High turnover of managers

A further contextual influence was the number of times the IPCCs’ manager changed. In the four years between the role being introduced and the action research study ending, the IPCCs had five different managers36_.

When the role was first introduced in 1996, the IPCCs were managed by the directorate’s senior nurse. After a few months, their management was reviewed and taken over by the directorate’s two operations managers (who job-shared the operations manager role).

My field notes reflect that in 1999 the whole Trust restructured its management arrangements and the operations manager posts were eliminated. Two months before the proposed restructuring took place, both operations managers left the Trust to take up new appointments and an interim operations manager was appointed until the new management arrangements took effect. The senior nurse initially held the interim post until the official interim post-holder took up post. Following extensive debate about who would be best to manage the IPCCs in the new organisational structure, it was eventually decided that the MED senior nurse (who had also served as the first interim operations manager after the original operations managers had left) would manage the IPCCs. By this point in time, this (senior nurse) post was held by a different individual to the one who had originally managed the IPCCs. As the organisational restructuring had also included an expansion of the directorate to include accident and emergency and the specialist medical wards, the senior nurse post now had a wider remit than previously. At the close of the study, this senior nurse left the NHS and the IPCCs were about to take up their sixth manager in four years.

Given the high turnover of managers, it is perhaps no wonder that the need for examining the implications of the role shift was not taken on by any single

individual. As a manager, it must be difficult to stand back and take the long-term

view if you yourself have not been in post for long and are continually responding to shorter-term priorities.

While two of the managerial changes could be accounted for by thoughtful review of who would be best to manage the IPCCs, it is clear that most of the disruption to the IPCCs’ management was a result of the wider organisational restructuring initiated by the Trust board in 1999. Some data were gathered on the rationale behind the Trust boards’ thinking and these indicated that the board was aiming at a greater devolved autonomy at clinical level.

The Trust’s view is that they are making these larger groups have more autonomy. All the directorates are going to have their little trust boards with these big nice units under them, and they will be autonomous. (Manager, 27049, Int)

However, in spite of the board’s intentions, these findings reflect that the process and outcome of these changes had a significantly detrimental effect on the ability of this directorate to keep a long-term reflective view on issues of service quality. Interestingly, managers who had been in post for longer than average made two of the most significant changes in the action research study. Early exploration phase interviews with social workers had identified that social workers had concerns about the IPCC role and felt that social work goals with patients were not well understood by directorate managers who seemed focused entirely on discharging patients quickly. The operations managers set up and facilitated meetings with social workers that led to a general improvement in relations between the directorate and the social work department. This was evidenced also by a

noticeable improvement in the quality of relationships between individual IPCCs and social workers.

While carrying out the observation work in August 1999, I was struck at the positive relationships between the IPCCs and their social work colleagues. Social workers frequently dropped into the IPCC office to exchange information or discuss a client. Interactions were warm and friendly, and there seemed a genuine trust in and reliance on what IPCCs did. (Field note extract, 18112: 1-4).

The work to achieve this change took place early on in the action research study before the operations managers had left. By that point in time, they had worked in the directorate for three years (although had not managed the IPCCs for that long) and were anxious to improve relationships with social work, in part to help speed

up patient throughput. Issues about training, regulation and supervision emerged later in the study after the operations managers had left the organisation.

The second significant change that was made was the change in the organisation of medical teams to a ward base in order to improve opportunities for

interprofessional working. Study findings during the exploration phase had identified that the IPCCs were making up for a mismatch in the way

interprofessional care was organised. While nurses and physiotherapists were ward-based, medical teams organised their input and patient allocation differently. This often meant that each ward had patients from up to twelve medical teams. Social workers attached themselves to medical teams rather than ward bases. These differing forms of organisation meant there were no coherent

interprofessional teams with stable membership. This led to instances in which, in the weekly interprofessional team meetings, one of which was held for each medical team, were officially attended by nurses from a number of wards. In practice, nurses were often not represented at all.

The raising and consideration of this issue during the study led to a change in the organisation of medical teams. The directorate’s clinical director who, by the end of the study, had been in a senior clinical management post in the directorate for nine years led this change. By the close of the study, the findings had persuaded her that organising the medical input to the wards in a different way may enable closer working relationships between doctors and nurses in particular, and facilitate the attendance of nurses at the weekly interprofessional meetings37_.

I went to the directorate meeting this evening at which [the clinical director] successfully persuaded her medical colleagues to ward-base the medical teams. There were some concerns that the change might narrow the range of experience some junior doctors get, or that some wards might end up with all the ‘heavy’ patients, but once a new system for allocating patients admitted to wards and medical teams had been agreed, most doctors there were willing to trial the idea if there was potential for improving interprofessional working. (Field note extract, 03041: 1-8) The clinical director admitted that the turnover of managers had been disruptive, and contrasted with her ability to keep some things going, because she had been in post for longer.

I think during the first year [of the study] the main change was the loss of the operations managers which was scheduled for October 1999 anyway, but happened around May 1999, and then we had a summer where things were slightly disjointed with nobody in the role, and then [the later head nurse for directorate] acting into it but she couldn’t actually contribute a lot. Now [the senior nurse] has been put in a more key role as the face of the service which she’s done very well. And I have continued as lead clinician, so there were various things that I was involved in that are continuing seamlessly. I think we haven’t lost impetus as a result of these changes but I think we’re standing still a bit. (Clinical director, 06060, Int) These findings illustrate how the high turnover of individuals managing the IPCCs meant that a reflective approach to managing the role based on a long-term

understanding of the issues that had emerged was difficult to achieve.

In summary, the findings have highlighted a number of features about the context in which managers operated which made it difficult to be reflective and proactive about the IPCC role. The existence of multiple pressures, of top-down targets including the need for acute efficiency and a high turnover of managers had constrained managers’ ability to attend to the role once it had been introduced and was seen to be successful and contributing to acute efficiency.