we have seen, beyond these links with secondary and tertiary care, there were also important connections within the PCT, with director-level support, and links with the community of primary care practitioners. At different points in time, the contributions of different networks to the sustainability of the service became important: from the initial acquiescence of tertiary care practitioners to enable the service to go ahead, through the building of support among patients, the public and primary care practitioners, to the role of key influencers within the PCT to support ongoing funding for the service. As we will see in the next chapter, these networks of influence had to continue to develop and mutate in response to ongoing contextual changes. The leadership of the service manager and lead nurse was thus crucial, but so too was the wider championing of the service by other stakeholders: “Yeah [service manager has] been working really hard on the project. But I do think as time has been going on some, of her responsibilities have been not delegated but other people have picked up the responsibilities as the project has been going on because obviously [service manager] has got other work commitments as well. And that’s the nice thing about the project team that really if [service manager] can’t do something there’s always someone there to pick that piece of work up for her.” (Internal evaluation lead, Case A) The service manager was involved very heavily at the outset of the service, but following the split of the PCT into purchaser and provider arms, just before the decision about ongoing funding was made, her direct input into the day-to-day functioning of the service reduced, since she remained in the commissioning arm while the service moved into the provider arm. However, her influence on the commissioning side remained important, and there was also key support from other local clinicians with influence. Despite organisational turbulence, then, the service was able to draw on useful networks within and beyond the PCT, and key champions in positions of both clinical and managerial influence were crucial to its initial sustainability—and remained so, as we see in chapter 5, into the medium term.

4.2 Case B Case B, the general practitioner with a special interest in genetics service, was successful initially in winning six months of post-pilot funding from the host PCT. Important factors in this initial sustaining of the service included its fit with the existing structure of regional genetics service provision, and initial support from GPs, from PCT managers and from local geneticists. However, notable also was a degree of ambiguity in this support that was less prominent in the other three cases, and which we pick up on in chapter © Queen’s Printer and Controller of HMSO 2013. This work was produced by Martin et al under the terms of a commissioning contract issued by the Secretary of State for Health

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5, in considering the failure of the service to maintain funding beyond this initial six months. Apparently crucial in the original ‘fit’ of the service in Case B with existing provision, and thus in the initial decision to sustain, was the careful negotiation of a role for the service with tertiary care geneticists. There was some ambiguity in the brief for GPSIs in Genetics that the Department of Health had provided when offering pilot funding, and unlike the GPSI service provided in some other pilot sites,99 here there was a delicate process of discussion which resulted in a remit with which both geneticists and the GPSI herself were content: “We didn’t see any great advantage in having [her] as a GP doing lots of genetics clinics. [.] It wouldn’t have fitted in with what we’re doing, and so as we set out through discussion early on, it became clear that the sensible thing was for the first bit of her work to be to establish whether or not there was a need for her, or whether in reality we should simply say, ‘Well that was a nice idea, but thank you and goodbye’.” (Clinical geneticist, Case B) “I’ve had a number of sessions with [clinical geneticist] and we decided I actually needed to look carefully at whether to set up clinics or not, [and at the question of] a useful and effective way to use my time, because I don’t want to be doing the same work as a genetic counsellor. [...] So with the clinics, I’ve decided to hold off [...] and at the moment, I’m concentrating on education.” (GPSI, Case B) Thus the service offered by the GPSI in Case B proceeded along non-clinical lines, offering a range of educational services to local primary care practitioners and providing advice on specific cases, but rarely providing direct clinical input to patients. The service therefore had a good initial fit with the existing structures and practices around cancer genetics. It worked to support GPs by providing information on clinical genetics, and thus offered a service that was not provided in other care pathways. Alongside this, because the GPSI did not see patients, the service did not duplicate what was offered by local tertiary care providers. Specifically, in providing an advisory service, the GPSI could be seen to offer a more accessible route to clinical genetics knowledge for local GPs. The GPSI gained support from and was of course well known to the PCT, and increasingly to geneticists in the region. As in Case A, considerable networking was important to consolidating the position of the service with various key stakeholders: “I’m getting into secondary care and meeting haematologists and paediatricians and the geneticists that I wouldn’t, never have normally have spoken to. Maybe sent them the odd referral letter but that’s all. I mean even working with the PCT as well.” (GPSI, Case B) © Queen’s Printer and Controller of HMSO 2013. This work was produced by Martin et al under the terms of a commissioning contract issued by the Secretary of State for Health

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Such networking was well received not only by primary care professionals, but also by those in the tertiary care genetics service, who saw the GPSI garnering a degree of interest in genetics and engagement in key questions that had hitherto been lacking: “[GPSI has] certainly brought benefits to the regional implementation groups, particularly from the primary care aspect, and [she brings] back issues from ... fellow GPs et cetera, and that’s been certainly helpful. And it’s helped in terms of the communication strategy and to also feed that information back up to other groups.” (Regional screening co-ordinator, Case B) Figures within the PCT also provided support in engaging primary care practitioners through integration into wider communications and educational events: “I think this is where [the] particular strengths are, has been to educational, PCT-sponsored educational events and the primary care interest groups, so they’ve been very active in that and advertising themselves and getting themselves known more informal and moving towards a more formal process for that.” (PCT senior clinical manager, Case B) However, there were signs that in this case, work to engage secondary care clinicians had been less successful than elsewhere. In providing an advisory service that might bridge the gap between primary and tertiary care, some felt that relevant secondary care clinicians—for example, those involved in perinatal screening services—had been missed out: “I think [the service] could be probably communicated better. I mean I feel quite sure that if I were to go out into some trust and talk to people who are offering screening for genetic conditions they probably are totally unaware of the project.” (PCT senior clinical manager, Case B) Despite the obvious support from the key advocates in the region it remained unclear how long support for the service would last. In part, as we will consider in more detail in the next chapter, this seemed to be associated with organisational changes that impacted on what was considered to be the appropriate scope for the service. Considerable networking and educational work took place among GPs and primary care practitioners within the PCT area, but mergers of the PCT meant that the potential clientele of the service expanded quite suddenly. Thus, as a screening co-ordinator commented, “it may well be that [the service was] advertised via [the original PCT] and via the communication links out within the PCT, but to maximise the impact they probably weren’t advertised regionally.” Work went into planning to try to secure ongoing funding, involving PCT managers, the GPSI and local and regional specialist commissioners. The © Queen’s Printer and Controller of HMSO 2013. This work was produced by Martin et al under the terms of a commissioning contract issued by the Secretary of State for Health

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local scope of the service meant that careful consideration was given, early on, to the question of how local funding might be provided, and what budgets might be drawn on: “I’ve spoken to [the GPSI] and also to [a regional specialist commissioner] about this, and we’ve had very early discussions around this, so they are aware that we do need to do something in the relatively near future. [...] We need to be in a strong position when it comes to renegotiating or certainly looking at extending funding through the PCT.” (PCT business manager, Case B) However, given the organisational turbulence associated with the reorganisation of PCTs, there was a sense that despite this careful planning and the buy-in obtained from various groups in primary and tertiary care, there was a need for the service to be championed from different constituencies: “I actually think, should it be public health or SHA level? Probably via the Department of Health, public health would be a good vehicle because of the change and reorganisation. And I think from a stability point of view for seeing through something when we don’t know what’s going to happen, we tend to change every 18 months. What will happen with the SHA structures? We’ll wait and see what happens, but my feeling will be public health is a good mechanism [for ensuring sustainability].” (Regional screening co-ordinator, Case B) Alongside this, the GPSI herself had found difficulties in ensuring that her networking was effective. Sometimes she found that in the context of a pilot service, other practitioners were hesitant to buy in fully: ”Partly the fact that you’re only a three-year pilot, sometimes it’s difficult to persuade people to really take you seriously and to invest, perhaps not money, but their confidence that yes actually this should work.” This challenge seemed much more prominent in Case B, where clinical service provision was not being offered, than in the other sites, where the pilot projects were accompanied by sustained efforts to secure changes in clinical practice and referral patterns to embed the services as part of a wider clinical system. We see the medium-term results of this in chapter 5, and discuss it further in chapter 6. Even at the point at which initial ongoing funding was secured, then, there were certain signs that the situation was less favourable for the mediumterm sustainability than in other cases. In the next chapter we consider this divergence further, and note how changes in organisation and NHS policy— as well as certain characteristics inherent to the service provided in Case C


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itself—contributed to the non-renewal of post-pilot funding beyond the first six months.

4.3 Case C A number of important factors helped Case C to sustain in the short term. The case for sustainability was improved by the development of a successful network of clinical advocates in related specialities across secondary and tertiary care, and the support enlisted from acute care doctors and nurses. There was also a neat fit with the wider organisational structure and the way in which other parts of the system provided care, and this helped the service become a key part of the care pathway. There was some success in the way the business case was presented to commissioners, and the network that had been developed helped at this stage to support the bid for ongoing funding. A key facet of the success of Case C in embedding itself quickly within the local health economy, and one to which various participants in this site returned again and again, was the development and mobilisation of networks of clinicians across the area. This served, first of all, to ensure that the service offered clinical provision that fitted well with existing provision, so that it received considerable numbers of referrals from an early stage. The service lead explained how a stakeholder event acted to connect and communicate with people whose influence and clinical behaviour were central for the sustainability of the service: “We are having a big stakeholder event actually in February, so we are going to feed back to all the stakeholder groups. I have done that on and off to various people, and given the feedback lectures, audit type lectures, to say ‘look, we are really good’.” Providing clinical evidence in the form of audit data, demonstrating the worth of the project and the improvements in practice over previous arrangements, was a crucial strategy in this case, especially in relation to work to convince sometimes sceptical doctors that their prior practice was deficient, and that there was thus a tangible clinical need for the service: “I don’t think the results are as dramatic as they thought in terms of the numbers of women, because this is a relatively small [cancer] network so you’re only talking about 100 women in 2005 who had an unnecessary mammogram. And this is a network that does something like 50,000 population mammograms per year so it’s small numbers. But from my point of view it’s critical, because these are women who are unnecessarily exposed to radiation and anxiety, and so we’ve done the job. We’ve kind of cemented it, if you think about the sustainability of this service in real life from next year we’ve cemented this now in the psyche of the network.” (Service lead)


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The language used by the service lead here suggests that discursive work was important, and the success of this work to convince key clinical stakeholders of the clinical value of the pilot project was evident in the way in which other interviewees spoke of the service. As a colorectal surgeon, and then director of the cancer network, enthused: “There was a definite gap in the system about good, scientificallybased clinical advice, and what we do with people with family history of cancer in general and about bowel cancer. And what advice we should tell the patient, and we had that gap and obviously there were some guidelines from different organisations: I think British Colorectal, the British Society of Gastroenterology had their guidelines which are quite broad and non-specific, and there were a lot of people felt the guideline didn’t apply to them. [So] we needed that clinical service like everybody else, like any other clinical service: that’s my take on it. So there was huge interest and real enthusiasm, and desire to see something like this happening in [Area C].” Even from a relatively early stage, then—and in contrast to Case B, and to a much greater extent than in Case A, above—the project had won the support of key stakeholders in the local area, who were convinced of the clinical need for the new service and of the value it added to existing, lessthan-ideal, provision. In addition to the use of evidence to convince professionals of the need for change, two other important aspects of the strategy used to network and obtain buy-in and commitment from key clinicians in the area should be noted, both of which seemed crucial to the groundwork that was put in place for the sustainability of the service in Case C. Firstly—in notable contrast, again, to the situation in Cases A and B—the service leads were able to draw on a functional, existing cancer network, where a collaborative ethos was already well established (in contrast to the situation in many other cancer networks).66 As a cancer network manager explained: “We [the cancer network] often are the conduit that say, ‘So OK then if we’ve got to become compliant with national policy for say head and neck cancers’, then the network is normally the forum that actually pulls all of the stakeholders together: commissioners, patients, whoever is going to be involved with that, and sits them in a room and say, ‘What does it need to look like, how can we get there, where is it going to be hosted?’ So often we deal with some of the challenging issues, because organisations traditionally stick to within their own boundaries of their organisations and only tell other organisations a bit. What this network does—I think that’s perhaps different to others—is that when there is an idea, we do pull all organisations together, so if there’s something to be developed we do it together. So the ownership and the buy-in is aimed for at the beginning, instead of © Queen’s Printer and Controller of HMSO 2013. This work was produced by Martin et al under the terms of a commissioning contract issued by the Secretary of State for Health

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saying, ‘Oh [Area C Hospital Trust] designed that, we don’t agree with it’.” In pulling together key stakeholders and seeking to secure engagement and ownership throughout the region, the cancer network offered a crucial framework for these initial efforts to embed the service in local provision. Whereas we saw in Case B above that for some stakeholders, the service was always seen as a temporary, time-limited ‘project’, here efforts were underway from the start to establish the service as an instrumental part of routine provision. Secondly, central to the success of Case C in becoming an acknowledged part of provision in the locality and region was the leadership distributed among key champions of the project, notably the service lead (a consultant clinical geneticist) and the lead nurse.7 Their work was critical to persuading key actors across the area of the worth of the project, and each was able to use their knowledge of the norms, expectations and culture of different groups of professionals to ensure that the service was aligned with their interests and so accepted by key stakeholders: “The breast team in this part of the network, are well on board with us and I think that they feel that we have done a lot of good and helped them out of a problem. So that’s good and the colorectal people I think are the same. The gynae people have always been supportive.” (Service lead, Case C) “I have to say that when I have spoken to nurses, they are there straight away, they know exactly what you are talking about and what you are trying to achieve and they are the engines of change if you like, they are the ones who just go off and do things. [...] The most important thing I would say, Graham, is understanding nursing culture. [...] I think for us going in it was a lot easier than a consultant going in and say these are our guidelines, these are what you’re going to use, this is our network approach. I think being a nurse, there’s ways around these things and saying, ‘Well actually, OK, the GPs do a good job; however we know you do a good job, we know you’re on the front line, we know you’re the people that are going to be doing this and bringing [patients into the service].” (Lead nurse, Case C) The success of this variegated, distributed approach to leading change and persuading others of the legitimacy of the pilot as a way of changing practice was evident in the way that other actors spoke of the team and the service they had introduced: “It was very, very efficient very, very quickly. And [service lead] is a particularly good public-relations individual, his ability to make fairly complicated genetics understandable and simple is not unique but almost unique. [...] The biggest thing is [service lead’s] attitude and the fact that they’re handy is a major © Queen’s Printer and Controller of HMSO 2013. This work was produced by Martin et al under the terms of a commissioning contract issued by the Secretary of State for Health

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influence. I feel particularly a lot more comfortable with his expertise than the previous expertise that we had from [tertiary care genetics centre].” (Gynaecological surgeon, Case C) Through this combination of contextual characteristics, active leadership work by service leads and other champions, the perceived need for the service and its fit with existing strengths and weaknesses of practice, the pilot in Case C seemed tangibly more established than Cases A and B from an early stage. This was borne out by data on throughput, which showed that significantly more patients were seen in Case C than in Case A (a clinically similar service funded through the same cancer genetics substream of the original pilot programme). Not all the networking work was quite so effective, though, and there were notable differences in the degree of success with which various clinical groups were engaged. Notably, GPs were rather more difficult to engage and garner support: “The GPs I found less easy to engage with, because it is very clear that GPs and hospital doctors are very, very different. [... At stakeholder events] they are either there because they had no home to go to, or because you were offering them a cheap sarnie, or maybe they have been sent by their PCT or their surgeries to find out what this is all about and I have only ever really come across a few faces who I have seen again and again, who are clearly interested and come along because they want to know.” (Service lead, Case C) Engagement of GPs was less important in this case at this stage, however, because this group did not represent its primary stakeholders or referrers. (Similarly, in contradistinction to Case A, it did not solicit self-referrals from members of the public, though some were seen.) The service was, however, successful in engaging—and becoming an integral part of the care pathway for—gynaecological, colorectal and breast cancer clinicians. With this integration achieved, the service lead and his colleagues were able to present a clear business case to commissioners. This was not, though, a matter of a simple case around cost-effectiveness or gold-standard evidence of worth, but rather around improvements in the quality of the care pathway and more appropriate care for patients: “You can see money going in but it’s very difficult to see, there’s no actual cost reduction. You could say that it’s more targeted, it’s more appropriate, the screening et cetera. People will get treated more appropriately, but in truth it doesn’t reduce the number of people requiring cancer treatment, it doesn’t reduce the cost of cancer treatments; in fact it actually increases the cost.”(Specialist commissioner, Case C)


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This led to some difficulties in making the case for “a service which had a long-term payback and not an immediate payback when pressure was being put on for waiting lists and things like that” (specialist commissioner, Case C). Consequently, the service found itself on a ‘grey list’ of services not seen as essential, but which might merit funding. The task then became one of describing the risks to local health care provision if the service was not refunded. Surviving this commissioning process was challenging, especially to a clinical geneticist whose previous experience had been with the relatively rarefied process of regional specialist commissioning. However, ultimately, the degree to which the service had embedded itself in the network of local provision made the task of convincing commissioners of the service’s value somewhat easier: “Everything until this point had been about saying we are brilliant, we do all this good stuff and we create downstream cost savings and the whole basket of outcome measures that we had measured. We had to throw that to one side again and say, ‘Well, what will happen if we don’t get funding?’ and I found that very difficult. The directorate manager and I sat one afternoon and we wrote a sort of doomsday account [...] basically saying, ‘Women will be mismanaged, money will be wasted on mammography, blah, blah’, and then they wanted us to quantify that in some way and of course, that is very difficult. We got to a stage where contracts were coming right up to the end of their dates and were about to expire and we had no definitive answer until almost the last day of the last financial year. [...] I don’t think I have ever seen a written document from the commissioners to say that they would commission this service. It all came dribbling through, which is apparently very normal.” (Service lead, Case C) Drawing on a mixture of information about the place of the service within wider provision, the endorsement of key stakeholders in the network, and audit-based evidence about the improvements in care that the service had created, then, Case C was able to win its initial battle for sustainability. Despite the apparently greater degree of clinical integration within key networks and greater patient throughput, however, the less direct access to PCT-based managers and commissioners than Case A meant that this road to sustainability was somewhat rockier, and was uncertain until the twelfth hour.

