Assignment Module 1: Organisations: Structures; Systems; Processes

Introduction

This paper describes the organisational aspects of an Integrated NHS trust

(St. Elsewhere NHS Trust). This is an organisation with responsibilities for the
provision of secondary and primary, physical and mental health care. The
paper discusses the aims and objectives of the NHS Trust, from a number of
clinical and non-clinical perspectives. It evaluates the nature of the co-
ordinated activity of the organisation and seeks to review the theoretical
models of organisational structure to critically appraise how well the structure
supports the nature of the clinical and non-clinical work. The paper focuses on
a number of key systems and processes, which are in place to deliver the
clinical and non-clinical services. It discusses how well these processes
facilitate the Trust aims and objectives with a case study from within the
clinical arena, which has an impact on organisational effectiveness. Practical
recommendations for change are evaluated in the light of contemporary
theory.

St. Elsewhere is a third wave NHS trust established in 1st April 1993. It has
responsibilities for the physical and mental health of its local population
(220,000). It employed approximately 4000 people working on three hospital
sites, one district general and two support hospital, and across the local
community with four community resource centres. It satisfies 95% of current
healthcare demands of local residents through these hospitals and clinics.
Approximately 50% of its staff are nurses, 16% administrative or clerical,14%
professional or technical, 12% ancillary, 6% medical or dental and less than
2% are senior managers or Trust board members.

It has undergone a recent change of Chief Executive with the retirement of the
previous Chief Executive, who had been with the organisation for twenty-five
years. This change has had a minimal effect on the aims and objectives of the
Trust although it had produced substantial change to the organisational
culture. Contemporary with the change of chief executive is a massive
reconfiguration of services between this trust and a neighboring trust, such
that both organisations may merge to become one single trust.

The stated mission of St Elsewhere NHS trust is: To become the best
provider of Healthcare by building on our firm foundations and continuously
evaluating and improving services to all our users. We will care about how
these services are provides through the development of an excellent
workforce. (Appendix 1) Throughout the organisation this mission is variously
translated as the strapline “Caring for and about people” and “An excellent
service to delight our patients”. A recent addition to the challenges for the trust
has been clinical governance. This is defined as: The culture and practice of
individual and corporate responsibility for high quality clinical services in a
learning environment. The aims and objectives of the organisation can be
grouped into those directly supporting clinical service; those aimed primarily at
organisational development and the creation of a learning organisation
(Pedler & Aspinwall 1998); aims focused specifically on training and financial
objectives.

Clinical service aims are as follows. The effective, rapid and early detection of
disease, both physical and mental. The promotion of speedy recovery and the
reduction of the effects of illness with minimisation of any consequent
disability and handicap. The maintenance and promotion of effective health
among the local population and ensuring that care is effective (the right care)
as well as efficient (the right way) through evidence based practice, clinical
audit and clinical governance, so minimising the amount of ineffective and
unnecessary clinical activity.

The aims and objectives relating to organisational development are described

in terms of working in constructive partnerships with other agencies and
industries to share knowledge and skill with all organisations and people who
can positively affect the health of the local population. The Trust also
endeavours to take into consideration the views of patients and service users
of how and where services are provided and seeks to delight our patients.
The Trust seeks to become a learning organisation and follow Revans (1998)
ecological formula : L ≥ C where L is learning in the organisation and C is the
rate of environmental change.

Training objectives are to value, empower and develop staff at all levels and
in whatever area of work. The financial aims of the trust were to ensure that
all staff, buildings and equipment were optimally used and that as far as
possible value for money was obtained at all times. The organisation sought
to reconcile potential conflict between aims by “Integrity of Intent”.

“Organizations are a system of co-operative activities and their co-ordination

requires something intangible and personal that is largely a matter of
relationships” (Bernard 1938). They are: “planned co-ordinated activity of a
number of people for the achievement of some common explicit purpose or
goal through division of labour and function and through a hierarchy of
authority and responsibility” (Schein 1988).

The co-ordinated and co-operative activity of St Elsewhere NHS Trust is

configured around a hospital directorates model (Appendix 2). The Trust
board is responsible for determining policy and for maintaining a strategic
overview. It has a centrally nominated chair and a chief executive with
executive and non-executive directors. The Trust management team (TMT) is
chaired by the chief executive and consists of clinical and non-clinical
directors with the medical director. It formulates policy and strategic options
for the Trust Board and implements agreed policy and strategy. There are
eleven directorates tasked with delivering clinical or non-clinical services. All
the directors are responsible for the operational management of the service.
Clinical Directors lead Directorate Management teams comprising a Clinical
Director (a hospital consultant in the clinical directorate) a general manager,
several hospital consultants representing relevant hospital specialties, senior
nurses, finance and human resource specialists. The Clinical Directors’
primary role is to provide clinical services to patients referred to them. They
have a responsibility to the Chief Executive for the effective use of the
resource they influence. The Directorate general manager is responsible for
the day to day running of the directorate.

