Download - Negotiating the Evolution of the Hr Function: Practical Advice From the Health Care Sector

NEGOTIATING THE EVOLUTION OF THE HR FUNCTION: PRACTICAL ADVICE FROM THE HEALTH CARE SECTOR

Steve Barnett*, Leicester General Hospital NHS Trust Dave Buchanan, Leicester Biisiiiess School, DeMoiitfort Uniswsi ty

Margaret Patrickson and Janny Maddern, lnteriintiorial Grndttnfc Scirool of Motiqernnt f , Uniziersity of South Australia

The abbreviation HR is used throughout this paper as a convenient label for the human resource function. This approach is adopted in the knowledge that some commentators see this merely as a fashion statement (Sims, Fineman and Gabriel, 19931, while others regard it as potentially reflecting a fundamental shift in approach to labour management (Storey, 1989; 1992). How is the function in hospitals responding to contemporary challenge and change? What are the implications for the hospital HR practitioner? These are the key questions addressed in this paper.

John Storey (1992) argues that HR managers have a choice of four roles: handmaidens are tactical advisers; regulators ensure that procedures and legislation are followed; advisers are consulted about the ‘human assets‘ aspects of strategic decisions; and changemakers help to frame both corporate and human resource strategy. Holt (1994) similarly argues that the HR function evolves from a welfare role, to an advisory and arbitration one, to line and senior management support, and finally to a proactive strategic change role. Fowler (1994) depicts 15 models of the personnel function, arguing that the advocacy of one would be inappropriate, given the diversity of circumstances that the function faces. Stephen Bach (1994: 1131, from a study of 24 NHS managers (mainly personnel specialists) and incorporating case study and survey findings, argues that the ‘potential for a strategic approach towards the management of staff in the NHS must remain at best uncertain’. Bach concludes that the hospital personnel function has limited credibility, is expected to make a narrow operational contribution, and has a peripheral position within trusts. This position arises, he claims, from a combination of severe budgetary pressures and external intervention, which limit the autonomy of trust management.

The HR practitioner is thus on the one hand presented with an apparent choice with respect to the organisational posture of the function. That choice is illusory, however, and would seem particularly constrained in a hospital setting. Storey and Sisson (1993: 52) note that many commentators assume that, ’to move up to managing strategically’ involves ’the appropriate degree of will on the part of the managers involved’. They argue that the function is affected by ‘situational constraints’ (technology, the industrial relations system, labour market features) and by ’generic impediments’ (short-term thinking, the dominance of accounting logic, the fragmented structure of large organisations). The evidence confirms that the textbook rhetoric of HRM is not widely reflected in practice (Sisson, 1994; Kochan and Osterman, 1994).

Arguing for the central role of the HR function, Lilley and Wilson (1994: 38) point out that payroll accounts for 80 per cent of a typical hospital‘s operating costs. Hospitals in Britain that have trust (ie quasi-autonomous) status now have freedoms in the employee management field. Stock, Seccombe and Kettley (1994) chart the growth of employment in hospital HR functions, based on the need to widen the range of local services. The British Association of Healthcare Human Resource Management argues that responsibility for HRM - pay, training, industrial

* Steve Barnett is now Director of Human Resources for Central Manchester Healthcare NHS Trust

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relations - should reside with the trust, and not in another (regional) tier of management (PM Plus, 1994).

Lilley and Wilson (1994) advance an aggressive and uncompromising argument for the introduction of local bargaining, and the consequent development of strong HR management functions in hospitals. Using the Homewood Trust Hospital (in Surrey) as an example, and forecasting a future ’jobs massacre‘ in health care in the wake of technological developments, they present a radical HRM agenda involving the ’disconnection’ of jobs, process re-engineering, customer orientation, and developments in patient-centred care with implications for work design, multiskilling and the erosion of traditional professional boundaries. Following American practice, some British hospitals (including Leicester General) are now applying business process re-engineering approaches to, for example, operating theatre work practices (Health Care Advisory Board, 1992).

Local freedoms thus offer scope for a range of HR initiatives. However, it may be difficult for the hospital HR function to contribute to organisational change because of the scepticism that surrounds the concept of management - the ‘grey suits’ - (Dopson, 1993; White, 1993; Edwards, 1993), and uncertainty surrounding the definition of the HR function itself (see the discussion in Sisson, 1994, chapter 1) . In search of explanations for the ’reality gap’, these issues are explored in this paper through examination, first, of practice in three hospitals in South Australia, and second, in a comparison with a British NHS Trust hospital. Each’s (1994) conclusions are here portrayed as overly pessimistic, and guidelines for the development of the strategic potential of the HR function are offered.

SOUTH AUSTRALIAN CONTEXT

The South Australian health system is complex and multilayered and defies simple description. As McEwen (1993a, p.15) points out, ’South Australia’s health system has to be seen as part of a national system in which responsibilities for funding, delivery of services, policy, practice and administration are shared - occasionally squabbled over and bungled - between the federal, State and local governments, public and private hospitals, private health insurance funds and a plethora of other interest groups.‘ The public health system in Australia is known as Medicare and its benefits are broadly the same as those available in Britain’s NHS - treatment is free at the point of delivery. There is mounting concern in Australia at the decreasing proportion of the population covered by private medical insurance and at the consequent pressure on the public system (McEwen, 1993b). As in Britain, increased workloads have meant longer waiting lists for elective surgery. This has led to ’management by horror story’, concerning the premature deaths and prolonged suffering of patients, and to acrimony about manipulation of theatre lists by clinicians to favour private patients (who attract higher fees; McEwen, 1993~).

