The question of improving efficiency in health organisations has come to occupy an important intellectual and practical space in the modernisation process of the National Health Service (NHS) in the UK. Issues concerning service integration, multi‐disciplinary and interagency working, and patient empowerment are increasingly important. These not only challenge the ways in which managers and clinicians work but also the taken‐for‐granted relationships between health care providers and their clients. A new culture and new relationships will have to be established in response to the rapidly changing environment of the NHS. Effective organisational leadership and team‐working are mechanisms central to a modern health service. Partnerships and collaborative involvement with various internal and external organisations are part of the new cultural change. In Organisation Development in Health Care: Strategic Issues in Health Care Management, Rushmer and her colleagues bring together a group of scholars and practitioners from a wide variety of disciplines and service specialisations to explore these aspects of organisation development from different perspectives.
The book is divided into four main sections. Section 1 consists of three chapters. The first two chapters outline the development of primary care in the UK, raising the issues of new partnerships required for new organisational structures and purposes. The third chapter attempts to address the issue of leadership in ensuring organisational effectiveness within a changing environment. Section 2 covers developing teamwork and interdisciplinary education. Examples of these are given across different geographical settings, i.e. Scotland, British Columbia and England. Section 3 is primarily about leadership on different levels and settings. Section 4 provides interesting insights on different forces of influence on future trends in health care.
Section 1 begins with a chapter by Benson and Wright, who outline the development of primary care through the late 1990s, in which fundholding practices evolved into Primary Care Groups. Although the chapter successfully illustrates the complex partnerships required in the new structure of one particular PCG, it misses the opportunity to explore the conflicts that emerged from the broadening of membership in the new organisation. However, this chapter does offer readers some insights into perceptions of the PCG board members. Indeed, one might expect such perceptions to be commonly held among members of newly formed Primary Care Trusts. In particular, issues such as teamwork and the inhibiting and facilitating factors identified for the development of collaborative relationships between primary care and local agencies, may still be relevant today.
Stephanie Williams provides an account of the setting up of Local Health Groups in Wales, and offers a view to the way in which primary care is being organised in the Welsh context. Echoing Benson and Wright, Williams’ study alludes to the conflicts and mistrusts that existed between general practitioners and their perceived managing organisations i.e. Local Health Groups. Some of the issues raised are similar to those in the previous chapter. Williams has identified a number of potential problems facing the new LHG, and offers clinical governance, leadership and public involvement as solutions to these problems. However, she presents these as if they were themselves without conceptual and practical problems. Indeed, at times one has the impression that managers are perhaps too ready to prescribe solutions to intractable problems. Philips, Nyumbu and Toner in the following chapter present their study on the adaptive capacity of leadership in practice. They outline a development programme, aimed at developing the adaptive capacity of leaders. They define the term adaptive capacity as a capacity to handle change by seizing opportunities and to determine the future within the constraints of NHS funding and DoH directives. This programme was designed and delivered by the staff themselves, and the programme was said to have been successful. Although this chapter is interesting, it lacks a critical edge. It is difficult to believe that there were no problems in developing people from such diverse backgrounds.
In Section 2, Rushmer, Parker and Phillips report on a project carried out to improve the performance of primary care teams through developing self‐directed primary care. Although the authors mention empowerment, there is no description of how such a process occurred. Although in the evaluation study some issues are raised about the development of leadership, there is a lack of exploration of the concept of empowerment and what it means in professional practice. In particular, there is a lack of analysis of power relationships internally and externally to the primary care teams. This uncritical analysis has led these authors to attribute mistakenly the “failure” of empowerment to the conflicts and tensions that exist between local innovations and central directives, thus providing a pessimistic outlook on the potential of empowerment. They conclude: “…it became obvious that to preserve integration between the teams in the NHS and conserve coherence and consistency in service delivery, empowerment had its limits” (p. 57).
Wyness and her colleagues provide a well‐balanced chapter on inter‐professional education. The chapter gives a clear description of the process by which the inter‐professional course was established and offers a critical analysis of its effectiveness, thus providing readers with valuable insights into the dilemmas that preface learning across professional boundaries. Downes and Sayers report on a new Primary Care Liaison Service in which G grade nurses were appointed to work across five Primary Care Groups. Attached to practices and working with GPs and their teams, these specially trained mental health nurses help primary care teams to identify, diagnose and treat mental health problems in elderly people. Working in the primary care context, these nurses have expanded their role to include assessment, training, health promotion, networking, and auditing, as well as giving advice and support to professionals in mental health issues. This chapter gives a good account of how the Primary Care Liaison Service has been developed and how mental health nurses have become a part of a primary care team.