Handy’s (1990) model of organisations would have describes the Trust under
the old Chief Executive as a spider’s web. The positive aspect of this was that
the Trust was infused with the culture and personality of the chief executive.
There was a very strong local identity. The Chief Executive was locally born
and bred. She had worked her way from a clerical post to General Manager
and then in 1993 had become Chief Executive. The Trust was there to serve
the local population. Executive and non-executive directors were strongly
encouraged to have an involvement with other local organisations, schools
etc, even if they were not local residents.

However, as Handy goes on to say such a style has limitations in larger more
formal organisations. As the organisation moved from a pioneer phase to a
rational phase (Pedler, Burgoyne & Boydell 1996) problems began to surface.
The Chief Executive held very strong theory X assumptions (McGregor 1960)
about the workforce. The majority of the previous, and still current, Trust
management team also held these assumptions. Many of the structures and
processes fed a command and control agenda. This was resisted by the
consultant body who attempted to bypass the formal structures. The Local
Negotiating Committee 1 worked predominantly in the shadows (Egan
1994,1993). In the past many processes which had been driven by the
Management, eg. RMI2, EFQM3 IIP4 have been externally and formally
supported by the consultant body but have not resulted in measurable or
permanent improvement. The consultant body had expressed considerable
cynicism about such management ‘bolt-on’s’. The new chief executive
espouses theory Y assumptions and the director of Human resources
together with the chief executive argue that the Trust management team, as a
group, is moving towards a ‘Y’ view of the workforce.

The new chief executive brought a change in organisation structure, much

more along the lines of the Task tribe (Handy 1990), with the appearance of
cross-functional teams (Proehl 1996). This new style has within it a strong
belief in devolution. There is recognition that the world is becoming
increasingly uncertain. Change is to be expected and embraced. The 1990’s
have seen considerable change in the national and local environment for the
Trust. The appearance and disappearance of the NHS internal market, local
reorganisation with possible future Trust mergers, the arrival of Primary Care
Groups to perhaps become Primary Care Trusts. The past seemed to be a
much quieter and unchanging country and now the organisation needs to be
more flexible and able to respond to change more speedily.

1
A representative consultant body established to meet with Management to discuss issues of common
interest.
2
Resource Management Initiative. This Trust had been one of three government pilot sites.
3
European Framework for Quality Management
4
Investors in People. The Trust undertook a commitment to achieve the IIP standard under the old
Chief Executive although it didn’t apply until the new Executive was in post.
Organisations are formed from three forces, Ideas, life stage and era (Pedler,
Burgoyne & Boydell 1996). The trust has moved from a pioneer company
with a dominant founder to a rational company characterised by management
systems, which have replaced the idiosyncrasies of the founder. The
management systems existed in the pioneer phase, which gave it a superficial
appearance of bureaucracy but the organisation was driven through a shadow
side (Egan 1994,1993). The current era is of equal importance. As described
above this is a time of rapid environmental change. The belief in the need to
develop as a learning organisation is in agreement with Reg Revans (1988).

If the learning rate inside is less than the rate of external change, then the
organization is declining or dying. With all organizations facing rapid and
unpredictable changes, this truth has become increasingly obvious; as
change accelerates so organizational death comes in many guises through
failure, acquisition, merger:

It is hard to see how a public service organisation such as an NHS trust could
‘die’ in the way that a private sector company might fail. Recent experience
from education may give useful insight. With failing schools being taken over
by ‘private consortia’ could this provide government with another model to run
failing hospitals? Even without such overt market forces, the desire within the
Trust to provide an excellent service should be a strong enough driver to
move the Trust to a greater learning orientation.

Handy’s model sheds little light on how the organisation is structured in detail.
Mintzberg (1979) describes five types of ideal organisational structure. He
begins at a simple entrepreneurial type, moves onto a machine bureaucracy,
describes an adhocracy, and professional bureaucracy and finishes with a
divisionalised organisation. His description of a professional bureaucracy has
within it much that accurately reflects the nature of the Structure of St
Elsewhere NHS Trust. He includes elements such as: Professionals working
autonomously supported by other staff in the organisation working along
machine bureaucracy lines; Simple systems; highly bureaucratic processes;
standards being defined by autonomous professional bodies outside the
organisation and performance being assured by professional training and
qualifications.