The HR agenda is extensive. The Australian Hospital Association (1989) identified 13 sets of pressures facing hospital administration, including finance, workloads, staffing, industrial relations, the public-private mix, the health system itself, waiting lists, management, governance, policy, technology and change, social, ethical and legal issues, and the aged.

The Labour administration in 1993 launched a Public Sector Reform Agenda (Sumner, 1993a). The role of ‘people management’ in the advocated culture change was expressed in a Ministerial Statement (Sumner, 1993b: 33):

One of the principal objectives of public sector reform is to empower staff to contribute to the revitalisation of South Australia. There is a significant investment by the South Australian citizens

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in people within the public sector and this investment must be well managed. Staff will not thrive in workplaces where managers operate by fear, oppression, selective information, intimidation or where the organisational shape is so rigid and hierarchical that good ideas can never be realised. Unfortunately, some workplaces still operate like this, but it can no longer continue. All agencies must move to become highly productive organisations where people want, and are able, to contribute to their full potential.

With such a wide, public, and pressing HRM agenda, one might expect to find the human resource function developing a central role in the hospital management process - strategic and operational. One might also expect to find that the situational and generic impediments arising from the unique characteristics of the Australian industrial relations system would consign the HR function to a limited and standardised posture.

Research design and methods The broad aims of this project were to identify the main triggers of organisational change and the HR management response to those issues. For these purposes, access was negotiated to the senior management teams of three hospitals in Adelaide - Ashford Community Hospital, Flinders Medical Centre and the Royal Adelaide Hospital. These hospitals offer different service profiles, and Ashford is private while the Royal and Flinders are public hospitals. Data collection involved repeat interviews (three) with a senior member of the staff of the human resource management division of the Health Commission, extensive document collection at the Health Commission and at the three sites, and structured interviews with senior hospital management and clinical staff. Document collection and preliminary briefing meetings captured information on hospital structure and history. Subsequent interviews then concentrated on pressures for and responses to change. Interviews typically lasted at least one hour - most were recorded and subsequently transcribed in full. Twelve senior managers were interviewed at both Ashford and the Royal Adelaide, and 17 at Flinders.

The account of the nature and development of the HR function at Leicester General is derived from the experience of the hospital’s director of human resources, who visited the Australian hospitals in 1993 and contributed to the data collection at those sites, as well as contributing to the aims and content of this paper as co-author.

The following accounts of the four settings and their HR functions draw primarily on senior management views. From their study of NHS provider units in 1992, Guest and Peccei (1994: 224) argue for ’a stakeholder perspective in which the subjective judgements of key interest groups become the most important indicator of HRM effectiveness’. It is not the aim of this paper to examine indicators or models of HRM effectiveness. However, while accepting that a wider view of personnel policies and their implications would be generated through more extensive data collection at other organisational levels, we follow Guest and Peccei in relying on the views of key stakeholders.

Figure 1 summarises the contrasts between the three sites with respect to the HR function’s orientation and position in the organisation. The contrasts in Figure 1 are also extended to Leicester General Hospital NHS Trust.

20 HUMAN RESOURCE MANAGEMENT JOURNAL VOL 6 NO 4

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Ash ford Ashford Community was a private hospital with 239 beds and around 750 staff. The hospital and its staff had created the atmosphere of a hotel. It was commercial in outlook, and employed managers with commercial backgrounds in key positions. While reliable figures were not available, the director of nursing claimed that staff turnover and absenteeism at Ashford were lower than in the public sector, because they had a higher number of mature employees, with better attendance records, who found Ashford ‘a comfortable place to work with less pressure.’ Senior management felt that, particularly in comparison with the city’s public hospitals, industrial relations were not problematic.

Power in decision-making lay with the board of management, and the chief executive and his team. The main changes at Ashford over the five years leading up to this study included the appointment of a new chief executive, the opening of new cardiac and intensive care units, the reskilling of nurses to staff those units, a building extension programme, the introduction of continuous quality improvement, and systems development to improve medical records and cost analysis.

The board of management had 18 members. Four were local government appointees. The remainder were elected from the membership of the Ashford Community Hospital Association, an organisation which hospital employees were encouraged to join. Of the 14 elected members, four were doctors. The aim was to ensure that the hospital was community-driven, not clinician- driven. The current chief executive was appointed in 1987, when it was recognised that this position required the expertise of a politically skilled manager rather than professionally qualified clinicians. There was no HR manager or personnel department. However, there was a Staff Development Committee chaired by the domestic services manager. HRh4 was regarded as a line responsibility. HR strategy, therefore, was implicit and was driven by the CEO and his executive team. As one senior manager explained:

We don’t have an HR department, as such. Our view is that, if you‘re a manager, that includes the management of your staff resources. And there are support mechanisms designed to assist managers in that role. But at the end of the day, they, if they are responsible to their people, then they need to be involved in the hiring and the firing, the educating, the development of their people.

We’ve got mechanisms like our staff development programme and that committee, we have it through nursing, in a whole heap of ways, we have it in the fact that we employ an outside agency to provide confidential counselling to our staff as they require it on personal matters, including financial counselling and so on. We have it through occupational health and safety. So that’s about it .

Following a visit from the chief executive to a hospital in the neighbouring state of Victoria, where he saw a successful quality improvement programme, the hospital launched its own programme, the ‘Ash ford Advantage’, in March 1993. This involved hospital-wide training in customer orientation and quality improvement, and the staff response was broadly positive, in the view of senior management. Interviews with more junior staff suggested that this picture of the quality programme was not merely a senior managerial gloss.

