DOCTORS PERSPECTIVES OF ORGANISATIONAL MERGERS JUNE 2012 MADELEINE KNIGHT
Contents 1. Overview...2 2. Introduction...3 3. Method...6 4. Survey results...7 5. Interviews...9 Clinical leadership and staff engagement...10 Organisational culture...11 Merger into larger organisations...11 Achievement of objectives...12 6. Conclusion...13 Doctors perspectives of organisational mergers 1
1. Overview The concept of integration in healthcare has gathered pace in policy discussions in the UK in recent years. With the aim of gathering doctors views on integration, a BMA study began to investigate this topic with a survey of members in July and October 2011 1. Following the survey, organisational merger was chosen as an area for further investigation as it can be viewed as a mechanism to bring about greater integration of healthcare services. Building on the results of the survey this project (one of three new reports on integration) examines the option of merging organisations for integrated care in more detail. Semi-structured interviews were carried out with a small number of respondents who had experience of organisational merger and a summary of our findings is reported. 1 BMA. Doctors perspectives of integration in the NHS: BMA interim report. 2011. 2 Doctors perspectives of organisational mergers
2. Introduction Definitions of integration in healthcare are broad and describe any activities intended to improve coordination of services around patients and address fragmentation in the healthcare system 2. Integrated care is often referred to as a principle which encompasses patient experience, efficiency, better coordinated care for multiple and long term conditions to reflect the elderly population and rising incidence of chronic disease 3. A strong case has been made for integration as a positive step to improve healthcare 4 5. However, the major question remains how this can be achieved 6. Healthcare services are fragmented for a number of reasons. Commonly due to separation between: Health and social care Primary and secondary healthcare Purchasing and provision of healthcare Integration to address this fragmentation can take a number of forms including 7 : Vertical integration, which brings together organisations providing services at different levels, for example primary and secondary care organisations Horizontal integration bringing together organisations providing services of care at the same level, for example merger of two acute hospitals Virtual integration involving partnerships and networks between organisations to encourage more coordinated working Real integration involving structural merger of organisations Organisational merger may be considered one option to facilitate integrated care 8. This project set out to understand whether real integration or structural merger of organisations, horizontal or vertical, can be an effective mechanism for integrating services in the NHS and whether this is a mechanism that doctors would welcome or find advantageous in integrating services. This is of particular relevance given the current policy context in the NHS points to a greater likelihood of organisational mergers with a variety of aims. 2 Nuffield Trust. What is Integrated Care? 2011. 3 Nuffield Trust. Towards integrated care in Trafford. 2011. 4 G Bevan. K Janus. Why hasn t integrated health care developed widely in the US and not at all in England? J Health politics, policy law. 2011. 5 The Kings Fund. Clinical and service integration the route to improved outcomes. 2010. 6 Nuffield Trust. Where next for integrated care organisations in the English NHS? 2010. 7 Op cit. Clinical and service integration the route to improved outcomes. 2010. 8 Ham, Chris J and De Silva, Debra. Integrating Care and Transforming Community services: What works? Where next? Health Services Management Centre. 2009. Doctors perspectives of organisational mergers 3
Current policy context In England, the current NHS reforms enshrined in the Health and Social Care Act 2012, promote the Government s desire for all trusts to achieve Foundation Trust status within the next three years. It is likely that some trusts will merge in order to meet the requirements for Foundation Trust status. In addition, the current financial situation within the NHS, in particular the Nicholson challenge to recoup 20 billion in efficiency savings by 2015, is a further factor likely to drive mergers in an attempt to reduce costs by consolidating services. The Transforming Community Services (TCS) initiative introduced in 2009, required PCTs to divest themselves of their provider arms, and some of the reconfigurations resulted in mergers. In Northern Ireland, Health and Social Care are integrated. A new Review of Health and Social Care Services 9 was announced in June 2011. The review is examining the future provision of services including acute hospital configuration, the development of primary health care services and social care, and the interfaces between the sectors. Mergers of organisations might be considered in this context. In Scotland, NHS Boards both commission and provide health care. This does not apply to social care. However, projected future demand for elderly care services has added to the desire to achieve greater integration between health and social care and Community Health Partnerships (CHPs), were introduced in 2004 as the means to improve delivery of health and social care in the community. In addition, a pilot is being introduced for NHS Highland in 2012. The NHS board and local authority will both be accountable for deciding the resources to be committed and the outcomes to be achieved for specific services. In Wales, NHS Boards both commission and provide health care, but social care is organised separately. The Welsh Government has committed to reshaping social care services in light of the challenges of rising demand, increasing expectations of quality and a poor financial outlook. NHS Wales and local government bodies will be expected to work together to form coherent, whole-system plans to deliver integrated services in their localities, and deal with the budgetary pressures they face. A key aspect of this exercise will be reducing the number of social services authorities to seven, to match the number of local health boards. 9 HSSPS. Review of Health and Social Care: Transforming your care. June 2011. 4 Doctors perspectives of organisational mergers
