SEDIMENTED ARCHETYPE CHANGE IN PUBLIC SECTOR ORGANISATIONS The Example of Managed Clinical Networks

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SEDIMENTED ARCHETYPE CHANGE IN PUBLIC SECTOR
ORGANISATIONSThe Example of Managed Clinical
Networks for Cancer

• Rachael Addicott
• Centre for Public Services Organisations
• rachael.addicott_at_rhul.ac.uk

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OUTLINE

• Context New Labour and Modernisation
• Managed clinical networks for cancer
• Case study findings
• Network governance and accountability
• Sedimented archetype change

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HISTORICAL CONTEXT OF THE UK PUBLIC SECTOR

• Bureaucratic hierarchy
• General management (Griffiths, 1983)
• Command and control
• Individualised performance management
• Internal market
• Division of purchasers and providers
• Dictated competition (LeGrand et al, 1998)
• Weak incentives and motivations (quasi market)
• Election of New Labour

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NEW LABOURSMODERNISATION AGENDA

• Loose term for a range of reform strategies
• Internal market was abolished
• Collaboration between purchasers and providers
• Modernisation Agency established in 2001
• Joined up government
• Further growth of performance management
• Commission for Health Improvement (CHI) and
  National Institute for Clinical Excellence (NICE)
• Legitimises a range of conflicting reforms

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MANAGED CLINICAL NETWORKSFOR CANCER

• History of poor clinical outcomes
• Ineffective communication between professionals
  and organisations
• Managed Clinical Networks (MCNs)
• linked groups of health professionals and
  organisations from primary, secondary and
  tertiary care working in a coordinated manner,
  unconstrained by existing professional and
  (organisational) boundaries to ensure equitable
  provision of high quality effective services
  (Edwards, 2002 63)

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CANCER POLICY DEVELOPMENT

• 1995 Calman-Hine report
• 1997 Election of New Labour
• 2000 NHS Cancer Plan
• 2000 Manual of Cancer Services Standards
• 2001 Modernisation Agency
• 99 NICE Improving Outcomes Guidance

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METHODOLOGY

• Comparative case studies of five London MCNs
• Interviews (117)
• Documentation
• Observation (urology and gynaecology)
• Tracer issues
• Centralisation of specialist services
• Budget and resource allocation
• Education and training activities

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CASE STUDY FINDINGS
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NETWORKS AND ACCOUNTABILITY

• Network Boards
• Sign-off and limited strategic control
• Traditional cast of players
• Strategic Health Authorities
• Localised performance management
• Department of Health and NICE
• Performance management
• Structural reconfigurations

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MIXED MODEL OF GOVERNANCE

• Competing policy initiatives undermine initial
  intention of networks
• Foundation Trusts
• Patient choice
• Non-transformational change
• Dominance of NPM framework

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TRACKS OF ARCHETYPE CHANGE

• Archetype (1) formal structure, (2) system of
  decision-making and (3) underlying interpretive
  schema
• Tracks of archetype change
• Inertia
• Aborted excursions
• Unresolved excursions
• Successful reorientations

Greenwood, R Hinings, C (1988). "Organizational
design types, tracks and the dynamics of
strategic change." Organization Studies 9(3)
293-316.
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ARCHETYPE CHANGE IN THE NHS

• Emphasis on formal structure
• Limited focus on systems of decision making
• No change in underlying interpretive schema
• Multiple and incomplete archetypes
• Partially formed
• Overlapping
• Conflicting

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SEDIMENTED ARCHETYPE CHANGE

• Enduring archetype hybrids
• Sedimented change (not transformational)
• Layers of different archetypes
• Unsuccessful de-coupling from previous
  orientations
• Contradictory and competing characteristics

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CONCLUSIONWHY DOES A HYBRID STATE ENDURE?

• Complexity of the public sector
• Constraining accountability and bureaucratic
  governance
• Combination of state command and control and
  medical dominance
• Externally driven change no internal motivation