The organisation culture and management style at Ashford thus substituted for a dedicated HR function. However, escalating HR problems and pressures were encouraging a recon- sideration of this position. With respect to staffing, for example, one manager argued that recruitment and selection were critical, but were not being conducted in a professional and

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controlled way, and that ’sometimes the wrong people are doing the interviewing‘. The position in which HR issues are seen as the province of line managers rather than a dedicated function could thus come under pressure. One senior manager (not in an HR role) endorsed this view:

I think human resource management, particularly for a larger private hospital, is becoming more of an expert area. I wonder if one day we won’t have some sort of human resource person with special training - not necessarily taking away the appointments, but at least doing the vetting; doing a lot of the preliminary work in getting people to a stage where you have got a shortlist of people, rather than having nurses, administration, finance and all these departments dabbling in it. I think it is getting to the point where you need an expert. I don‘t think we‘ve reached that at the moment. I personally think we’re getting close to it, but I think you should throw that question at the CEO because I think he’s a bit against it.

From a senior management perspective, Ashford thus appeared to have an effective HRM system, with few recruitment or industrial concerns, in the absence of a formally established HR function, the creation of which had been considered but not agreed.

Flinders Flinders Medical Centre, opened in 1976, was the first hospital in Australia to combine teaching, research and medical services, and was the only major acute care hospital in the southern metropolitan region of Adelaide. The hospital had 516 beds and employed 2,390 (full-time equivalent) staff.

The integrated concept of the centre was based on a model for patient care, teaching and research different from that which had evolved in Adelaide. This was recognised in the organisation structure of the centre, where professorial heads of academic units were also heads of the hospital departments. The centre also had over 60 committees reporting to the board of management. The department heads in this structure had clear executive powers and also had a joint university-hospital role. Each department head was supported by a three-member team, comprising a chief resident, an assistant director of nursing and an administrative officer (a version of the clinical directorate model; Edwards, 1993; Rea, 1993). Power in key decisions lay with heads of departments through the Medical Advisory Committee.

At the time of this study, the centre was planning its next strategic review, to be held during the first half of 1994. The draft agenda for the review conference included many of the issues that had faced the executive committee in 1989, including legislative, social and political changes, pressures on education and research developments, increases in workloads and waiting lists, resourcing changes, bureaucracy, the management structure, and work satisfaction a t all levels. Some of the commentary in the draft agendas for the 1994 strategic planning conference suggested a sense of desperation. Under the ’resourcing’ heading, the draft read, ‘does anyone understand the impact o f . . site industrial negotiations and the funding of pay awards, penalties under Medicare for increased private bed days?’, and ’can things get better?’ The ’workloads’ draft asked, ‘can we afford psychiatry, fertility, geriatrics and other low volume or high cost services?’ And, as a further indicator of forthcoming HR prrssures, the draft agenda concerning ‘work satisfaction’ read, ’are key senior staff enjoying work enough to continue, and who will replace them?’

The CEO had a background in hospital administration in Britain. However, neither he nor any other members of the senior management team had significant industrial or employee relations experience. In the early 1990s the hospital had a reputation for its history of industrial

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disputes, one of which had deteriorated to an extent where direct State Ministerial intervention was considered necessary.

The major changes experienced by Flinders Medical Centre in the five years prior to this study, as well as the events following the last strategic review in 1989, included a new cardiac surgery unit (1 992), a new transplantation and immunology centre (also 1992), a management decentralisation project in obstetrics and gynaecology in 1992-93, and a review of the organisation structure by consultants Booze Allen Hamilton in 1992. The Booze Allen Hamilton report was critical of the centre’s management structure in which the chief executive had over 20 heads of department reporting directly to him. Although those department heads have considerable autonomy in running their sections, the consultants felt that the CEO’s span of control was too wide. Their report advocated the appointment of a chief of staff, to whom department heads would report, and to whom the CEO could offload a significant number of medical co-ordination and planning issues. The consultants’ report also noted the lack of a dedicated HR function, and advocated the creation of an appropriate position. The previous director of administrative services had recently retired, and the centre’s executive group decided to restyle that post as director of administrative and human resource services and, at the time of this study, had been given Health Commission approval to recruit to that post. It was anticipated that the post would be filled during the first half of 1994.

This would be the first time the centre had a manager clearly and exclusively responsible for HR issues. The holder of this post would not become a member of the centre’s executive group, chaired by the chief executive. He or she would instead report to the senior director, corporate affairs, who reported direct to the chief executive and who was a member of that group. This reporting relationship was not seen as significant to other members of the senior management group because, as a member of the management team of the hospital, the new director could have direct access to the chief executive who operated an ’open door’ policy, and who ‘doesn’t really wanna be bogged down with disputes with porters and orderlies which really shouldn’t take up his time’ (in the words of another senior manager). The board of management formed a human resource and industrial relations sub-committee in 1993, chaired by a board member who was also an academic in a local institution. It was not proposed to put the new director of administrative and human resource services onto that committee because, according to one manager, ’it is seen as too sensitive to discuss staffing matters at the board with members of staff present’.

As the main factor triggering the establishment of this new HR role was the recent and poor industrial relations history of the hospital, many of the centre’s other managers saw this clearly as an IR troubleshooting and firefighting role. Asked to give a view of the significance of the development of this new post, one senior manager illustrated the hospital’s industrial relations context with the following anecdote:

Well, I think it’s probably a very important role because one of the difficulties, I guess, that we have is dealing with unions and also with the concept, I suppose, that we do need to try and get greater flexibility within a lot of our workforce. Again, I can give you a small example. We were finding that we were running out of towels on the wards. And the reason was quite simple. There just weren’t enough being put there. But our very lowly paid orderlies refused, as part of their negotiations, to count towels. So the way that it was dealt with was to put a line on all our cupboards, and they just filled the cupboard up to that line. That was fine until we got a new batch of towels, and they were obviously fatter and thicker, so you could only fit a smaller number of


BARNETT ET AL

towels up to that line. So we were running out of towels because perfectly educated people would not count, all because of the industrial relations bind we’ve got ourselves into. They just refused to do that. That’s very trivial, but nevertheless I think it typifies the sort of craziness it’s got into.