Existing literature on integration in healthcare suggests that organisational merger is not necessary or sufficient to bring about integration of services and improve care for patients 10 11 12. In addition, it has been recognised that structural change can have disadvantages 13 suggesting that other approaches should be taken to bring clinical staff together 14 and coordination of care should be the focus, rather than organisational merger 15. These arguments call into question the case for organisational mergers for integration. We decided to investigate doctors views of organisational mergers and the potential for mergers to deliver integration to see if they shared this view. The main research questions were: Do organisational mergers bring about integration of services in the eyes of doctors? What have doctors experienced to be barriers and enablers to organisational merger? What have doctors experienced to be barriers and enablers to integration of services in merging organisations? 10 Op cit. Integrating Care and Transforming Community services: What works? Where next? Health Services Management Centre. 2009. 11 Ramsay A and Fulop N. Integrated Care Pilot Programme: The Evidence Base for Integrated Care. Department of Health. 2008. 12 Burns, L.R. and M.V. Pauly. Integrated Delivery Networks: A Detour on the Road to Integrated Health Care? Health Affairs 21: 128-43. 2002. 13 Op cit. Where next for integrated care organisations in the English NHS? 2010. 14 Op cit. Integrating Care and Transforming Community services: What works? Where next? Health Services Management Centre. 2009. 15 Op cit. Integrated Care Pilot Programme: The Evidence Base for Integrated Care. Department of Health. 2008. Doctors perspectives of organisational mergers 5
3. Method An initial set of survey questions were trialled in a general survey of members in July 2011. Following these initial findings a longer survey, specifically looking at different aspects of integration was conducted in October 2011 16, which included a section specifically on organisational mergers. Building on the results of the surveys a small number (n=7) of semistructured telephone interviews were carried out with respondents who indicated that they had experienced an organisational merger for integration. 16 Op cit. Doctors perspectives of integration in the NHS: BMA interim report. 2011. 6 Doctors perspectives of organisational mergers
4. Survey results The initial survey questions asked in July (n=303) showed that doctors do not find organisational mergers to be a high priority for integrating care. When asked how important they considered various factors to the integration of healthcare services, the most popular options were: 1. Creating joined-up care pathways (53.4 per cent) 2. Shared information technology systems (51 per cent) 3. Shared guidelines and protocols across organisations (48.7 per cent) Merger of organisations was the lowest ranked (13.4 per cent) in the list of factors. However, the factors which came at the top, including shared IT and shared protocols could arguably be more easily implemented through organisational mergers. Analysis of the responses to the October survey (n=369) showed that those who had experienced organisational merger had a negative view of the disruption caused and the relative benefit derived from mergers. Respondents from across the UK indicated that the most important barriers to achieving joined up care pathways were: 1. Conflicting organisational priorities (47.8 per cent) 2. Separation of purchasing and provision (England only) (20 per cent) 3. Lack of coherent information technology systems (19.2 per cent) This suggests that doctors recognise organisational factors to be the most important barriers to integrating healthcare. Such organisational barriers may be seen to be potentially overcome by organisational mergers. Respondents to the same survey found the most important enablers to achieving joined up care pathways to be: 1. Collaborative culture e.g. ethos of shared values (29.9 per cent) 2. Good professional relationships (28.2 per cent) 3. Effective clinical leadership (26.8 per cent) In contrast to the barriers, doctors saw the soft factors including ethos and relationships, which are factors amenable to medical practise as potential enablers of integration. The focus for enablers relates less to the organisational structure. When asked, what their reaction would be if services in their area were merged with another organisation in order to be able to deliver more integrated services, respondents across most sectors (social, secondary/tertiary, community, commissioning) were neutral, and respondents in primary care were mostly welcoming. This does not suggest a particular enthusiasm for merger, but nor does it suggest strong opposition. Doctors perspectives of organisational mergers 7
When asked what their main concerns would be if such a merger were to take place the responses were as follows: 1. Whether the merger would achieve objectives (46 per cent) 2. Competing priorities between the merging organisations (33.5 per cent) 3. Disruption to patient care caused by the merger (19.9 per cent) When asked more specifically about organisational mergers. Respondents were overall neutral to this option. Responses suggested they were open to the possibility of mergers if the intention was to improve patient care, but there was also a degree of scepticism that it may not achieve this. Many of the survey respondents questioned whether there is a genuine need for organisational mergers given that the desired outcome of joined up care for patients can be achieved without the costly and difficult merger of organisations. Instead, many felt that efforts should be focussed on establishing more joined up ways of working, and promoting a common ethos of shared values to include cooperation and pragmatic problem solving. The cost of mergers was queried as an unnecessary expense by survey respondents, especially if it resulted in additional layers of management structure. A number of respondents cited poor previous experiences of merging organisations, resulting in poorer patient care due to the distraction of efforts and time required by the merger. Detracting time and resources from patient care with a potential decline in standards was a commonly cited concern. However, some respondents felt that if a merger occurred for the right reasons with efficient planning and insight, some benefits could ensue. This was particularly noted in light of pooling budgets for health and social care. When asked if they had been involved or are currently involved in a merger of organisations for the purpose of integrating services, the majority (78.5 per cent) had not. There have been relatively few mergers to integrate services in the UK. There is little evidence, and little experience of this among doctors. As few doctors appear to have experienced organisational mergers for integration we were interested to find out more about the experiences of those who had been through mergers in light of its future relevance. 8 Doctors perspectives of organisational mergers