4.4 Case D A number of central themes emerge from Case D. These include the fit with existing practices, the insulation of the key stakeholders from external politics, the combined relative power of the key stakeholders, and finally, the links that those stakeholders had to those in charge. © Queen’s Printer and Controller of HMSO 2013. This work was produced by Martin et al under the terms of a commissioning contract issued by the Secretary of State for Health

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In some ways, the challenges faced by the service in Case D differed significantly from those in the other three cases. Though funded through the same pilot initiative, and seeking like the other cases to build connections between clinical genetics and other, ‘mainstream’ disciplines, the reconfiguring work required to achieve this took place largely within the boundaries of one large hospital trust. A central theme that emerges from Case D and its progress towards initial sustainability is the way in which the service’s leads worked actively to fit in with existing practices. This was presented in several ways. An important strategy was to present the cost of the service as something that was already being incurred, and the project as a sensible reorganisation. A clinical biochemist explains how “these patients would have to been [seen] and their costs would be passed on but in another clinic.” Similarly, the service’s lead nurse presents it as a more streamlined and higher-quality way of providing a clinical service that would otherwise fall to others within the same department: “And I think because we’re developing more genetic tests we’re able to give people more options that there’s a need for this role and for the clinic otherwise I don’t know who, who the role would fall to, normally the [mainstream clinical discipline department].” As a result of this, those in positions of managerial authority were relatively relaxed at the prospect of a service which seemed to offer a better quality of care, the prospect of retaining or increasing income from clinical provision and genetic testing, without the need for major administrative reorganisations beyond those which the leads themselves would be instigating: “[The service leads have] longstanding interest in this area, and their enthusiasm, they really wanted to do this and so that was a key driver. It was also clear when we started to think about what the clinic would do that it would be much better for patients, if it worked for them to see all the specialists that they need to see at one go. So I suppose the driver we thought we could provide a better service which was very important, together with the enthusiasm and the expertise to put the whole package together locally.” (Clinical director, Case D) Through time, the new service became increasingly embedded within the host department. In part, this process built on similar uses of clinical audit as noted in Case C above, demonstrating the clinical appropriateness of the new approach to provision. However, this resulted in quite a different dynamic of sustainability: “I think often in the NHS people just carry on regardless, and then they become an established part of the furniture. Yes, it’s a bit like squatting in a clinic isn’t it, squatters’ rights! So this month I haven’t felt particularly threatened for our existence, as opposed to last month or the month before. It’s partly because © Queen’s Printer and Controller of HMSO 2013. This work was produced by Martin et al under the terms of a commissioning contract issued by the Secretary of State for Health

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the clinic has got a momentum of its own now. If you like, it works, and we’ve shown that we can do what we said we’d do.” (Mainstream consultant clinical specialist, Case D) While similar strategies of alignment and evidencing to those deployed in other cases were important here, then, they seemed to result much more directly in establishing the service as part of routine provision. Whereas in other cases such work could only go as far as to create a set of conditions that seemed likely to precipitate favourable pronouncements from external commissioners, managers and other decision makers, here the clinical embedding of the project was much more closely and directly tied into its organisational embedding. A number of factors were important in this difference. Firstly, as already noted, Case D was relatively insulated from wider external politics, reconfigurations of organisational boundaries, and the vagaries of an increasingly market-based commissioning process. The service constituted a reorganisation of clinics for which there was an established clinical need and which was the responsibility of the hospital departments providing staff. Once the pilot phase was over, then, the service leads did not need to negotiate its existence with external stakeholders but only within their departments. Related to this, the relative power of the service’s joint leads–both honorary consultants with considerable experience within the hospital and established relationships with key others—put them at a relative advantage in entering these negotiations. This had already put the service leads at a considerable advantage when seeking to apply for external pilot funding: “I think we were sufficiently well known, sufficiently senior and sufficiently motivated to say, ‘We are going to do this, and it doesn’t matter what on earth you say, we’re going to do it’. So I think we rather got away with it from that point of view, I don’t think anybody was going to turn round, but it partly was also because we were bringing in money to do it, I think if we’d been saying, ‘This is what we want to do, we haven’t got any money, you’re going to pay for it’, I think probably more people would have stood up and said, ‘Oh steady on’.” (Consultant clinical geneticist, Case D) Beyond this, it also secured a relatively smooth passage for the continued provision of the service—at least as far as those parts of it that did not require specific extra funding were concerned. The arrangements necessary to enable the genetics and mainstream consultants to provide a joint consultant clinic, therefore, were relatively easy to make. Finding ongoing funding for the clinic’s nurse, however, was not cost-neutral: it meant finding funding several sessions of nurse time which represented an additional cost to the department.


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Again, however, the relative power and influence of key stakeholders in Case D was crucial in finding finance for this from various other sources. One such source was the development of genetics tests, which provided an additional income stream for the trust. A strong, mutually beneficial relationship was thus forged between the clinical service and the hospital’s laboratory services: “One of the tests we’ve been setting up is linkage analysis where you need several family members for that test. The clinicians have been really helpful in trying to recruit family members to come and give a sample for a genetic test even if the family members might not be affected. [...] And we realise that they have limited clinic time to see these people, they might only see them once a year. So it’s a two-way thing that they realise we need them and we realise that they can’t just ring up and say come in next week and give your blood.” (Laboratory scientist, Case D) The academic connections of the service leads were also helpful, enabling them to part-fund the nurse post following the cessation of pilot funding through a clinical research centre, since samples from patients in the clinic were (subject to appropriate consent) also used for research purposes. Thus a combination of influence inside the organisation of the departments hosting and contributing to the service, and an ability to harness other sources of income deriving from the wider networks of influence enjoyed by the key stakeholders, were crucial to the strategy for sustainability in this case. Beyond the department itself, the service relied to a very limited extent on the endorsement of wider stakeholders. Its existence was largely invisible to GPs, for example, for whom referral procedures remained the same as ever; now, though, patients with possible inherited conditions and their families would be seen in a much more ordered, efficient manner. Case D’s service leads did, though, see some worth in seeking to publicise the reconfiguration they had led to other, specialist audiences, to seek to spread this way of working to other locations where it might be beneficial, to help the consolidation of their own service locally, and to ensure that demand for genetic testing in this area (which might directly benefit their trust as a provider of genetic tests) remained buoyant: “It’s quite important that we keep ourselves on the national map, because out of sight is very much out of mind in health care, who sees visibility at the national level as important. This is a good model and I think it’s useable elsewhere. This isn’t dependent on our personalities, this way of doing things. [...]The business plan needs to show added value, so what goes on in the rest of the country [is important]. We have provided at the moment I think probably what is a new, unique service. The other reason that I think nationally is important is the issue of genetic testing. [...] © Queen’s Printer and Controller of HMSO 2013. This work was produced by Martin et al under the terms of a commissioning contract issued by the Secretary of State for Health

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The specialist commissioners are then required to make available whatever the allele prevalence within their region’s worth money for the testing.” (Mainstream clinical specialist, Case D) Even though its position within the hospital and department was assured, then, there was ongoing work in Case D to consolidate further; while there was not the same direct reliance on external networks for sustainability, the contribution that this wider organisational and policy environment could make to the sustainability and spread of the new model meant that there was ongoing work to secure influence and change further afield.

4.5 Key themes The four ostensibly similar clinical genetics services studied show considerable differences in their early paths towards sustainability, reflecting their divergent contexts and processes. The most marked difference, perhaps, is between Cases B and D, where there were notable contrasts in the discursive approaches to sustainability (an extra, ‘advisory’ service providing added value to primary care practitioners, versus an ostensibly rational reorganisation of existing practices to provide core patient services more efficiently and effectively), in the audiences to whom these arguments were addressed, and in the degree to which they faced external dependencies in terms of resources and power. What is evident from the breadth of the cases, in terms of the changes they were seeking to embed and the contexts in which they were seeking to do this, is that there is no single path towards short-term sustainability; project leads had to account for their settings and frequently adapt their approaches through time in order to achieve ongoing funding and acceptance by wider stakeholders. Alongside this, though, there are a number of common themes that are evident across the case study sites. In varying ways and to differing degrees, there is a reliance on a network of wider stakeholders. The identities and roles of these stakeholders reflect the contexts in which the different services operate. In Case A the heavy reliance on patients and the public (as a means of putting forward the ‘patient-centred’ service and the public demand for it145,146), and engagement of GPs, reflects its primary care setting, while in Case C the main stakeholders to whom appeals were required were referring doctors and nurses in the network of cancer provision in the region. Echoing some of the key messages from the literature on implementation of new ways of working, then, our findings suggest that alignment with the expectations of others is crucial in sustainability too,22,24,26,33,41–43 and that a network of advocates and champions is important to the process of embedding and consolidation.5,7,22,24,42,58,59 Also evident, though is that existing, institutionalised power relationships must be central in structuring these networks. In the two cases not led by clinical geneticists (Cases A and B), buy-in from tertiary care clinical © Queen’s Printer and Controller of HMSO 2013. This work was produced by Martin et al under the terms of a commissioning contract issued by the Secretary of State for Health

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genetics departments as ‘sponsors’ of the service seemed crucial, providing credibility and a degree of clinical accountability without which the services would likely not have been viable. We see in the next chapter that a waning of this support seemed to undermine the case for further funding in Case B. Meanwhile in Case C, an initial lack of engagement with local commissioners created considerable difficulties for the service such that the decision to provide ongoing funding came at the last minute; though the networks of clinical support invoked were important in this ‘rescue’, the need to build networks and relationships with those in positions of power in relation to resource allocation decisions was also evident. It is telling, perhaps, that the project (Case D) with the leads in the greatest position of power in relation to both clinical and resource-allocation decisions, and the fewest external dependencies, seemed to rely to a much lesser extent on wider networks of support. We pick up some of these themes in chapter 6. First, however, in chapter 5, we resume the story of sustainability of the four cases, bringing them together in a more integrated account of their continued journeys towards sustainability, as these built on these initial steps and sought to consolidate their positions in a changing NHS.


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5 Embedding sustainability for the medium term and beyond We move on in this chapter to consider the ongoing sustainability of three of the services, and the factors that stopped the fourth from achieving this, in the medium-term period beyond the initial decision to re-fund services locally following the pilot period, covered in chapter 4. As we shall see, some of the challenges and opportunities that were important in the initial achievement of sustainability remained crucial concerns as the services sought to establish themselves for the longer term. However, a notable finding of our study is the way in which, for various reasons, the dynamics of sustainability shifted through time. Thus while there were some persistent themes in the services’ ‘sustainability journeys’, there were also significant shifts in the actors and debates surrounding them, and consequently to remain successful in sustaining themselves, services frequently needed to reframe or even reinvent themselves to appeal to the right audiences, criteria of success and policy agenda of the time. In contrast to the previous chapter, in this chapter we present an explicitly integrated, comparative analysis of the four services studied from the start. Having set out the forms taken by the services and their initial trajectories towards sustainability, it now makes sense to compare the relative success of these approaches, and the similarities and differences between the policies that each needed to pursue in seeking to ensure its longer-term survival in the contemporary NHS.

5.1 Evidencing services’ value As noted in passing in the previous chapter, providing clear evidence of worth, in terms of effectiveness and cost-effectiveness, was an impossible ambition for the services. The nature of the field of genetics, in which ‘upstream’ prevention or advice could not easily be understood in terms of longer-term savings to the health service or improvements to individual wellbeing (especially within a bounded health economy), meant that the case for each service was difficult to make in the purest, health-economic terms. It was also noted that the maximum of three years that each service had spent in its pilot phase was insufficient to provide much by way of evidence of throughput, estimates of cost per patient or quality and safety of the service provided. Such challenges continued to affect the four services as they moved beyond their pilot period with local funding. This seemed to reflect not just the specific challenges of evidencing the value of preventive genetics services, but also more generic issues likely to be faced by small-scale services of © Queen’s Printer and Controller of HMSO 2013. This work was produced by Martin et al under the terms of a commissioning contract issued by the Secretary of State for Health

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this nature. Relatively low levels of throughput combined, in a number of cases, with lack of managerial capacity to put together a clear evidence base for the services, and this caused ongoing challenges for Cases A, B and C. “Whilst they are collecting data, it’s difficult to demonstrate their value or the amount of money they’re saving because commissioners are looking for cost savings. So whilst they’re collecting data on number of people they’re seeing, times they’re seeing people and their demographics, it’s difficult to give a precise amount of money they’re saving.” (Macmillan regional manager, Case C) In the absence of such unambiguous cases for ongoing provision, then, staff in each case had to work with evidence of varying forms and levels of quality to put forward their case. Lack of ‘gold standard’ evidence was not, it was clear, an absolute impediment to sustainability (and it is worth noting here the limited extent to which evidence is influential in decisions and actions about adoption and sustainability, as noted in chapter 2), but it did mean that staff found themselves having to provide heterogeneous cases for ongoing funding to heterogeneous audiences. Cases A and C, for example, both drew on the accolades given to them during their pilot phase (a national award and status as the pilot with the greatest throughput respectively) in ongoing claims for funding, and such arguments seemed to hold some sway with commissioners and others involved in continuing funding decisions. ‘Softer’ forms of evidence, around issues such as patient satisfaction, also contributed significantly towards cases for ongoing funding: “We won a national award which also helped quite a lot. [...] So that helped as well, plus because we've done patient evaluations, I think the patient’s voice has quite a big say in what goes on as well. If we can prove that patients like the service and that the service has done them good, then I think, you know, that will create advocates for the service.” (Lead nurse, Case A) “There was a [...] national review of the services and [Case C] was at the top or was very near one of the top ones in the country and so certainly there was an element of, ‘Are you honestly going to consider decommissioning the day after a report comes out that says this is the best in the country?’, then we take a decision to say, ‘Oh no, no we don't want this’, so that, I think, probably played into some of our thinking about, well OK, there is insufficient information at this moment in time either way, therefore, the status quo is to keep funding the service until we can get that additional justification out of the service and then we can made a decision.” (Business manager, Case C)


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Crucial, then, was finding the right evidence for the right audience at the right time. If high-quality, research-based evidence could not be found immediately, then other resources could be drawn on, at least temporarily, to fill the gap and provide some short-term ‘breathing space’ for the services. Relatedly, a successful strategy deployed by staff in Cases A and C was to highlight the potential risks associated with withdrawal of funding for their services. As we saw in the previous chapter, in Case C, this was a question specifically asked by commissioners of the many ‘grey list’ services they were asked to fund which lacked cast-iron commissioning cases; in Case A, too, drawing attention to the negative consequences of removal of the service was an approach applied in ongoing deliberations with commissioners and the Professional Executive Committee within the PCT: “The key thing was highlighting the risks of withdrawing the service and trying to home in on that, just to make our case a bit stronger really. We had only had one person at that point that had been put in to early screening and they'd found a cancer. [...] And because we're not a huge town, it is quite big really, but we're not huge. The numbers weren't that big to have generated more at that stage.” (Commissioning manager, Case A) With the possible exception of Case D, furthermore, such cases had to be made to multiple constituencies. We saw in chapter 4 that a range of stakeholders needed to be engaged in discussions about sustainability, and the primary research carried out in this study added further to our understanding of the terms of these discussions and the stakeholders involved. Owing to the nature of the services and their focus on genetics, there was in some cases initial confusion about whether appeals should be made to local or regional specialist commissioners. Even once this had been resolved, however, it became apparent that making a business case to commissioners located in one or more PCT was only half of the challenge; additionally, a key task was to identify the ‘influential others’ whose support or otherwise would feed into these decisions, and to find the right arguments to appeal to these stakeholders. In Case A, for example, a crucial ongoing ‘champion’ for the service was a PCT director, who was able to articulate the case for the service in terms that would substitute effectively for the lack of a clear cost-effectiveness case: “My role was to scope out, number one, whether there was a need for it, which was interesting because defining a need for a genetic service wasn’t the easiest thing in the world, because research, if you'd squash empirical research or demographic data or programme budget data, you won't necessarily come to the conclusion that you need a genetic service. However it was definitely a population requirement for more support I think. Cancer services and cancer knowledge services, because they reach the demographic we have, and also because cancer and the © Queen’s Printer and Controller of HMSO 2013. This work was produced by Martin et al under the terms of a commissioning contract issued by the Secretary of State for Health