It would seem clear where the majority of the new director’s efforts would be channelled, given the pressing nature of that range of industrial relations issues, and the absence of other senior management expertise. According to another senior manager, the post would become ’a buffer for people above who don’t want to be involved in the sticky business of unions and disputes and all of that sort of stuff.’ While the main thrust of the new post would be to ’keep the lid’ on industrial relations issues, some senior managers also saw this development as an opportunity to manage an organisation culture change, to become more customer-oriented, and to consolidate and formalise staff development.

The management decentralisation project in obstetrics meant that the department was run by an executive committee (clinical directorate) comprising the professor of obstetrics and gynaecology, the assistant director of nursing and a business manager (half time). Their position descriptions identified their responsibility for personnel issues arising in the staff groups reporting to them, with regard to recruitment, selection, work allocation, training, development and motivation. The role of the executive committee was set out in a manual for delegations of authority. Any attempt by a future director to ’recapture’ an HR agenda would thus meet with these documented procedures.

The evolution of the HR function at Flinders Medical Centre was thus part of a wider series of organisational developments. Those changes were designed in part to deal with continuing pressures on resources and workloads. The introduction of the new HRM position was designed particularly to address a weak record of industrial relations in the context of further known developments and pressures in the HR domain.

Royal The Royal Adelaide, established in 1840, was the first colonial hospital in South Australia and was seen by the medical community as the leading public hospital in the State. The hospital had three campuses, the main one of which was in the city centre. It had over 1,000 beds and employed 3,400 (full-time equivalent) staff. The hospital was administered by a board of directors who, as at Flinders, were appointed by the State Minister of Health.

There were many long-serving staff at all levels in the organisation, which carried a strong sense of tradition. The culture was bureaucratic, driven by rules and procedures. In casual conversation with visiting researchers, staff spoke in terms of ‘the way we do things at The Royal’, and one senior manager interested in organisational culture change identified this affinity with rules, procedures and tradition as a major barrier. Power in key decision-making lay with the medical staff who were represented on the hospital’s main decision making forum, the Operations Committee, which advised the board. The manager, personnel and payroll, was one of four managers reporting to the director, information and resources.

Changes in the hospital in the five years before this study included a savings campaign in 1991-92, producing AU$1.7 million worth of reduced costs; cost savings generated by innovations recommended by Booze Allen Hamilton consultancy; the closure of 100 beds, in 1989, by ministerial dictate; and a hospital reorganisation at the end of 1991 into functional services.



The consultants’ review revealed the limitations of a traditional centralised approach to hospital management. The power of the professions and the unions meant that some key decisions appeared to be based on considerations other than patient interest. In the words of the CEO, the problems of the organisation stemmed from the assessment that:

. . . the hospital was too large; had poor communication systems acmss departments; its centralisation made decision-making difficult and slow; managers did not feel that they had control over their departments, and roles and responsibilities conflicted between departments and divisions. The major bed closures had created a lack of corporate culture, commitment and ownership associated with loss of morale. As a result of the closures, staff were unwilling to risk the challenge of change because of the lack of incentives. The budget system was seen as untrustworthy. Discussion at staff level indicated a need for the hospital to redefine its mission as an academic centre to heighten corporate culture and staff commitment; encourage more efficient utilisation of hospital resources; clarify roles, responsibilities and authorities of management and re-energise medical staff.‘

The Booze Allen review considered the structure of clinical directorates to determine ‘the appropriate direct patient care organisational structure’. The model advocated was the decentralised approach of the Johns Hopkins Hospital, in the US, introduced in 1973 (and described, for example, in Boyce, 1993). The Johns Hopkins approach is to organise the hospital around a number of functional services which purchase support from central hospital units - or from other providers if the quality is appropriate and the price lower.

The six functional service groupings established included orthopaedics; gastroenterology; cardiology; haematology and oncology; general medicine; and neurology. This was a variant of the approach adopted at Hinders, here with the functional service run jointly by a clinical director and an assistant director of nursing, supported by an administrative officer and a (financial) resource consultant. These autonomous services operated within the context of institutional policies concerning objectives, capital, prices and personnel issues. Functional units run in this way, it was felt, could deliver savings in personnel, supplies, test volumes, x-rays ordered, and length of stay. Functional units can also help to control costs through their ability to mount a collective challenge to central administrative functions.

The annual report at the end of 1992 claimed that, ’there is a clear and strong body of opinion that this decentralised organisational model is working in a productive, effective and co- operative manner.’ One analysis of the experience (Giardini, 1993) found that levels of satisfaction with the approach were high among clinical directors and assistant directors of nursing.

The Royal Adelaide Hospital had a personnel manager with an administrative and advisory role, dominated by the concern with adherence to the terms and conditions of awards, with respect to all the hospital’s non-medical and non-nursing staff. The personnel manager had a senior personnel officer and three other staff. The hospital had no management development function. Personnel issues arising on a day to day basis were the responsibility of the administrative officers in the functional services, each reporting to their respective clinical directorate. There was no formal link or reporting relationship between the personnel officer and the administrative officers. HR strategy was ‘issue driven’ by the CEO and the Operations Committee. For example, an appraisal system introduced in 1993 was triggered by a memo from the CEO to the personnel officer, asking the latter to implement it, without prior knowledge, consultation, or design input with regard either to the scheme or its implementation.


