Using the classic division of resources into information, finance, people (in this case staff); plant and equipment as a classification system participants' comments on the resource implications provided further insight into participants' perceptions of the impact structure has on the organisation. No participant addressed the information, finance, staff and plant and equipment implications.
Did/could not answer the question
2 (3.27%) participants did not answer the question
1 0 .63%) participant felt they could not answer the question
Information
1 ( 1 .63%) participant commented (indirectly) on information as a resource:
Significant resource implications for information training and so forth [50]
Finance
Management/top level structure
5 (8. 1 9%) participants commented on 'management or top level' structure: Evaluated by percentage cost of the management structure [4]
Considerable reduction in the amount of resources going into management [ 1 5] The resource implications are quite huge supporting an infrastructure and significantly higher remuneration at top level [23]
There 's too much money going into the management structure and not enough into the workplace [37]
Financial issues
5 (8. 1 9%) participants referred to financial issues:
If you put in another layer by definition you have a cost increase [ 1 1 ] It's supposed to be cost neutral [ 1 4]
We might get savings out of this [ 1 6]
The overhead costs don 't seem out of line but it has a lot duplication in it [22] I don 't think it's any cheaper than the last structure [48]
Primary driver
2 (3.27%) participants referred to finance as the primary driver:
It 's essentially a money game rather than efficiencies in medical practice [3 1 ] It's all dollar driven [36]
Staff
Skilled Staff
4 (6.55%) participants referred to difficulties obtaining skilled staff:
There 's a five year gap of not having people [nurses] prepared [with knowledge and experience] [2]
We are going to need more nurses skilled in [X] care [ 1 3]
There is difficulty attracting a sufficient breadth of good staff [22] [There is an issue] with finding enough people with skills [40]
Management Iclinical
4 (6.55%) participants commented on numbers of management and clinical staff: Corporate and commercial levels have shrunk in proportion to all [3]
It 's important not to have too many managers [6]
Proportion of management to clinical staff. They were weighted heavily at the management end [7]
It downsizes-actually right sizes-the organisation. There are fewer managers, greater accountability; multi-skilling [35]
Decreasing numbers
2 (3.27%) participants commented decreasing staff numbers: When staff have left they haven 't been replaced [ 1 9]
There is considerable pressure on keeping staff numbers down and I think that is counter productive [6 1 ]
Plant and equipment
The computers are breaking down all the time. We need computers and we need them to work [5]
Duplication
7 ( 1 1 .47%) participants commented on duplication:
There are issues around the division into services e.g. how to get a helicopter view, the duplication of resources and things falling through the gaps [ 1 7]
It leads to a lot of duplication and also no cross fertilisation [ 26]
Much greater probability of re-duplication of effort because it is so de-centralised
[44]
Lots of duplication of everything [47]
Duplication. If you look at it overall it 's the same. Different names tweaked differently. More bureaucracy [59]
Developed a silo effect where every service is responsible for its budget and their dollars and won 't share [58]
Geography
3 (4.9 1 %) participants commented on the influence of geography: Geography markedly influences structure and in turn costs [9] There are resource implications in having multiple sites [ 1 8] It requires additional travel [43]
Remaining
We 're still going through the process. There was a sort of added bureaucracy [ 1 ] I find it unwieldy. Unless we do something about it [a problem with medications] ourselves it doesn 't get resolved [22]
Personally the resource implications are phenomenal. The structure creates an enormous workload [27]
It's important not to overload managers [52]
Huge implications. It 's not that people don 't try. It 's because they 're not sure perhaps of what they should be doing [53]
1 participant felt there were no resource (staff) implications-None [54]
Some answers were irrelevant e.g. I think the RHA and such like are a waste of money, or compromised anonymity.
Only one participant made reference to strategy.
Other comments made by participants
Other comments by participants which were not specifically answers to the previous questions but which include reference to the structure include:
Workforce related comments
6 (9.83%) participants made workforce related comments:
There are fundamental issues that have to be addressed with nursing workforce. The clinical people have very little management experience [2]
My role is sort of constantly changing [3 1 ]
I discovered a couple of weeks ago that I am not actually under her [manager]
There 's been so many changes [33]
I don 't report to anybody. No-one. I suppose in theory I report to her but we work as a team [37]
You feel so very vulnerable in middle management. You 're sort of between a rock and a hard place [38]
In between restructuring they don 't actually allow people to actually express how they feel [48]
Time related comments
5 (8. 1 9%) participants made time related comments:
It took three months to get the structure into place [3]
I don 't think anyone wants to quantify the time spent in focus group interviews, the meetings, the questionnaires [7]
It 's taken time for people to define and I guess grow into jobs [30]
Over the years I can see we have evolved back to a charge nurse situation [in the wards] [32]
They change monthly. You can 't keep up with it. They [managers] all go home on Friday night [36]
The influence of contracts
3 (4.9 1 %) participants commented on the influence of contracts:
I rather suspect that the method of purchasing is starting to dictate how services are provided and that 's not always in the best interests of care. Its absolute death to
innovation in terms of services modelling [2]
Our's [service] is pretty much guided by our contract with the RHA [23] The structure doesn 't fit the contracts which go across services [52]
Practical problems
2 (3.27%) participants commented on practical problems:
If we have an unresolved problem that crosses services it gets lost in the system {21] I have a budget but I'm dependent on others [outside their control} doing their job well to balance my budget [42]
Other
I don 't believe any restructuring that has gone on has actually altered the way the work gets done [7]
I think we are losing the good with the bad in this constant revamping. I don 't think we are taking adequate time for analysis [29]
The implementation has been appalling [44]
It has become very fragmented and people are inclined to forget how inter linked services have to be [47]
We had the impression that there was no structure at all. It [old structure]was completely decimated [6 1 ]
Financial imperatives and the problem of duplication are clearly identified. [It should however be remembered that at the time of the interviews service management with its inherent duplication of resources predominated. Since that time duplication has been generally recognised as a significant problem.]
With some exceptions (travel and some concern about the supply of appropriate staff) the downstream consequences of putting a particular structure in place do not appear to be appreciated. With the exception of the comment about computers there is no reference made to plant or equipment. The failure of participants to clearly identify the resource implications of implementing a particular structure is important in light of current staff shortages.
The structure of a eRE has significant implications for patient care, efficient and effective staffing, managing the budget and the maintenance and purchasing of plant and equipment. The structure must mesh with health personnel legal and career
requirements and be congruent with contract requirements and health sector education structures. Many eRE services operate 24 hours a day 7 days a week and a number of eRE services are provided at a distance from the main eRE base. These and other factors make the design, implementation and evaluation of the eRE structure a difficult and complex task.