Research Context

This research commenced in 2010, when amidst the context of a worldwide recession (DoH, 2010b), a new coalition government advised that up to £20 billion of efficiency savings would need to be made by 2014 (DoH, 2010a). Referring to this necessity, the NHS chief executive stated that the NHS needed to work towards increasing quality and productivity by ways of innovation and prevention, as the NHS was,

“...about to enter perhaps the toughest financial climate it has ever known,” (DoH, 2009a, p. 2). With this task in mind, the Quality, Innovation, Productivity and Prevention (QIPP) initiative was set up by the government’s Department of Health for the NHS, with the ‘QIPP financial challenge’ aiming to help identify and implement c. £1.4bn of these efficiency savings (NHSI, 2013b). The NHSI designed the Productive Series as part of their on-going work to deliver on QIPP (NHSI, 2013b), and PCS is part of this Productive Series.

The focus of this thesis examines the implementation of PCS in a Community Services healthcare organisation. Johns (2001) submits that in research concerning organisational behaviour, context should be provided on both substantive and methodological aspects. Substantive information concerns the organisation and employees, including the time that the organisation is situated in and the nature of work that employees engage in. The methodological aspect focuses on the author of the research (termed ‘the Researcher’) and how they had access to the organisation. These contextual areas will be described below.

2.1.1 Substantive Context

The organisation under study (under the pseudonym ‘South Astford Community Services’, or SACS) is a Community Healthcare Services organisation in East Anglia, which provides general healthcare

interventions in various sites located across the community, in patients’ homes, and from three community hospitals, providing mainly secondary or tertiary care to patients, and often with a view to avoiding the admission of patients into acute care settings. The organisation serves a population of over 1.9 million people, and has a workforce of over 1,100 staff (SACS, 2012a, Appendix B). A full list of teams involved with the PCS programme is displayed in Table 2 (page 46), however in brief, staff range from district nurses and health visitors, to physiotherapists and smoking cessation advisors. There were 849 staff in the services implementing PCS (SACS, 2012d). These included managers, team leaders, clinicians, Healthcare Support Workers and administrators. The organisation also has a range of support services (for example Finance and Human Resources), however staff in these departments were not expected to implement PCS due to their lack of direct contact with patients.

At the beginning of the study in July 2010, SACS was an organisation within the NHS, so in the

preceding years it had experienced the changes that been mandated through various policies and reforms.

Prior to 2006, its services had been part of three previously existing NHS Trusts, and between 2006-2008 SACS was part of the local Primary Care Trust (SACS, 2012b, Appendix B). In 2008, as part of the

Department of Health’s initiative ‘Transforming Community Services’, where the organisation, as a Provider of healthcare had to separate from the Primary Care Trust Commissioners (DoH, 2009b), SACS became an Arm’s Length Trading Organisation (SACS, 2012b).

Alongside the organisational changes described above, as part of the (now disbanded) National Programme for Information Technology [NPfIT] (see Robertson et al., 2011), and as mandated by the organisation’s Strategic Health Authority (SHA) at the time, SACS had also invested in the electronic records software, SystmOne. A support team had been set up to roll this system out, and this started to be implemented in clinical services in 2008. By March 2011, SystmOne had been rolled out to some extent within the majority of clinical services. One month later, SACS became a Social Enterprise, a Community Interest Company [CIC] in its own right and separate from the NHS that it had been part of since its inception. In March 2012, the PCS implementation concluded, although the semi-structured interviews that inform part of this research took place from April-July 2012.

During this research period also came the publication of the Francis report (see Francis, 2013) following the failings at Mid-Staffordshire NHS Foundation Trust, which challenged the quality of clinical care in the NHS. As noted above, the NHS was also experiencing a time of austerity, responding to David Nicholson’s call in 2009 to release £15-20 billion in efficiency savings between 2011-2014 (Nicholson, 2009), which itself came within the context of a global recession. Also, for the first time in the history of the NHS, NHS organisations started to go into administration (South London Healthcare NHS Trust in 2012, followed by Mid-Staffordshire NHS Foundation Trust in 2013, see ITV, 2013). Although the Francis report and the special administrative measures taken did not occur in the organisation under study, these events and the need for efficiency savings occurred at such a significant and public level that they can be considered as indirectly forming part of the organisational context.

