Mergers and takeovers in the NHS have had a bad press. Economic analysts have stressed that there is probably insufficient slack in the system to produce large savings, particularly where there remains a need to keep a safe level of service on dispersed sites.
Where trust merger is thought to be a Trojan horse for hospital reconfiguration, it is bitterly opposed by the public and staff - as reported at Kidderminster and other areas.
3When it is reported that the projected millions of pounds of savings have not been delivered - as in the case of Edgware General and Barnet General hospitals - it is not surprising that merger and takeover are feared to be more damaging than constructive when it comes to developing better local services and conditions for staff.
Professor Alan Maynard has called for research into the true costs and benefits of mergers.
2The research on imposed change, of which removal of the board and amalgamation of services must be a prime example, suggests that the impact on the remaining staff will be negative.
5Having initially experienced relief at finding their post secure, they are left with many uncertainties about how they will be managed, and how work will be spread among fewer and more junior staff.
The takeover of Horton General Hospital trust, in Banbury, by Oxford Radcliffe Hospital trust in 1998 had all the strangeness and uncertainty of an arranged marriage. Oxford Radcliffe had been formed from two specialist acute units located in Oxford, with links to Horton largely confined to receipt of tertiary referrals. As a small district general hospital, Horton had always had a question mark about its viability hanging over it.
It had suffered the stress and indignity of countless reviews, culminating in a full public inquiry in 1996 headed by Sir Arthur Davidson QC. The inquiry found that its services were fiercely guarded by local people and held in high regard by professional bodies despite its size. The outcome was a decision endorsed by the trust board to seek amalgamation with an unspecified partner to achieve cost savings and to retain local acute hospital services. Eventually amalgamation went ahead with Oxford Radcliffe - a trust based 25 miles away, with six times the turnover of Horton.
As outgoing chief executive of Horton, I set up a project to evaluate the impact of the takeover on beliefs of staff in both original trusts about their organisation's culture.
The joint project steering group, led by the boards of both original trusts, endorsed the project.
The study looked at the impact of trust dissolution and absorption on the corporate culture as perceived by Horton General Hospital staff, in Banbury, and staff at the two Oxford sites: the John Radcliffe and Churchill hospitals. These three, together with Radcliffe Infirmary, now form Oxford Radcliffe Hospital trust.
Phase one was conducted in March and April 1998, and phase two in April and May 1999, a full year after amalgamation. In order to represent the diversity of staff groups, 70 staff were randomly selected each time from the payroll and slotted into categories of professional groups. They included part-time and bank staff, producing a stratified random sample.
Staff were briefed and approached to consent in a letter from the trust chief executives. In phase one, 46 staff - 23 from each of the original trusts - responded. In phase two, 50 staff responded - 19 from the Oxford sites and 31 from Banbury.
Participants were sent the corporate culture questionnaire produced by Saville and Holdsworth. This has 150 questions and takes about 45 minutes to complete. Areas covered include the organisation's concern for quality, safety and customer satisfaction, concern for employees, career development, equal opportunities, employees' influence on decision-making and communications within the organisation. It is computer-scored, and only group responses were released to the research team.
The questionnaire covered 21 aspects of corporate culture, in four main areas: performance, human resources, decision-making and relationships.
Participants were asked to say whether they strongly disagreed, disagreed, were unsure, agreed or strongly agreed with statements about each aspect. Responses were scored, and the scores divided into broad bands.
There were 14 aspects on which there were detectable differences in scores (of at least two bands) between staff from the Oxford sites and those from Banbury. Of these, differences on 10 aspects reached statistical significance before the trust takeover.
One year after takeover, there were fewer differences.
Staff from the Oxford sites and Banbury differed in attitude by at least two bands on 11 aspects, and only four of these reached statistical significance. While the results show there has been a convergence of cultures, it is instructive to see where the changes have occurred, and how they may relate to management action (see figures below).
Staff attitudes on performance showed no differences between those from Oxford and those in Banbury, when considering commercial orientation or concern for quantity - that is, their perceived workload. But staff at Horton (Banbury) expressed greater concern for quality, concern for customers and giving employees the equipment to do the job. After takeover, the Oxford hospitals showed greater similarity to Banbury on most aspects of corporate culture, but with Banbury still retaining the customer focus and quality concern that may be part of the ethos of a local hospital.
