Patterns of Strategic Change in Health Care: District Health Authorities Respond to AIDS*
| DOI | http://doi.org/10.1111/j.1467-8551.1992.tb00033.x |
| Date | 01 March 1992 |
| Published date | 01 March 1992 |
British Journal
of
Management,
Vol.
3,21-37
(1992)
Patterns
of
Strategic Change
in
Health Care:
District Health Authorities Respond to AIDS*
Ewan Ferlie and
Chris
Bennett
Centre
for
Corporate Strategy and Change, University of Warwick
SUMMARY The literature on strategic change is based mostly on research in the private sector.
This paper suggests that change in public sector organizations is equally worthy of
study and can
offer
novel insights. Findings from research into the development
of
services for HIV/AIDS in
NHS
health districts are used to illustrate six generic themes
in strategic change processes. The
first
theme concerns the role of context in potentiating
change, and in promoting a diverse response in different localities despite unifying
government guidelines. A second theme introduces the initiators of change, the ‘product
champions’, a less homogeneous group than is sometimes suggested. Although personal
status, energy and pro-activity were shared characteristics, individuals differed in style
and methods used to attain goals. Theme three highlights social movements
as
mediators
of change. Consumerism has affected both private and public sector industry, hut for
HIV/AIDS the process has been particularly visible. The mobilising role of crisis comes
next. A three phase model is suggested, linking ‘crisis-as-threat’ and ‘crisis-as-oppor-
tunity’ theories. A fifth theme concerns changes in organizational culture provoked
by HIV/AIDS, and the role played by symbolism
-
often unpredictable and not easily
manipulated by management. The last theme is organizational learning; how learning
about HIV/AIDS diffused through the districts, and how well learning generalizes to
other issues. In conclusion, it is argued that the study of processes
of
change in a
public
sector
organization can contribute to general models of strategic change and
help to develop organizational theory.
Introduction
The strategic change perspective on decision-mak-
ing within organizations is developing rapidly, but
primarily within the context of private sector man-
agement, as any perusal of the
British Journal
of
Management
indicates. Yet public sector organiza-
tions can also provide a fruitful field for such ana-
lyses. In particular, the health care sector has
perhaps been somewhat neglected in the develop-
ment of the emerging strategic change perspective,
although analyses of health care settings have in
the past often been influential in building other
organizational theories, For example, the study of
A
revised
version
of
a paper
first
given
at
the
Strategic
Management Society
Workshop
‘Leadership and
the
Management
of
Strategic Change’, Robinson College,
Cambridge, December 1990.)
an innovative Medical School contributed to the
formation of the organizational ‘life cycle’ perspec-
tive (I(lmber1y
et al.,
1980). Hospitals have also
provided research settings for contingency theorists
(de Kervasdoue, 198 l), students of professionalized
organizations (Bucher and Stelling,
1977)
and the
validity
of
the population ecology perspective has
now been explored within the field of voluntary
social service organizations (Singh
et al.,
1986).
Strategic service change is a particularly fruitful
area to study because it represents the cross-over
point between management ‘means’ and service
‘ends’. Such a focus helps get
us
away from examin-
ing the managerial process in splendid isolation
from end results and connects management with
the design of new service systems. This article exam-
ines the organizational and managerial response
by the National Health Service to the
HIVlAIDS
epidemic as an interesting example of a strategic
1045-3
172/92/01002
1-1
7$08.50
0
1992
by
John
Wiley
&
Sons, Ltd.
Received
19
June
I991
Revised
10
October
1991
22
E.
Ferlie
and
C.
Bennett
change process taking place within health care.
It used to be argued that health care organiza-
tions were unlikely to exhibit strategic change. The
picture painted was one of a complex and pluralist
organization characterized by continual negotia-
tion between shifting power blocs (Strauss, 1978),
where professionals were more dominant than
managers; operating on the basis
of
collegial norms
(Bucher and Stelling, 1977), and where there was
also much uncertainty about the real locus of con-
trol (Alford, 1975) within the system. The dominant
mode of decision-making was thought to be highly
incremental (Hunter, 1980), with profound
obstacles lying in the way of the expansion of low
prestige and powerless services. The hospital per-
haps represented the archetype of the professional
mode of organization, which may be in a state of
perpetual change at a micro level but extremely
stable at a strategic level (Mintzberg, 1990). At
worst, stasis could result, or perpetual ‘conflict
without change’ (Smith, 1981).
This view of health service organizations and the
way they operate may now be in need of substantial
revision. The introduction of general management
in the NHS in the mid-1980s was in part justified
by the need to increase the rate and pace
of
strategic
change and reduce implementation deficits in sec-
tors such as psychiatry, where long-standing poli-
cies for change had only been implemented in a
very patchy manner (Wing, 1991). There is now
evidence to suggest that, at least in some localities
and for some health care issues, strategic service
change accelerated rapidly in the late 1980s (Petti-
grew
et al.,
1991a). HIViAIDS is an example
of
one such issue, and the response of districts that
were early in perceiving it to be a problem can pro-
vide a demonstration of the processes and factors
involved in achieving such accelerated change.
HIV/AIDS first emerged as an issue in the early
1980s but the epidemic has not yet abated, neither
has a cure been found. Thus, in terms of both times-
cale and magnitude, the HIV/AIDS issue has ‘stra-
tegic’ implications, and the NHS response to the
issue can be usefully used for analysis as a discrete
example
of
a strategic change process. We do not
suggest that these responses are ‘typical’
of
the
NHS as a whole, but rather represent the experience
of
management under conditions
of
high policy
drama. Such conditions may, however, expose
decision making processes which would otherwise
remain hidden. Turner (1957) was an early expo-
nent of studying social dramas to increase under-
standing of social interaction, and a number
of
others (see for instance Almond
et
al.,
1973; Turner,
1976; Pettigrew, 1979; Hardy, 1985; Hickson
et
al.,
1986; Strong and Robinson, 1990) have explicitly
used key points in organizational histories to illu-
minate process.
The article contains a major empirical element,
drawing on nine intensive, longitudinal, case stu-
dies of the organizational and managerial response
to HIV/AIDS in different health districts, some of
which were key national centres with a high level
of prevalence of the virus amongst their patients.
Here we attempt to relate these data to some more
general strategic management questions. The struc-
ture of the paper is as follows: first, we review some
recent strategic change literature and specify some
themes for investigation; second, methodology is
outlined; third, the empirical data base is presented
and reviewed; fourth, the implications of the find-
ings and a possible future research agenda are con-
sidered.
Some Relevant Strategic Change
Liter at ure
The strategic change literature has been usefully
reviewed by Johnson (1990), together with a con-
sideration of possible implications for empirical
research. He notes first of all the retreat from long-
range, formalistic approaches to strategic manage-
ment, and a move towards seeing organizations as
containing important social, political and cognitive
elements.
A number of consequences follow from seeing
the world in this new way. One is
a
new recognition
of the importance of antecedent conditions in
influencing change, and an increased interest in stu-
dying the role of ‘change agents’, and how they
secure change within complex organizations. This
directs attention to the micropolitics of decision-
making within organizations and how ideas for
change are generated and steered through organi-
zations. Stocking (1985) introduces the notion of
the ‘clinical product champion’ as one important
facilitator of innovation in health care settings,
although this role was not explored in a fully ‘pro-
cessual’ manner.
Second, attention is directed to the social, politi-
cal and cultural context of organizations. Organi-
zations may be seen as complex social systems
which may be grossly disturbed by a major and
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