BMJ  2005;331:1272 (26 November), doi:10.1136/bmj.331.7527.1272-a

Letter

Invest in people, not restructuring

EDITOR—O'Dowd reports mixed views but palpable overall concern from health service managers about current proposals to merge primary care trusts.¹ Some argued that such restructuring would put trusts back 18 months or more, but others thought not.

The little evidence available shows that restructuring is often futile, fails to achieve its objectives (usually, of saving money), causes disruptions that may last beyond 18 months, and has unintended consequences such as pushing people into new relationships they may not want and causing others to leave because they dislike the new arrangements.^2-4 It is not difficult to imagine this: many organisational relationships are built up over years, and wholesale restructuring can perturb them. Some relationships never recover, and morale suffers. Fulop et al's work on NHS trust mergers underscores this view.⁵

One peculiarity of restructuring is what it tells about those who sponsor it. Advocates of restructuring are promoting a simplistic idea, assuming that if they alter the formal arrangements such as the boxes on the organisational chart, and the official reporting arrangements, they will achieve meaningful improvement of health systems. Few organisational scholars believe that this enhances performance, arguing that it is much more sustainable to try to change other aspects of systems such as the way teams work together or the clinical and organisational cultures and subcultures.

Perhaps we could encourage those in authority to look beyond the formal structure of the NHS, and concentrate instead on what really matters—the way in which people provide services to patients, how they relate to each other and their clients, and how teams work. The money spent on restructuring could be turned into investment in people delivering care.

Centre for Clinical Governance Research, University of New South Wales, Kensington, NSW 2052, Australia
j.braithwaite{at}unsw.edu.au

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Competing interests: None declared.

References

1. O'Dowd A. Health service managers play down fears over primary care trust reorganisation. BMJ 2005;331: 1104. (12 November.)[Free Full Text]
2. Fulop N, Protopsaltis G, Hutchings A, King A, Allen P, Normand C, et al. Process and impact of mergers of NHS trusts: multicentre case study and management cost analysis. BMJ 2002;325: 246-9.[Abstract/Free Full Text]
3. Braithwaite J, Westbrook J, Iedema R. Restructuring as gratification. J R Soc Med (in press).
4. Relman AS. Restructuring the US health care system. Issues in Science and Technology Online 2005;summer 2003. www.issues.org/issues/19.4/ (accessed 17 Nov 2005).
5. Fulop N, Protopsaltis G, King A, Allen P, Hutchings A, Normand C. Changing organisations: a study of the context and processes of mergers of health care providers in England. Soc Sci Med 2005;60: 119-30.

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