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mortality rates of cancer, we're nowhere near what we want them to be. [...] So I do tend to step in every now and again. I'm not suggesting I step in to protect it, but I think services like that that are not tariff-based services, they're not protected by patient flows and choice and all that sort of stuff and market forces. They do need a different level of support and leadership to bring it to the forefront of decision makers.” (PCT director, Case A) We consider the role of such ‘Networks of support’ in more detail later in this chapter. Services, then, needed to draw on diverse forms of evidence in order to make their cases effectively, and in Cases A and C, this seemed a key component of their ongoing funding. In Case B, however, it was clear that similar efforts were not so successful. In part, this was because the service delivery model—an advisory service for primary care practitioners to ensure that patients were managed appropriately in primary care or referred to geneticists if necessary—leant itself even less effectively to the kinds of arguments around throughput and cost-effectiveness than Cases A, C and D. Where the latter could provide facts and figures about numbers of patients seen, numbers of onward referrals and so on, the GPSI service in Case B could not readily offer this level of evidence, relying instead on broader figures for the entire PCT areas covered. “It’s very difficult to cost things in genetics isn’t it, because we’d looked at 40% of the referrals to the genetics department about possible familial cancer, were found to be low risk. So you could say that if we could educate GPs not to refer those 40%, then that would be a cost saving. But of course if you educate GPs they'll also pick up a lot of people who should have already been referred. It wasn't like saying well if I do this job I will do, I'll save you money because I can do 50 endoscopes wasn't it? [...] I like to have thought that, you know, several years down the line we could have looked at the impact on referrals and the appropriateness. We might not have cut the number, but I think we would have reduced the number of inappropriate referrals and that may not have saved money, but it would have been a safer system.” (GPSI, Case B) Beyond this, however, it was also evident that the wider arguments deploying ‘softer’ evidence did not hold the same sway in Case B as in the other sites. There was evidence of good satisfaction with the service and growing recognition of what it offered among local primary care practitioners, but ultimately this did not suffice as justification for sustaining the service beyond its initial six months of post-pilot funding. Thus, as in Case C, an initial decision about whether to re-fund the service on an ongoing basis was deferred pending evidence of its value and its importance to local GPs and other primary care practitioners:


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“In that particular year there was no clear decision taken because there were some intentions to hold back and reserve and fund a number of developments non-recurrently and then take another look at the situation as the following year progressed, because we knew there’s a clear requirement to find some funding or to terminate the service when the third year ended. There was an agreement made that there would be non-recurrently a six-month extension, during which period the service was to be communicated to the practices and the PBC groups and their view on the value of the service was then to be taken into consideration.” (PCT general manager, Case B) However, in the end, the decision not to re-fund the service appeared to come back to the lack of evidenceable throughput or output from the service: “They got slightly ahead of themselves thinking about quite a range of things they could do and so to a certain extent in discussion with them it was about keeping focus on one or two things that they could demonstrate that they’d delivered that would make a real difference, and I think they did do that, to be fair, particularly having the website going. But just doing that took such a lot of time that, in the end, it probably didn’t deliver enough to make it really something that must carry on.” (PCT former senior clinical manager, Case B) Ultimately, then, the failure of Case B to maintain its sustainability beyond the first six months post pilot was justified in terms of this lack of clear evidence of benefit: “it was almost a luxury that wasn't required,” as a senior manager in the PCT had it. But beyond this challenge of evidencing an advisory service that did not provide measurable throughput or outcomes, there were wider factors that appeared to impede medium-term sustainability here, which played out differently in the other sites, as we explore in more detail below. In Case D, meanwhile, the rather different organisational set-up meant a rather different role was required for evidence. As in the other sites, unambiguously proving effectiveness or cost-effectiveness in ‘gold-standard’ terms was difficult if not impossible to achieve. However, the key audience to which such arguments about the effectiveness of the service needed to be put here was internal, and this meant that the nature of the evidence required was somewhat different to that required in Cases A, B and C: “We’ve overcome a relatively large degree of scepticism about people viewing us as unnecessary but I think gradually we’ve changed the way people think, [...] purely based on delivering a good service that works, that the patients certainly enjoy, the outcome measures are good, diagnostic yield goes up and it’s not had the effects that I think some people predicted of taking out © Queen’s Printer and Controller of HMSO 2013. This work was produced by Martin et al under the terms of a commissioning contract issued by the Secretary of State for Health

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the key group of patients out of general medical clinics into a different clinic. So I think it’s worked on the basis that people can see that the clinic has worked.” (Consultant clinical geneticist, Case D) The key challenge here, then, in a service development that took place within, and was funded through the budget of, an existing mainstream clinical directorate of a hospital, was around ensuring fit with existing practices and demonstrating the quality and safety of the new mode of provision. Given this advantage, arguments about effectiveness, patient need and alternative forms of evidence of value took a lower profile than in other cases. The main battle to be won was about the feasibility of the service: if it could be shown to provide for a patient group in a way that made better use of resources than the incumbent alternative, this evidence of its worth sufficed: “The long term viability is very, very strong, it’s viewed as an essential service, the patients need to be seen by a [clinical specialist in the mainstream clinical area] and they need to be seen by a geneticist, so they either come to our clinic or they get pushed back into the existing clinics. [...] I think we’re probably pretty cost neutral for the trust, the activity we’re doing is probably no different to what would be happening in the clinic and we’re probably a little bit more economically efficient I would guess.” (Mainstream consultant clinical specialist, Case D) Of course, this necessitated other forms of persuasive and adaptive work, and we will consider some of these later on in the chapter.

5.2 Appealing to the right agenda in a shifting policy context In trying to craft evidence-based business cases for their ongoing funding using various forms of evidence, the services’ staff found themselves in a wider policy environment which did not seem as favourable to genetics service developments as that in which pilot funding had been offered. Across all four cases, stakeholders commented that a macro-level policy context that had (in the early 2000s) seemed positive for new provision to bring genetics and mainstream care closer together had been lost; consequently, earlier (and generally rather vague and aspirational) commitments offered at this time in support of original bids to provide ongoing funding beyond the pilot period did not hold. Cases A and C, with their cancer genetics provision, and Case D, integrated into the mainstream clinical directorate in which the service was provided, could tie into other agenda. In Case A, for example, the PCT which initially hosted the service was in the process of seeking to move the provision of a range of services away from acute care providers into the community, with a view both to providing care closer to home and to avoiding breaches of © Queen’s Printer and Controller of HMSO 2013. This work was produced by Martin et al under the terms of a commissioning contract issued by the Secretary of State for Health

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the 18-week waiting time limit, and as such Case A was held up as an example of this progressive movement: “It was already existing at the time that the 18-week programme was set up but it was probably only one of a couple of examples of a community based genetics service, so that’s why they were involved in the development of the eighteen week commissioning pathway because in order to deliver fast rapid care, you usually need to shift it out into the community. There needs to be a real change in the patient pathway and so [lead nurse] came along to the meetings [at the PCT] just to describe how that service had been developed and commissioned and the range of services it offers.” (GP, Case A) Meanwhile, the clinical leads in Case D could point to a range of similar developments in joint clinics for specialist patients that lent further support to the approach taken by their service: “I think the whole package is that we can very, very clearly argue that the whole patient experience is improved on this one and actually devoting a little bit more time to these patients works very well. And there are plenty of other models for that, I mean, specialist services for diabetes where there are multidisciplinary clinics, specialist services for genetic forms of cancer, where you have a lot of different specialist input, all tend to have measurable better outcomes across the board, not just patient satisfaction.” (Consultant clinical geneticist, Case D) Case B, on the other hand, seemed especially vulnerable to a shift in government focus away from the integration of genetics with other disciplines and with primary care. Here, it seemed, the lack of a clear set of ‘thou shalts’ from policy makers meant that the service was unable to command a great deal of interest from PCT managers, especially given its lack of measureable throughput, as discussed above: “The non-sustainability I just put down to political reasons really in the end, and in the end I mean whatever successive government brings in new ideas and really throws out the old ideas and genetics wasn't the priority any more. If it had been a priority we could have been flavour of the month.” (GPSI, Case B) “The money wasn't there, there wasn't identified any money, but I think there’s also that it wasn't priority for the Primary Care Trust, nobody had any targets to reach for genetics, there was no ‘must dos’ about genetics and so it was easy for it to slip down the radar. [...] The priorities were the national priorities to do with waiting times, with, cancer, for heart disease, for prevention, so there were quite a large number of priorities for any Primary Care Trust, we didn’t have unusual priorities other than the national priorities in health. And there were so many, there still © Queen’s Printer and Controller of HMSO 2013. This work was produced by Martin et al under the terms of a commissioning contract issued by the Secretary of State for Health

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are, but there were so many it’s quite hard to do anything other than to meet the priorities, perhaps.” (PCT former senior clinical manager, Case B) Given wider funding pressures as the NHS budget remained level in the face of growing demand, finding funding for what was perceived as a relatively ‘niche’ concern, and which was not required by central edict, proved too much for commissioners in Case B’s PCT. As a consultant clinical geneticist here acknowledged, although the service was a useful and worthwhile supplement to the work of specialist genetics provision from his point of view, “when we’re in a position where it’s not clear how we’re going to continue to provide what everybody would regard as core NHS services, then slightly unusual developments are much less easy to make” (Consultant clinical geneticist, Case B). The apparently strong support from clinical geneticists described in chapter 4, based on a clear division of labour between the clinical work of the tertiary centre and the advisory work of the GPSI, thus wavered through time. Ultimately, it seemed that a ‘cutting up’ of the territory between specialist and generalist that had served both parties well in the short term99 eventually cost the GPSI, who was left with the part of service provision that was seen as an ‘optional extra’ rather than a core clinical service.

5.3 Networks of support Given the lack of ‘top-down push’ for ongoing provision, what seemed all the more crucial for sustainability, in Case B and elsewhere, was a groundswell of ‘bottom-up pull’ for the services they were providing. We saw in the previous chapter how, in Cases A and C in particular, the networks of support for the services offered by, respectively, GPs, patients and the public, and secondary-care clinicians, seemed crucial in their initial re-funding post-pilot. In Case B, however, such a network had never been quite so well formed in the first place, and this absence seemed to continue, making the decision not to sustain the service more straightforward from the PCT’s point of view: “It would be a concern if we were failing our patients by not providing this particular service, but I haven't heard them shouting.” (PCT senior clinical manager, Case B) “The service was popular with a small set of practices and clinicians. [... The medical director of the PCT] probably had very limited awareness of its existence during the three years that it was in place. [...] There [might] have been a more active programme of canvassing and support and awareness raising which would have potentially resulted in a different decision.” (PCT general manager, Case B) A lack of policy push, and insufficient backing from the primary stakeholder group—GPs who might make use of the service—was compounded by a © Queen’s Printer and Controller of HMSO 2013. This work was produced by Martin et al under the terms of a commissioning contract issued by the Secretary of State for Health

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sense from the area’s tertiary care genetics service that, as noted above, the service was not essential to clinical genetics provision locally: “From our point of view if this was going to be sustainable it had to be not northern genetic service, because if it was going to be northern genetic service then that wasn’t the model that we would choose to operate. In other words if Primary Care chose to establish GPs with a special interest we would definitely work together – that was no problem at all, there wasn’t any question of that. However, we wouldn’t choose to employ GPs on a sessional basis to work as part of our genetic service, that didn’t make sense and it still doesn’t make sense.” (Consultant clinical geneticist and senior clinical manager of genetics centre, Case B) “I think what [the service] really needed to succeed, and perhaps didn’t have, would have been from this department a very strong sense of, ‘Yes, this is needed and we need to push the PCTs to continue funding this’.” (Consultant clinical geneticist, Case B) For those in the regional genetics service, a model like Case B, while useful, needed to be underpinned by support from primary care; it was not the model that those in the genetics service would themselves have chosen to improve links with primary care. Case B, then, seemed to suffer from the fact that it had broad support from a number of constituencies, but strong championing from none: it seemed to fall between the agenda of a number of stakeholder groups. In contrast, with Case D, as we have seen, such extensive networks of support were never so necessary. Here, the limited set of stakeholders to whom the service needed to appeal, and equally importantly the relative power of its two leads—both consultant physicians within the hospital— meant that the network of support was both readily accessible and relatively easy to influence. “[The consultant in the mainstream disease area] is the person who largely puts the case forward for continuing our service but I think the clinical director and the other consultants are beginning to appreciate that actually we are providing quite a valuable service here. It’s not unusual to be referred a patient from one of our colleagues for assessment and for a genetic assessment and consultation. If there’s any suspicion of a family history now, our consultants will refer them to us and [the two lead consultants] will put their heads together and see the patient, discuss the family history and you look at the more unusual genetic conditions which might apply.” (Nurse, Case D) Cases A and C, however, both relied to a much greater extent on various external constituencies to provide networks of support that were vital to their ongoing survival. In these cases, in contrast to Case B, service leads were able to gather significant and active support from a number of key © Queen’s Printer and Controller of HMSO 2013. This work was produced by Martin et al under the terms of a commissioning contract issued by the Secretary of State for Health

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stakeholder groups. Case A continued to garner significant support from general practitioners, clinical geneticists, and key champions within the PCT, as well as maintaining the strong public profile that had been helpful in its initial bid for ongoing funding post-pilot. Case C, meanwhile, maintained the support of a network of secondary care clinicians to ensure that the service remained at the front of the minds of those who relied on the service as a key link in the chain in the cancer-genetics care pathway. The role of these networks of support to Cases A and C was important in at least two ways. Firstly, on a substantive level, they helped to ensure that the services became an integral part of routine care pathways for genetics patients. Whereas in Case B, the nature of the service meant that it was inevitably something of an adjunct—an extra advisory service for GPs rather than an essential point of access to genetics provision—in Case A and especially Case C, the services were effectively embedded into the standard referral route for patients with suspected inherited cancers. Thus those at various points in the care pathway—from GPs through to specialists—were aware of, made use of and enforced a system of referrals in which the services provided by Cases A and C were a key node. As a gynaecologist who referred patients to and received referrals from Case C put it: “We’ve got an established service that everyone knows about, and the route for all these patients is through [Case C service], so there isn’t any gynaecologist messing around—in my view, that’s what I would have called it, they’d be messing around with patients who had been referred by their GP. Now these patients are all passed through [the service] before they come to gynaecology. So they may still come, but they come with expert information upfront about the risk and the options that they’ve got available. If they then choose risk-reducing surgery, then they’ve come through appropriately to the gynae service.” (Consultant gynaecological oncologist, Case C) In Case A, similarly, concerted and ongoing effort had gone into ensuring that local GPs were aware of the service and were now, increasingly, referring to it by default, rather than sending suspected cancer-genetic patients to secondary or tertiary care clinicians. This was reinforced with the help of the tertiary care genetics service, which would refuse direct referrals and instruct GPs to refer instead to Case A’s service. In both cases, then, the services were embedded within care pathways to such an extent that they could be portrayed to commissioners as a crucial part of provision. In Case C in particular, the service was presented as an indispensible part of the cancer care pathway, such that its decommissioning would result in significant problems for other services: “In the end [our case to the commissioners] was more, ‘If you don't fund this there's going to be a great black hole that no-one


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can pick up’. I think that’s how it was funded in the end.” (Lead nurse, Case C) “If it wasn't sustained then it still has to be done. It's not an additional service, it's the beginning of the, it's a step in a long process and so you can't get rid of it, but something has to replace it.” (Genetic counsellor, Case C) Presented in this way to commissioners, any decision other than to fund the service on an ongoing basis started to look inconceivable. Disrupting an established care pathway by removing a key part of it would cause substantial headaches, and even despite the lack of cast-iron evidence of cost-effectiveness described above, the anticipated cost of reorganising an entire care pathway would seem prohibitive. Though they had to make the case to a rather less predictable and more diffuse audience, the service leads in Case C in particular were able ultimately to make an argument that reflected that put forward in Case D: that this service was doing something that had to be done, in a way that was (probably) more effective and (probably) no more expensive than any alternative, and the transaction costs associated with decommissioning it and rebuilding the old, (probably) inferior way of working would be prohibitive. Secondly, however, on a rhetorical level, the service leads in Cases A and C were also able to draw on these networks of clinical supporters to provide direct endorsement of the case for ongoing funding. Again, this was especially notable in Case C. Here, a commissioner involved in decisions about funding for the service described the way in which the service drew directly on the testimony of clinicians involved in the care pathway to argue the case for sustaining the service: “The trust have used those experiences of peers and then got far more sophisticated. [...] They made sure that we had [information on the service] ahead of us, and then made much more active use of clinicians directly. So if there was an issue, they will get the clinician in, get the clinician to talk about the pressures and the issues rather than just the usual management faces, which is effective, because it allows you to have a proper dialogue and helps you understand.” (Business manager, Case C) Essentially, then, the service leads and the host trust in Case C drew on the endorsement of a wide range of clinical stakeholders in the service to make a case to commissioners that was difficult to reasonably refuse. Clinical opinion was a crucial resource in the quest for ongoing financing. Budgetary constraints and competing pressures from other, core NHS services meant that commissioners would only release purse strings reluctantly. However, by harnessing such clinical input, a case was made that took advantage of the knowledge asymmetry between expert clinicians and non-expert commissioners to make a clear case for ongoing funding:


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“We [commissioners] are expected to cover a vast area and to make decisions about investments, and no way can you be the expert on all of those areas. So something like this, it’s a good example because if we wanted to go somewhere and say ‘Genetic services, is it good value?’, well who would we go to? [...] So how we both clinically and managerially make these decisions—that sort of come home to me in a couple of areas—is that we are very much reliant upon the providers, and it is about giving time to commissioners to understand the problem.” (Commissioner, Case C) In Cases A and C, and in a different way in Case D, then, clinical networks of support for the service were a crucial part of ongoing sustainability— clinical networks that were notably lacking in Case B. Alongside clinical networks, the importance of managerial networks of support should not be overlooked. In Case D, alignment with the clinical director of the department in which the service was sustained was seen as crucial. In Case B, as we have seen, the service had limited managerial support from its PCT, especially given the lack of top-down compulsion around genetics services from central government, perceived limited uptake by local GPs, and the equivocal support offered by the regional genetics service. In Case C, located in an acute hospital trust but reliant on primary care-based commissioners for ongoing funding, certain managers were crucial. In particular, the input of trust business, planning and commissioning managers into constructing a business case for the service which appealed to policy and financial agenda—alongside the clinical case offered by the network of clinical supporters detailed above—seemed crucial to ongoing decisions to re-fund the service: “If we hadn't had a key helpful person from this trust [we might have faced difficulties]. So there was a relatively junior business planner who was [...] keen to do things, and I think that was key as well. So when you're negotiating through third parties, if you've got a relatively jellyfish-like third party, you haven't got a hope in hell. If you've got someone who's engaged, who's listening and helping, then that's much better. I would say that is absolutely fundamental to our sustainability.” (Consultant clinical geneticist, Case C) In Case A, hosted by a PCT, the role of managers in fitting the service in with a number of agenda—the strategies of the PCT itself, the interests of the PCT’s professional executive committee, and the priorities of commissioners—was also crucial. Following the split of the PCT into purchaser and provider arms, the service was divided from one of its key champions who moved into the opposite arm. However, it maintained links with a director-level manager who was instrumental in using managerial technologies to ensure the service’s alignment with a number of agenda important to these constituencies: © Queen’s Printer and Controller of HMSO 2013. This work was produced by Martin et al under the terms of a commissioning contract issued by the Secretary of State for Health

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“We use stakeholder mapping to and particularly people who have used the service of families of people who have used the service, as a means to determine the value that they attribute to the service. [...] It's almost like a balanced scorecard approach for stakeholders. So you ask a series of stakeholder tribes to give a view on the validity and the value of that service and then you balance all these, the output’s at the end a reasonable exercise. So you not just ask one group of people, you ask a whole range of different people.” (PCT director, Case A) Subsequent to the split of the PCT, Case A’s service was moved, along with other services in the PCT’s provider arm, into a new community services provider organisation, located within a local mental health care trust. Once again, however, it pursued and maintained links with a director-level stakeholder in the new organisation, this time a local GP and member of the trust’s board, who had previously championed the service within primary care, and who was now well positioned to support the service as it became a provider in a more open, competitive market: “Now that they’re within our organisation, what I think will happen, something that I'm taking forward through that organisation, that we have to nail—we have to sell the services. [...] Historically the previous provider organisation wasn’t keen on doing that. It’s not big bucks, it’s not a big bucks service, but [new host organisation is] aware that you don’t have to go after the big bucks all the time. If you can get several small-buck things working, then the assimilation of both savings and also funds from working them all together add up.” (GP and director of new host organisation, Case A) In Cases A, C and D, this combination of clinical and managerial networks of support ensured buy-in from, and appeal to, a crucial range of constituencies, the support of each of which was central to sustainability in a number of ways: the embedding of the services within the wider pathways of care to which they contributed, rhetorical support from clinicians whose views were implicitly or explicitly drawn upon in decisions about ongoing funding, and the substantive financial, organisational and clinical arguments put to formal decision makers for the sustaining of the services.

5.4 Leaders and champions Broad networks of support, then, seemed crucial to the sustainability of the services; within these, particular roles of key champions and leaders were especially prominent. In Chapter 4 we noted the particular leadership role, for example, of various actors distributed throughout the system in Case C, who worked to influence and garner support among diverse stakeholder groups. Also notable were the key forms of leadership that individual service leads and their colleagues needed to exercise in order to exert © Queen’s Printer and Controller of HMSO 2013. This work was produced by Martin et al under the terms of a commissioning contract issued by the Secretary of State for Health

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influence on those with formal and informal decision-making power: with the exception, perhaps, of Case D, the leads were in positions of comparative weakness relative to decision makers, and so needed to work carefully to enlist the support of others for their services. To some extent, such forms of leadership and distribution of leaders remained important as services sought to maintain the place they had won with their initial post-pilot funding. In Case A, service leads described the ongoing tenacity required to keep the service at the forefront of the minds of those responsible for its sustainability: “just being persistent, not giving in” (lead nurse, Case A). Similarly in Case C, the lead clinicians continued to tap into their networks to maintain allegiances and secure ongoing support for the ongoing existence of the service: “you need to continue networking, you need to continue building on your strengths, your links, your people out there” (lead nurse, Case C). However, also tangible was something of a shift in the nature of the leadership roles deployed in support of the services through time, as they moved on from having surmounted the initial challenge of post-pilot sustainability towards seeking instead to maintain this achievement. In Case C, for example, the consultant clinical geneticist who had developed the original bid, overseen the pilot and led the application to local commissioners for ongoing funding took a much more back-seat role after post-pilot funding had been secured: “Now that it's a sustained service I have almost no day-to-day role apart from to provide supervision when it's required. [...] What has happened as I've become busier and engaged in other projects of a similar nature, my leadership has changed and [lead nurse’s] leadership has grown. And I think the reason why this service has remained successful from say 6 months after we were, our contract was negotiated, has been [lead nurse], she's kind of developed the view that this is her service now and she has changed it to the way she wants it to be and she now owns it and she now leads it very well indeed. And she's a very sort of personable sort of person who can negotiate well with other people and has formed a tight network based on trust and friendship.” (Consultant clinical geneticist, Case C) In Case D, similarly, the assertive advocacy that was initially required to convince sceptics of the service’s worth, and fight battles over funding, clinical space and organisational fit, was replaced by a form of leadership that was arguably more transactional in nature, oriented towards maintenance rather than change: “It’s partly because it fills an important clinical need for patients with rare disorders. It’s partly because we’re—I, we, actually all of us now—quite passionate about it, and very committed. So if I’d said, ‘Oh sod it, I don’t care anymore’, this clinic wouldn’t be © Queen’s Printer and Controller of HMSO 2013. This work was produced by Martin et al under the terms of a commissioning contract issued by the Secretary of State for Health

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happening. [But now,] nobody’s preventing us from doing it [...] But again, that’s because we extracted patients who had a need to be seen, and just put them in a different format, which is what [the service] was designed for. So we weren’t trying to introduce anything unnecessary; we were trying to make better what needed to be done, and I believe that we’ve achieved that now.” (Mainstream consultant clinical specialist, Case D) There was, then, something of a shift in both the style of leadership required, and in some cases in the personnel called on to enact it, as services moved from the initial struggle to secure ongoing funding to the less active work of maintaining it. Crucially, however, these earlier leaders and forms of leadership became not redundant, but dormant. In Cases A, C and D, a ‘steady state’ of sustainability could not really be considered to have been achieved. Although cases for maintaining and re-funding the services had been made and accepted, as we see in the next section, ongoing organisational turbulence, and the provisional nature of the arrangements made to secure sustainability, meant that the services needed to remain adaptable in the way they presented themselves, the stakeholders to whom they appealed, the agenda with which they aligned, and the leaders and champions on whom they drew.

5.5 Temporary fixes, shifting contexts, new networks To varying degrees and in different ways, the shifting organisational contexts in which they existed impacted significantly on the sustainability of the services in Cases A, B and C. The organisational environment of Case D, sustained within the existing budget of a hospital department, meant that it was relatively insulated from such turbulence, though as we shall see later on, this did not quite mean that it could have been considered to have reached a ‘steady state’. We have already noted how a change in policy-level emphasis away from the mainstreaming of genetics reduced the willingness of PCT commissioning managers in Case B to find ongoing funding for the service. This was compounded by changes in PCT boundaries towards the end of the pilot phase of the service, which involved the merger of several formerly separate PCTs, and had two notable consequences. Firstly, a service which had previously been confined to the area of one, smaller PCT, was now potentially available to GPs across a much wider area. While on the face of it, this might have increased the viability of the service, in practice it left the service vulnerable to a view that it was inequitable in provision, since it was used disproportionately by GPs whose practices were within the original boundaries, and where most effort had been expended publicising the service and forging relationships: “it was based very much in [Area B1] and used by [B1] GPs, but not all [B1] GPs. And so it wasn’t available to GPs in [Area B2] or [Area B3]” (PCT senior clinical manager, Case B).


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Secondly, the shifts in boundaries, and wider changes in the form and function of PCTs, brought with them changes in personnel that impacted significantly on the service. Notably, it was removed from its PCT-based manager when the PCT split into purchaser and provider arms: as the manager described, “my job was much more out of that and in the commissioning side, so I had a slightly less direct involvement at that time, although because there was not really anyone else to do it, I did carry on to an extent” (PCT former senior clinical manager, Case B). Furthermore, the merger of the PCT with its neighbours resulted in a change of medical director, so that an original sponsor of the project (who had committed, at least on paper, to seek to maintain the service) was no longer in a position of influence. Case A faced similar challenges when its host PCT split into purchaser and provider arms, but as we have seen, although “the senior managers within the provider arm didn't have as much insight in to the service” (service manager), the service did retain a number of senior-level advocates in key positions who helped to ensure that it continued to meet the right agenda. Nevertheless, this change left the service in something of a state of “limbo” (GP, Case A), since it lacked managerial capacity to assist with further service development—including progress on plans to expand the service to meet demand in neighbouring PCT areas, something which had been anticipated from early on in the pilot phase. What efforts there had been to secure spread to neighbouring PCT areas has been abortive, since neighbouring commissioners had their own priorities which were not so well aligned with what the service offered: “We're tried embedding it at the cancer network so the other towns would pick it up, but each PCT has their own agenda. I know when the world class commissioning came out I know one out of our two neighbouring PCTs doesn't have cancer as one of their priority areas. And they've got a similar population and it's like, ‘How can you not have it as a priority?’” (Service manager, Case A) In the absence of work to spread coverage, the service in Case A risked appearing over-resourced, leaving it vulnerable to attempts to reduce its funding. In the event, however, commissioning arrangements remained in place over several years until, in 2011, it was transferred, with other services in the provider arm of the PCT, into a separate community health services provider organisation. Case C, too, faced some difficulties due to boundary changes. A merger of cancer networks meant that it offered a service to one part of the area but not the other, leaving it open to concerns about equitability similar to those expressed in Case B, but these did not translate into an issue at the level of the unit at which funding decisions were made—the PCT. Indeed, here, the inequity within the region was seen more as an opportunity than as a


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threat, since it might in future form the basis for a case for expansion of the service beyond its initial territory: “Within this region we have two different service models. One employed at secondary care and one at tertiary care. Different costs, broadly similar outcomes and that has never been questioned by commissioners. And it's about time it was. I don't think that [Case C] would be threatened by that kind of examination, because I think the overall conclusion would be well actually you get better value for money with a mainstream service than you do for a tertiary service. But I think that would be a difficult process. I think it should happen, but I think it will be difficult.” (Genetic counsellor, Case C) Regardless of this potential for wider expansion, what was clear in all cases where sustainability in some form had been achieved was that this was not a matter of the achievement a finished model of service delivery and finalised position within the care pathway. In all cases, sustainability was a work in progress, an ongoing project which required compromises and temporary fixes along the way. Even in Case D, where the path to acceptance by key decision makers and embedding in routine clinical practice had been rather simpler than in cases where a broader range of external stakeholders were influential, certain makeshift arrangements were necessary. For example, the post of the nurse co-ordinating the clinic was financed in part through research monies rather than through mainstream departmental service funding. Making these arrangements had not been difficult, since the service leads were research-active and the role included collecting samples for research purposes. However, this reliance on ‘softer’ money was an ongoing concern for the service leads, who continued to seek more permanent stream of funding from within their department: “We are slightly vulnerable inasmuch that certainly [service nurse], for example, is still dependent on [research] funding. [...] We’ve been quite lucky because of the existence of the [research institute] in providing greater flexibility than most other places would have had. But I think if I were going to do this again, I would want to take part in a project whereby it had already been envisaged that if projects really were successful, what strategies had been built into place to say if that works we will then ease you into a more sustainable for three years in the expectation that your trust will then pick it up.” (Mainstream consultant clinical specialist, Case D) The temporary fixes embraced by the services, and the changing organisational frames of reference that surrounded most of them, also meant that they found themselves on somewhat shifting sands in terms of the stakeholders with whom they had to engage, and the criteria of success © Queen’s Printer and Controller of HMSO 2013. This work was produced by Martin et al under the terms of a commissioning contract issued by the Secretary of State for Health

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by which they were being judged. Consequently the networks of support on which they relied for backing were themselves subject to change, and especially notable in Cases A and C were a steady expansion of the networks within which the services sought influence. In particular, with the advent of Clinical Commissioning Groups in which GPs and other primary care professionals would take a lead role in commissioning decisions, a key concern for leads in both cases was to ensure visibility among GPs and engagement with their interests. In chapter 4 we noted the particular reliance, in its initial case for sustainability following pilot funding, of Case A on a strong profile among the public. More latterly, the service shifted the focus of its engagement work towards GPs: “One thing I would say about service profile is it changed dramatically is when we first started in the pilot phase, it was very much self referrals that outweighed any professional referrals. Whereas now I would say that's reversed and self referrals probably come at the bottom of the referral rate and it's hospital and GP referrals that probably top. [...] We don't know in the new wide world when GPs do take over the bulk of the money, I don't know how GPs will feel about patients referring themselves in, because they're not going to have control of that budget. If they're doing self referrals into a service and I think that might come to a halt anyway that GPs won't want patients referring themselves, because they will want to know where their monies are going.” (Lead nurse, Case A) Similarly, in Case C, the emphasis on obtaining buy-in from a network of largely secondary-care clinicians which had dominated early efforts to build support was displaced by greater efforts to secure referrals from—and engagement with—primary care clinicians, given the expectation that in due course, they would form Clinical Commissioning Groups that would inherit the funding commitments of PCT-based commissioners who had so far agreed to fund the service: “Before it was set up, there was little connectivity between the genetics and the general practitioners; now they’re embedded in the GP practices, each and every GP practice in their geographical area are engaging and referring in to the service. They’re averaging, I think, well they’ve had several thousand referrals over a five-year period which, again, from one of the reports I read about it, they tell me that there is great connectivity between primary care professionals and acute where, in the past, it wasn't as solid.” (Macmillan regional manager, Case C) “I would say in all of the practices that there are certain GPs that are really really good, we get, across the board, our referrals come equally across the board, so there’s no sort of one area, one PCT that refer especially good, they’re all exactly the same © Queen’s Printer and Controller of HMSO 2013. This work was produced by Martin et al under the terms of a commissioning contract issued by the Secretary of State for Health

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and we did a piece of audit work which I presented recently in a conference, which looked at the, the, the degree of agreement between the initial risk from the referral letter and the final risk after the process, and we compared two time periods five years apart and we’ve found that the degree of agreement now is much much better than it used to be, and that must in part be, well in significant part I think, be due to the effects of education so people are starting to realise that some of these families are actually low risk. So they’re learning and they’re not referring those in.” (Consultant clinical geneticist, Case C) Even here, however, the services still faced shifting sands, and future uncertainties over whether prior work to engage the right constituencies was likely to remain essential given these changing networks of influence and support. In Case C, work by commissioners to address concerns about the financial implications of consultant-to-consultant referrals meant that the existing care pathway and network of clinical support, which had taken so long to develop over the course of the pilot and post-pilot period, now faced challenge: “One of the big-ticket agenda items that commissioners are discussing at the moment is the fact that sometimes we refer to other consultants in the trust and we would gain income on the back of that activity. So commissioners have a strong view that in certain cases when we've seen a patient perhaps we should refer them back to the GP for the GP to have a discussion as to whether the GP can handle that particular patient without referring in to secondary care, because there may be some other primary care services out there.” (Planning and commissioning manager, Case C) Ongoing organisational change, then, meant ongoing uncertainty not only around the question of how the services might be judged, but also what stakeholders and agenda to engage with in seeking to secure the best chance of ongoing sustainability, development and organisational fit. Crucial, then, was ongoing vigilance in the face of a volatile organisational landscape, and a chameleon-like ability to adjust to new stakeholders, new agenda, new policy frameworks. As an interviewee in Case A noted, this meant reflexivity and ongoing re-evaluation of worth for multiple stakeholder groups: “[What is needed is] evaluation and continuous development and improvement and the mistakes I've seen a lot of services make is that they try really, really hard to establish because they think there's a need to convince people there's a need to get funded they start seeing stakeholders, but then it stops. And they think, ‘Well that's good enough, once we've got off the line and we're established, that's all we need to do’. But it isn't, that's actually when it starts. And the difference, between the ones who've got © Queen’s Printer and Controller of HMSO 2013. This work was produced by Martin et al under the terms of a commissioning contract issued by the Secretary of State for Health