BARNETT ET AL

The personnel manager explained:

The new functional services are self-contained. The day-to-day personnel function is devolved to the management of those units, and I provide a personnel service on a consulting basis. 1 give them the information they need to manage the issues themselves. This means advising on awards, on legislation, on the selection process, on conditions of employment and so on. But they make the decisions in the service units now. The director of nursing is still holding control of those issues for nurses. The functional units also now deal with their own clerical and allied health staff. This shift has been facilitated by the creation of that new post, the administrative officer. The admin officers don’t have any personnel or HR qualifications; most of them have degrees or diplomas in business studies. The admin officers d o see people issues as the problem. The administration itself is relatively easy. There is no regular forum in which 1 meet the admin officers to discuss personnel or industrial relations issues. We have no management development plan. I circulate course advertising that comes in, nd hoc-, from outside providers. If somebody wants to do a course, the cost comes out of my cost centre budget. We have a lot of staff on further degree work, but I can’t tell you who or how many; 1 don’t have records of that.

Given the scale of the current and forthcoming HR and IR issues facing this and other hospitals in Australia, the personnel function at the Royal Adelaide would appear to be accorded a relatively traditional, administrative role. While funding issues remained critical, one senior manager commented that, ’budgeting pales into insignificance in the face of the human resource issues that are much harder to get on top of.’ The same senior manager continued:

About 75 per cent of the hospital’s budget is spent on people. Everyone agrees that HR is a key function. But HR at the Royal Adelaide is low in the organisation structure and is not influential. Is that a problem? Nursing and medicine have traditionally handled their own HR issues. The domain of personnel here includes allied health, clerical and non professional staff. This could have changed five years ago, but the chap left. Devolution will push issues and skills out to the [functional] services. Does that leave no place for a strong central HR function? Well, we do need to drive policy, draw on expert advice.

The hospital had no plans at the time of this study to redefine its personnel activity. Staff recruitment, training, appraisal, discipline and staff development issues had, it was felt, been adequately devolved to the functional services. Strategic discussion of HR issues fell to the operations committee, none of whose members could be said to represent a qualified or experienced voice of the HR profession.

THE HRM CHOICE REVISITED

The term ’human resource management’ has been used since the mid-1980s to describe an approach distinct from traditional ‘personnel management’. Storey (1992) identifies 27 ‘points of difference’ which distinguish the two approaches. Whereas personnel tended to be seen as marginal to corporate strategic planning, HRM was seem as a central contributor. Personnel was thought to be concerned with the procedures of recruitment, training and payment systems, whereas human resource management was thought to be concerned with the organisation’s mission, values and culture. Storey also depicts a choice of four roles for HR managers, based on the function‘s location on two key dimensions. The first of these dimensions concerns whether the function is seen as strategic or tactical in outlook and contribution. The second concerns whether the function is interventionist in its approach or consultative. These dimensions are plotted in Figure 2.



A ? 6 k z REGULATORS

Flinders (new post)

FIGURE 2 TheHJ7M choice

8 5 s !!i

HANDMAIDENS $

Ashford (line managers)

Royal (personnel and admin officers)

STRATEGIC

CHANGEMAKERS

Leicester (since 1992) h

ADVISERS

termism and ironically, because of the ‘tradition of voluntarism’ in UK labour law - those persons running organisations in the UK who want to move up to a strategic plane in HR/IR face an uphill struggle. Moreover, the range of options open to them will usually turn out to be more severely constrained than they had imagined or had been led to expect.

The interplay of historical and contextual forces thus both locates and constrains the HR position. The ability of the function to adopt a strategic stance in hospitals in South Australia is made awkward by the interventionist role of the Health Commission in employee relations, and by the lack of a clearly articulated State health care strategy as a platform for HR strategy at hospital level. The wider State political and organisational context thus conspires to confine the choices to the tactical domains of the regulator and the handmaiden. Other factors restricting manoeuvrability are organisation culture and management style (as at Ashford), the priorities attached to particular problem domains (as at Flinders), and issues of wider organisational restructuring (as at the Royal). It is also apparent that the expertise and personalities of key individuals shape perceptions and the development of particular roles and functions - this was evident at all three sites involved in this study.


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This may appear paradoxical. The HRM issues are multiple, visible, and potentially overwhelming in their impact on hospital management, operational efficiency and quality of patient care. These issues are hardly new. The significance of the HR agenda is rehearsed regularly in the Australian media. Management bookshops and journals are populated with materials on HRM, which is also a popular theme of management briefings, seminars and conferences. Yet the personnel functions at the three hospitals involved in this study, in terms of organisational position and influence, are a significant distance from the contemporary image of the changemaking, strategic HR function. The apparent paradox may be explained, not only by the features of the national Australian industrial relations context, but also with reference to the local shaping factors, past and present, which condition the status and perception of the personnel role, and the manner in which it is conducted, in different ways, within existing structures. Figure 3 summarises the local shaping factors, including the criteria on which the effectiveness of the HR function is assessed, with respect to the four hospitals.

How should the practitioner respond in these circumstances? Dunphy and Stace (1990), argue from their research in the Australian financial services sector that the HR approach should be linked to the organisation‘s ’change game plan’. They distinguish four HR models, each with a distinct emphasis. A task-focused strategy emphasises costs and wturns, workforce planning and reviews, tangible reward systems, formal skills training and multiskilling, formal industrial relations procedures, and a business unit culture. This approach should be used when services are faced with major change, and where there is a need to deliver rapid changes in structure and culture. A developmental strategy emphasises the growth in individuals and teams, internal development, intrinsic rewards, organisational development and a strong corporate culture. This approach should be used in the context of market growth, when product innovation and creativity are required. A turnaround strategy emphasises organisational change, career restructuring, downsizing, external recruitment, executive teambuilding and breaking with the traditional culture. Dunphy and Stace believe this stance is appropriate when the environment has changed dramatically, where the organisation is not ‘in fit’, and where there is a need to abolish traditional practices, and to introduce radical work restructuring. Finally, a paternalistic strategy emphasises procedures and uniformity, concentrates on operational and supervisory training, and operates within the framework established by collective agreements. Dunphy and Stace argue that this has limited application, in stable monopoly contexts, with mass production, where HR strategies are tools of consistency and control, and the emphasis is on formal job descriptions and industrial relations procedures.

