EXTENDED CASE STUDY 9

Midshires College of Midwifery and Nursing1

Background

The cornerstone of the British welfare state, since its inception after the Second World

War, has been the National Health Service (NHS). Such is, or at least was, the NHS's

standing that it was often referred to as "the envy of the world". However, since the early

1980s, it has experienced successive waves of increasingly contentious change. One of

the most far-reaching changes was heralded by the then government's 1989 White Paper

"Working for Patients" (HMSO, 1989), which came into operation in 1991. This was

aimed at creating an internal market within the NHS, primarily through the division of

"purchasers" and "providers" of medical and other services into separate, semi-

autonomous bodies – e.g. GP Fundholders and NHS Hospital Trusts. The rationale

behind the internal market was, according to two senior figures in the NHS (Carr and

Donaldson, 1993:23):

... the belief that a market system of care would induce positive behaviour [by managers and
professionals] which would work in the interests of patients, and that it would bring
accountability and value for money within a proper management framework.

Nor, it should be said, did the advent of a New Labour Government in 1997 appear

to alter this approach, despite talk of modifying or eliminating the internal market (Cook,

1998; Salauroo and Burnes, 1998).

This case study describes how the management and staff within one particular part

of the NHS, colleges of midwifery and nursing, coped with the new NHS. In line with

the market-led approach, the NHS Executive Board decided that colleges of nursing

1    
The research for this case study was undertaken with Mohammad Salauroo of the University Of
Hertfordshire School Of Nursing.

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needed to be able to offer a wider range of services and expertise than in the past, and

therefore a programme of merging colleges of midwifery and colleges of nursing to form

larger organisations was initiated. In the case in question, it was decided to merge five

existing colleges to form the new Midshires College of Midwifery and Nursing. These

colleges, between them, serviced hospitals in ten different Health Authorities.

The Health Authorities, in consultation with the Regional Health Authority,

appointed a Steering Group of senior managers, drawn from the Boards of Governors of

the five colleges, to oversee the merger. The Steering Group comprised General

Managers from hospitals (NHS Hospital Trusts) within the Health Authorities, Chief

Nursing Officers, and representatives from the Regional Health Authority, some 24

members in all.

The remit of the Steering Group was fairly straightforward: to oversee the

amalgamation of the five colleges. There seems to have been no formal acknowledgment

that this amalgamation was in any way different from previous ones. However, there

were a number of issues related to the changing nature of the NHS which made this

process significantly different and inherently more complicated than past

amalgamations:-

 There was uncertainty over the demand for nurse education in the future (both
in terms of numbers and function).

 A potential conflict of interest existed between the General Managers on the

Steering Group on the one hand and the new college on the other. The General

Managers, under the new purchaser-provider system in the NHS, would in

future not be tied to a particular college of nursing in terms of nurse education.

They could, if they so wished, put their requirements out to open tender to any

college in the country, as one Trust elsewhere in the UK had already done. In

addition, and in the short term more probably, they could seek alternative

suppliers for post-experience courses, or even provide these courses themselves

in competition with the new college. Indeed, two of the Health Authorities had

already established their own organisation for delivering post-experience nurse

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 education in competition with the new college. This is perhaps why some

members of the Steering Group suggested that the new college should not have

in its remit the provision of post-experience courses (with implications for the

jobs of some 30 per cent of existing staff in the five colleges to be

amalgamated). Therefore, key players in establishing the college found

themselves placed in a somewhat ambiguous position with regard to its purpose

and remit.

 It was expected that qualifications gained at the new college would be validated

by a higher education institution and that eventually, as similar colleges were

doing, it would actually merge into the university sector.

It might have been expected that the Steering Group would seek to clarify these key

issues before proceeding to resolve the structure and organisation of the new college.

After all, how could decisions regarding its structure and functioning be resolved in

advance of key decisions on student numbers, course content, areas of operation, and

whether or not it would merge with a higher education institution? Nevertheless, the

Steering Group avoided consciously tackling these issues prior to commencing the

merger process.

