The managers readily identified a set of common values which they perceived were manifest by the constituent practices in their primary care trusts (box). These values are characteristic of the clan-type culture described by the competing values framework. Some of the participants referred to the benefits of these values to patients and to the NHS. However, most spoke about the negative impact of the values on the ability of managers to improve the “performance” of their primary care trust. In broad terms managers agreed that the term “performance” described the primary care trusts' capacity to improve the health of the local population and reduce inequalities. They thought that this would be difficult to achieve unless the practices changed their culture to one that valued greater collaboration and sharing of expertise, and a willingness to be more flexible in the way that they operated. In the competing values framework, this suggests a desire to change the dominant culture of general practice from “clan” to “developmental,” and this would be achieved by maintaining the relationship based orientation but changing the focus of the practices to one that is more outward looking ().
When questioned in detail, however, managers clearly differed in the ways that they thought this change should be achieved. Some focused primarily on outputs and outcomes, and their discussions were dominated by the need to achieve objective government targets. They made few references to how these targets should be achieved. Others, however, spoke principally about the need to improve processes, and their contributions were dominated by references to “getting the right culture” in order to achieve change. Outcomes, though acknowledged as important, were not the immediate concern of this group of managers. These different management objectives were reflected in contrasting management styles, which can be described as directive or facilitative ().
Comparison between directive and facilitative managers
Managers' perceptions of the current cultural characteristics of general practice
A sense of history and tradition: Manifest by an awareness of the work that has gone into building a practice and a feeling that “we've always done things this way and don't see any reason to change for change's sake.” A feeling that new initiatives come and go but that general practice goes on unchanged
A sense of cohesiveness and loyalty to the practice as an organisation: Manifest by a tendency to support the practice in preference to any other organisation
A strong orientation towards professional autonomy: Manifest by a suspicion of anything that potentially erodes this autonomy
A tendency to be inward looking: Manifest by a resistance to work with, be compared with, or learn from other practices
A tendency towards paternalistic leadership styles: Manifest by a lack of strong and radical leadership at a practice level
A directive style was more common among senior managers than middle managers. This was particularly true for executive directors—eight out of 10 executive directors had a predominantly directive style, in comparison with three of the nine non-executive directors and two of the 20 middle managers. Directive managers showed a willingness to challenge the prevailing values manifest by the health professionals, such as their “rigid and inappropriate desire... to remain autonomous” (chief executive). They wanted to achieve measurable outcomes within a short period of time, and their narratives were dominated by references to the need to be more responsive to patients. They sought greater uniformity between practices—one senior manager expressed a desire to produce a new “corporate identity” (chief executive) for his primary care trust. The approaches of directive managers largely ran against the grain of the values embedded in a predominantly clan culture—for example, the desire to introduce greater uniformity and the use of directives (hierarchical cultural attributes), and the promotion of competition and target setting (rational cultural attributes). Directive managers described the main obstacles to cultural change as relating to the individuals concerned, rather than relating to organisational or environmental factors.
A facilitative style was more likely to be used by middle managers than by senior managers—18 of the 20 middle managers had a predominantly facilitative style. Facilitative managers spoke about their desire to work with the prevailing values shown by general practices, and were less inclined to challenge these values:
“We have one practice which has all along believed that clinical governance was rubbish... I have never challenged them and never had an argument with them that their view of the world is not right because I think that if we can get them by action to change... they will realise that they have changed without me having to rub it in” (clinical governance lead).
They regarded the facilitation of cultural change as their raison d'etre and expressed a desire to encourage a change in values from within, rather than forcing change from outside. They made few references to government targets, financial incentives, or competition but spoke frequently about “building relationships based on trust and respect” (locality manager) and “encouraging dialogue” and “understanding what makes the practices tick” (clinical governance lead).
Facilitative managers adopted strategies which were aligned to their philosophical approach and compatible with the prevailing clan culture. They placed considerable emphasis on evolutionary and developmental change. For example, they highlighted the importance of practice visits by primary care trust managers:
“Before decisions are made, we consult with practices about how they feel. It's a bit time consuming but it's worthwhile because at the end of the day, the value of any relationship or the way it develops is based on the amount of communication between parties. If managers are just stuck away in offices dictating from the centre, then clearly you are not going to have the same collaboration or co-operation as you would have if people meet and discuss problems on a regular basis” (chair of local health group)
In addition, they encouraged practices to set aside “protected time” for learning and used respected peers to promote new ideas. They also attempted to influence general practitioners (who they saw as resistant to change) by working with their practice managers and practice nurses (who they saw as more willing to embrace change).
“We've done a lot of work around CHD registers... and the original work—creating a lot more sharing amongst GPs about CHD, getting enthusiasm going—came from the nurses not from the GPs” (chair of primary care trust)
Facilitative managers did not completely dismiss demands to produce measurable improvements. They felt, however, that real change would not happen, or at least would not be sustained, without attention to the values of those who deliver health services. They regarded this as a complex and time consuming task and dismissed “quick fixes.” They described the main obstacles to cultural change in environmental or organisational terms, rather than relating to the attitudes of individual health professionals.
Tensions between managerial approaches
The different management styles seemed to result in tensions between managers in five of the six primary care trusts. Conflict was particularly marked between the senior managers with a directive style and middle managers with a facilitative style and was more likely to be recognised and voiced by the middle managers. Middle managers thought that they were more in tune with the needs of those working in the front line of the service and criticised their senior colleagues for being out of touch. They saw themselves as the ones who “did the real work” and stated that they often felt excluded from the strategic thinking of the senior managers. Middle managers saw themselves as “buffers” between the demands of senior managers and their perception of the willingness and capacity of the practices to embrace change. Tensions were exacerbated in two of the primary care trusts because middle and senior managers were based in different buildings, and were more commonly expressed in the three primary care trusts that had undergone recent mergers.