Hospitals in South Australia are not free to choose between these strategic options in the current organisational and political climate. Where the role exists, it is paternalistic in emphasis: environmental pressures imply one of the other three strategies. However, it is not clear which approach Dunphy and Stace would recommend. They each appear relevant in the current hospital sector context - major changes, increasing demand, and the need to change traditional practices.

What other options for change and development are open to the HR practitioner? In search of guidance, we turn to recent experience in Britain. The trends and pressures in health care in Britain and Australia are broadly the same - political intervention, funding cuts, demographic pressures and technological developments. As Australia moves to enterprise bargaining, British NHS Trusts are moving to local collective bargaining. The HR agendas are thus similarly pressing.


BARNETT ET AL

We will outline the development of the HR function at Leicester General Hospital NHS Trust since 1990. Until the end of 1991, the function was organised on traditional lines, with personnel and training sections providing a range of standard services, such as recruitment advertising, selection, appointment procedures, payroll management, and a range of standard training programmes. Following the appointment in quick succession of a new chief executive and director of human resources, a review of the personnel function was undertaken. This generated a number of critical themes: lines of accountability were unclear; response times were low; advice on some critical personnel issues was not always given with conviction, and was often incorrect; there was no real understanding of, or commitment to, the concept of customers; there was no clear understanding of the role of the HR directorate and the added value i t could contribute; workforce information was poor; and the backlog of work was significant.

The renamed HR function at the beginning of 1992 had low levels of credibility and influence in the hospital, consistent with Bach‘s (1994) findings from his study carried out around that time. IHowever, there were also significant pressures for change at this time within the NHS. The government had embarked on a policy of ‘charterism’. In the search for efficiency, there was increased emphasis on clinical outcomes. To improve effectiveness through competition, the government had sought to establish a purchaser-provider split in the health care system and to develop the internal market (with, for example, general practitioners holding their own funds with which to purchase hospital care on behalf of patients). Hospitals were invited to become self-governing trusts, with attendant freedom to determine pay and conditions locally. These pressures generated a new focus on labour productivity and on value for money. Leicester General became a trust in 1993.

It became clear that a new and strategic approach to the management of the workforce was required. The trust thus decided to embrace the principles of human resource management, and a new structure for the function was introduced. New appointments were made with an emphasis on introducing well-qualified and experienced HR professionals (not all from within the health service). The function was reorganised to concentrate on two broad areas of activity. The first concerns operational support based on clear service specifications and professional standards, agreed between the directorate and other managers. The second concerns a high quality, high visibility specialist consultancy support in all aspects of HR management and development throughout the hospital. The strategic objectives of the directorate were shaped around pay and rewards, communication systems, flexible employment practices, the use of service level agreements, consultancy expertise, training and management development, and HR planning.

It is also instructive to compare the three Australian and one British HR functions explored here in terms of the measures of effectiveness applied at each site respectively. As shaping factors, these criteria condition both the activity itself, and the expectations held of the function by other staff and managers.

The senior management teams at each of the four sites covered here had different perspectives on the effectiveness of their HR function. Again following Guest and Peccei (1994), ‘effectiveness’ is here defined in terms of the expectations of key stakeholders. The effectiveness of the function at Asliford was expressed in terms of low labour turnover, low sickness absence, high levels of job satisfaction and motivation, an ongoing ability to ’poach’ key staff from other institutions, continuing commercial viability of the hospital and retention of market share, high levels of investment in training, and excellent staff facilities. This could be described as a



‘good housekeeping’ orientation. The effectiveness of the personnel function at the Royal was expressed in terms of adherence to established policies and procedures, non-interference in line management, processing payroll matters, smooth handling of contracts of employment and letters of appointment, posing no threat to existing professional boundaries, and the provision of low level internal consultancy support. This could be described as a ’rule policing’ Orientation. The effectiveness of the new HR function at Flinders was expressed in terms of the extent to which other key managers could be relieved of tricky industrial relations issues, improvements in the industrial relations climate, the rapid resolution - or avoidance - of disputes, the development of standard policies and procedures, the provision of support to implement (but not to shape) strategic decisions, and improved recruitment and retention. This could be described as a ’troubleshooting‘ orientation.

The effectiveness of the HR directorate at Leicester was expressed in terms of continuing ability to attract and retain staff, the placement of high quality employees in key positions, the removal of traditional professional boundaries and barriers, the development of teamwork and multiskilling, contribution to planning and implementation of organisational development and staff training measures, the integration of HR strategy with corporate business plans, and contribution to securing market share and the advance of quality standards. Consistent with a strategic or ‘changemaker’ role, the function was expected to drive culture and other organisational change programmes, to position the hospital against national standards and targets (for example with respect to labour efficiency indices), to establish national and regional recognition and publicity for HR practices and initiatives, and to maintain the industrial relations climate.

