POWER, GOVERNANCE AND KNOWLEDGE: The Example of London Managed Clinical Networks Rachael Addicott Centre for Public Services Organisations 26 January 2005

History of poor clinical outcomes Ineffective communication between professionals and organisations Cancer services in the UK

Network model Cancer : Managed Clinical Networks Difference to private sector –Regulation –Standards / guidelines –Trust

What is a Managed Clinical Network? “…linked groups of health professionals and organisations from primary, secondary and tertiary care working in a coordinated manner, unconstrained by existing professional and (organisational) boundaries to ensure equitable provision of high quality effective services” (Edwards, 2002: 63)

Managed Clinical Networks Professional Education Structural Reconfiguration Surrender Sovereignty Calman-Hine report (1995) NHS Confederation (2001) NHS Cancer Plan (2000)

Novel Managerial Techniques Lozeau et al (2002) Corruption of a novel managerial technique introduced from the private sector –Total Quality Management –Strategic Planning Compatibility gap between technique and organisational reality

Compatibility Gap Lozeau, D., Langley, A. & Denis, J. 2002, "The corruption of managerial techniques by organizations", Human Relations, 55(5): Organization Technique Organization Technique Organization Technique Organization Loose couplingTransformationCustomization Corruption

Research Question Has the managed clinical network model for cancer technique been successful in transforming the organization, or has the new rhetoric of knowledge management through networks been corrupted by the existing organizational structure and culture?

Methodology Case studies –Five London networks –Key stakeholders Data from five case studies –Documentation –Observation (urology and gynaecology) –Interviews (113)

Tracer Issues Centralisation Budget allocation Education & training Decision making Knowledge management

How did the networks compare? Network ANetwork BNetwork CNetwork DNetwork E Purpose of network Implement govt policy Unclear to network members Implement govt policy Improve care Common guidelines Improve care Common guidelines Approach to networking Non-directive Unsuccessful bottom-up Non-directive Successful bottom-up Top-down Educational activities Multi site Single discipline Minimal Multi-site Multidisciplinary Single site Single discipline Approach to organisational change Reactive Loose (bottom-up) ReactiveInclusive Authoritative Centrally driven

Fixed behaviour and Power Structure Limited flexibility or resource for innovation “Initiative fatigue” – lack of stability Power concentrated at the centre Accountability and performance management devolved to the periphery

Low Level Knowledge Creation Central control over knowledge diffusion Minimal education and training –Exception of nursing Shift in emphasis to structural issues –Education not in remit Increased multi-organisational working not multi-disciplinary working

Compatibility Gap “There were pockets of things happening for doctors but I think that has sat on the backburner because there was so much going on about funding” (Lead Cancer Nurse) “I don’t think that education and training is a huge feature on our agenda at the moment because there are so many other things” (Chair of Network Board) “We used to get on very well as a group and now we don’t because we are the enemy. We are the poachers. It is very sad because urology originally has been very friendly and now it is pretty ugly” (Urology Consultant)

Compatibility Gap (Lozeau et al, 2002)

Compatibility Gap Customisation : one positive outlier –Pre-existing relationships –Appreciation of local context More impact than centrally driven performance targets

Conclusion Conflicting top-down instruction Maintenance of relationships Adaptation to local context