Contextualising the coordination of care in NHS trusts: an organisational perspective

Abstract

This thesis has two principal aims. The first is to understand why change oriented towards improving the coordination of care for long term users of healthcare (and related) services is so difficult to achieve. The second is to identify possibilities for how these difficulties may be overcome. During the three-year period 2002-2004, two NHS Trusts instituted a particular means for coordinating care, integrated care pathways (ICRs), as 'the way that clinical work is done here'. These change efforts were instigated as part of a collaborative NHS modernisation project. Despite similarities between the Trusts and their change programmes, the organisational outcomes from the modernisation project differed. This thesis identifies factors that contributed to these differing outcomes. The research was framed within an organisational perspective drawing upon recent organisational theory and a relevant research approach; interpretative structuralism. This approach used a variety of research techniques (historical analysis, document review, surveys and interviewing) to examine the social contexts underpinning prevailing thinking within the NHS about how clinical work should be organised and managed. The results showed that many factors in the wider context of the NHS and the local clinical 'shop floor' operate to fragment thinking about how care should be organised. In one Trust several factors contributed to its greater success in implementing ICRs. These included (i) coherence and congruence amongst the senior management in conceptualising and pursuing more product oriented approaches to clinical management, (ii) clinically led services and devolution of authority, (ііі) a willingness of all staff (including senior management and clinicians) to be self critical and thoughtful in making suggestions for improving clinical performance, and (iv) an ability by senior management to interweave five key themes in clinical service provision throughout the organisation. These themes were patient experience, service redesign, financial balance, the inter-relationship between these three, and integrated governance of the resulting organisational processes and outcomes. The results also showed that local contextual factors such as the character of the local electorate and the style and expected longevity of the senior leadership can undermine success in achieving agreed goals for coordinating and managing care.