Strategy in practice: inside the NHS

The NHS is a target for much strategising, be it from politicians, management consultants, regional health boards or individual health providers and hospital trusts. A recent and potentially highly controversial initiative is the introduction of the independent sector, specifically ‘CATS’, into the health service. Dr John Mackness and Rosalind Way of the Health Leadership Academy, Lancaster University Management School, explore the intention of CATS, the implications for clinical pathways and delve into the perceptions of those who are in and use the health service and the impact upon health care delivery

Massive resources, external political pressure and internal energy from managers, clinicians and nurses are going into the modernisation of the NHS. Since the NHS Plan came into being in 2000, there are more doctors, nurses and support staff; many facilities have been improved and new equipment purchased. Waiting times have come down and standards have improved.

Lord Darzi of Denham’s next stage review in October recognised the progress that has been made and yet the vision of a ‘world class’ NHS which is fair, personalised, effective and safe continues to many people to be still a good way off. Lord Darzi calls for some immediate steps to stimulate the rate of change including greater patient choice, bringing GP services closer to poorer communities with more flexible opening hours, introducing new providers – ie the independent sector - better procedures to manage standards of care and safety in hospitals, more MRSA screening and greater public consultation.

Our research starts amidst this situation and the perception, amongst six local primary care trusts, that a new way of organising clinical assessment and treatment services (CATS) through participation with the independent sector is a major catalyst in the change process. The six PCTs have commissioned the Health Leadership Academy in the Lancaster Leadership Centre at Lancaster University Management School to find out how CATS is being perceived by clinicians, GPs, nurses and patients and to assess how best, if at all, to involve the independent sector in delivering CATS.

NHS PCTs describe CATS as being “designed to provide additional capacity to help the NHS to achieve its objective of reducing the time our patients wait for diagnosis and treatment. The PCTs in Cumbria and Lancashire intend to commission CATS services from a number of centres throughout the region where patients will receive expert clinical consultation, diagnostic tests and minor treatments.”

Additional capacity will be provided by introducing the concept of a ‘one stop shop’ for diagnostics and treatment services rather than the current situation of several visits to see consultants, have tests and receive advice about treatment.

Our findings to date suggest that far from CATS receiving an easy transition into the health service, the issue is surrounded by confusion, resistance and organisational pre-emptive strikes.

there is no consistency on what CATS is perceived to be by the BMA, clinicians and GPs, some PCT members and especially patients. In addition the key players, GPs and acute trust clinicians, are particularly resistant due to their belief that CATS will introduce discontinuities between themselves and patients.

despite CATS remaining in the planning stage there is genuine and relatively fast change in the NHS and its provision of current, and previously poorly delivered, services. This has been attributed to the threat of the implementation of CATS and its inherent link with the future introduction of the independent sector. The latter is associated with reduction in the need for NHS capacity resulting in the closing of wards and clinics and loss of jobs.

representatives from the independent sector are confused about the Department of Health’s intentions and the amount of services they will be able to provide, seemingly due to the above. Once promised 173,000 treatments they are now being offered 43,000 – the financial viability is not secured.

PCT commissioners remain positive and the introduction of CATS into the area, at the time of writing, is set to go ahead. The potential for CATS to transform current commissioning practices however remains a debateable issue.

So what does this tell us about the processes of formulating strategy in practice within the NHS?

Some suggested areas of discussion and further research are identified as follows:

the threat of a new and potentially challenging strategy such as the introduction of CATS can act as a catalyst for changing existing and often poorly functioning organisational practices and behaviours

once the ‘flywheel of change’ has started turning, creative energy is released and this leads to innovation and new ideas about what might be possible, both within the existing system and potentially any new system

leaders of change should not be tempted to ease the pressure in order to maintain the momentum of change – the threat of CATS will not work twice and, with its imminent introduction, how will this affect change?

change can occur even without, or due to the lack of, clear messages about the processes involved from the Department of Health, PCTs, GPs, acute trusts and patients.

Further research will be conducted into these fields in order to gain deeper insight into the social practices that occur in the context of organisational change in and around the NHS and how these impact upon organisational members and their practices and wider society. The Health Leadership Academy at Lancaster University Management School will undertake this research and evaluate and disseminate findings to a wide audience of academics, practitioners and those in strategy and policy development.