5. Interviews In order to investigate the themes arising from the surveys, the interviews aimed to find out what mattered to doctors about their experiences of mergers. The questions aimed to discover what had been especially helpful or problematic in their experience of the merger, and whether they viewed the mergers to have resulted in greater integration of patient care. Themes investigated in the interviews included communication and leadership, staff engagement and input, relationship building and evaluation. Those interviewed had experienced a variety of different organisational mergers including: mergers of acute trusts, PCT clustering, and mergers of community and acute trusts. In the majority of cases the aim of the merger had, in the view of the interviewee, been to make financial savings and not primarily for the purposes of integrating services. A number of the interviewees questioned the financial argument for mergers and were unconvinced that mergers would reduce costs. However, the lessons from these experiences of merger can equally be applied when considering mergers that aim to integrate services. The interviews indicated concerns around organisational merger in light of continual organisational change in the NHS. A number of the interviewees described a feeling of uncertainty during the process of organisational mergers, which was worrying for staff. Some interviewees saw this to be a result of the constant change of organisational restructures following successive rounds of NHS reforms. The clustering of PCTs only to be followed by a new system of smaller Clinical Commissioning Groups, therefore greater in number, was given as an example. It was felt that a constant churning of organisations is not helpful to the aim of improving quality and efficiency and that allowing time for structures to settle and mature would provide an opportunity for this development. The rate of change is demoralising and you haven t really settled into one job before somebody tells you you have to apply for a job with another organisation Following the experience of a merger, a number of interviewees felt that it takes time for things to settle down. The change to working life was described as particularly difficult for those staff that are moved to a different site. One interviewee described an example where staff were made to feel unwelcome. It is also difficult for all staff to grow accustomed to changes to their working pattern and protocols that may be the case when services are closed or merged. The issue of staff morale was also raised as an issue in situations where the argument for merger is organisational failure. This is felt keenly by staff working in the failed organisation and this description may not be reflective of the trusts clinical activities. Doctors perspectives of organisational mergers 9
Clinical leadership and staff engagement As described in the literature on integration, genuine consultation with all stakeholders including staff, patients and the public is essential to a successful organisational change in order to bring about more integrated services 17 18. There was a breadth of experience across interviewees in terms of the attempts made by their organisations to communicate with and involve staff in the changes occurring during the merger. While most interviewees described some attempt to communicate and explain changes to staff, few had experienced a genuine two-way staff consultation exercise. Some consultation exercises were perceived as tokenistic. Interviewees said: They clearly had a blue print that had to be met and suggestions that didn t fit it were ignored There were a couple of meetings where people came and told us what was happening In most examples discussed, clinical leaders, such as medical directors were involved in the implementation of the merger. Those in formal leadership roles that were interviewed felt more comfortable with the degree of input from clinical staff. This may indicate a difference between the experience of those in direct communication with trust management and in an influential role and doctors on the ground that may feel relatively disempowered. However, in some examples it was felt that although doctors were involved in decisions, they were under pressure to work within a narrow framework. For example, one interviewee described how due to time pressures and top down directives they felt the care pathways they were involved in designing were not ideal. This suggests that consultation with staff should take place from the beginning of the process to allow meaningful input and genuine two-way communication should invite and consider the views of staff before decisions are made. The need for clear career paths to lead to clinical leadership roles was mentioned by a number of interviewees corroborating findings from other BMA research 19. The requirement for doctors to 17 Ernst & Young, RAND Europe and the University of Cambridge. National evaluation of the Department of Health s integrated care pilots. 2012. 18 Op cit. Towards integrated care in Trafford. 2011. 19 BMA. Doctors perspectives on Clinical Leadership. 2012. 10 Doctors perspectives of organisational mergers
