Summary report of the independent evaluation of One Dorset Pathology [ODP]

Abstract

Background: this report describes the findings of an independent evaluation of One Dorset Pathology [ODP], one of the 10 workstreams of Developing One NHS in Dorset Vanguard. ODP can be conceptualised as collaborative journey towards a first-class integrated pathology service for the whole of Dorset and implementing a clinically led joint venture to improve both quality and efficiency supported by appropriate IT [a single Laboratory Information Management System], equipment [a Managed Equipment Services], pathology hubs and Essential Service Laboratories, and staffing skill mix.

Aims: the key aims of the evaluation were 1) to find out how the ODP shared vision been understood and implemented; 2) to gain a better understanding of the main drivers and barriers to the implementation of ODP (the new integrated organisational framework joint venture for shared services); 3) to ascertain the extent to which better collaborative working has developed or been enabled.

Methods: the evaluation was underpinned by the NPT framework (sense-making, participation, collective action and reflexive monitoring). The evaluation surveyed clinical and medical staff (grades, types of work, hospitals and pathology specialties) (n=61) with a representative sample of face to face interviews (n=12) selected among those who volunteered to be interviewed. Documentary analysis of the progress of ODP was used to contextualise the empirical findings.

Results: key drivers were IT and equipment; standardising procedures and processes; more collaboration and co-ordination between the Dorset Hospital Trusts and ODP leadership were leading in successfully restructuring pathology. Key barriers were: complicated contextual historical issues; costs and unequal access to resources; limited communications; feeling excluded from the ODP process; not enough clarity on ‘how staff would fit in the organisational structure; working relationships likely to be disrupted in a context of already heavy workload; impact of ODP on routine practice not valued; resistance to change and ODP leadership perceived as neither consistent nor effective.

Sense making: respondents disagreed they made sense of the various ODP roles and responsibilities [38% agree and 62% disagree] with only Managers and SBMS agreeing. Respondents agreed they had a good knowledge and understanding of the purpose of ODP [51% agreed and 48% disagreed] with the BMS disagreeing. Respondents agreed that they valued what ODP was trying to achieve [58% agree and 42% disagree] with the BMS and the Consultants disagreeing.

There was little evidence of a high level of coherence or sense making associated with a clear and explicit shared vision. The main goal of ODP was ‘saving money’ which might compromise rather than improve quality. If quality was improved, it would be at considerable anticipated cost. ODP was understood as disruptive. On the one hand, the disruption was worth it because the quality of services would be enhanced. On the other hand, the disruption was seen as a source of anxiety and frustration because of a lack of a shared understanding of how aims, purpose and benefit of ODP and various roles and responsibilities would impact on daily routine and future job roles.

Participation: pespondents agreed that they were open and willing to work in new ways to achieve the goals of ODP [74% agree and 26% disagree]. They agreed that ODP would impact on routine practice [86% agreed and 14% disagreed] but disagreed that they valued its impact [38% agree and 62% disagree] with only the Managers agreeing. Respondents disagreed that key individuals were driving ODP forward and were getting others involved [41% agree and 59% disagree] with only Managers and MLAs agreeing.

Just under half the interviewees agreed that it was the furthest Dorset had got to in terms of successfully restructuring pathology and that ODP was more likely to succeed than previous attempts at restructuring pathology because the leadership was better and ODP was necessary to avoid duplication of work and standardise processes. On the other hand, the leadership was perceived as well-meaning, but neither effective nor consistent. It had not sufficiently considered all areas and specialisms and should spend some time ‘on the shop floor’ understanding current issues before planning future changes. Goals were not transparent and senior management and consultants were protecting both their own jobs and own specialisms by blocking forward movement.

Collective action: apart from MLAs, there was disagreement that changes in working practices linked to ODP would be easily integrated into existing work [30% agree and 70% disagree]. Respondents disagreed that work would be appropriately allocated to staff who have the required skills [40% agree and 60% disagree] but SBMS and Managers agreed. Respondents disagreed that training [23% agreed and 77% disagreed] and resources [24% agreed and 76% disagreed] were sufficient and that there was adequate support from the ODP management team or leadership [38% agreed and 62% disagreed].
There was a disagreement that ODP would not disrupt working relationships [2.9] [24% agree and 76% disagree]. However, there was agreement that trust was maintained in the work expertise of colleagues [7.2] [76% agreed and 24% disagreed].

Reflexive monitoring: respondents disagreed that they had access to information about the impact of ODP [39% agreed and 61% disagreed], but the Managers agreed. Respondents disagreed that they had the opportunity to modify how they worked with ODP [25% agreed and 75% disagreed], but Managers agreed. Respondents disagreed that they valued the effect of ODP on their routine practice [42% agreed and 58% disagreed], but both Managers and MLAs agreed. Respondents agreed that they believed that ODP was worthwhile [58% agreed and 42% disagreed], but BMS and Consultants disagreed. Respondents disagreed that their colleagues believed that ODP was worthwhile [22% agreed and 78% disagreed], but Managers were not sure.

Not knowing enough about the structure of ODP and how existing staff would fit in was a major concern causing much anxiety. A majority discourse was that any benefit would be at a considerable anticipated cost. A minority discourse was that disruption and hurdles on the way would be worthwhile in the end. Respondents cannot make sense, or have not signed up to ODP and believe that they will not be able to enact it in a way that works for them or they do not have enough information to meaningfully assess its effects and its value (May and Finch, 2009).

Conclusion: at the time of the evaluation (end of November 2017 to mid-March 2018), ODP was not yet in place and hence the activities of the Benefits Realisation Document and associated system level changes had not been implemented. Nonetheless, progress had been made. After a working group completed the specification for the procurement for the Laboratory Information Management Systems, it was put out to tender at the end of January 2018. Another working group is completing the specification for the procurement of equipment. Certain key roles (e.g. some medical staff and Quality Manager roles) were being recruited on an ODP basis as part of a single clinical, medical and managerial structure. The Blood Sciences and the Cellular Pathology hubs had not been finalised. A specialty-specific reconfiguration groups of laboratory and medical staff was looking at Staffing and Skill mix and Estates requirements (including developing model footprints for hubs and Essential Service Laboratories). The structure of ODP or the content of the Full Business Case including revisiting the Outline Business Case recommendation of a hosted contractual joint venture were a work in progress still to be finalised and agreed by Executive Steering Group and the Dorset Hospitals Trust Boards.

Recommendations: respondents and interviewees recommended better leadership, better communications, and a more inclusive approach with more opportunity to be meaningfully consulted. As Dorset will be a chosen site in the first wave for Accountable Care Systems and RBCH will become the major emergency hospital and PH the planned care hospital, collaboration and co-ordination between DCH, PH and RBCH towards an integrated Dorset-wide approach should continue to focus on standardisation across Dorset, developing joint strategies, sharing best practice and learning from the process. ODP will now be situated within One Acute Network [OAN] which builds on the achievements of Developing One NHS in Dorset. OAN is a portfolio within Dorset’s Sustainability and Transformation Plan (STP) which encompasses the development of business support services, a network of clinical services across Dorset [Dorset Clinical Networks], the implementation of the CSR, and clinical redesign of services in the East of the county and the potential merger of RBCH and PH Trusts.

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