The delivery of clinical services at St Elsewhere NHS Trust, much like the
remainder of NHS hospitals, is structured around individual consultants
working with individual timetables. The remainder of the clinical staff working
is configured around the consultants to support their work. Operating theatre
staff are employed to work at times to be available for the consultants
operating list. Nursing staff shifts are timed, in part, to work around consultant
ward rounds. Junior doctors are attached to, and psychologically owned by,
individual consultants. Medical records and clinic staff work to support the
needs of an individual consultant’s outpatient clinic. The consultants primarily
define the services provided by the organisation. The consultants work as if
they were private, independent contractors rather than hospital employees.
The job description of each consultant is primarily defined by him/herself, The
annual job plan review in theory brings some organisational accountability.
The process should mirror what elsewhere in the organisation is referred to as
individual performance review (IPR). In reality it is managed by the Medical
Director (a consultant) who has no direct knowledge of the apraisee’s
performance. It is supported by minimal documentation and is aimed at
generating new job plan, that is a role with fixed sessional commitments
rather than professional or organisational developmental goals. As a
consequence the job plan review does just that. It reviews the job, not the
individual. This was despite the management initiatives taken years before
following the Griffiths Report (DHSS 1983) intended to replace the old
consensus management model with it’s strong sense of confederation of
disparate occupations (Strong and Robinson 1988) with greater management
accountability.

Even Mintzberg’s model must be considered too simplistic to encompass a

complex and diverse organisation such as St Elsewhere NHS Trust. Morgan
(1997) describes an approach of organisational modelling as metaphor, which
allows organisational enquiry in a multidimensional fashion. Developing the
ideas of Taylor’s scientific management and Weber’s classical management
theory he presents a machine metaphor for understanding organisations.
Detailed elements of the Trust reflect the notion of organisation as machine.

Nursing staff on the wards are rostered in shifts to cover the full twenty-four
hours. Whilst the care is delivered by individual nurses the care process runs
constantly and consistently as if it were in perpetual motion, never stopping
and never resting. The procedures for nursing are organised, each staff
member given their jobs in detail and following highly prescriptive rules.
There is an explicit written process for every conceivable nursing task. Each
time a task is performed the nurse is expected to conform with the written
protocol to the letter. This ensures conformity with standards and delivers
care to a high order but tends to dehumanise the most humane of
professional creating considerable role tension. It works against the aims of
the trust to empower individuals to solve their own problems and it creates a
culture of inflexibility. The bureaucratic nature of hospital wards with fixed
visiting, timed consultant ward rounds and nursing hand over with staff
working shifts creates tension for seeking to deliver a patient/user focused
services. Time taken to complete paperwork, required by the machine, eats
away at time for listening, for helping feeding, for caring. The machine
becomes very efficient but not completely effective.

A previous director of nursing held a very command and control model for the
nursing staff within the trust with theory X assumptions and Argyris’ behaviour
A (1971). An example of this mechanistic method was the requirement for
daily reports from all the senior nurses in each clinical area of any untoward
occurrence. It was expected that any incident occurring on the ward would be
reported up the chain of nursing managers to reach the director of nursing.
The incidents were then dealt with centrally and not directly by the staff
involved. This distancing of problem and solution may well have become part
of the organisation’s learning disability (Argyris 1996, 1990, Argyris & Schon
1996). The consequence of this has been the development of a very slow
response to problems in the ward area. It also has lead to the widely held
assumption amongst nursing staff on the ward that improvements in clinical
service are ‘someone else’s job’. 5

In an environment that is becoming increasingly command and control and

with central government adopting theory X assumptions about the whole of
the public sector, it is very difficult for senior nurse managers to manage the
Trust nursing staff in anything other than a machine bureaucracy. Service
standards are externally defined with tighter and tighter reporting
requirements. Episodes such as Beverley Allitt6 have reduced government
confidence in local monitoring systems and have required more cumbersome
and impersonal structures to ensure that minimum safety standards are
maintained. Central government sends out daily edicts about waiting list
targets on which the trust has to deliver. The Trust has little choice but to
meet government financial and service targets even though this may conflict
with some of its aspirational aims and objectives.

The pathology service provides haematology, biochemistry and

histopathology investigations for in-patients and outpatients. These services
operate in a very mechanistic fashion. Tests are requested through highly
formatted forms with tick boxes. Blood is taken by phlebotomists who have no
knowledge of the tests requested. The samples are delivered by porting staff
whose jobs are explicitly specified and the samples are processed by MLSO’s
in a machine laboratory. The whole process functions very efficiently and
copes very well with the huge numbers of repetitive tasks. The process only
operates in a specific way and at specific times. Blood can only by taken by
phlebotomists at specified times. Only certain tests are available. The
laboratory copes very poorly with irregular requests at unscheduled times.
The machine is very inflexible. This combination of structure and process also
tends towards poor moral and reduced self-esteem. The staff are observed to
work to their minimum job specification. They hold to rigid break times and are
unavailable during times. This militates against an ‘excellent service which
delights our patients’.