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longevity and value in comparison to those who get decommissioned and don't have perceived value, is all to do with how they set up to evaluate their outcomes and value and learn from that evaluation, pick up their weaknesses, develop their weaknesses into strengths and continue along that process.” (PCT director, Case A)

5.6 Biding time and seizing the day The three cases sustained into the medium term, then, found themselves in a somewhat ambiguous situation. They had been successful to date in achieving ongoing funding but, in varying degrees, had had to embrace compromises and temporary fixes which meant they fell short of the embeddedness and consolidation which, in some definitions,18 characterise real sustainability. In Case D, staff continued to look for opportunities to find a more permanent means of funding the nurse who co-ordinated the multidisciplinary clinics than the current, unsatisfactory, fix with soft money. Cases A and C, moreover, faced a paradoxical situation whereby the arrangements which had secured their immediate sustainability and helped to shield them from the vagaries of changing commissioner priorities and expectations now compromised their ability to adapt further in response to the changing environments they faced. Case A, for example, found itself in a situation where successive changes in organisational environment—as it moved from an integrated PCT, into that PCT’s provider arm, and then into a separate community health care services provider organisation—had meant that it had lacked sustained, stable and consistent input from managers. As noted above, a key to the service’s long-term survival, as far as its leads were concerned, was the ability to embed it beyond the PCT boundaries and spread the model to GPs in other, neighbouring PCT areas. With redundant clinical capacity within the service, it was necessary to find wider markets or risk being seen as unviable in the long run. The move into a separate provider trust, able to offer its services to a range of purchasers in an increasingly market-based PCT, seemed on the face of it, then, to bode well for Case A: “I know that the organisation that they’re now under is probably far more responsive than what they were under before. To allow for that. I think that there’s certainly capacity within the service to comfortably buffer a lot of changes.” (GP and director of new host organisation, Case A) Hitherto, the lack of management attention to the service on the part of the PCT, given more pressing concerns such as successive reorganisations and larger-scale service commissioning, had meant that the service had maintained a relatively low profile. As one interviewee commented, this had perhaps been something of an advantage for the service, allowing it an easier ride than it would endure once part of a more commercially minded © Queen’s Printer and Controller of HMSO 2013. This work was produced by Martin et al under the terms of a commissioning contract issued by the Secretary of State for Health

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provider operating in a competitive market: “when PCT providers were part of the PCT commissioner, there was more of a tendency to be able to protect the early development projects like this. But because all the community provider arms were taken out of PCTs, [...] they have to be more commercially minded” (PCT director, Case A). However, it had also meant that the service had never been exposed to the opportunities that might accompany such challenges. Thus the service leads yearned for the chance to put themselves forward as a ‘worthwhile risk’ for their provider; the alternative was becoming a forgotten service, lacking the opportunity to develop itself, and thus stagnating: “In the grand scheme of things we don't cost an awful lot of money but, and if they actually rolled our service out properly across the sector which would include [neighbouring PCT areas], we would actually be very cost effective. But it's whether that process will take place.” (Lead nurse, Case A) The move into the new community health care services provider organisation took place right in the middle of this study’s fieldwork period, and as such it is difficult to say whether it resulted in the desired shift in managerial disposition towards the service. However, follow-up interviews with the service leads suggested that in common with the PCT before it, the new trust found that it had rather more pressing issues to deal with around contracts and subcontracts for much larger-scale services covering higherprofile and more common clinical conditions, and consequently a scheduled review of Case A’s service had been postponed, in the first instance, for 12 months. In Case C, similarly, the decisions of commissioners had, paradoxically, simultaneously offered some security to the service, and risked stifling its further development. Block-funded by a consortium of PCTs rather than funded on a payment-by-results basis, the arrangement limited the risk to both commissioners and provider trust by fixing a (relatively small) sum to secure ongoing provision of the service. As a consequence, the service had been given a relatively quiet time by commissioners after the initial decision to provide ongoing funding post-pilot had been made: “The commissioners haven't pushed us down a very strict route of providing information activity on a monthly basis like we would do for some of the normal acute activity. So we've done very little really. [...] You could say it's a lack of interest by commissioners. It's probably also because it is funded on a block contract. If it was funded on a cost-per-family or a cost-per-patient-seen or that type of thing, obviously we would have to provide the information on a monthly basis, because we wouldn't get the money following the service. So I think probably because it's based on a block contract and probably because the service itself isn't screaming and saying actually we need more money because


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we've got too many referrals coming in, it's probably had less scrutiny.” (Planning and commissioning manger, Case C) Once again, however, this was something of a mixed blessing for the service. In purely financial terms, it had seen a rise in referrals which meant that an increase in activity had not been matched by an increase in income. This had been dealt with internally by changing roles and redistributing workloads within the team. On a longer-term basis, however, there was a sense that inattention on the part of commissioners risked, again, stagnation, and the possibility that the value of the service might be forgotten: “We've spoken to the lady in finance they don't see it being a problem. It's the same as anyone now, there's cuts everywhere. Because we're a very small service we, you know, there's a threat that we might be cut, but once again because we're a very small service and we don't cost very much and that's in our favour as well.” (Lead nurse, Case C) Given this inertia, the advent of Clinical Commissioning Groups was seen as a welcome development by Case C’s leads; and as we have seen, its staff were already seeking to engage proactively with GPs to ensure that the value of the service was well known. In all the sustained services, then, there was a sense that sustainability remained a live project; while they had made varying degrees of progress towards embedding themselves, and though stakeholders varied in their views of the extent to which the services’ future was secure, in no case could the sustainability which had been achieved be said to be a final, steady state. Rather, in each case, leads found that they had to bide their time and embrace opportunities to demonstrate their worth as they arose, even if these opportunities also constituted potential threats. However, there seemed a risk that as small services in an NHS undergoing big changes, they could find themselves marginal to the concerns of key decision makers. While this could be advantageous in the short term, in the longer term it could result in stagnation due not to complacency or inflexibility, but as a result of the uncertain dynamics of the wider environment in which they were vying for attention.

5.7 Implications for services The analysis above holds some important implications for those leading services seeking sustainability, and for those attempting to make reasonable judgements about resource allocation. Key notable points include:  Difficulties in generating high-quality evidence of effectiveness of the utility of services are not necessarily fatal to the prospects of new services of sustainability. A range of other arguments can be mobilised © Queen’s Printer and Controller of HMSO 2013. This work was produced by Martin et al under the terms of a commissioning contract issued by the Secretary of State for Health

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effectively to support sustainability. This presents an opportunity for the skilled service lead, and a set of challenges for commissioners and other decision makers, especially in situations of knowledge asymmetry. How are they to make fair and reasonable decisions in a resource-limited context between different services making incommensurable arguments about their worth? (See also section 6.5 below.)  Notwithstanding the above, service leads need to ensure that the aims of their services are aligned with wider agenda and priorities. Again, there is flexibility in the ways this can be accomplished, and the cases studied here aligned themselves variously with central government agenda and locally determined priorities and organisational discourses. However, leads need to be alert to the ‘shifting sands’ of these agenda, priorities and organisational structures, and ready to re-present or even reconfigure the focus of their services in order to maintain these alignments. (See also sections 6.1 and 6.2 below.)  Networks of support also seem crucial to sustainability, including connections with both managers and clinicians. At their most effective, these managerial and clinical networks are complementary, with a substantive place embedded in referral pathways underlying the rhetorical support of influential clinicians within those pathways, and this rhetorical support feeding into managerial decisions made about service provision—particularly, as noted above, where there are knowledge asymmetries between commissioners and providers. Again, this presents particular challenges for commissioners. (See also sections 6.3 and 6.4 below.)  Our analysis suggests that it is considerably more challenging to make a case for a project with less tangible outputs in the current NHS environment. Despite the point above about the range of alternative discursive strategies for making the case for sustainability beyond costeffectiveness, the story of Case B suggests that where a service innovation does not involve a measurable throughput of patients (and where it is no longer supported by alignment with wider priorities), making a case for its continued existence is very difficult. (See also sections 6.2 and 6.3 below.)  The findings covered in sections 5.5 and 5.6 above make it clear that sustainability is not a binary state, a threshold to be passed, a box to be ticked off once and for all. Rather, the progress of the cases towards sustainability constituted ongoing journeys, and the outcomes at the end were partial, provisional successes. As a PCT director in Case A put it, “the ones who've got longevity and value in comparison to those who get decommissioned and don't have perceived value, is all to do with how they set up to evaluate their outcomes and value and learn from that evaluation, pick up their weaknesses, develop their weaknesses into strengths and continue along that process.” Continued vigilance, learning and adaptation is required of service leads in a turbulent NHS environment.


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6 Discussion: key issues in sustainability In this chapter we continue and advance the analysis developed in Chapters 4 and 5 of the nature, challenges and facilitators of the sustainability of organisational innovation in the NHS. We pick up on key themes highlighted in earlier chapters, and note how these relate to, build on and conflict with existing knowledge from the limited literature on sustainability discussed in Chapter 2. We also return to the four key areas of importance noted in Chapter 2 to be of particular potential importance in efforts to secure sustainability of new services, drawing on our empirical findings to consider how these issues come into play in the sustainability process, their consequences for the nature of services sustained and of sustainability itself, and the implications of this for change and innovation in the NHS more broadly.

6.1 Sustainability in practice: key issues in medium-term sustainability Our findings suggest a number of confluences and some divergences with the more general literature on organisational change in health care services covered in chapter 2, which as noted is concentrated at the ‘front end’ of change, with little ‘downstream’ coverage of what happens later on in attempting to sustain change. In our secondary analysis of data from the earlier evaluation and the analysis of new data collected in the course of this project, we have a rich, longitudinal data set which covers a period of five-to-six years of the development of the four services studied. What our findings highlight in particular is that sustainability is a moving target, and part of a continuum rather than one option in a binary sustained-unsustained division. Others have pointed out that legitimate evolution in the way in which services are provided renders the idea of sustainability as a fixed state to be achieved unhelpful;18 our working definition of sustainability and approach to sampling explicitly took this into account. What our findings also show is, however, that several years down the line, services seem unlikely to be said to have ‘achieved’ sustainability and moved into a steady state where, as a part of routine service provision, they have moved beyond this question. Rather—and especially in a policy context which embraces more and more positively the dynamism, reinvention and innovation that are said to be produced by a more marketised system—sustainability remained an ongoing process rather than an achieved state. The four cases varied in the extent to which this was the case, in ways related, as we have seen, to the nature of the change, the context they found themselves in and the strategies pursued to achieve © Queen’s Printer and Controller of HMSO 2013. This work was produced by Martin et al under the terms of a commissioning contract issued by the Secretary of State for Health

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sustainability. They could be located at different points on the sustainability continuum. For some, sustainability was more of a ‘passive’ concern, needing only occasional review and action on the part of leads; for others, ongoing active work was needed, especially in turbulent organisational contexts. For all, though, there remained more or less pressing concerns about ongoing viability, changing stakeholders and criteria of success, and continued funding. In some ways, this might be understood as a positive feature of an NHS in which active work is undertaken to move beyond traditional, perhaps overly cosy, relationships between referrers, purchasers and providers to help new ways of working and innovative service models break into the market (see section 6.2 below). On the other hand, there were particular challenges for small, clinically led services of this kind that made the challenge remaining ‘above water’ more acute. Their relatively small size meant that they often lacked the managerial capacity, and a clear evidence base, to make their cases as strongly as possible, while their often boundary-crossing remit meant that they required the acquiescence of multiple groups of stakeholders, and had to appeal to changing criteria of value. Where discrete services (such as, for example, treatment centres) with a clearly defined patient group, an easily ‘segmentable’ care pathway and strong evidence of cost-effectiveness (or at least cost savings), the task of sustainability is perhaps more straightforward. A risk is that the joined-up, boundary-crossing nature of these services puts them at a disadvantage in a marketplace where tangible benefits and the ‘bottom line’ are central. Another is the risk of neglect and stagnation, discussed under section 5.6 above. To varying extents, many of the issues identified in the literature review as of potential relevance in the quest for sustainability also seem important from our empirical work. We considered the relatively marginal role of evidence in section 5.1 above,18,40 and return to the crucial discursive work around framing value and aligning stakeholders in section 6.5 below. Alignment with existing organisational arrangements22,24,26,33,41–43 was a crucial component in the success of Cases C and D in particular, and here we would highlight the connection between alignments with the substantive pattern of clinical work (referrals, organisational boundaries and so on), the networks of support among clinicians engaged in that work, and networks with management colleagues who were able to translate these clinical concerns into the language of resource allocation (see also section 6.3 below). As we made clear in section 5.3, these networks of support fed into each other, each supporting the other in the quest to gain buy-in from different groups of stakeholders. This kind of alignment seemed crucial to sustainability. However, alignments that served this purpose at one point in time could not be guaranteed to remain useful at a later date. This was most evident in Case B, where the convenient and mutually agreeable division of labour between the GPSI and the specialist geneticists described in chapter 4 © Queen’s Printer and Controller of HMSO 2013. This work was produced by Martin et al under the terms of a commissioning contract issued by the Secretary of State for Health

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became problematic for the service later on in chapter 5. Changing stakeholders and criteria of value changed this asset into a liability, and similar—though less extreme—challenges could be seen in Cases A and C. Here, the extensive networks of support built up early on, though not disadvantageous later, became rather less useful as organisational boundaries shifted, commissioning arrangements changed, and expectations about what the services could provide moved on. In Cases A and C, the ‘low profile’ that came with existing commissioning arrangements was both useful and potentially challenging, as it afforded them cover from the full scrutiny of commissioners and the full pressures of a more open market, while also limiting their ability to respond to change and develop their service models. Once again, changes through time meant that sustainability was a constant, but changing, challenge. Adaptability was paramount;32,42,46,47 planning important but limited in the face of such unknowns.23–27

6.2 Policy and changing organisational structures We noted in Chapter 2 that the shifting policy and organisational context of the NHS may have considerable consequences for the sustainability of clinically led, ‘bottom-up’ services such as our four case studies, and in Chapter 3 we highlighted that clinical genetics in particular has been subject to considerable shifts in policy emphasis, as well as nebulous commissioning arrangements that cause some ambiguity for new, ‘mainstreamed’, boundary-crossing services such as these. The four cases studied were affected by shifts in policy and organisational structures to differing degrees. At one end of the scale, Case D seemed relatively insulated from such turbulence, and was reliant to a much greater extent than the other three on internal rather than external politics. At the other end, stakeholders in Case B were quick to attribute much of the blame for the ultimate demise of the service on changing policy priorities, and in particular the reduced currency of clinical genetics after initial enthusiasm for the 2003 white paper had died down. The range of experiences across the four sites, however, suggests that there were multiple mediating factors beyond this less favourable policy context, and indeed Case C in particular was just as dependent on PCTbased commissioners as Case B. Certainly, what was notable in Case B was the fact that wider structural changes to the NHS seemed to result in a local organisational set-up that was less supportive of the GPSI service, with a change in managerial staff and the expansion of the territory covered by the PCT as discussed in Chapter 5 coinciding with a perceived lower prioritisation of genetics services at a national level: “When [the larger merged PCT] took over those responsibilities, first of all there was a big reduction in commissioning management capacity and secondly, a shift in priorities. The focus was very much on broader issues of the public health agenda, of © Queen’s Printer and Controller of HMSO 2013. This work was produced by Martin et al under the terms of a commissioning contract issued by the Secretary of State for Health

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secondary care contracting and the whole range of national targets, the set of performance indicators that were developed by the Labour Government which were deemed to be the principal focus of primary care commissioners of the PCT organisations. So there’s a shift in emphasis and a shift of focus.” (Regional specialist commissioner, Case B) The specific local realisation of nationally instigated changes, then, made a tangible difference to the way in which these impacted on service sustainability, as did the ability of service leads to adapt to these changes in the manner in which they framed their service. We highlighted in section 6.1 our finding that medium-term sustainability in our four case study sites could not be understood as a final, fixed state; the changing organisational context in which these services were being delivered augmented the extent to which reinvention and reframing was an ongoing necessity for survival. Where services were able to ‘piggyback’ onto wider, more prominent health care agenda, the marginality of clinical genetics to commissioners seemed less prominent. For several services, this had been a key means of increasing their visibility to key decision makers from the start.15 Case C’s successful engagement of the cancer network and alignment with concerns around the capacity of ‘mainstream’ cancer services to provide high-quality care represented a notable example of this, as did Case A’s successful alignment with its host PCT’s priorities around public health, prevention and health promotion. But as we have also seen, such strategies could be fragile in such a dynamic organisational environment. With the organisational changes that began with the split of PCTs into purchaser and provider arms, and is set to culminate in the delegation of commissioning decisions to Clinical Commissioning Groups, such strategic alignments started to become less straightforward, and Case A found itself more susceptible to shifts in commissioners’ priorities. As a GP commented, engaging these new groups and finding new alignments was likely to be crucial: “I think it would be a number of things [that might endanger the ongoing existence of the service], particularly one of two things. One of them is a lack of engagement with a client, which is two clients: the public and the commissioner, which is the clinical commissioner. So if they get that connection wrong it's going to fail. And the second thing that will make it fail is a lack of alignment or cohesion within the wider area which this service fits in to. So if they can't robustly describe the value this service would have on the whole of cancer care then the more likely the risk that this service won't be commissioned for the future.” (GP, Case A) Prior research has highlighted the way in which power and information asymmetries result in a continuing relationship of dependence between commissioners and providers.70,75,147 For small services such as these in a shifting commissioning environment, building functional relationships with © Queen’s Printer and Controller of HMSO 2013. This work was produced by Martin et al under the terms of a commissioning contract issued by the Secretary of State for Health

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commissioners would seem to be a crucial step—especially where (as with Cases A and B, but not Cases C or D) they exist outwith the domain of traditional, powerful providers of care and guardians of specialist expertise. In Case C, there was a sense that knowledge asymmetries worked to the advantage of the new service, enabling the critical mass of clinical expertise from secondary and tertiary care to act as a ‘technology of persuasion’ that made it difficult for primary care commissioners to do anything but fund the service (see section 5.3). For the primary care-based services, on the other hand, the relationship seemed to need to be more collaborative and negotiated. It will be interesting to see how the advent of Clinical Commissioning Groups, put forward in part as a means of overcoming the knowledge asymmetry in the commissioning process, will affect these relationships—though it is worth noting that this is not the first example of clinical involvement in the commissioning process, and that previous efforts such as the world-class commissioning initiative were seen as having been limited in their effect in improving the power of commissioners.75,147,148 In all, then, the dynamic policy and organisational context of the NHS proved an ambiguous backdrop for these services, offering opportunities and threats. What was clear above all, though, was that for small and new services like these, still without a foothold and often with a limited set of sponsors, leaders and advocates, responsiveness was key. Reorienting, realigning and reframing (see also section 6.5 below) could be the difference between a service which sank below the waterline and one which became increasingly buoyant.

