Organisational resistance

Knowledge underpinning the implementation of an innovation is not necessarily objective but socially constructed within an organisation or system (Greenhalgh et al., 2004). As mentioned in Chapter One, underlying cultural values have historically shaped the trajectory of health system reforms in New Zealand (Aston & Tenbensel, 2010). Organisations are cultural identities, how the social construction process influences change requires greater understanding (Davies, Nutley & Mannion, 2000). It is this culture within a social system that determines system readiness. Harvey and Broyles (2010) agree that the strength of organisational culture should not be underestimated

and that challenging traditional cultures can be difficult. The more the balance between the risks and benefits of an organisation reflect an organisation’s established power base, the greater is the likelihood that the innovation will be implemented (Greenhalgh et al., 2005). This section of the chapter explores the possible causes of organisation resistance across Tairawhiti.

Devlin, Maynard, and Mays (2001) state that while structural changes and changing laws may create a new ethos; they serve to distract attention from making change at a service level, especially if the issues are not structural. People may get embroiled in the process of change, hoping that all deep seated issues will be resolved by the changes taking place. As the following manager suggests, the foundations of a system must be robust for primary health care change to occur:

We still haven’t got the foundations strong and we are going to keep changing things at a higher level than thinking about the patients, getting it right for them and then building on it. I think the reality is far from equitable, and I think because the foundations of what is quite shaky still, I do have trouble with the next steps. I believe you should sort out the first steps and then build on changes and new initiatives.... I don’t believe the basics have ever been fixed. (I.3, p.1)

This excerpt suggests that the funding and employment model across the health system in Tairawhiti was not conducive to a primary health care approach. Making minor changes did not supersede traditional approaches to health service delivery. Greenhalgh et al. (2005) confirm organisations provide different contexts for innovation and it is the structural as well as cultural features which influence the likelihood of success. Organisations with a better receptive context for change are better able to assimilate innovation (Greenhalgh et al., 2004). The social dimensions of change and the characteristics of the people who make up that social system cannot be underestimated (Rogers, 2003). Tradition for example, has a significant part to play in the way health care systems of a country are shaped (McMurray & Cheater, 2003). The Primary Health Care Strategy challenged the traditional health care system in New Zealand. Institutionalisation can also be seen as the

enemy of change as it is said to bring stability and thus raise resistance (Burns & Scapens, 2000).

For the decision-makers, the Primary Health Care Strategy confronted DHB priorities. Secondary care dominated both the agenda and expenditure in all Tairawhiti DHB Board minutes. The Chief Executive, quality and employment, technical, financial, funder and governance reports which feed into these meetings, were predominantly hospital focussed. This is despite the fact that the provision of secondary care services does not equate to the largest health care gain for communities, although it does consume the largest portion of the health spending.

Lack of visible primary health care activity supported the generalised perception that the DHB looked after its secondary concerns first, as the following manager’s comments suggest:

I think a lot of that funding is held onto by the DHBs. (I.1, p.2) I think our funders, I don’t think that they understand or have a full commitment to what primary health care does. I think they are actually more focused with secondary care services. (I.1, p.11)

I think the challenge will be around the mind-set, around evolving primary health as a core function of health like you know all you get is hospital, hospital, and hospital. (I.9, p.1)

There was some misunderstanding in the meaning of the title District Health Board. Rather than understanding a DHB as the entity charged with keeping a district or regional population well, community based participants saw the DHB as synonymous with the hospital provider arm. In fact, the combined purchaser-provider function did encourage the use of hospital services first (Mathias, 2009). Gauld (2009a) states that secondary care remains under DHB control, but it becomes problematic when increasing funding constraints force the financial focus on maintaining crucial hospital services. Still, DHBs are responsible for meeting the health and disability needs of their entire geographically based communities (Cordery, 2008; MoH, 2007a).

The MoH did show tolerance of short-term teething problems and allowed flexibility during the transition period (MoH, 2001). This was to enable each DHB to develop initiatives to suit the unique needs of their district. At the same time, this flexibility legitimised minimal change. Flexibility allows for reinvention, refinement or modification to suit the needs of the adopters (Greenhalgh et al., 2004). Instead of focusing on the individuals changing, the diffusion of innovation theory explains change as being the evolution of products or behaviours so they become a better fit for an individual or group (Robinson, 2009). Limited primary health care activity supported the notion that the DHB instigated actions based on what met their own needs:

I think they (the DHB) only used the bits of the Strategy that fitted in with what they like. Because it is broad enough that you could have had any number of focuses and it would have still have the Strategy intent. (I.5, p.5)

When the government gave a directive to the DHB they responded, but only to the extent required to report on that activity. For example, each DHB was required to look at devolving services to primary health care. Devolution was mentioned in a number of the DHB district annual plans:

TDH has indicated in its District Services Plan that areas of secondary care that could be provided in primary care will be assessed and, if appropriate, will be shifted to PHOs. A report on the process to identify those areas will be prepared by the end of 2003/04. Therefore 2004/05 will be a year for acting on these changes (TDH District Annual Plan, 2004/05, p.32).

This was updated in the 2005/2006 District Annual Plan where it states under a heading ‘Ensuring Primary Care Services are in the Best Place for People’:

TDH has developed a draft tool for assessing and evaluating the best place for primary care services. The tool will assess and evaluate TDH Provider Arm primary care services that may be better placed in the PHO environment. A working group will be formed to identify services that may be shifted. The group will evaluate the risk to TDH Provider Arm and ensure capacity in the PHOs to take on the management of any transferred services (TDH District Annual Plan, 2005/06, p.54).

Devolution was again reinforced in 2009 when DHBs were asked to provide plans for shifting some secondary services to more convenient primary care settings as part of the district annual planning process for 2009/10 (PHCS Implementation Programme, 2009). This was confirmed by the following manager:

One of the Minister’s desires is to see more services that he would perceive to be hospital based services to be delivered in primary care closer to patients. (I.4, p.15)

In a subsequent summary report, only two items were identified for devolution in Tairawhiti: minor surgery which was later discontinued and post-acute pulmonary and cardiac rehabilitation which was already occurring in the community setting (PHCS Implementation Programme, 2009). A claim from one of the TDH managers suggested that devolution of services was not a simple process, especially for smaller DHBs such as Tairawhiti:

You know one of the other things that we’ve got to do and it’s going to be more tricky for us here than it will be in Auckland or you know in bigger centres is the whole integration of things like district nursing into, not into but with primary care. I think that is something that needs to be thought through. What is the model that will work for Tairawhiti? Because I just cannot see the district nursing services being broken up between the two PHOs. (I.4, p.15)

Consequently, compared with other DHBs, the proposal for devolution in Tairawhiti was meagre. The DHB was accused of being selective in its commitment to devolution by other non-DHB managers:

I think a lot more services could be devolved. I think the movement has really only happened you know, with the devolvement of services put there in the last couple of years. (I.1, p.2)

I would personally like to see district nursing and public health come right out of the hospital because I think they actually belong more in primary care. I think the long-term conditions centre shouldn’t be up at the hospital because most of that stuff is primary health care based. (I.7, p.13)

To conclude this section of the chapter, the Strategy required a change in traditional thinking. This resulted in organisational resistance demonstrated by inactivity in implementing system-wide change. At the same time, the DHB was charged with providing essential hospital services and thus accused of looking after their secondary interests first. There were multiple layers of opposition and the resistance exhibited by GPs is discussed next.