CONCLUSIONS

Three possible sets of conclusions emerge from these contrasting accounts. First, one explanation for the ’reality gap’ between rhetoric and practice lies with the impact of local shaping factors. The position and contribution of the HR function reflect specific features of each organisation’s history, structure, and management style. Aspects of the national setting, including the political context, are significant, but impinge in different ways on different hospitals and do not offer adequate explanations for the HR posture on a single site. Explanations appear to lie with the interplay between national systemic issues and local history and conditions. This contention, if accurate, would explain the ’housekeeping’ orientation at Ashford, the ’troubleshooting’ orientation at Flinders, the ’rule-police’ orientation at the Royal Adelaide, and the strategic orientation at Leicester. Second, a further explanation for the reality gap appears to lie with the contested ownership of the HRM agenda. Health care is a politicised domain in which multiple professional groupings, each highly status and reward-conscious, actively seek to protect and if possible extend the respective boundaries of their autonomy. Initiatives that threaten those boundaries and areas of autonomy can anticipate resistance. Third, the implications for the HR practitioner lie with the negotiated evolution of the function: negotiated -due to the contested ownership of the agenda, particularly with respect to job boundaries, management control, work organisation, career progression, training and development, and reward systems; and evolution -because the local shaping factors have to be addressed in a manner sensitive to context, history, and current expectations.


BARNETT ET AL

Local shaping factors The HR function is not well developed in hospitals in South Australia. The explanation for this lies in the context within which the function operates. Some of the key context factors are national and historical, and concern the nature of the industrial relations system and the organisation of health care at the State level through the Health Commission, which performs many traditional IR and HR functions. The national and State shaping factors thus dictate a constrained, paternalistic approach. The pressures and trends of the past decade, however, have weakened the position and strengths of traditional systems and, as indicated earlier, the pressures for change are substantial in the face of a widely recognised and pressing HR agenda. Factors supporting the further development of the HR role include local autonomy with respect to employee relations, the continuing search for efficiencies which in turn implies changing working practices, and locally recognised inadequacies in the ability of current arrangements to cope with the pressures. Other factors constraining the HR function to a traditional procedural and paternalistic emphasis include the lack of a local HRM tradition; the lack of understanding and credibility of the function; the continuing suspicion of general management; the limited criteria on which the function is assessed; and the views of key players in individual institutions with respect to how HRM issues should be handled.

To the extent that the shaping factors lie with aspects of national politics, culture and legislation (as Storey and Sisson, 1993, conclude), then there may be little that the local function can do to reposition. But there are pressures for change at a national level, too. The role of the Health Commission and the industrial relations system are not 'national givens'. Different institutions experience and have responded to the national cultural and political context in different ways. And many of the shaping factors are amenable to management or manipulation at the local level. The choice of positioning for the HR manager may not be free and open, but the scope for a proactive approach to repositioning the function is not wholly constrained.

Contested ownership Strauss et nl(1963) argue that the patterns of behaviour evident in a hospital organisation, and resultant patterns of change, stability and conflict, can best be understood if the organisation is viewed from a 'negotiated order' perspective. From this position, rules and structures can be seen as defining only to a limited extent, and over limited time periods, patterns of behaviour and interaction. In their view, order is maintained and change is achieved through continuous negotiation and renegotiation between the different professional and non-professional groups, and patients. The manner in which groups and individuals engage with the negotiation process is thus critical. As Strauss et al (1963: 312) illustrate, with respect to the engagement of non- professionals:

. . .one may begin by stating that, like anyone else, they wish to control the conditions of their work as much as possible. Of course, they must negotiate to make that possible: they must stake claims and counterdemands; they must engage in games of give-and-take. Among the prizes are: where one will work, the colleagues with whom one will share tasks, the superiors under whom one will work, and the kinds of patients with whom one will deal. Illustrating from one area only, that of controlling superiors: aides have various means of such control. These include withholding information and displaying varying degrees of cooperativeness in charting or in attending meetings.



The HR function is implicated, from this perspective, in a ‘great web of negotiation’. Although the HRM agenda is extensive, pressing, and strategic, other groups can claim or have claimed ownership of specific agenda items. Line managers at Ashford own their separate recruitment and selection processes. Senior hospital management at Royal Adelaide own initiatives in HRM, such as appraisal and rewards, beyond the administration of contracts of employment. Senior management at Hinders want to delegate the industrial relations problems to an HR specialist, but retain ownership of strategic decisions, and deny that specialist formal direct access to senior management decisions. The medical and nursing professions at all these locations retain ownership of training and development, and career progression systems. The HR function at Leicester, in contrast, is successfully evolving a strategic position, in the face of similar ownership contests. How has the Leicester function addressed the ‘negotiated order‘ to achieve this?

Negotiated evolution Given the existence of local shaping factors and the contested ownership of the HRh4 agenda, it is unrealistic simply to advise the HR practitioner to select a strategy (for example, ‘let’s turnaround’), or to choose one or two of Fowler’s 15 models (‘we are industrial relations firefighters and specialist advisers’). An evolutionary approach, sensitive to the idiosyncrasies of the local context, is clearly required. This can be described as a negotiated evolution approach, and can be illustrated by experience at Leicester General where the following strategies have been developed.

The credibility building measures deployed by the HR directorate at Leicester General have included:

appointing professionally qualified staff with broad-based experience; demonstrable understanding of the business and its main processes; ability of HR practitioners to speak the professional language of the business; ability of the HR function to influence and to articulate the organisation culture and core

maintaining a ’lean’ function, as an overhead, and avoiding public complaints about

operating a ‘bureaucracy-free’ function; building and maintaining an effective and problem-free industrial relations climate, working to rapid response and turnaround times within Service Level Agreements; being proactive in seeking out problem areas in the organisation and helping to resolve

avoiding existing ‘success stories’; identifying low cost, low risk HR initiatives which generate substantial returns for the

consistently demonstrating a keen interest in and sympathy for (internal) customers’

v a 1 u e s ;

workloads;

them;

function’s credibility;

problems.