As the last comment suggests the other aspects of organisational structure

and process cannot be described using Morgan’s machine metaphor. Each of
the clinical directorates function, more or less as a self-managed team. This is
particularly the case following the new chief executive’s devolution program.
Having given away power and control the Trust has begun to take on a
federalist culture (Handy 1994) with allegiance to both the local directorate
and the global trust. This has, in part, resulted in a considerable diversity of
structure and process between directorates. This is in stark contrast with the
distinctly ‘one size fits all’ culture which was characteristic of the previous
chief executive. Strategies such as ‘Investors In People’ (IIP) have been used
5
The director of nursing related an episode dealt with as a complaint. A patient had become very
breathless and uncomfortable during the night. The nurse on duty had telephoned the doctor and had
dutifully recorded this in the nursing notes. Twenty minutes later the patients wife complained that
nothing had been done and the patient was still very uncomfortable. The nurse again telephone the
doctor and recorded it in the nursing cardex. Subsequently the nurse was asked to reflection why she
had done nothing to make the patient more comfortable while waiting for the doctor .
6
Nurse Beverley Allitt was found to have killed several children over a prolonged period of time whilst
working as a paediatric nurse in the UK in the 1990’s
in all areas of the trust as developmental tools, with the expectation of
universal success. There had been much frustration by the old chief executive
that certain directorates, especially those with a strong professional
beaurocracy, had remained completely unchanged by the process. Across all
the clinical directorates the consultants had completely sidestepped the IIP
initiatives, viewing them as management tools for control. The failure of this
type of strategy with the consultants may have been because it had,
embedded in it, values that were incongruent with the consultants
professional bureaucracy.

One particular directorate is configured much more along the lines of a matrix
organisation (Mullins 1996). Physiotherapists, occupational therapists, speech
and language therapists, dieticians and nurses are organised in functional
groups. Rather than being managed by heads of service they are managed by
a single professional in their functional area, eg. in-patient services or
rehabilitation day unit. This directorate operates on a much more democratic
basis with information flow bottom up as well as top down. Information
transfer is through weekly, face to face, semi-formal team briefing rather than
only through highly formatted monthly board meetings and endless bits of
paper.

Each functional team meets together with its manager for dialogue and
discussion. This directorate’s focus is on the end product, ‘excellent service
which delights our patients’, rather than divisional, professional contributions.
Regular feedback from and planning involvement with service users occurs.
This directorate has developed innovative and novel solutions to adapt to it’s
changing environment: A rapidly aging population; a social service strategy
which encourages frailer older people to remain in their own homes and away
from nursing homes; An expectation by service users of choice fueled by The
Patients Charter. The same staff working part-time in the rehabilitation day
unit and part-time as part of the community out-reach team. Patient’s
treatment can be tailored to either day unit based or home based. Some
patients can move from one to the other as their condition changes with the
same staff continuing treatment. In another area rehabilitation staff work along
side care assistants in a local authority part III home, the ‘Oaks Villa’ project.
The local authority provides accomodation and care. Therapy services are
provided by staff from this directorate within the Trust. The project is jointly
funded and jointly managed.

In discussion with the general manager of this directorate, a physiotherapist, it

was identified during the application for a government Charter Mark, that
much of the excellent practice expected for a successful Charter Mark
application was already in place and had been so for some time. The culture
of this directorate was organic (Morgan 1997). It was an open system
balancing it’s own perceived internal needs with it’s changing environmental
circumstances. Its individual performance review (IPR) processes were
supportive; developmental and generated SMART (Hersey and Blanchard
1993) goals. It regularly listened to its users about how they experienced the
service. They commissioned audits involving a consortium of disabled people
across the local community about the places where services were provided.
They asked about how staff treated them. They used their service users as a
developmental resource to improve the ways their service was delivered.
Much of their process uses Peters’ (1997) understanding of excellence. They
view every bit of their service though the eyes of their users. In understanding
its phase of life it had reached a greater organisational maturity than much of
the remainder of the Trust.

It is perhaps no coincidence that just as strange animals have developed in

Australasia, isolated from the contaminating effects of the rest of the world;
the processes and structures within this directorate have developed in relative
isolation from any contaminating effects of consultants or nurses. There are
no doctors who have managerial or direct organisational involvement in this
directorate. It is an almost totally doctor-free zone. There are very few nurses
who work within this directorate. The organisational protection from the toxic
effect of the professional bureaucracy inherent in consultant behavior may
have played a very important role in allowing this divergent model to evolve
and grow. The result of this isolation however has left the remainder of the
clinical directorates unchanged. The incongruence of structure and process
between this directorate and other unreconstructed clinical directorates,
where the dinosaurs live, has created difficulty.
.

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