Staff did not differ markedly on how much they felt cared for as employees, their opportunities for career development, rewards for performance and equal opportunities. But work in the smaller hospital at Banbury was perceived as more rewarding.
Staff from both organisations perceived a stronger emphasis on career development after the merger. This may reflect the provision of continuing professional development, in part a response to clinical governance, as well as the continued commitment of Horton to the Investors in People scheme.
Decision-making In all but one aspect, the Oxford sites reported less positively on how decisions were made than in Banbury before the takeover. After a year, decision-making at the Oxford sites was rated more positively.
What is strikingly different is the reversal of responses on perceived rate of organisational change. After a year, Horton is perceived to be in relative stability whereas the Oxford sites are seen as subject to increased change.
Oxford Radcliffe Hospital trust staff may well have experienced flux due to the absorption of the Radcliffe Infirmary trust and the consequent relocation of Oxford services that was imminent when the second phase of the study was carried out.
It is in this area that there were the most marked differences before takeover, with staff at Horton giving more positive scores on all dimensions - relationships between levels of authority, between peers, within multi professional groups, the effectiveness of communications and the awareness by individuals of the organisation's goals - than the Oxford sites staff.
This reflected both the ethos of a local hospital and the accessibility of local trust management.
These areas also pose a greater challenge to managers of the larger organisation, since cost savings were largely achieved through stripping out local trust management.
At the time of the merger, management of the Oxford sites was undergoing change, with the introduction of team briefing and other communication initiatives already in place at Horton. After the takeover, there were noticeable improvements at the Oxford sites and positive attitudes at Banbury were maintained, perhaps assisted by e-mail and innovations in radiology telematics. Yet while day-to-day communications have improved overall across the trust, there is reduced awareness of the organisation's goals at Horton. This seems to be a consequence of the trust and the hospital no longer being synonymous. The corresponding marked improvement for Oxford-based staff suggests there is a need to engage staff specifically in remote sites in strategic issues.
The three aspects of corporate culture that generated extreme scores in 1998 continued to do so in 1999. Staff reported a very low perception of reward by pay and promotion for effort, which can be traced to the minimal impact of performance-related pay for all but a few managerial staff.
There is an extremely high concern for safety, gratifying in the context of clinical risk management and clinical governance. And as noted above, there was extremely low awareness of organisational goals at Oxford Radcliffe Hospital trust in phase one of the study, but this is now less marked across the sites at phase two.
There has been some convergence of staff cultures on sites 25 miles distant, and progress in integrating the staff of the Oxford and Banbury sites into a more common culture.
There is now a greater perceived emphasis on career development in both areas, which may be a response to professional development in both areas, and re-accreditation for Investors in People at the Banbury site.
But some of the strengths of Horton's culture, in particular access to strategic information, is now less apparent.
There remains a clear challenge to the larger trust to address the problems of communication and awareness of organisational goals across all sites. Given the smaller management resources left after cost savings in senior management, walking the sites and being present at all hours in the hospital and local community are not feasible.
The challenge is to communicate more smartly, using new technology and effective briefing systems, and to adopt evaluated best practice across all sites, irrespective of who first had the good idea. In this way, the advantages of integration with a larger and more stable organisation, along with the advantages of small local site working relationships, can make the impact of takeover work for all.
1 Goddard M, Ferguson B. Mergers in the NHS: made in heaven or marriages of convenience? Nuffield Occasional Papers Health Economics Series: paper 1. Nuffield Trust, 1997.
2 Maynard A. Hospital mergers: blissful ignorance or high risk taking? British J of Healthcare Management 1997; 10(3): 512.
3Gould M. Closed to argument. HSJ 2000; 110 (5687): 11-12.
4 Whitfield L. Sorry is the hardest word. HSJ 1998; 109 (5625): 16-17.
5 Stuart R. Experiencing organizational change: triggers, processes and outcomes of change journeys. Personnel Review 1995; 24 (2): 3-88.
Research with staff in two organisations involved in a merger revealed some convergence of cultures one year after the merger. But staff from the smaller organisation perceived some losses.
Staff from both organisations felt poorly rewarded for their work.
Staff from the smaller organisation perceived relationships in the organisation more positively than those in the larger one, before and after the merger.
Staff saw their employers as very concerned with safety before and after the merger.