Discussion

The purpose of this study was to explore staff members’ perceptions of an implementation of the Productive Community Services programme, and to examine the implications of their experience for healthcare staff, implementation teams, and commissioners. Previous research on the Productive Series

programmes has identified a bias towards the publication of positive results (Wright and McSherry, 2013), and although there were positive outcomes reported by staff members (see page 91), many spoke about the more negative aspects of the implementation. These were not just in terms of negative outcomes (e.g. SystmOne processes taking longer, see page 99), but in terms of a lack of impact from the

programme (e.g. little impact or no impact, see page 91). Much of the previous research on Productive Series programmes used staff members that were highly involved in or leading implementations (see page 20), and although this study required that team members had taken part in at least one exercise, this was probably the lowest level of involvement criteria that could have been used to be able to draw enough information from participants about the programme. In fact one of the staff members who fit the criteria as she had taken part in the ‘Workload Analysis’ for Module 4 declined to be interviewed stating:

“I would prefer not to be interviewed as I do not know about the PCS programme and other members of my team have not heard about it either.”

Email correspondence from Administrative Team Member 02/05/2012, Scheduled Therapy

If members of staff that took part in a PCS exercise did not know about the programme (and other evidence from the interviews suggested this was the case too, see page 81), then staff that did not have any contribution towards the programme were likely not to have any knowledge of the programme at all.

This suggests that the communication about the PCS programme did not reach all staff, but also that there was either no noticeable positive impact from the programme, or that any positive impact created during this time was not associated with PCS. For managers and implementation teams rolling out PCS or other similar programmes, this highlights that communicating information about the innovation, and about improvements made as a result of the innovation, is important to enable a fair evaluation of the programme’s impact on staff.

For those staff members that did report a positive impact from the programme, such as the saving of time, it was noted during the analysis that none of them specifically reported what this saving of time had enabled them to do instead, or where else this time had been allocated. Wright and McSherry (2014) found a similar problem in their study using interviews and focus groups (see page 21). This again highlights the importance of clearly associating the programme with its resulting impact on staff, but goes

further to suggest that the impact recorded by the implementation team needs to both capture the

efficiency (the time saved), and the improvement (what was done with this time saved). This should help provide a clearer picture of the relative advantage of the innovation (Greenhalgh et al., 2004; Rogers, 2003) so should increase the chances of other staff members, or on a wider scale, other organisations, adopting the innovation.

The subtheme regarding ‘Relevance’ was also described by Bradley and Griffin (2015) who identified a recurring pattern where different types of staff felt that the programme was not relevant to them but might have been to other types of staff, who also felt that the programme was not relevant. By including the PCS Team focus group in this study, this analysis suggests that this lack of perceived relevance was known to the PCS Team, and was attributed to the targets that had been set by the Commissioners (on liaison with the PCS PM and senior management) at the beginning of the implementation that could not be changed. On the one hand this suggests that Commissioners need to be flexible with targets so that if they are felt to be irrelevant for some services the targets can be adjusted, but it also questions whether some generic organisation-wide targets are appropriate for diverse organisations like Community Services. Pay-for-performance targets regarding patient outcomes are often ‘risk-adjusted’ to

acknowledge the variation in patient case-mix (Eijkenaar, 2013). As the data from the PCS Team focus group suggests, a similar process is required when commissioning programmes like PCS. Organisational targets and implementation plans need to be reviewed for each individual service as to their relevance, as otherwise time can be wasted, improvements aren’t made and staff are left disenchanted with the

programme. As NHS providers are encouraged to use commissioned funding for innovations (see NHS England, 2014a), more research into this area would be beneficial.

Organisations also increasingly rely upon Information Technology (IT), and this analysis identified that IT-related issues affected the implementation, not just due to users’ lack of computer literacy which has been documented in the literature (NHSu, cited in McVeigh, 2009), but also due to poor mobile reception in the field, and the increased information documented in SystmOne in comparison with paper notes

(which has also been documented in the literature, see Hippisley-Cox et al., 2003). In terms of

productivity, managers in organisations need to understand the role of IT in efficiency, for example in trying to resolve issues of mobile connection and ensuring computer equipment is adequate for users. In addition, in the context of this study, the PCS PM had a background in IT, and so may not have fully empathised with the clinical staff who mainly perform clinical interventions and use computers very rarely. Although this also highlights the need for organisations to provide appropriate IT training for clinical staff, implementation teams need to bear in mind that if IT is used as part of an improvement innovation, staff may need a substantial amount of support in order to realise the benefits.

