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Chapter 12 ■ Diagnosing change

and six. These views we expected alongside other views. Each of the 45 wished
to see at least one of the following:
– greater clarity of roles and job descriptions starting at board level and
throughout the organization;
– improved decision making, particularly at the UMT;
– improved professional representation;
– more authority to business improvement of support to directorates;
– managers and/or specialty managers.
Many were clearly concerned, however, that fewer, larger directorates implied changes
in the workload of the clinical director which they, as individuals, would not welcome.
Some made the point that they did not know whether clinicians would wish to take on
the larger management roles implied by a rationalized structure.
(c) The remaining 22 interviewees wished to see no change to the existing clinical
directorate structure; however, all of these people wished also to see one or more
of the changes listed under (b) above. In addition, two stated explicitly that they
felt there were too many directorates. Clearly, therefore, while there is contro-
versy over whether or not to rationalize the clinical directorate structure there is
a strong measure of agreement that significant management and other changes
are necessary. It is difficult, therefore, to accept at face value the views expressed
by a number of people that a period of stability is needed after so much change,
and that this is a reason not to rationalize the clinical directorate structure
because the people saying this are calling for other changes in any event. It is
important, however, to take note of this desire for a period of stability (see
below). One commented that he believed in smaller directorates but he noted
that the existing directorates were not all working effectively and that there was
a need to build up the role of specialty managers. Another indicated that the real
constraint to a rationalized directorate structure was split-site working.
(d) Fifty-one of 67, commenting on the structure, proposed that the roles of clinical
managers, business managers and nurse managers should be defined and/or
standardized across the structure.
(e) Fifteen of those commenting on structure argued that professional representation
should be strengthened. Most commonly this point was made in relation to med-

ical representation; however, some made it with respect to nurses.
(f) Many interviewees argued either that support services should be devolved or that
greater continuity be achieved (e.g. by nominating finance staff to take responsi-
bility for particular directorates) and/or that service agreements be established.

Conclusions and recommendations
13 The first point to make is that the expressed need for a period of stability is accepted.
This will allow consolidation of achievements to date and concentration on the
development of the trust and its services/businesses. It follows that to be credible any
recommendations must be seen to deal with the relevant issues. Moreover, it must
be clear that any changes are fundamental enough to deliver significant improve-
ments along the lines of the management review. Finally, any changes should be
consistent with, and preferably supportive of, the patient-centred care initiative cur-
rently being planned.

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