6.3 The NHS professional context As we discussed in Chapter 2 (sections 2.2.1 and 2.2.2), the emphasis on quantification of activity and impact, as part of a more businesslike approach to NHS management, is increasingly a feature of the NHS commissioning and provision landscape and one which has been depicted as controlling professionals or provoking acts of resistance. However, in a contractual environment, where care is reimbursed mainly via tariffs and services are increasingly subject to pressure to provide evidence of costeffectiveness, the services we discuss were not subject to reimbursement by tariffs. From the point of view of sustainability beyond the pilots, it might therefore make sense for services to maintain a low profile, in a context where they are unable to demonstrate value for money. The lack of tariff reimbursement represented a double-edged sword which ensures income is guaranteed for the duration of the contract, but meant that any increases in activity did not attract additional income. An understanding of the contracting landscape and financial regime is evident in Case C. The comments below suggest that this is less a case of clinicians resisting scrutiny and control (as might be predicted from much of the ‘professions’ literature discussed in section 2.2.2), than of co-operation between clinician and manager and an active and ongoing participation in © Queen’s Printer and Controller of HMSO 2013. This work was produced by Martin et al under the terms of a commissioning contract issued by the Secretary of State for Health

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this process as a means of securing continued funding for the service. Furthermore, this co-operative approach to securing ongoing provision took place not just within the organisation that hosted the project in Case C, but across the commissioner-provider fault line: “If you went on open payment by results you could decide to really go for it and you could actually tap into whole new markets, generate lots of income for this trust. If a commissioning organisation can secure a block contract they’ll be able to ride the storm.” (Lead nurse, Case C) “I suppose it is both the blessing and a problem for the service, in that as a block it is a discrete amount that is clearly earmarked to a particular area and so it knows what it’s got to function on. That potentially though is a risk because someone new, and as we move into GP consortia and break things down again, you’re going to have people potentially sitting round the table who, again, won't know what the service, and they will say, ‘Hang on, we’re spending three hundred grand on that’. If the model was tariff based, that mitigates some of those kind of things but it again, sets up its own set of risks, in that particularly when you’ve got not a high-cost service, but particularly where you’ve got a situation where a patch may have no activity for one year and then next year it has quite a lot of activity and, therefore, the charge goes up and, again: ‘Well why, last year you did zero, why are you doing 100 this year, that’s not fair, how can we plan, how can we’. So in effect, I think the current block model is probably the best way of doing it.” (Business manager, Case C) “The key things have been to demonstrate activity levels which have slowly, slowly risen, despite the fixed funding. So you know, a way of demonstrating that they're getting good value for money, but also looking at the output, the outcome in terms of their success as a triage organisation. Looking at their, I suppose what we're trying to do is say this is just as effective now as it was five years ago during the peak of the project and it still provides value for money. It provides a service that no-one else can provide, it's cheap, it's about all those sorts of things. And really it's so embedded now in a number of different pathways that if you were to remove it now, it would cause a lot of problems actually. Which is no way to sell a service but we had to employ those tactics when we were negotiating the block contract in the first place.” (Consultant clinical geneticist, Case C) As the quotations above illustrate, embedding the service in an existing pathway was key to its success, in terms of initial funding beyond the pilot. Furthermore, this was not a matter of simply working with managers within the host organisation to develop a business case to ‘sell’ to the commissioning organisation: rather, it involved some negotiation and co© Queen’s Printer and Controller of HMSO 2013. This work was produced by Martin et al under the terms of a commissioning contract issued by the Secretary of State for Health

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operation with commissioners, especially in the primary care-based cases, reminding us of the way in which such interactions, even within an increasingly marketised NHS, cannot be reduced to simple principal-agent relationships.75,85 However, the clinical lead’s recognition of the need to demonstrate rising activity levels and outcomes in this case, as part of a process of securing funding, highlights an appreciation of the wider business environment, as well as a proactive approach. Whilst services may not be able to demonstrate the extent to which they are cost effective (see section 5.1), the fact that the service in Case B was GP led and provided little or no clinical input means that it was (likely to appear to be) relatively high in cost, and evidence of benefit was at best uncertain. “I find it hard to see how you could justify paying a GP to see genetics patients, when there were genetics counsellors doing the same job who were probably considerably cheaper so that, so I mean if there are GPs around still doing it, well, they’ve obviously managed to make a very good case for themselves, but we struggled to make a case for it really, I couldn’t see how it was of any benefit to the patient or, or cost effective. They [the PCT] never said that to us, that they wanted us to provide a clinical service, but if it’s the case, and I can see that maybe, maybe it is the case that they would have looked more seriously on us if we had actually been seeing patients.” (GPSI, Case B) The acknowledgement above that ‘seeing patients’ might be viewed more favourably than an advisory service was prompted by a specific question about that, and is in stark contrast to the quote above from Case C about demonstrating rising activity levels. These quotes highlight differences in attitudes and awareness in relation to quantification and the ‘businesslike’ contracting environment, but they also draw attention to the proactive nature of the clinical lead in Case C in contrast to the GP in Case B, who has no business manager support and limited experience not just in genetics (see below) but also in terms of business case requirements. “I think this is a problem with genetics generally actually, that there is a view that if you just devise big enough protocols and things then there is no need for a diagnostic process. Whatever’s cheapest! [That] will appeal to commissioners. As a society, we’ve drifted away from understanding the importance of experience. In terms of genetics [the GPSI] clearly wasn’t [experienced], she was learning about that, but she wasn’t very experienced in terms of primary care.” (Clinical geneticist, Case B) In contrast, and in keeping with the trend to transfer medical tasks to nonmedical clinicians, the service model in Cases A and C involved delegation to less costly nursing staff; Case D too was very reliant on nursing input. © Queen’s Printer and Controller of HMSO 2013. This work was produced by Martin et al under the terms of a commissioning contract issued by the Secretary of State for Health

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“The service is cheaper, if not as cheap to offer, so I mean you win all round. It’s not only more efficient, it’s better for the patient so it’s a bit of a no-brainer really. With any of these community services it’s important you get the clinical governance of them right so the people working in them are properly supported. [...] I think often nurses are better at that relationship with a patient than many doctors. I think they have time - rather than having quite a rushed outpatient appointment you can design a service like this so patients are given time to actually ask questions and if they think of questions at a later date they ring up and clarify them. It’s a much more patient-centred way of delivering care.” (PCT director, Case A) As the quote above (from a GP) illustrates, delegation to nurses is viewed as a positive development, as opposed to something encroaching on to medical territory. The depiction of nurses as better than doctors at the ‘softer’ relationship skills resonates with the literature on the gendered nature of health care work,149 which suggests that much less value is placed on nursing work compared with that undertaken by doctors. However, this characterisation also helped to facilitate the extension of nursing roles in this case (as in Cases C and D), albeit within relatively circumscribed boundaries that remain overseen by medical professionals.100 This participant, however, also went on to elaborate that not all nurses would be able to fulfil this role. This, then, is not a blanket acceptance or an endorsement based on abstract principles but, as might be expected, a favourable impression of the incumbent, which appeared to help to increase acceptance amongst medical professionals. “Competence and be self-motivated and have a pride in your work and [Case A nurse] certainly has got those. I think if you haven’t got that skill set you ain’t going to work in that sort of service really, so I suppose it’s a bit of a self-fulfilling prophecy that if you’re prepared to actually work and set something like that up, you’re going to have the skill set necessary to sustain it.” (GP, Case A) In Case D, nurse input was introduced into a context which was already characterised by a willingness to delegate medical tasks to nurses. “It’s an unusual one because it’s multi-disciplinary, but in [this clinical discipline] we’re quite used to – I mean, in terms of subspecialty interests – but in [this discipline] we’re used to multidisciplinary units because we have a lot of nurse practitioners looking after the needs of patients, and patients who are approaching [chronic care needs], so it’s not alien to think that you can have a multi-disciplinary service.” (Mainstream consultant clinical specialist, Case D)


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Taken together our data suggest a capacity for flexibility in role boundaries, which is not always apparent in published studies, which emphasise conflict and resistance in relation to changes in health services contexts.62 In relation to the quantification of service activity and related costs, clinicians are neither vehemently opposed to nor actively embracing tariff-based contracts. Rather than resisting tariffs as attempts to standardise and control clinical practice in Case C, as the quotations above highlight, clinicians perceived that tariff-based funding will be beneficial in some circumstances and not in others. An ability to read the landscape and a willingness to adapt accordingly thus appears to be influential in contributing to sustaining innovations. The fact that this is much less evident, or absent entirely, in Case B provides support for this interpretation. The willingness to keep an open mind on the issue of tariffs is likely to be facilitated by the fact that definitions of service are not being imposed or handed down by central or local commissioners. Rather, in a context where commissioners are somewhat distanced from the service (not just geographically removed, but in terms of their clinical expertise—cf. section 6.1 above), and where it represents a tiny proportion of their budget, any move to develop the substantive contents of cost per case contracts and contract currencies is likely to be informed primarily by the clinicians and local managers, as opposed to commissioners. On account of this knowledge asymmetry, commissioners then found themselves reliant on a dialogical rather than a confrontational relationship with providers; consequently a shrewd clinical lead such as Case C’s was able to forge strategic relationships with managers which are productive for all and advantageous for the sustainability of the service. Part of this flexibility and willingness to recognise constraints on funding is also evident in relation to nursing roles. Where possible, services have been developed to allow for task delegation to lower cost staff in Cases A, C and D. In Case D, for example, funding was secured for a full-time research nurse to enable the service continue. The fact that the additional nurse component of the service was not funded as part of the existing tariff and the time limited basis of this resource meant that various options for future funding were being considered. In contrast to the depiction of services at site B as being at the mercy of the commissioners, here once again the active engagement of clinicians in securing this funding appears to have been instrumental to its survival thus far. A further factor which appears to have contributed to sustainability relates to clinicians’ willingness to take on broader management (i.e. non-clinical) tasks in relation to service development. Furthermore, although we undertook only a small number of interviews with non-clinical managers, there is clear evidence that clinicians and managers working together contributed to the success of the service in Case C in terms of its ability to secure funding to date, echoing some findings from elsewhere.109 Our data suggest that discussions of service change and sustainability which © Queen’s Printer and Controller of HMSO 2013. This work was produced by Martin et al under the terms of a commissioning contract issued by the Secretary of State for Health

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emphasise tension and conflict may understate the extent to which local clinicians and managers co-operate, including across organisational boundaries. Furthermore, our findings also illustrate that rather than disputing the rules of the game (in terms of the requirements to secure funding, to compete with other priorities, to present a business case and so on), clinicians are active players who understand those rules and try, for the most part, to comply with them wherever possible in order to further their objectives. All in all, then, our findings mirror some of the more recent literature in the sociology of professions, which has moved from analyses framed in terms of conflict and professional conservatism towards a recognition of the ways in which clinical professionals strategically interact with the wider governance frameworks of management and the market.106 Success in sustaining clinically led innovation appears to rest on an ability to understand, negotiate and occasionally bend the rules of the game, rather than refusing to play altogether.

6.4 Leadership In section 2.2.3, we proposed an ideal model of the trajectory for leadership in which individualised leadership required in mandated service changes is progressively displaced through time by a more distributed form of leadership required in order to ensure fit with existing systems in a more emergent way. In several of the case study sites, however, empirical reality did not reflect this model. As we consider the variation in trajectory and effect of leadership in our four case study sites, the importance of contingent factors that frame leadership, particularly professional hierarchy, becomes apparent. Interestingly, our analysis also suggests that some health care professionals and managers were willingly but subtly co-opted into leadership roles associated with innovation, as leadership was distributed, and that this process was important to sustainability in Cases A and C in particular. Our study shows contrasting leadership trajectories for each case, where some apparently move from individualistic leadership to emergence of larger-scale distributed leadership as predicted by our model, whilst others reveal more concentrated leadership, perhaps in a more strategic collective. Meanwhile, we also note some failure to distribute leadership. In Case A, then, there was a significant degree of distributed leadership right from the start, owing perhaps to the nature of the service innovation in this site. As a project that took place in primary care, it required buy-in from a wide range of stakeholders from the PCT, local GPs as well as the acquiescence of the area’s tertiary care genetics service. In Case B, by contrast, there was little distributed leadership throughout the course of the period following the pilot, despite the best efforts of the stakeholders involved. The GPSI remained the sole champion throughout, failing to © Queen’s Printer and Controller of HMSO 2013. This work was produced by Martin et al under the terms of a commissioning contract issued by the Secretary of State for Health

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achieve significant buy-in from the PCT and securing only wavering support from the genetics centre. Distribution of leadership in this case seemed necessary—again, given the relationships of dependency in terms of funding and referrals that exist in primary care—but was not achieved. The hospital-based setting of Case D, by contrast, meant that leadership here was largely individualised from the start, and remained so without causing problems for the sustainability of the service. There were occasions on which the two leads of the project needed more broad-based buy-in from clinical directors and other resource managers to ensure continuation, but in the main, leadership could remain unproblematically located with the two servvice leads without difficulty for the service. As one put it: “It’s a wheel and I suppose I’m somewhere near the middle; I think of it as my clinic. Maybe that’s too autocratic, I don’t know, but I also recognise that I’ve got a team, that I couldn’t do it without those people, and I’m quite careful to include them in everything.” (Mainstream consultant clinical specialist, Case D) Of the four cases, Case C followed a sustainability trajectory most closely aligned to the model put forward in chapter 2, owing to the nature of the service. As one of the two projects that involved the implementation (with adaptation and flexibility) of a relatively clearly set out, evidence-based model (see table 2), initial leadership was relatively top-down and individualised. However, at a very early stage this developed into a more pluralistic model of leadership in which, as in Case A, distribution to other stakeholders was important. In both cases A and C, the shifting nature of the groups of stakeholders to be engaged and the criteria by which the services were judged (see chapter 5) necessitated further distribution to wider leaders. Overall, then, this suggests perhaps that while the model intimated in chapter 2 may represent a viable means of widening the range of actors who can influence change,112 it is heavily mediated by wider aspects of the innovation being sustained and the wider health care context. Several of these factors are noted elsewhere in this chapter, but it is worth drawing attention in this section to some of the particular issues that seem to facilitate or impede the viability of distributing leadership, and to influence the manner in which it is realised. Most notable in Case B was the failure to distribute leadership beyond the GPSI who led this innovation. In part, this seemed due to the primary care context in which this service operated, which—as noted in relation to Cases A and C—necessitated a complicated web of networks for sustainability, to a tangibly greater extent than in hospital-based settings. Chapters 4 and 5 documented the difficulties faced by the GPSI in engaging PCT managers in leadership roles, and in garnering more than subdued support through time from specialist geneticists. Her position in the inter-professional hierarchy as a general practitioner, then, seemed to present a severe impediment to © Queen’s Printer and Controller of HMSO 2013. This work was produced by Martin et al under the terms of a commissioning contract issued by the Secretary of State for Health

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the distribution of leadership, mirroring some academic critiques which suggest that the professional institution is an under-acknowledged mediator in normative prescriptions for more distributed leadership.112 However, the success of distribution in Case A—led by a nurse whose position in the interprofessional hierarchy would normally be seen as less advantageous than that of the GP—suggests that other factors are also at play here. Both the nature of the innovation and the degree to which it had, from the start, played into existing organisational agenda thus seemed crucial in facilitating leadership’s distribution in Case A and impeding it in Case B. Whereas in Case A, there was buy-in (or at least acquiescence) from the start across a range of stakeholders in primary and tertiary care, forming the basis for the distribution of leadership, this could not be said to be the case in Case B, where there had been at best lukewarm support: “I think that were some of us who felt—myself included—that this was something which was important to explore because there was a possibility that there might be something interesting in there. I don’t think there was anyone who absolutely felt we have to go this way. I think there were a number of my colleagues who felt that this was never going to work and was never a viable way forward.” (Former senior clinical manager, genetics centre, Case B) This has some important implications for the model of leadership advocated for sustainability based on the literature in chapter 2. In particular, it suggests that—in the absence of absolute mandation from above to ‘force through’ the embedding of an innovation—the notion that individualised leadership can feasibly develop through time into more widely distributed leadership as needed is flawed. In Case A and especially Case C, networks of support were invoked at a relatively early stage, so that even when the formal clinical processes and position in wider referral and financing systems was still being developed by key individual leaders, the wider stakeholders to whom leadership was to be distributed through time were already being groomed for the role, engaged in the advantages of the service and co-opted towards joint aims. While there may not have been an explicit strategy to involve these stakeholders at this early stage, there was ongoing work that meant that these services were seen as viable and desirable in a way that Case B, as evidenced by our findings, never was. While a model of a progressive shift from individualised towards distributed leadership may seem viable—and may appear, on the service, to reflect the development of leadership responsibilities through time as initial implementation is replaced by medium-term embedding—it seems unlikely to work in complex systems such as the NHS, where power is distributed among multiple actors, the engagement of all of whom is necessary to longer-term success. In short, the distribution of leadership to a variety of stakeholders in key strategic positions seems necessary at an earlier, rather than a later, stage in the trajectory of innovations towards sustainability.