Developing the Strategy

The Steering Group decided that merging the five colleges could and should be managed

as a straightforward and uncomplicated, almost mechanical, process. In November 1992,

they appointed a Project Leader, on a fixed-term contract of two years, to complete the

task of merging the colleges by October 1994.

The appointee was the Principal of one of the colleges being merged. He had no

direct experience of merging colleges, but had only two years' service left prior to

retirement. This meant that, unlike the other four college principals, he would not be a

potential candidate for the principal's post in the new college. Surprisingly, the Project

Leader was given no budget or dedicated secretarial or administrative support. He could,

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though, call on the resources of the five colleges, provided that the principals agreed.

Within forty-eight hours of his appointment, the Project Leader contacted the

principals of the other colleges, by fax, and announced both the formation of a Project

Board and its membership. The membership included the Project Leader and the

principals of the five colleges, including the acting principal from his own college. There

were also three external members brought in as advisors to the project group. These were

a Finance Manager and a Personnel Manager from the Regional Health Authority and

the Education Officer from the English National Board for Nursing.

By the time of the Project Board's first meeting, the Project Leader had produced a

plan which, amongst other objectives, proposed the immediate integration of some

administrative processes and the centralisation of student recruitment. The core of the

plan was the establishment of four sub-projects aimed at integrating the major functions

of the five colleges: pre-registration courses for nursing; post-registration courses for

nursing; midwifery education; and education support services.

The first meeting of the Project Board discussed its own membership, the Project

Leader's project plan, the roles of the Project Board members, communications, the

development of new courses, and the accountability of the Project Board to the Steering

Group. The Project Leader stated that he had been given clear instructions by the
Steering Group, and that the task of the Project Board was to get on with the job of

integrating the five colleges as laid down in his project plan. This first meeting set the

pattern for the future; the Project Leader would act as the only conduit between the

Steering Group and the Project Board, and questions relating to the pace, purpose and

form of the proposed merger were not part of the Board's remit. Within these constraints,

scope for questions and initiatives existed, but the Project Leader had the final say on all

matters.

Time for a Rethink

In February 1993, some four months after the first Project Board meeting, a one-day

staff conference was organised for everyone employed at the five colleges. The purpose

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of the day was to brief staff on developments and get feedback from them. It was

apparent as the day progressed that, although staff in the colleges were enthusiastic about

the change, and indeed appeared to have more enthusiasm and ideas than the Project

Board itself, there were key issues which were not being addressed and which were

causing increasing concern. The obvious issue for staff was that no one seemed to have a

clue as to how many staff would retain their posts in the new college, or what mix of

skills would be required. However, staff were just as concerned, if not more so, by the

lack of any clear direction for the new college: What was its mission? What

products/services would it provide? How would it be structured? Who would make these

decisions, when and on what basis? What seemed to shock and dismay many of the staff

was that the Project Leader seemed as uncertain and powerless as themselves regarding

these issues.

The conference brought home to the Project Leader the lack of progress made

towards amalgamation. The sub-groups had met frequently and produced extremely

detailed plans; but the ability to turn these plans into actions seemed to elude them,

partly because key issues had still not been resolved. For the Project Leader, the

conference had crystallised a number of his concerns regarding both the pace of the

amalgamation and the effectiveness of the Project Board system.

between the Project Board and the Steering Group; having critics in both camps but

supporters in neither. In addition, some members of the Project Board were meeting

informally but regularly to discuss and promote alternative ideas to those of the Project

Leader, though whether he was aware of this was unclear. Similarly, Board members

were seeing members of the Steering Group informally as well. So a great deal of

behind-the-scenes lobbying and jockeying for position was taking place. This was hardly

surprising, given the uncertainty - particularly over jobs - which was present.

Shortly after the staff conference, the Project Leader called a one-day Project Board

meeting to discuss progress, and he invited the Chair of the Steering Group to part of the

meeting. Though members were told that the meeting was to examine the situation and

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discuss options, they were in effect presented with a fait accompli by the Project Leader.

