Abstract
Pettigrew A, Ferlie E, McKee L. Shaping strategic change: making change in large organizations. The case of the National Health Service. London: Sage, 1992
At the time of publication, Andrew Pettigrew and colleagues' book received wide acclaim as a balanced and rich contribution to the study of strategic change. Eighteen years since publication, it remains a relevant analysis of how new processes and environmental factors impact on health care, and how strategic change is dependent on locale, fiscal situation, structures, politics, and people. It can help illuminate current issues in the commissioning landscape in the English NHS outlined in the recent White Paper.1
Pettigrew and colleagues highlight that much research on organizational change is ahistorical, aprocessual and acontextual. They advocate longitudinal and historical accounts of strategic change, with an emphasis upon action, as well as structure, and the competing versions of change held by various actors. Through a comparative case analysis of a limited number of in-depth cases, they examine the interplay of the context, the process and the content of change, at the system level within the English NHS, and seek to explain the differential achievement of change objectives. A central concept within this processual analysis, which foreshadows more recent interest in institutional work, is that of legitimacy. ‘If one sees major change processes at least partially as a contest about ideas and rationalities between individuals and groups, then the mechanisms used to legitimate and de-legitimate particular ideas or broader ideologies are crucial.'’ They also stress the need to explore how context is a product of action and vice-versa. Finally, they note that outer and inner context of change are linked, so that we need to consider how exogenous factors interact with, and are mediated by endogenous factors. They emphasize that features of inner and outer context should not be seen discretely but that they represent a highly inter-correlated combination, which taken together may raise energy levels around change in ways that are highly location specific.
Through their analysis, they identify eight features of outer and inner context for change in health care, as follows: quality and coherence of policy; availability of key people leading change; intensity and scale of long-term environmental pressure; supportive organizational culture; effective managerial-clinical relations; co-operative inter-organizational networks; simplicity and clarity of goals and priorities; fit between the change agenda and locale. We now re-visit each of the eight factors for organizational receptivity to change as a framework for illustrating how the commissioning agenda in the health (and fundamentally interdependent social care sector) may emerge, and how this book remains a text of contemporary relevance.
Quality and coherence of ‘policy’
In the case of commissioning, current policies state: ‘[t]he government will devolve power and responsibility for commissioning services to the healthcare professionals closest to patients: GPs and their practice teams working in consortia.'’1 Although there remains little detail and much remains out to consultation, processes of commitment-building and buy-in from interest groups are underway, allowing, in Pettigrew and colleagues' terms, groups to be ‘scripted in’ rather than ‘scripted out’. The lack of detail on realistic financial frameworks and transition process is worrying, as receptivity in this case may depend on marrying strategic ambition with operational realities. There is no doubt that process components have not been worked out to any extent and somehow the top-down approach needs to marry up with the bottom-up work that now needs to be done.
Availability of key people leading change
The leaders of commissioning change are drawn inevitably from two sources, one being the Primary Care Trusts (PCTs) and the other being medical professionals. Those rising from within the ranks of medical professionals to new consortia leadership roles have a significant role to play, particularly given the large number of community medical practices that will need to be included in consortia. Meanwhile, PCT managers may experience job insecurity and may look to find roles within the new consortia they are helping to build. Another key element in leadership will be the role of the big health care consultancies and private sector providers and how their influence will come to bear on the new commissioning landscape.
Intensity and scale of long-term environmental pressure
The continuing pace of NHS reform means that the organization is constantly under pressure to change. During 2011/12 this may turn out to be the most disruptive, fundamental and ongoing shift for the NHS in its modern incarnation. Whether the most recent financial crisis is indeed a critical factor in the overhaul of the health system, or whether it is an ideological foundation and opportunistic moment for the coalition government is a debate to be had elsewhere. What is certain is that the pressure to deliver services through a restructured commissioning process will re-shape the dynamics of power between organizations at all levels. The intensity of the pressure on a range of institutions and people will undoubtedly result in unintended consequences.
Supportive organizational culture
Pettigrew and colleagues noted that: ‘culture refers to deep-seated assumptions and values far below surface manifestations, officially espoused ideologies, or even patterns of behaviour. The past weighs a heavy hand in shaping these values, setting expectations about what is and what is not possible. This may be both a strength or a weakness, as difficult experiences in the past are projected forward'’. The NHS is made up of many different organizational cultures, and each of these will impact on how the changes to commissioning will emerge. Considering the development of commissioning consortia, each particular locale will have PCT cultures, GP and professional cultures, and a culture of working with local authorities. History and the recent past, in each area and sub-area will affect how individuals ‘come to the table’ and how they feel they can proceed. Even beliefs around change itself, for example whether change in the health sector is evolutionary and incremental (i.e. this change to commissioning is a movement in a positive and developmental way), or whether it is episodic and has an end-point, will be significant.
Effective managerial-clinical relations
Related to organizational culture is the important element of how managers and clinicians work together in any given locale, as well as the over-arching requirement now for clinicians to become much more involved with commissioning, now with the funding packages to do it (which was not always the case with practice-based commissioning). Identifying and understanding these relationships before and during the design and change process will be critical to managing barriers that may emerge due to history, culture, patterns of power, and patterns of politics.
Cooperative inter-organizational networks
Both the formal and informal inter-organizational networks will be influential in how the commissioning change process takes place. The layers of stakeholders in each area will interact in a multitude of ways, (i.e. how active have PCTs been in local authority partnerships and planning organizations) and the history and culture of these networks can be either enabling or disabling to rapid, fundamental shifts in ‘how things are done’. The role of networks as arenas for trust-building, bargaining and deal making will be at least as important as any structural and institutional role, if not more critical.
Simplicity and clarity of goals and priorities
Pettigrew and colleagues noted that managers varied greatly in their ability to narrow the change agenda down into a set of key priorities and to insulate them from the constantly shifting short-term pressures that kept appearing, resulting in ‘meaningless’ priorities. With this came the warning to ignore or minimize some of the ever changing pressure, use some to amplify change objectives and be persistent and patient in pursuit of objectives over a long period of time. In the current context, this advice rings true, given the time-limited agenda for shifting to consortia commissioning (to be formally established in 2012/13). There will be an inordinate amount of guidelines, consultations, and directives being published, and the intense pressure to respond to requests at every planning meeting. Undoubtedly, the whole agenda will shift and change as the realization of what needs to be done, and how it can be done, becomes apparent. Being focused on relatively simple and clear goals will be the only way to survive the onslaught.
Fit between the change agenda and locale
As various sizes of consortia begin to take shape, there will be a number of important factors related to locale to be analysed. The British Medical Association's initial observations states, ‘there can be no one-size fits-all approach’.2 They discuss how the ‘natural clinical community of the local hospitals and local health economy’ must be a key design factor, including sensitivity to social communities. There is clear encouragement to work towards larger, rather than smaller consortia, ‘it is unlikely that consortia with populations of less than 500,000 will find it easy to manage financial risk, while they may not have sufficient management resources to function effectively nor take advantage of the economies of scale necessary to ensure that commissioning is efficient'’.2 Whether consortia covering this population size and larger will truly be able to take account for all the differences of their particular environments and different needs is questionable. Indeed, there may be little ‘fit’ currently between the massive change agenda and some locales.
In conclusion, ongoing academic study, focused upon changes in commissioning, may develop ideas developed by Pettigrew and colleagues around local level agency in strategic change further, i.e. the who, where, what, how, and with what consequences of local level agency. In short, our retrospective review of this book leads us to call for studies of commissioning that foreground local level agency around commissioning changes, which seeks to explain differential rates and content of strategic change locally.