Service Abbreviation

Assessment & Rehabilitation Unit ARU C 1-2 3-9

CareCall D 1-2 3-6

ENT, Audiology & Paediatric Audiology C 1-2 3-6

Falls Prevention D 1-2 3-6

Paediatric Occupational Therapy & Physiotherapy Paed. OT &

PT C 1-2 3-6

Paediatric Speech & Language Therapy Paed. SALT B 1-9 N/A

Palliative Care C 1-2 3-6

Parkinsons Service D 1-2 3-6

Phlebotomy B 1-2 3-6

Podiatry Service D 1-2 3-6

Rapid Assessment Unit RAU B 1-9 N/A

Safeguarding Team, Domestic Violence & Looked After Children C 1-2 3-6

Scheduled Therapy B 1-2 3-6

School Nurses (5 locality teams) SN B/D 1-2 3-6

Smoking Cessation D 1-2 3-6

Specialist Healthcare Tasks & EPIC C 1-2 3-6

Tissue Viability & Lymphoedema C 1-2 3-6

Unscheduled Therapy B 1-2 3-6

Wheelchair Service D 1-2 3-6

Table 2: Teams taking part in the PCS implementation

*Long Term Conditions services included the following teams: Chronic Obstructive Pulmonary Disease (COPD), Oxygen Service, Coronary Heart Disease, Pulmonary Rehabilitation and Heart Failure, excluding Parkinsons

NB. This table indicates the teams as they were dealt with by the PCS Implementation Team, which was generally by service specialism or service. For the purpose of the module assessments, according to the service specialities and the way that service specialities were allocated to PCS Co-ordinators, there were 38 services. If taking all individual and locality teams into account (e.g. counting Tissue Viability and Lymphoedema as two separate teams, and School Nurses as five separate locality teams), there were 62 teams participating.

2.1.2 Methodological Context

During 2009-2010, the Senior Management Team (SMT) at SACS considered applying to become a Social Enterprise, which required them to satisfy the Primary Care Trust and the Strategic Health Authority that they would be able to survive financially as an independent company. In order to help support their case, they felt it would be beneficial to implement PCS to demonstrate that efficiencies were being sought. Therefore in June 2010 they seconded the PCS Project Manager (PCS PM) from within the organisation to start assembling a project team to implement this programme. Two of the PCS Co-ordinators (PCS Co-Co-ordinators ‘B’ and ‘C’) were seconded from their clinical roles within the organisation, while the other PCS Co-ordinator (‘D’) and the PCS Project Officer (PCS PO) were appointed externally. The SMT also used their existing links with the University of Essex and allocated funding for a senior academic (the ‘Project Reviewer’) to provide expert advice to the project, and also a

‘Research Analyst’ to be part of the implementation team, in order to help with the collection of data.

This enabled the Research Analyst, the Researcher, to have access into the organisation. The implementation of PCS was initially financed by the organisation, with reimbursement provided by

‘Commissioning for Quality and Innovation’ (CQUIN) funding which was dependent on certain targets being achieved. The targets (see page 59 and Appendix C) were designed on liaison between the PCS Project Manager (PCS PM), members of the organisation’s senior management, and the CQUIN Commissioners.

2.1.3 Theoretical Framework and Methodology

By taking on the role of Research Analyst in the PCS Team, the Researcher had access to the data generated during the programme, through the various quantitative and qualitative follow-up and cross-sectional studies carried out as required by the implementation. The Researcher was also able to evaluate the process of the implementation by using aspects of Participant Observation, which involved having access to qualitative data generated during the programme, and semi-structured interviews. Using four

elements that help to develop a research study (Creswell and Clark, 2011; Crotty, 2003), the following section will discuss the research paradigm underlying the research, the theoretical perspective taken, the methodological approach and the methods of data collection carried out.

2.2 Research Paradigm