He made a number of major announcements at this meeting which in effect tore up the

previous four months' work:

 The Project Board was to be disbanded and replaced by an interim Management

Committee for the new college.

 The four existing principals would become part of the Management Committee

with specific areas of responsibility.

 The role of the existing principals in the five individual colleges would be

replaced by the appointment of heads of sites.

 The sub-projects were to be abandoned; in their place, the Project Leader

announced a structure for the new college which would, he stated, be fully

operational by October 1993.

Despite these changes, decisions had still not been taken regarding the number of

students the new college would have in the future, whether it would be allowed to offer

post-registration courses, or whether it would be moving into higher education. Without

this information, it was almost impossible to determine staffing levels and the skill mix

for the new college, or judge the appropriateness of the proposed structure. In such a

situation, inevitably, staff morale continued to decline, especially amongst staff on short-
term contracts. One example of this was the high number of staff, especially in

managerial positions, who were on long-term sick leave with stress-related illnesses.

An Exit Strategy

The creation of the Management Committee appeared to have had little positive impact

upon the new college. The new structure still only existed on paper. The reports from the

Management Committee were vague, irregular and fragmented. However, the

appointment of a new Chair of the Steering Group began to clarify some major issues,

especially staffing levels. The new Chair came in with a sense of urgency to resolve

staffing issues because it had been decided by the Regional Health Authority that his

Trust would take over formal responsibility for the college in April 1995. This meant

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that any redundancies that might arise, and any associated costs, would be borne by his

Trust.

As a condition of his Trust taking over the college, he got the Regional Health

Authority to guarantee the new college the same level of pre-registration work (training

student nurses) in 1994 as in 1993. However, in 1995, the guarantee would be reduced to

50 per cent, and in 1996 it would be eliminated altogether. This did not mean that the

new college's workload in this area would necessarily decline. It did mean, though, that

it could expect to face competition for the work. The situation with regard to post-

registration courses (up-grading the skills of practising nurses), however, was still

unresolved, as was the question of the link with higher education. On this latter issue, it

had been understood informally that the final decision would be known in December

1993 but, like other deadlines for this decision in 1993 - May, June, July, and September

- it came and went with no decision being made.

Therefore, nearly two years after the merger process officially began, key issues

around which the future of the college revolved had still not been resolved. Most staff

still did not know if they would have jobs with the new college, although those on short-

term contracts were informed by open fax messages to each of the college's sites that

their contracts would not be renewed (this was later rescinded). In a similar vein, a
leaked letter from the Project Leader to the Regional Health Authority discussed

redundancy arrangements for permanent staff. Not surprisingly, as 1994 progressed, the

climate in the organisation deteriorated drastically and any sense of optimism had all but

evaporated.

In October 1994, the Project Leader was replaced by a Principal, an outsider,

appointed to take charge of the new college. However, he was only appointed on a two-

year contract and his main remit was not to complete the formation of the new college,

nor to resolve the outstanding staffing and workload issues per se. Instead, his priority

was to negotiate the incorporation of the new college into a university and thus remove

responsibility for its running and funding from the NHS.

In effect, the Chair of the Steering Committee, along with the Regional Health

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Authority, appeared to have decided that the exit of the college from the NHS was

preferable to attempting to resolve the issues facing the college. As with everything else

to do with the college, this took longer than expected, and was not finally accomplished

until November 1997 when the college became part of a local university. In the interim,

the original Principal left and was replaced. Even then, the College's future seemed

somewhat vague. Unlike other colleges of nursing which amalgamated with universities,

it did not become part of the university proper. Instead, a separate, arms-length

relationship was maintained. It had its own structures and practices, which remained

unsettled for some time, and the college's staff were not appointed on the same basis as

other university staff.

