Loss associated with subtractive health service change: The case of specialist cancer centralization in England

OBJECTIVE

Major system change can be stressful for staff involved and can result in 'subtractive change' - that is, when a part of the work environment is removed or ceases to exist. Little is known about the response to loss of activity resulting from such changes. Our aim was to understand perceptions of loss in response to centralization of cancer services in England, where 12 sites offering specialist surgery were reduced to four, and to understand the impact of leadership and management on enabling or hampering coping strategies associated with that loss.

METHODS

We analysed 115 interviews with clinical, nursing and managerial staff from oesophago-gastric, prostate/bladder and renal cancer services in London and West Essex. In addition, we used 134 hours of observational data and analysis from over 100 documents to contextualize and to interpret the interview data. We performed a thematic analysis drawing on stress-coping theory and organizational change.

RESULTS

Staff perceived that, during centralization, sites were devalued as the sites lost surgical activity, skills and experienced teams. Staff members believed that there were long-term implications for this loss, such as in retaining high-calibre staff, attracting trainees and maintaining autonomy. Emotional repercussions for staff included perceived loss of status and motivation. To mitigate these losses, leaders in the centralization process put in place some instrumental measures, such as joint contracting, surgical skill development opportunities and trainee rotation. However, these measures were undermined by patchy implementation and negative impacts on some individuals (e.g. increased workload or travel time). Relatively little emotional support was perceived to be offered. Leaders sometimes characterized adverse emotional reactions to the centralization as resistance, to be overcome through persuasion and appeals to the success of the new system.

CONCLUSIONS

Large-scale reorganizations are likely to provoke a high degree of emotion and perceptions of loss. Resources to foster coping and resilience should be made available to all organizations within the system as they go through major change.

What if Marie Kondo Wrote an Organizational Change Book? Making Space for Subtractive Change

Subtraction neglect is a real problem in our lives and organizations. Additive change, increasing the number of activities, tasks, and goals, is the unrelenting norm. Subtractive change removes things. For people and organizations starved from bandwidth, and change scholars and practitioners seeking new capabilities, subtractive change offers opportunity to make organizational change both kinder to people and more effective. I offer a few ideas for promoting subtractive change in scholarship and practice: the difference between Virtuous Subtraction realizing value and Exploitative Subtraction deflecting burdens on to others; the essential roles of reflective practice, awareness of organizational history, and mindful attention to stakeholders in Virtuous Subtraction; and Anticipatory Subtraction where practices are time-marked with start and/or stop dates to call attention to opportunities for review and updating; and legacy-building practices to respect the value served by subtracted practices.

Partner opportunism and willingness to engage in project relationships

Purpose

The paper seeks to understand the implications of partner opportunism for project relationships.

Design/methodology/approach

Based on the theoretical literature, the paper presents a conceptual model considering the perspective of the organization impacted by partner opportunism.

Findings

The model proposes that partner opportunism lowers willingness to engage by creating perception of loss. The undesirable impact of opportunism on perceived loss is less if the partner has made high relation-specific investments. Also, the negative impact of perceived loss on willingness to engage is less if the partner is difficult to substitute.

Research limitations/implications

The model can be tested in the context of information technology (IT) relationships because of scope for opportunism in IT project relationships. Data can be collected through experimental vignettes.

Originality/value

The model contributes by investigating novel aspects of governance, behavioral consequences of opportunism and relation-specific investments in project relationships. The paper suggests that organizations can protect themselves against the ill effects of partner opportunism by enabling their stakeholders to invest substantial time and effort in the relationship and fortify relational quality and bonding.