Table 3 Trust, context and culture

03

District general hospital in an urban location. 50% shortfall in consultant staffing in A&E and reliance on bank/agency staffing in AMU in particular. Well networked to other services in the locality.

Hierarchical

Reduced financial deficit but still had large deficit of over £20 million

Requires Improvement

This organisation focused on complying with the standards. Policies, processes and protocols were important in this hospital. They had implemented some changes by the introduction of more acute care physicians but there was the sense that more consultants were needed in order to deliver.

07

Teaching hospital in an urban location in a deprived area. History of organisational turbulence as two separate organisations merged into one Trust a few years prior to fieldwork. Staff recruitment an issue in this Trust.

Hierarchical / clan

Agreed to deliver a deficit of no more than £35 million in 2018/19

Requires Improvement

Focus on compliance with standards. A merger between two different hospitals had led to a more hierarchical approach in order to effect change. Over the past few years they had focused on recruiting new staff for the emergency pathway but were still exploring how staff could work differently.

10

One hospital in a group of 3 in a relatively affluent urban area. Good links with other services in the locality. Recent change of board leadership; consultant body described as ‘the old fashioned firm structure’.

Hierarchical / clan

Had met their control total

Good

Focus on compliance with standards, use of audit to monitor. The hospital was reported to be hierarchical and reactive in implementing new policies and structures. The consultant body was reported to be ‘clannish’. Management were still working out where the gaps were in 7 day service targets. Changes to the consultant contract meant consultants were asked to conduct ward rounds at the weekend.

11

District hospital. Staff recruitment difficult. The location was felt to be a deterrent as it was an expensive area to live in. Trust was in financial special measures at the start of the fieldwork.

Hierarchical / clan

£12 million deficit against a planned deficit of £7 million

Requires improvement

Commitment-based strategies. Organisation with a community feel, with stability and loyalty. Focus was on best interests of patients. Delivery was through incremental change and collaboration.

12

Large teaching hospital and major trauma centre. Difficulties in recruiting to acute general medicine but not to specialist branches.

Hierarchical / clan

Deficit of over £8 million

Good

Focus on compliance with standards. There was seen to be a need for policies and procedures to maintain standards, and that innovations could be slow to implement and the organisation could suffer from micromanagement. New doctors were being told they would undertake acute medicine for 50% of the time and take part in the weekend rota, and contracts were short term.

16

One of three hospitals supplying acute and maternity services located in a deprived area. Good links and access to the services supplied by the other Trusts.

Developmental

In surplus by over £7 million

Good

Commitment-based strategies. The focus was seen as being on the best interests of patients. This site used cooperative and collaborative strategies including peer pressure to achieve change. Management was heavily invested in achieving consensual change.

17

Hospital in a rural location. Significant problems with staffing at all levels and a high number of locum consultants; great difficulties recruiting staff. A&E in nearby location closed in the evenings adding to pressure on acute services. Isolated from other services.

Hierarchical / clan

Financial special measures

Requires Improvement

Focus was on compliance with standards. The organisation was dealing with a legacy of poor performance and trying to instil good practice. There was a tension between encouraging innovation and controlling policies and procedures. The management did not have a specific plan or programme to meet the 7 day standards but were trying to use resources efficiently and centralise. They were working hard to recruit internationally, and improve the workforce with leadership programmes and centralise job plans. Yet there was a sense of great strain in this organisation.

18

Large teaching hospital. Interviewees state that they have been meeting 7 day standards for some time. The hospital is well staffed.

Developmental / rational

In surplus by over £20 million

Good

Commitment-based strategies. This site framed changes in terms of best interests of patients. Change was being achieved through collaborative strategies including gaining consensus through participatory discussions with staff.