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Early engagement of potential leaders, then, seems crucial, but so too does a breadth of distribution that allows adaptation to changing circumstances, organisational parameters and criteria of evaluation—except where, as in Case D, sustainability can be achieved within a relatively closed system where the influential stakeholders are known, engaged and relatively static. Through time, organisational change affected Cases A, B and C, and again seemed to be costly to the sustainability prospects of Case B (see sections 6.1 and 6.2 above). The breadth of interests and network of stakeholders engaged as distributed leaders in Case A proved crucial, as GPs who had previously engaged on a clinical basis (as referrers or more informal ‘champions’ of the service among their peers) started to take a leading place in new commissioning and providing organisations set to take central roles following current NHS reforms. Again, this seemed more a matter of serendipity rather than careful strategic planning, but it nevertheless points towards the merit of a breadth of leaders with appeal to different constituencies, whose roles can potentially develop through time. Arguably, the expansion of the role of these leaders took place by stealth, as initially referring and clinical contributions to the service mutated into more formal, managerial roles as advocates and representatives at a strategic level within their organisations. If not an unwilling transition in roles, then certainly this was a noticeable one for these leaders, notable from the way in which one of the GPs in Case A describes his changing involvement, from initial clinical support to representation in resource allocation decisions as a commissioner: “I did have some very early involvement in the development of the service. […] So I certainly was supportive right at the start of the development of seeing this as a service that was embedded locally within [Area A]. [… Now] I think we need to be more understanding as commissioners as to what we really get out of a service and so we need sort of to look at a more outcome driven method of commissioning that's not just about an outcome of how many we see. You know – because if you were to take that approach you would probably say, ‘This could well be an at-risk service’. We might have to tweak it so it fits in with the vision and it fits in with the financial aspects.” (GP and locality commissioning lead, Case A) A process whereby actors were subtly ‘co-opted’ or ‘transformed’ into distributed leaders, then, was noticeable in Cases A and C in particular, where a network of clinically or managerially engaged stakeholders was developed into a distributed body of advocates and leaders whose work on behalf of the services seemed crucial to their survival, embedding and further extension. Our comparative cases show leadership trajectories that in varying degrees diverge from the ideal model. In sum, drawing upon our empirical analysis, we explain this as follows. First, we see that distributed leadership is © Queen’s Printer and Controller of HMSO 2013. This work was produced by Martin et al under the terms of a commissioning contract issued by the Secretary of State for Health

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mediated by the effects of professional hierarchy. Leadership initiatives in healthcare commonly encompass attempts to re-stratify the workforce, and create new professional elites, a move which may be subject to contestation.140 Those leading service change cases were in some cases decoupled from wider clinical work and professional arrangements, and also (in Case B) from managerial arrangements. As Gosling et al. suggest, distributed leadership evokes an aspiration about the way leadership should be configured, and draws attention to iterative relations between leadership, followership and context.150 But it is a conception of leadership that requires unpacking, especially in terms of its empirical manifestation. Our empirical analysis shows how professional power and hierarchy, fractures between organisations and professions and the nature of the innovation to be sustained mediates the ‘ideal’ leadership trajectory prescribed in more normative literature.112 Second, we cannot ignore, in what arguably continues to be a centralised health care system in England, the influence of performance and economic regimes of control upon leadership. As noted in section 6.2 above, the most noticeable effect of this was upon engagement of PCTs, which were expected to sustain funding following cessation of pilots. Distribution of leadership outwards from the core leadership team at inception of the pilot to PCT commissioners was crucial to sustaining innovation, and through time further wider changes necessitated engagement with other organisational actors, too. Third, the role and contribution of individuals as continuing sources of organisational influence within a distributed framework, has not been adequately clarified in the literature to date.120 The current high profile accorded to distributed leadership runs a risk of replacing one longstanding pattern in leadership, focused on individualism, with a polar opposite. However, commentators argue that leadership configurations fuse different degrees of focused and distributed tendencies.150–153 Indeed Bolden et al’s research, though carried out in higher education, may represent a more accurate description of situated leadership practice that includes both individual leadership and collective leadership working in tandem, rather than instead of one another or in linear sequence.151,152 They note that, in a professional bureaucracy such as a health care organisation, pressures for top-down influence in times of change exist in dynamic tension with traditional values associated with professional collegiality and hierarchy.151 Our analysis highlights that some sources of influence carry more weight than others, and are anchored in different sets of resources, such as managerial accountability upwards as the senior lead, or influence as an equal among a network of professional peers, or lateral but formally mandated roles in positions of influence in stakeholder organisations in the commissioner-provider nexus. Finally, individual leaders also work to bring their followers into taking on the mantle of leadership. This does not appear to be a process of unwilling © Queen’s Printer and Controller of HMSO 2013. This work was produced by Martin et al under the terms of a commissioning contract issued by the Secretary of State for Health

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co-optation, but in some cases it did involve an evolution of roles into ones that carried increasing importance in terms of their leadership function. This chimes to some extent with analyses that focus less on what leadership is, and more on what it does, and how change initiatives impact upon the roles and even identities of public service professionals.154 In particular, such initiatives may have a co-constructive effect, whereby individual professionals, perhaps involuntarily and to some extent unwittingly, become governed at a distance through their enactment of leadership roles, and more likely to acquiesce to such changes.

6.5 Discourse and framing As discussed in chapter 2, central to efforts to secure (or resist) organisational change is discursive work oriented towards the establishment of particular ways of framing reality, likely to favour a desired set of changes or the maintenance of changes already achieved. Our empirical cases offer contrasting examples of the micro-level ‘institutional work’ that constitutes such framing strategies, which had varying degrees of success. In common, the four cases faced a powerful predominant discourse around the need for cost-effectiveness and efficiency which, as discussed in chapters 3, 4 and 5, to differing extents did not strongly favour the kind of preventive, relatively low-volume work they were carrying out. However, there were noticeable contrasts in the way in which the four case study projects responded to this challenge by framing themselves differently, in the degree to which the contexts in which they worked supported them in this endeavour, and in the extent to which stakeholders directly involved in the projects were able to influence wider stakeholders to create strategic networks that would be more receptive to these alternative framings. In Case D, this was a relatively straightforward process. As in the other cases, there was no gold standard evidence of the greater clinical effectiveness of the new approach to service delivery, but the service leads were able to articulate and evidence ideas about the more patient-centred nature of the service they provided, and the greater clinical quality that resulted from this: “One of the initial observations that we certainly did make was that even patients who came from the general clinic to our clinic, a lot of them were inadequately treated, certainly in terms of blood pressure, before they came, and that’s dramatically improved, so I think the whole package is that we can very, very clearly argue that the whole patient experience is improved on this one and actually devoting a little bit more time to these patients works very well.” (Consultant clinical geneticist, Case D) In a position of relative authority within their departments, and with only their immediate clinical peers to convince of the worth of the new service model, since this was a matter of internal service reorganisation rather than © Queen’s Printer and Controller of HMSO 2013. This work was produced by Martin et al under the terms of a commissioning contract issued by the Secretary of State for Health

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something to be commissioned by external commissioners, the consultants leading this project were able to mobilise a discourse of ‘clinical quality’ that differed significantly from criteria of cost-effectiveness or efficiency by which others might seek to judge the service. Given the minimal apparent extra expenditure required to make the service viable (since it largely involved reallocation of existing resources rather than requiring investment in new resources), such a framing seemed sufficient to convince this audience of the worth of the new service: “We extracted patients who had a need to be seen, and just put them in a different format, which is I think what the thing was designed for. So we weren’t trying to introduce anything unnecessary; we were trying to make better what needed to be done, and I believe that we’ve achieved that. [...] The amount of information and empowerment that we can give patients, I would use as a big selling point. I think they get a better level of service than they have had before and I think that’s worth sustaining.” (Consultant mainstream clinical specialist, Case D) Here, then, ‘clinical quality’ proved an effective ‘vehicle’ for putting forward the case for the service to peers who clearly recognised the legitimacy of such an ambition—at least in a context where it posed minimal threat to them both in terms of their professional jurisdictions and resource allocation. In other cases, too, the discourse of clinical quality was mobilised in pursuit of sustainability. Core stakeholders in Case A, for example, were conscious from the start of the fact that “our service is not good from a numbercrunching point of view” (service manager, Case A), and that this gave rise to a fundamental mismatch with discourses of cost-effectiveness, economic value and efficiency. However, here a number of wider discourses were mobilised which—though perhaps lacking the clout of an unambiguous case of cost-effectiveness—nevertheless had some sway with key stakeholders in the wider health economy. Thus those involved with the service aligned it with a wider shift towards community-based services ‘closer to home’ that were seen as a key part of the local PCT’s (and the national government’s) strategy for health care provision. They also emphasised the quality of provision provided by the service, harnessing patient surveys that showed high levels of satisfaction with the service, and drawing on the input of involved patients to communicate the benefits of the service to commissioners and other wider stakeholders and thereby give life to a notion of ‘clinical quality’ that clearly displayed the service in a good light: “The two patient users always came with us [to launch events] and presented as well, and no matter what we said about the benefits of a family history service, having two patients there telling their story—if they spoke first there was no point in us even getting up, we felt, at some points!” (Service manager, Case A) © Queen’s Printer and Controller of HMSO 2013. This work was produced by Martin et al under the terms of a commissioning contract issued by the Secretary of State for Health

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Alongside this, as we saw in chapter 4, the service leads devoted considerable effort to publicising the service to a wider audience. Overall then, a combination of these framing activities whereby actors continually “pushed to keep a high profile” (lead nurse) and were “just being a bit persistent” (service manager) ensured that the public and key professional stakeholders understood the benefits of the pilot (constructed in terms of this particular articulation of ‘clinical quality’ which reflected well on the service), serving to create a normative network of support to construct a ‘need’ for the service, and were key in securing initial immediate post-pilot funding for continuation from the host PCT. As we saw in chapter 5, the service subsequently moved into a community health care services provider organisation. Though our data on this new arrangement come from an early stage in the move, there were signs that this discourse of clinical quality aligned well with ideas that were already prominent within this organisation, perhaps to a greater extent than in the former PCT host (even if we allow for the hyperbole in this excerpt from the following participant, a director of the trust): “It’s an amazing organisation to work for because compared to a lot of other trusts they’re very much driven by patient care and quality….. So I'm really, really keen that we try and expand this service across other PCTs, franchising it out maybe.” (GP and director of new host organisation, Case A) Whether such an ethos could translate in the long term into a viable business strategy for this new organisation is perhaps moot, but in the short term, at least, it boded well for the service as the discourse of clinical quality around which it had sought to articulate itself seemed to align well with that of those who now had managerial responsibility for it. In Case C, the network of stakeholders to whom discourses about the worth of the service needed to be directed was more complicated than in Case A, and thus the strategy for framing more variegated, though once again it depended at its heart on articulating a notion of clinical quality that would present the activity of the service in a positive light. To a greater extent than in Case C, though, the heterogeneity of the network of clinical actors who had a stake in the service (as potential referrers or receivers of patients, and as those who had provided services that covered similar clinical territory and which might therefore have perceived themselves as competitors) meant that a good deal of more active engagement and ‘meaning making’ work was required here. Thus, when engaging clinicians within the network, it was not only important to be able to identify a ‘route in’ to the ‘right people’ through existing contacts, but also to speak the right language and frame the pilot in ways that aligned with their interests. The lead clinician on Case C referred to this as a process of “farming,” in which constant re-education and profile raising were crucial, coupled with creative framing depending upon the nature and language of the particular professional audience: © Queen’s Printer and Controller of HMSO 2013. This work was produced by Martin et al under the terms of a commissioning contract issued by the Secretary of State for Health

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“I mean there are obviously numerous ways of doing this, and you needed to choose a technique which works for that particular audience.” (Lead clinician, Case C) So, for example, in terms of gaining the support of secondary care clinicians, the lead clinician and nurse described how the support of mainstream consultants as ‘champions’ had been crucial to the sustainability of the pilot. Here, framing the pilot in terms of a discourse of ‘clinical quality’ was effective and persuasive, centred on appropriateness of referrals and the problems associated with not identifying at risk patients, and conversely, screening those not at risk. However, it was also important that this framing was intra-professional, delivered by a fellow consultant – the clinical geneticist – and that he was able to frame this within the language of ‘audit’ with which consultants were familiar, and thus presenting evidence of value in terms of ‘facts and figures’: “How did we do it? Well interestingly through audit, so we did some collaborative audit and we demonstrated the, the, the benefit of introducing a service like this, so effectively we just spoke in their terms, we presented data that they would understand, because they like audit and things, and it was incontrovertible, they settled after that […] and I think that doing sort of facts and audit is probably quite a good way to change a clinician’s or surgeon’s behaviour.” (Lead clinician, Case C) This strategy for alignment met with success, as reflected by the endorsements of a number of consultants within the network who identified the improvement in referral practices for patient benefit: “It’s a phenomenal improvement, and it’s something really close to my heart. Now I no longer think of it, but previously I used to worry that there were patients out there that were being inappropriately managed. Decisions were being made by people that weren’t, in my view, practising appropriately. The expertise was lacking in primary care, big time, and lacking in general gynaecology big time – and that, in my mind, is now gone.” (Consultant gynaecological oncologist, Case C) “It was a very patchy approach. And I think that’s one of the reasons I linked up with the genetics unit to try and unify that so that all patients were getting a very consistent approach. A lot of people were not getting the right test at the right interval. And we published on that. And we demonstrated and it's quite clear from when we did that audit that, you know, we weren't scoping people who needed it and we were scoping people who didn't need it. So changing to this system has dramatically changed that. I think we, I suspect we do fewer screening tests overall, so that saves the NHS money, but I'm absolutely confident that we're now getting the right people at the right intervals. So © Queen’s Printer and Controller of HMSO 2013. This work was produced by Martin et al under the terms of a commissioning contract issued by the Secretary of State for Health

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providing a better quality service that's costing the NHS less money and it's rare that you can say that, but I'm sure that that's the case here.” (Consultant gastroenterologist, Case C) Framing the pilot for engagement with primary care was somewhat more challenging and less successful, not least due to the structural constraint of having to cross the boundary of hospital and community-based medicine and professional memberships. Here, rather than employing the language of ‘audit’ mobilised with secondary care consultants, success in aligning with practice nurses relied more heavily on trust, promoted through an emphasis on being an assistance, rather than a threat, to existing roles and practices, whereby they would be helped to deliver a higher-quality service to patients rather than encroach on their territory or create additional work. Beyond the success of engagement of clinicians, the pilot ultimately required the support of commissioners for ongoing sustainability. The pilot had been successful in securing initial post-pilot funding from the region’s PCTs, but there was a need to ensure that this was going to be sustained in the long term in the face of uncertain future funding arrangements and financial cuts. This then meant negotiating with commissioners, and a need to frame the pilot creatively beyond the clinical quality discourse mobilised with clinicians above. Successful clinician engagement was not insignificant here, though its role was indirect insofar as it “didn’t help us with funding negotiations, but it meant that referrals have continued to come through” (lead clinician). Here, there was something of a rapprochement with the dominant discourse of ‘cost effectiveness’, as those involved with the service sought to re-articulate the discourse of clinical quality in a language that would speak to the core concerns of commissioners. This was a process which the clinical geneticist who had led the pilot termed “facts and figures leadership,” whereby the ability to demonstrate measurable benefit through robust data collection on activity levels was key to persuading commissioners of the pilot’s value and served as a resource for any future demands. This had initially been very difficult during the pilot phase due to the short time scale involved, but had become easier as data of throughput and referrals became established over time: “The key things have been to demonstrate activity levels which have slowly, slowly risen, despite the fixed funding. So you know, a way of demonstrating that they're getting good value for money, but also looking at the output, the outcome in terms of, you know, their success as a triage organisation. … this is just as effective now as it was 5 years ago during the peak of the project and it's still provides value for money. It provides a service that no one else can provide, it's cheap, it's about all those sorts of things.” (Consultant clinical geneticist and lead clinician, Case C) “From a PCT point of view, so it was the simple argument of, well provide us with some indication of what this service does and what its benefits actually are and within that, well we wanted to © Queen’s Printer and Controller of HMSO 2013. This work was produced by Martin et al under the terms of a commissioning contract issued by the Secretary of State for Health