The Outcome

This case study shows that the market-orientated environment in which the NHS is now

operating has brought about significant changes in relationships between all parts of the

NHS, and not just between purchasers and providers of patient care, although for

obvious reasons it is the latter which has been the focus of most attention. The creation

of the NHS internal market was not just an attempt to create a more efficient method of

distributing resources. It was also seen as a key element in creating a more

1991; Rothwell, 1994). However, the process of creating such a culture brings with it a

large degree of uncertainty, dislocation and conflict, as the case study illustrates.

In this study, we can see how this conflict of interests, together with a failure to

appreciate the implications of the new arrangements within the NHS, acted to undermine

the effectiveness of an approach to the management of change which assumed that

stability was possible and conflict was absent, or at least easily resolvable. In particular,

there are three issues which seem of major significance in understanding the

development of the change process in this instance:

1. The move from a stable to an uncertain environment: The NHS was no

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 longer operating in a stable environment. Even leaving aside the question of the

level of overall funding, the introduction of the internal market was likely to

have an enormous impact on the location and flow of resources in the NHS. It

was also apparent that no one could predict who would be the winners and losers

in that particular game, or when - if ever - a stable state would again emerge.

Therefore, the environment for the NHS was becoming increasingly uncertain

and unpredictable. In such a situation, the assumption by the Steering Group that

the merger of the colleges could be conducted in a planned and, almost,

mechanical way was clearly flawed.

2. The Project Leader: Many of the problems which then arose in merging the

colleges can be traced to the Steering Group's misconception regarding the

nature of the change process in this instance, and especially the choice of Project

Leader. This job was given to a man who could have been expected to

amalgamate the separate colleges efficiently, almost as if dealing with model

building blocks, if he had been operating in a stable environment with a

bureaucratic culture amenable to his autocratic style. When it became clear to

him that this was not the case, the Project Leader lacked the aptitude either to

win over his own colleagues (who in some cases were apparently actively
working against him) or to confront the Steering Group with its own indecision.

This was not a shortcoming on his part; rather the fault lay with those who had

chosen a manager with a traditional bureaucratic approach to change to

undertake a complicated exercise in an uncertain and, as it transpired, hostile

situation. Nor did this situation end with his replacement or the College's

incorporation into the university sector. Instead of lessening, it appears to have

become endemic. This was not because it was inevitable. As Salauroo and

Burnes (1998) showed, other colleges and other parts of the NHS did find

themselves able to create a more stable climate. Rather it was because those

responsible for developing and implementing the College's strategy did not take

the steps necessary to resolve the issues causing the uncertainty.

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 3. Conflict of interests: It can be seen that the potential conflict of interests both

among and between members of the Steering Group led to key issues concerning

the college's future workload, and thus staffing needs, not being addressed in

advance of (or even during) the merger process. Instead of resolving issues

regarding student numbers and the scope of its activities, the Steering Group

appointed a Project Manager whose style and track record could almost

guarantee that these issues would not be raised or resolved. Small wonder,

therefore, taking into account the absence of any firm decision about the new

college's role and workload, and the turbulent environment in which it would be

operating, that this approach failed. Nor, perhaps, is it surprising that those who

found themselves responsible for the College's future within the NHS should find

it easier to develop an exit strategy for the College than to resolve the problem

issues, which would have been necessary if it were to remain part of the NHS.

The lesson for the NHS, and for other public sector organisations in the UK, is that

conflict and ambiguity are an inevitable outcome of the changing environment in which

they now operate; and that these adjustment difficulties, and the culture change which is

accompanying them, cannot be dealt with as though they either do not exist or do not
matter. Different situations do call for different approaches; a style of management

suited to a stable state situation may, as in this instance, be totally unsuited to a more

dynamic situation. Yet the culture of organisations in the UK, as Hofstede (1980 and

1990) noted, tends to be one where organisations are seen as well-oiled machines which

pursue rational ends and where personal conflicts and ambitions are subjugated to the

needs of the organisation. In such situations, it is frequently not seen as legitimate to

acknowledge conflicts of interest.

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