maintain a certain amount of clinical practise in order to retain GMC registration was mentioned by two interviewees as a restriction on the amount of time doctors can commit to medical leadership roles raising concerns that this may be a limiting factor in clinical influence. Organisational culture Some interviewees described clear differences of values, and expectations, between organisations that merged. Interviewees mentioned that responsibilities varied across the same roles in different organisations, and that cultures differed with regard to access to services. It was felt that doctors that were moved into new organisations took a while to get used to how things are done in the new system. However, it was felt that these cultural differences settle over time, both differences among staff and between management styles. There was an impression that staff that are moved into a trust were expected to take on board the host trust s way of working, some described this as the dominant trust taking over. Despite none of the interviewees having received any training or formal activities to integrate staff from different organisations, more than one interviewee mentioned a feeling that doctors pull together to make things work and that this informal relationship building ultimately ensures services run effectively. This indicates the need for organisational stability to allow the values and relationships that are so important to joined-up working to develop. Merger into larger organisations A number of interviewees mentioned the larger size of the new/resultant organisation pointing out that communication is less effective in large organisations. This can affect both the communication between hospital management and others where clinical staff are communicating with colleagues on different sites. Logically, it was felt that communication is particularly difficult where sites are far apart. Merging trusts can also produce a feeling of disenfranchisement and reduced professional autonomy among staff. This is particularly true where services are reduced to simplified arrangements, it was felt that already underfunded or undervalued services are particularly at risk of being sidelined. One interviewee who worked in a service that was merged into a larger organisation said: I think it s a de-professionalisation and de-personalisation of the job. I now feel like someone who turns up, does the job and leaves again, I don t feel any loyalty to the trust to do anything extra for them when previously I would have done when I felt we owned the services and wished to develop it Doctors perspectives of organisational mergers 11
Some positive aspects of larger organisations were noted, however. Larger departments mean that a broader range of specialities are represented and reduces the need to refer patients outside of the department. In addition, better rotas, and less time on call were mentioned. Achievement of objectives Those that experienced mergers that were not aimed to improve integration of services did not feel that any improvement had been made in the integration of services. They were also not convinced that the objective to improve the organisations finances was achieved by the mergers. Those describing experiences of integration that had occurred in order to integrate services, between acute and community care, for example, found that this had been successful in improving the service for both patients and the doctors working in those services. 12 Doctors perspectives of organisational mergers
6. Conclusion This project set out to examine doctors views of organisational mergers in light of the potential for this to help integrate healthcare services. The current policy context across the UK suggests that organisational mergers are more likely to happen in the future. However, the literature on integration suggests that mergers are not necessary or sufficient to bring about integration of services. In order to investigate doctors views we conducted surveys and interviews to gain a greater understanding of their experiences of mergers and the potential of mergers for integration. The findings of both the surveys and interviews indicate that doctors are sceptical about the potential for mergers to bring about integration. The main concerns raised identified the disruption caused during mergers, and that this may not bring the hoped for benefits to patients. The anecdotal evidence shows this was the predominant view of those that had experienced mergers which were not implemented for the primary purpose of integration and situations in which integrating care was the main aim. The two interviewees working in integrated organisations that combined care across the acute and community sector and health and social care were more convinced of the benefits. This suggests that if integration is a purposeful aim there is more potential to achieve improvements in integrating care. Where future organisational mergers are considered, whether the primary objective is integration or not, consideration should be given as to how services can be better integrated by the merger. These findings suggest that doctors largely agree with the literature that suggests that mergers in themselves are not sufficient to cause integration. However, there may be benefits from integration if this is built in as an objective for the merger. Doctors descriptions of negative experiences reported in both the surveys and interviews are a clear sign that there is work to be done in ensuring that merging of organisations does not alienate the medical workforce. In doing so, this could damage services, and possibly act as a barrier to integration. A number of the experiences mentioned in the interviews could give this impression, such as lack of ownership, lack of consultation and input to changes in services, and difficult relationships between staff moved onto new sites. It is important that lessons are learned from previous experiences of organisational mergers and attempts to integrate services. None of the interviewees had been aware of an evaluation of the merger activity in their organisation. Even after accounting for our small number of interviews this is a worrying finding. If organisational mergers are to become more common, to meet with the aim of integration or in order to implement other policy measures, proper evaluation is essential in order to learn from previous experiences. Doctors perspectives of organisational mergers 13