Previous research proposes that senior leaders’ support and encouragement is the most important factor in the success of the Productive Ward (National Nursing Research Unit and NHS Institute for Innovation and Improvement, 2010b). This analysis suggested that some managers supported their staff, including using a hands-on approach to help encourage their staff to continue the work. However, there was also a perceived lack of support from management, or staff were unsure of the support from management, which indicates that although managers may have supported the programme, their support wasn’t always

observed by staff. As similarly proposed by White et al. (2013) and Wilson (2009), management support needs to be tangible. This analysis highlights that managers also need to be careful about how they manage the innovation message, as many staff reported that they carried out the programme because their managers had said that they ‘had’ to do it. Although this might be true to a certain extent (and is part of the problem in implementing a programme from the top-down which aims to be led from the bottom-up), implementation teams need to engage managers so that they can see the potential benefits of the

innovation, so that rather than motivating staff to carry out the innovation work ‘because they have to’, they can motivate staff to carry out the innovation because it is likely to have benefit to them and their patients. Again, this can be helped by ensuring that the implementation is made relevant to managers and their teams, and that the implementation team members have the appropriate skills to engage, which was not always the case (see page 86).

The theme of ‘Individual factors’ acknowledges the role that individuals have in an implementation; that their attitudes and behaviours can affect the effectiveness of an implementation, such as being resistant to change. However the Quality Improvement literature suggests that the failure of initiatives is often down to issues within the organisational system rather than individuals (Pollitt, 1996; Walshe and Offen, 2001), and the wider analysis here reinforces this proposition, demonstrating the many other issues with the implementation that were also likely to affect the programme’s effectiveness. Similarly, research suggests that it is not the initiative itself that affects the effectiveness of an initiative, but how the initiative is implemented in the context (Boaden et al., 2008; Kaplan et al., 2010; Powell et al., 2009). A lot of the issues identified, such as the importance of communication (Lewis et al., 2006), the importance of visible management support (Wilson, 2009) has already been highlighted in previous research, which indicates a lack of knowledge transfer (Berta et al., 2005) from the available literature to implementation teams. This suggests that future implementations might be improved by addressing these factors where possible, so that individual staff members have the greatest possible opportunity of engaging with the programme.

This would mean that those who are inclined to change and improve their work are supported by the organisation and innovation to do so, which may in turn help others who are less inclined to change to challenge their thinking and behaviour. As healthcare organisations may increasingly rely on using internal implementation teams to roll out innovations in order to avoid paying external consultants, further research on knowledge transfer to implementation teams would be of benefit.

3.4 Conclusion

Interviews with 45 staff and a focus group with four members of an implementation team were carried out to explore perspectives of an implementation of PCS, and to look at the implications of their experience for healthcare staff, implementation teams and commissioners. Five main themes were identified in the data; Past Experience; The People Involved in PCS; The Process of Implementing PCS; The Impact of PCS; and Other Possible Factors Affecting PCS. Positive impacts of the programme included time savings and more efficient processes. Negative impacts included increased time in using the electronic patient record software, or where there was little or no impact despite the work carried out during the

implementation. However the analysis identified that there were various issues in the implementation that were likely to reduce the effectiveness of the programme, including a lack of communication about the programme, a lack of understanding about the programme, and a lack of perceived relevance. Many of the issues identified are already highlighted in the literature as being important aspects of implementations, which suggests that knowledge transfer needs to improve for implementation teams, and more research in this area would benefit healthcare organisations. Analysis of the PCS Team Focus Group data also

identified that the lack of relevance was at least partially due to the commissioned targets being inflexible, and the way that they were implemented was not relevant to all services. Findings from this analysis suggests that if Productive Series implementations are funded by pay-for-performance schemes, then these targets need to be reviewed as to their relevancy for each service taking part. Future implementation teams also need to focus efforts on engaging managers, so that they can visibly and genuinely motivate their teams to take part in the process, rather than mandating their co-operation.

Contribution to knowledge in Chapter 3:

 The findings suggest that the pay-for-performance targets shape the way that the innovations are implemented, and this in turn is likely to contribute towards staff members’ perceptions of the programme’s relevance

 The findings indicate that communication during implementations of change in community healthcare needs to be improved, so that staff are aware of and understand the innovation, and so that there are clear links between the innovation and its resulting benefits. This should enable fairer evaluation and a greater chance of innovation spread.

 The findings suggest that where healthcare innovations such as PCS or Lean result in time saved for staff, efforts should be made to demonstrate how this has improved care or increased time spent with patients.

 The findings indicate that internal implementation teams require greater support and improved knowledge transfer to implement change, as the change literature already identifies many of the issues encountered.