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know what the level of activity was by a PCT and what the outcomes and why it was all going on.” (Business manager, Case C) Alongside this alignment with the cost-effectiveness agenda in its communications with commissioners, however, was a recognition of the need to go beyond it, and be creative in mobilising other persuasive discourses, in light of the challenge of showing financial benefit of such small scale and specialist services. A key way that this was accomplished was to raise a ‘black hole’ argument (see section 4.3), pointing to the dangers of removing a service that was now so embedded and integrated within network practices. This discourse of ‘clinical need’ was thus identified as a defensive but effective means of making the case for Case C, as it had been in Case A, and there was evidence that this had been taken on board by commissioners and other network clinicians alike. Thus, similar to Case A, politically aware and creative framing of the pilot in Case C in ways that mobilised diverse discourses in order to align with both professional and commissioning audiences alike, was crucial to the success in ensuring funding and sustainability of the service. There was a recognition that this creative framing, or the capacity to ‘reinvent’ the service, was likely to be necessary into the future in order to capitalise on opportunities for further expansion into new clinical areas for longer term sustainability: “It's taking the service out in to different areas that we didn't do. Looking at public health agendas and things. It's always being mindful of what's changing in the NHS and how we can link into, you know, what's going on out there.” (Lead nurse, Case C) In contrast, in Case B, attempts to frame the service in terms of criteria against which it would do well were much less successful. Here, too, there was an effort to move the framing away from notions of cost-effectiveness and towards an (again, somewhat broad and slightly nebulous) notion of ‘clinical quality’. So why were these efforts less successful in this case study site? Apparent is a lack of creativity in framing the pilot service to fit with local priorities of the host PCT, a situation to which a number of interrelated factors around the nature of the service, local priorities and structural constraints contributed. Thus, as we have already noted above, Case B was particularly vulnerable to the shifting priorities of the changing context that was associated with the end of the pilot phase and top-down endorsement from the government’s mainstreaming genetics agenda, as an educational, advisory service. Its activities posed a challenge for sustainability, since here (to a greater extent than in Cases A, C and D) the aims of the project did not easily fit with the predominant ‘cost-effectiveness’ discourse of the PCT, centred around national targets and incentives in other areas. Here, as elsewhere, the service lead sought to reframe the service in terms of an alternative discourse of ‘clinical quality’: © Queen’s Printer and Controller of HMSO 2013. This work was produced by Martin et al under the terms of a commissioning contract issued by the Secretary of State for Health

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“I think things got a bit skewed though, because whenever I put forward bids people wanted me to show that I was saving money. However, we're supposed to be in the business of improving health, not saving money, you know.” (GPSI, Case B) However, the GPSI and wider stakeholder acknowledged that this ‘clinical quality’ discourse had not been persuasive in securing funding within a wider discursive context in which concerns for ‘cost-effectiveness’ dominated, perpetuated by a number of targets and incentives at the forefront of the minds of managers and commissioners of which genetics and small-scale educational initiatives were not a part. In contrast to Case A, then, this was an arena where preventive initiatives were not a priority in the face of such other competing demands. This discursive misalignment ultimately meant the GPSI found it hard to engage and persuade those with the power to influence and make commissioning decisions: “It was very much money, money, money, what can we get out of this and I think he, you know, he couldn't argue, he wasn't bothered about the quality, you know, there I was talking about risk and reducing risk and you know, improving people's health and you know, making something a safe health service, but the bottom line was he, maybe he was under pressure though, you know, he obviously wanted to try and make sure that they weren't overspent. And those things don't necessarily go together do they?” (GPSI, Case B) This view was to some extent endorsed by a senior manager within the PCT, who emphasised the way in which the absence of a supportive environment that might be more receptive to this notion of clinical quality undermined the capacity of the pilot to engage with funders and influential others as champions: “It wasn’t a priority for the Primary Care Trust. […] No-one had any targets to reach for genetics, there were no ‘must dos’ for genetics and so it was easy to slip down the radar to some extent. [...] If it had been something that I really, really had to deliver because either I’d really believed in it or because it was just something that the PCT must deliver then perhaps myself or other people involved would have been able to put more time into it to really make it go.” (Medical director, Case B) While both a rejection and difficulty aligning with the ‘cost effectiveness’ agenda in a somewhat unreceptive context contributed to a situation of discursive misalignment in Case B, there were also certain structural constraints that arguably shaped and compounded this process. Significant was the extent to which the GPSI lead was isolated in primary care, with respect to wider activity in genetics in the region, meaning not only that the service remained small-scale and specialised, but that it failed to link up in any integrated way with secondary and tertiary care – and crucially therefore, was not able to mobilise a discourse of ‘cost effectiveness’ based upon added value of integration favoured by PCT commissioners, or to © Queen’s Printer and Controller of HMSO 2013. This work was produced by Martin et al under the terms of a commissioning contract issued by the Secretary of State for Health

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engage support of other professional stakeholders as champions from these areas in the quest for sustainability. The importance of such integration for framing a persuasive case was borne out by PCT managers. In Case B then, while initial post-pilot funding was secured in the shortterm from the PCT, they were unable to construct a persuasive case within the wider discourses of value demanded by commissioners dealing with tight budgets and competing demands for longer-term survival. In short, Case B suffered from being “alive at the wrong time and [...] a shift in emphasis in commissioning priority” (PCT Manager), making it inherently difficult for such a service to ‘tick all the boxes’. In contrast to the other cases above, the challenge of an unreceptive context was one that proved insurmountable through framing activities of the pilot leads. Across the four cases, then, a number of key points emerge from this analysis of the pertinence of discourse and framing to sustainability. Firstly, while prominent, discourses of cost-effectiveness appear not to trump every other consideration in the minds of commissioners and other decision makers in the NHS. Reframing service provision in terms of other discourses that abound within the health care system can be a powerful strategy for securing the future of services which—for a variety of reasons, from the scale of provision to the nature of the clinical area in which services are provided—find it difficult to articulate an unambiguous case for themselves in cost-effectiveness terms. As we saw in section 6.3 above, strategic alliances between clinicians and managers can be productive in finding the right articulations for a variety of audiences,133 and this is central to the efficacy of discursive framing as ‘institutional work’ to realise particular desired outcomes.127 However, it also suggests that however powerful some actors may be in maintaining and altering existing institutions,128 in an NHS context where an increasing variety of forces drive behaviour (see section 6.2 above), they also need to engage others in this work if it is to be successful. Secondly, ‘clinical quality’ appears to be a powerful alternative discourse, judging by the success with which three of the services drew upon it in making cases for their sustainability to key decision makers. This is perhaps not surprising in a post-Darzi NHS, in which quality is seen as the cornerstone of NHS provision.80 A perhaps more important insight from this study is the flexibility with which discourses of ‘clinical quality’ can be deployed, which seem to incorporate and sometimes go beyond notions of effectiveness, safety, and patient experience. Quality would appear to be an important discursive vehicle for proponents seeking to sustain services, but its definitional ambiguity makes it a flexible criterion which is perhaps more open to co-option than (comparatively) stable, measureable criteria such as cost-effectiveness and patient throughput. Others have found similar flexibility in other key health care discourses.132–134 Finally, ability to harness these discourses in pursuit of sustainability is not equally distributed across NHS stakeholders, and its effective use depends on a number of criteria: professional position (cf. section 6.3), available © Queen’s Printer and Controller of HMSO 2013. This work was produced by Martin et al under the terms of a commissioning contract issued by the Secretary of State for Health

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networks of clinical and non-clinical champions to whom leadership can be distributed (cf. section 6.4), and the extra-organisational policy context (cf. section 6.2). Thus, as might be expected from the discussion above of the relationship between professional position and institutional work,128 discursive framing is not an independent resource that can be deployed freely by NHS stakeholders in pursuit of particular objectives, but is closely tied into wider aspects of the political economy of the health service.


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7 Conclusion In this final chapter, we summarise our contribution and make recommendations about foci for future research. We also note, first of all, the wider dissemination activities that we are currently pursuing alongside this final report to attempt to ensure that the findings from this work reach those in the NHS who might reap most benefit from them, in a form that is useful and accessible.

7.1 Dissemination within the service While this final report provides an overarching summary of our findings, and peer-reviewed journal articles will ensure that our study makes a visible contribution to the academic literature, we were also keen to ensure that our work is accessible to those in the NHS who might most benefit from its insights, including clinicians leading change, managers in provider organisations and commissioners. With this in mind, we engaged a number of service-facing organisations with a view to putting together joint written outputs and dissemination events, but unfortunately, owing to personnel changes and strategic reorganisations at these bodies after the study was funded, several of these proved impossible to arrange. Instead, with the NIHR’s approval, we decided to focus our dissemination work on joint activities with Collaborations for Leadership in Applied Health Research and Care (CLAHRCs). CLAHRCs are NIHR-funded, regional partnerships between universities and NHS organisations intended to carry out research and facilitate the translation of that research into sustainable changes in NHS practice. As such, they represent the ideal vehicle for disseminating knowledge about feasible strategies for ensuring that reconfigurations of NHS practice are maintained and embedded through time, since they have links with the breadth of actors—clinicians, managers, commissioners and increasingly Clinical Commissioning Groups—whose roles, as we have shown, are essential to making this happen. To date, we have established links with three of the nine CLAHRCs (those for Leicestershire, Northamptonshire and Rutland, for Nottinghamshire, Derbyshire and Lincolnshire, and for Birmingham and the Black Country), and are at varying stages of progress in planning with them a number of forms of dissemination tailored to the groups noted above. In doing this, we have been able to take advantage of the particular strengths and relationships that each CLAHRC has developed to date. For example, the CLAHRC for Leicestershire, Northamptonshire and Rutland has established notable links with Clinical Commissioning Groups in its area, including ‘GP fellows’ whose role involves finding ways to feed evidence into the nascent © Queen’s Printer and Controller of HMSO 2013. This work was produced by Martin et al under the terms of a commissioning contract issued by the Secretary of State for Health

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Groups’ work, and we plan to work with these individuals and others to ensure that our findings have a route into GPs’ commissioning practice, and take a format that will be relevant and useful to them. This work will take place over the summer and autumn of 2012.

7.2 Concluding remarks Through reanalysis of an older data set and collection and analysis of a new one, this study has sought to build a longitudinal understanding of sustainability of organisational innovation that starts to fill in a crucial gap in the current evidence base. Our study concentrates on one particular clinical area which in some ways is idiosyncratic in its organisational and clinical characteristics. In other ways, however, as we noted in chapter 3, it typifies other clinical areas that have been subjected to a ‘modernising’ policy influence over the last 15 years, and which do not enjoy the profile, resources and top-down change agency of clinically prominent areas of NHS provision. Furthermore through our sampling strategy, we sought to permit an explicitly comparative approach to analysis that would highlight the influence of differences in the background characteristics of our case study sites, and which helped us to identify some of the key influences on trajectories towards sustainability of features such as health care sector (primary versus hospital care), professional lead, and basis in an evidencebased model. Our findings add to and to some extent alter the nascent literature on sustainability of organisational innovation. Our key findings are presented in chapters 4, 5 and especially 6, and we will not repeat them at length here. However, we have added nuance and further empirical flesh to the emergent notion in the literature that sustainability should not always be conceived of as a fixed state, reflecting fidelity to a newly introduced innovation. In particular, we highlight how it is, at least when the changes involved are complex, organisational and affect multiple stakeholders, an ongoing process, not a threshold to be crossed so that sustainability has been achieved. Sustainability thus appears more like a continuum rather than a binary state, with ongoing work needed well beyond the initial introduction of a change—though sustainability seemed to require more active work in some of the four cases studied here than others, where sustainability was generally passive, requiring only occasional intervention. The process, and its chances of success, were shaped by local contextual conditions, including the roles and interests of the stakeholders concerned. This need for ongoing work on sustainability was exacerbated by organisational turbulence in the NHS, which meant that services needed to be cognisant of shifting criteria of worth, and new agenda to tie into. Finding the right networks of supporting stakeholders was crucial, and seemed important from a relatively early stage in the sustainability journey. With the exception of one case, a heterogeneous mixture of clinicians, managers and representatives of different organisations was important to © Queen’s Printer and Controller of HMSO 2013. This work was produced by Martin et al under the terms of a commissioning contract issued by the Secretary of State for Health

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sustainability, and the relative importance of these shifted through time as well. In appealing to these stakeholders, the more successful services were able to frame and reframe themselves in terms of flexible terms of reference: an absence of gold standard evidence was an impediment but was not fatal to these services, which were able to draw on an adaptable notion of ‘clinical quality’ in putting their work forward to those in positions of power. This work involved collaborative relationships across the clinicianmanager boundary and often across sectors, too; where some services were able to draw effectively on knowledge asymmetries that made them more able to impose their standards on others, there was also a considerable degree of negotiation between, for example, commissioners and providers that seemed crucial to fostering an environment in which these services had space to develop, consolidate and embed. Despite this, though, none of the services could be said to have secured its place indefinitely in its local health economy. Six-to-seven years after they had been originally introduced as pilots, their existence remained, to varying degrees, under threat, and changes in the organisational fabric of the NHS posed further challenges (and offered some opportunities). As discussed in the previous chapter, this might be understood as a healthy sign of a competitive, innovating NHS in which nothing can be taken for granted and overly cosy relationships between purchasers and established providers have been put aside. However, the small-scale, specialised nature of these services arguably meant they faced greater risks than larger services with greater political clout or more easily evidenceable value. In an NHS context which is set to remain turbulent for some years to come, and in which innovation is seen as a crucial means of maintaining patientcentredness and improving quality, it will be important to ensure that the fragile shoots of novel approaches to service provision are not trodden underfoot in the rush to deal with ‘big ticket’, macro-level challenges.

7.2.1 Recommendations for further research Our findings raise a number of questions that would benefit from further research effort. First of all, though we have sought to generalise from the specifics of our case studies and the features of the clinical-genetics field which appear to be relevant to other areas of NHS provision that are not national priorities, it is clear that the robustness of our findings would be strengthened by comparative work that covers other clinical fields. While our sampling was theoretically informed, it was also opportunistic to the extent that our sample frame included only those projects which had been included in our earlier study (which were also chosen through theoretical sampling). Our study is also small in scale, and we must be cautious in generalising to other fields of NHS provision. It would also be particularly interesting to study the fate of organisational innovations that take place in fields such as cancer, which are the subject of © Queen’s Printer and Controller of HMSO 2013. This work was produced by Martin et al under the terms of a commissioning contract issued by the Secretary of State for Health

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national focus, that reflect other priorities and interests: for example, those that derive from the priorities identified by local commissioners, or reflect local clinicians interests, or build on the suggestions of local patient involvement initiatives. Beyond this, our research raises a number of specific questions that might be addressed in future study: 









With the advent (or rebirth) of clinically led commissioning, how will those in commissioning roles interact with business managers and others on the provider side? Will we see a shift in the relationship, or will commissioning continue to be dominated by information asymmetries, prior relationships and institutional forces that determine the boundaries of commissioning decisions?155 Following on from this point, the role of business managers and others in provider organisations who lubricate and mediate the commissioning relationship seems worthy of particular attention—particularly as current NHS reforms and the transition to a provider environment comprising foundation trusts, independent-sector organisations and practitioner-owned social enterprises come about. What role can such individuals play in facilitating or inhibiting the ongoing existence of clinically led changes? A particularly pertinent question would appear to be the construction of ‘quality’ and ‘value’ by those in commissioning and wider managerial roles, in the absence of ‘gold-standard’ evidence of clinical or costeffectiveness. Such constructions and judgements would appear from our study to play a crucial role in critical decisions about funding, and given the need for optimal utilisation of a static NHS budget, greater knowledge about how such views are reached, and the nature of the influences on these, would appear to be of vital importance. We suggest that the ‘co-option’ of a range of stakeholders in powerful positions into ‘leadership’ roles constitutes a double-edged sword, both in terms of their role in making decisions about ‘quality’ and ‘value’, and in terms of the identities and roles of the individuals themselves. Whose interests do they serve in taking on this mantle? Further research on this ‘darker’ side to distributed leadership would be of considerable interest, perhaps in the context of the development of ‘discursive networks’ of support that we detail in the previous chapters. What of longer-term sustainability? In the contemporary, competitive NHS, can a final, ‘binary’ sustained state ever be achieved? Is reframing, reorienting and remarketing an inevitable feature of the contemporary NHS, even for larger and apparently established services? If so, what are the positive and negative implications?


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