The function at Leicester has also taken active steps to ensure that HR issues are considered central to a wide range of management and organisational decisions. In other words, HRM is consistently on the decision-making agenda. The approaches to agenda management used have included:

34 HUMAN RESOURCE MANAGEMENT IOURNAL VOL 6 N O 4

BARNETT ET AL

consistently keeping ’people issues‘ at the centre of business decision-making; ensuring that resources and developments are designed to improve demonstrably the

sensitivity to the politics of the organisation and working to influence the key poiver

developing influential internal and external networks; controlling key business processes including rewards systems, industrial relations and

developing an HR strategy which is an integral element of the hospital’s business plan; using key employment statistics as part of the business data - turnover, absence,

identifying additional resources to be ‘given up’ to service and functional areas; utilising investment appraisal discipline to examine major HR initiatives and to ensure

contribution which people at all levels are able to make;

brokers;

productivity measures;

productivity, payroll costs, workforce monitoring;

that returns can be quantified.

The HR function has also sought to improve credibility and to sustain a key position on the management agenda by demonstrating coiitiizuous delivery of results. This has been achieved through the following activities:

systematic dissemination of HR initiatives, in local press, on local radio, in the hospital journal,

advertising external networks and introducing them into the organisation; meeting targets and standards set out in Service Level Agreements; securing external sources of funding for project activity and for research; the development of a Staff Charter; maintaining a visible presence at all influential meetings (board, committees and so on); managing change successfully and smoothly and demonstrating that the desired goals are

publication of productivity gains associated with service developments; being associated with the success of others; demonstrating ability to react flexibly to customers’ requirements and not being constrained

and in professional publications;

being realised;

by the rules of the organisation.

The HR function at Leicester General has used a range of other influerzciizg techniques. The HR directorate budget has been deliberately underspent. Staff benefits and improvements to the working environment have been introduced. The function has been visibly responsible for the recruitment and promotion of high quality staff, and for heavy investment in employee development. HR staff demonstrate strong internal consulting skills. The I-IR function has been willing and able to challenge management thinking and to influence management style. The function’s influence has been further enhanced by its ability to draw on external examples of best practice, by its leading role in local pay bargaining, by shaping and facilitating major change and re-engineering projects (such as a Workforce Utilisation Review), and by working with multi-disciplinary project groups.

We first considered the nature of the HR function in three hospitals in one Australian city, within one industrial and employee relations system. The well-known and long-established features of the Australian system clearly contribute to, but do not in themselves explain, the



apparent diversity of HR practice, or the lack of development of the function faced with significant and widely recognised pressures. Instead, we have sought to demonstrate how the gap between HR rhetoric and practice - the ’reality gap’ can be explained by considering the contested ownership of the HRM agenda, and by exploring the local shaping factors that determine the nature, scope, orientation and status of the HR function at each site. To portray the human resource practitioner as someone faced with an interesting and wide choice of models, but heavily constrained by national systemic and political forces, is oversimplified and unnecessarily pessimistic. We have sought to illustrate, through the experience of one NHS Trust hospital in Britain, how the HR practitioner can engage effectively in the contest for ownership of the agenda and address the local shaping factors. In conclusion, what is offered here is a proactive and optimistic approach to the negotiated evolution of the HR function, through credibility building, agenda management, continuous delivery, and other influencing techniques.

REFERENCES

Australian Hospital Association, 1989. The Health System: Issues for the Next Decade. Sydney:

Bach, S. 1994. ‘Restructuring the personnel function: the case of NHS Trusts’. Human Resource

Boyce, R.A., 1993. The Organisational Design of Hospitals: A Critical Review, North Ryde NSW.

Carr, P. and Donaldson, L. 1993. ‘Managing healthily: how an NHS region is promoting change’.

Health Care Advisory Board, 1992. Hospital of the Future Volume 1: Toward a Twenty-First Century

Dawson, P. 1994. Organisational Change: A Processual Approach, London: Paul Chapman. Dopson, S. 1993. ’Management: the one disease consultants did not think existed‘. Templeton

Dunphy, D. and Stace, D. 1990. Under New Management: Australian Organisations in Transition,

Edwards, B. 1993. The National Health Semice: A Manager’s Tale, 1946-1992, London: The Nuffield

Fowler, A. 1994. ‘Personnel‘s model army‘. Personnel Management, Vo1.26, no.9,34-7. Gardner, H. (ed). 1989. The Politics of Health: The Australian Experience, Melbourne: Churchill

Livingstone. Giardini, M. 1993. ‘The Booze-Allen & Hamilton consultancy at the Royal Adelaide Hospital:

An analysis of a planned organisational change process’, unpublished Masters Degree dissertation, Hinders University of South Australia, June.

Guest, D.E. and Peccei, R. 1994. ‘The nature and causes of effective human resource management‘. British Journal of Industrial Relations, Vo1.32, no.2,219-42.

Holt, B. 1994. ‘Benchmarking comes to HR. Personnel Management, June, 32-5. Kochan, T.A. and Osterman, I? 1994. The Mutual Gains Enterprise, Massachusetts: Harvard

Lilley, R. and Wilson, C. 1994. ’Change in the NHS: the view from a trust’. Personnel Management,

Australian Hospital Association.

Management Journal, Vo1.5, no.2’99-115.

Australian College of Health Service Executives, Monograph Series.

Personnel Management, October, 48-53.

Hospital, Washington DC: The Advisory Board Company.

College Management Research Papers, no. MRP94/2, December.

Sydney: McGraw Hill.

Provincial Hospitals.

Business School Press.

May, 38-41.

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The authors wish to acknowledge the support provided in the conduct of this research by the clinical and management staff at the hospitals involved. They also wish to acknowledge the advice of John Storey and anonymous reviewers on previous drafts of this paper, while confirming that the flaws are entirely the authors’ responsibility.
