A Middle Manager's Response to Strategic Directives on Integrated Care in an NHS Organisation: Developing a Different Way of Thinking about Prejudice

Abstract

This thesis examines a middle manager’s response to strategic directives on integrated care in a National Health Service (NHS) organisation and the development of an awareness of prejudice that acknowledges its relationship to the process of understanding. The research focuses on an integration of two community NHS trusts and an NHS hospital trust into one integrated care organisation (ICO). A change programme was initiated and promulgated on an assumption that integrating the three organisations would facilitate integrated care. However, despite the use of organisational change approaches (such as communication plans and systematic approaches to staff engagement), implementing the strategy directives in practice remained problematic. What emerged during the integration process was resistance to change and a clear division in the different ways of working in the community NHS trusts versus the community and hospital trusts – differences that became apparent from the prejudices of individuals and staff groups. The proposition is that prejudice is an important aspect of relationships whose significance in processes of change is often overlooked. I argue that prejudice is a phenomenon that emerges in the processes of particularisation, which I describe as an ongoing exploration and negotiation in our day-to-day activities of relating to one another. Our pejorative understanding of the term ‘prejudice’ has overshadowed more subtle connotations, which I propose are unhelpful in understanding change in organisations. However, I suggest a different way of thinking about prejudice – namely as a process that should be acknowledged as a characteristic of human beings relating to one another, which has the potential to generate and enhance understanding. The research is a narrative-based inquiry and describes critical incidents during the integration process of the three organisations and focusing on interactions between key staff members within the organisation. In paying attention to our ongoing relationships, there has been a growing awareness of disconnection from traditional management practices, which advocate systematic approaches and staff engagement techniques that are designed to encourage cooperation and reduce resistance to proposed change. This thesis challenges assumptions surrounding prejudice and how middle managers traditionally manage organisational change in practice in their attempts to apply deterministic approaches (which assume a linear causality) to control and influence human behaviour. I have taken into consideration a hermeneutic perspective on prejudice, drawing on the work of Hans Georg Gadamer, and have argued from the viewpoint of the theory of complex responsive processes. This offers an alternative way of thinking about management as social processes that are emergent in our daily interactions with one another, that are not based on linear causality, or on locating leadership and management with individuals. It provides a way of taking seriously the relationships between individuals by paying attention to what emerges from the interplay of our expectations and intentions. This leads to a different way of thinking about the relationship between prejudice and strategic directives, which I argue are not fixed instructions but unpredictable articulations of our gestures and responses that emanate from social interaction and continually iterate our thinking over time. This paradoxically influences how we make generalisations and particularise them in reflecting on and revising our expectation of meaning I suggest that it is not possible to predetermine a strategic outcome; and that traditional management practice, which locates change with individuals – and reduces aspects of organisational life, such as resistance, into a problem to be fixed – obscures our capacity to understand the processes of organisational change in the context of a much wider social phenomenon. I therefore conclude that my original and significant contribution to the theory of complex responsive processes and to practice is encouraging a different way of thinking about prejudice – as a process that can be productive and generate understanding, when considered as encompassing our expectations of meaning, linked to our own self-interests. This then opens up possibilities for transforming ourselves in relation to others – and, through this process, to transform the organisations in which we work.