There are five chapters on leadership in Section 3. All but one is concerned with the development of leadership at board level in the primary care in the UK. Bussell and colleagues examine the roles and function of board members of a Primary Care Group and identify corresponding managerial training needs. Other perspectives on leadership covered include effective leadership styles (Palmer), strategic leadership emphasising system complexity (Jumaa and Alleyne), and a Costa Rican ’s experience of developing a training programme for middle‐level health managers in managing sustainable health and information systems (Rojas, Haran and Marr). However, in Rojas, Haran and Marr's chapter, while they acknowledge the critical issues in evaluation and provide some useful ideas of how a training programme can be evaluated, their approach to evaluation with the use of experimental method requiring matching control groups may not be so easily applied in the day‐to‐day working environment of the NHS. Currie and Procter's chapter on the role of middle managers reveals an interesting dimension in the current theory and practice surrounding the concept of leadership. The structure of the hospital setting in which the study was carried out, was most interesting. The case study focuses on the Theatres Project carried out by a group of middle‐level managers in an acute hospital. The project involved the harmonisation of terms and conditions of employment and pay of nurses and the theatre practitioners. They illustrate the process by which middle managers were able to implement the strategy of the board in a way that allowed the development of a local pay policy. This chapter provides valuable insights into the considerable influence of middle managers in the realisation of strategic change.
Recurrent themes surface from the first three sections of this book. The need for Primary Care Groups to meet the key objectives of the Health Improvement Programme in the areas of cancer, coronary heart disease, accidents and mental health, require primary care organisations to address the health needs of the population, rather than of individuals. The expansion of the roles and functions of primary care organisations require enhanced managerial skills in such areas as communication, budgetary control, managing meetings, negotiation and performance management. The theme of the need for effective styles of leadership is apparent throughout.
Although these chapters provide readers with a range of examples and discussions from various perspectives, the common problem with them is the lack of clarity in the presentation of their methods of study. Space constraints necessarily limit the depth of coverage. However, research processes are important in qualitative research and should be adequately described. Sketchy pictures presented will inevitably raise questions over validity and claims. Moreover, the many claims of success made by these authors are not balanced by critical reflection on the limitations of their methods and barriers confronted by their studies. The notion that the development of staff in the NHS, which is riddled with unequal power relationships between clinicians, staff and patients, is without problems is incredible. For example, the very conditions that would test the leadership model proffered by Jumaa and Alleyne are dismissed, with the assertion that their model of leadership would work as long as it operated in an environment free of discriminations and unequal power relationships – “A successful implementation of LEADLAP requires that racism, sexism, ageism, and discrimination based on disabilities, sexuality, accent, class and country of origin, religion, cronyism, nepotism etc. are not used as the basis to offer rewards and services in the new NHS” (p.121).
Addressing issues in future trends in development, Lerer and Kimberly's leading chapter in Section 4 introduces the scenario method, which is an increasingly popular tool in strategic planning. The description of a “typical” scenario exercise carried out by MBA students doing a health‐care management elective, is stimulating. It provides an overview of the current thinking on the macro level of health care systems and of the possible linkages with the micro level of health care.
Simoens and McMaster's analysis on the concept of trust and the erosion of trust in the NHS through successive reforms, is also stimulating. They provide a good overview of the concept and theory of trust and a sober analysis of the way in which the internal market created by the previous Conservative Government represented a significant change in the ethos of health care in the public sector, which resulted in a deterioration of the degree of trust in the health service. They suggest that three factors contributed to the erosion of trust after the reforms: the role of managers, the contractual relationship between purchasers and providers and the performance assessment framework.
With the growing pressure on the NHS resources charity organisations are increasingly important as partners in the delivery of health care. In this chapter, Coid and Crombie lead us into the labyrinths of the funding arrangements in the voluntary sector in Scotland. While the funding of voluntary organisations allows lay people to be involved in health care, there is no central policy on the amount of grant to be provided and no explicit guidance on priorities of care. They suggest that the uncoordinated approach to funding may disadvantage certain care groups.
The final chapter in Section 4 offers a view to the future through a particular technological perspective, i.e. the use of telecommunications and computer‐based systems to enhance the delivery of health and social support services to people in their own homes. Levy and colleagues’ examination of the impact of “telehealth” on the health‐care system based on a critical analysis of power and systems, is a refreshing way of ending the book.
In summary, the book is a useful resource for readers who wish to gain an overview of some of the main issues of organisation development in health care, and understand the approach to these issues taken by scholars and practitioners in the management disciplines. As with any such volume, one might criticise the selection and balance. For example, the amount of space devoted to primary care in the UK is huge compared to developments in other parts of the world. Although the idea of the book originated from an international conference involving over 20 countries, the perspective remains Anglocentric. However, readers who wish to gain some insight into organisation development issues in the UK will benefit from this collection.
