This article is an adaptation of an essay submitted in the course of a postgraduate diploma in occupational therapy, 1997.
Local authority occupational therapy teams often have long waiting lists for assessment. Inevitably, clients experience problems and changes of circumstances whilst waiting to be assessed. This report aims to examine alternative means of addressing these problems in the period before cases are allocated to an occupational therapist. It will not examine specific strategies for reducing the waiting list. The report uses an ethnographic method of working with the team and experiencing the process of change from within the team. It should be noted that the author's position as a student on placement meant that the full subjective experience of being a team member in the midst of a change process cannot be claimed. In order to preserve the confidentiality of those involved, the borough is not named, and references, where necessary, have been made anonymous.
The service under consideration is an occupational therapy team in a local authority social services department. The authority covers an inner city area that, according to its community care plan (Borough, 1996), is among the top three boroughs in Britain for most measures of poverty and deprivation. The borough has a relatively high proportion of residents with distinct cultural needs and first languages other than English. The occupational therapy team "provides a specialist assessment to children and adults of all ages who have permanent and substantial disabilities, mental health difficulties or learning disabilities." (Occupational Therapy Service, 1997) The bulk of the service's work is concerned with the commissioning of equipment and adaptations to facilitate activities of daily living. At the time of writing, the average length of time spent waiting for an assessment was approximately eight months. The service consists of 5 administration workers, 6 OT assistants, 10 OTs, 3 senior practitioners, 3 team managers and a service manager.
The report examines a proposal to form a distinct team within the service that will deal with clients awaiting assessment and as yet unallocated to an OT. The existing organisation of the teams splits the OTs into two teams of five, with three OT assistants, a senior practitioner and a team manager in each team. The remaining team manager, senior practitioner and five administration workers form the duty service. The service manager oversees the three teams. Each day, one of the OTs works with the duty team to deal with the office-based work whilst a second does the duty visits. The therapists take turns to fill these roles on a rota basis. Whilst all of the administration workers are nominally members of the duty team, three of them perform administrative duties for the whole service, while the other two work as information and advice workers for the duty team. An OT assistant works two days a week, nominally with the duty team, but based at a local hospital running a drop-in service. Thirty-five percent of clients referred to the occupational therapy service are seen by the duty team.
Examining the change in duty work will enable a consideration of structural changes, the merits of different structures and the management of the process of change.
The perceived disadvantages of the present system relate to consistency and continuity. Each time a therapist takes a turn on duty, they are unaware of issues that have been dealt with in the last few days. Each time a client contacts the duty team they may speak to a different, as yet unfamiliar, member of the team. Each time a therapist spends a day in the duty team (one day a week, not allowing for leave) they are unable to deal with their allocated casework, leaving clients and other agencies without a point of contact. Cases that are dealt with more than once on duty are likely to experience a discontinuity of approach, and a possible lack of consistency in the way they are handled.
In an attempt to address these problems of discontinuity, inconsistency and disruption of allocated casework, it was proposed that a dedicated duty team be created. The proposed team structure included a new duty team with, as before, a manager and senior practitioner, but with the addition of two OTs who would work exclusively on the duty system and an OT assistant who would run the one-stop service and perform other duty functions as required. The five administration posts remain, although the workers must apply for new posts. The other two teams would lose an OT and an OT assistant each. An OT assistant post, currently vacant, is deleted. The rest of the structure remains the same, except for the service manager post. This is to be deleted, leaving the service under the overall control of the disability services manager, who also manages the physical disability, learning disability and sensory impairment care management teams and the building's support staff. This loss of the service manager has potential implications but these are beyond of the scope of this report.
The new structure attempts to deal with the problems of the previous arrangement, placing the same therapists on duty each day, with the same OTA. This also means that the duty team's liaison with other services, such as the care management team, is made more consistent. The service is likely to see an increase in efficiency, as therapists will not need to spend time catching up with developments over the days prior to their duty shift.
The proposals have the broad support of staff members, whose main concern is the uncertainty over the administration posts and the loss of the OT assistant and service manager posts. Despite the two lost posts, most team members felt that the changes were better than they could have been and are thus broadly optimistic about the changes.
The implications for clients can be looked at in terms of their experiences in dealing with the occupational therapy team whilst awaiting allocation. The new system will mean that when they contact the team directly it will be more likely that they will be able to speak to the same person they spoke to previously. It will be more likely that the person they are dealing with will be familiar with the progress of their case, thus being able to respond quickly rather than having to peruse previous notes in a case file. The same advantages are likely to apply in the liaison between the team and other agencies. When Staff Nurses contact the team regarding hospital discharges, they will be dealing with the same therapist on Friday that they spoke to on Monday.
Discussions amongst staff raised the concern that the removal of one therapist from each of the two fieldwork teams would cause an increase in waiting lists. There would be fewer caseworkers to take on the cases waiting for assessment. The discussions concluded, however, that this would not be the case. While the strength of each team would apparently be reduced by 20%, in reality no such reduction would occur. The one day a week that each of the therapists spent on duty would be eliminated, thus increasing the time available for their allocated casework by the same 20%. Furthermore, the removal of the interruption to their week's work would probably mean that their efficiency would be increased. They would not have to return from duty the next day and spend time catching up on missed calls and correspondence from the previous day. They would also have to spend less time answering calls and taking messages for colleagues who were on duty.
Having considered the changes with regard to the organisational systems and their efficiency it is now necessary to examine the process of change with respect to the management of the people involved. Changes in the occupational therapy service must be set in the context of the wider changes sweeping the organisation. A new chief executive, appointed just over a year ago, instigated a "radical and far reaching change programme to transform the culture of the council and the quality of its services..." A councillor described this as "a superficial facelift [that] is causing a climate of fear." (Anonymous, 1997) The councillor accused the chief executive of cutting a swathe through the personnel department, causing the loss of "virtually every member of the team" and insulating him from "democratic accountability". The "change programme" was characterised by a top-down approach that criticised the standards of services but was seen to offer no concrete proposals for improvement. The OT service manager quoted the chief executive as saying "if it ain't broke, break it." Stationery was reprinted, reputedly at great cost, in new corporate colours with a new corporate logo. An example of this that attracted resentment from the Occupational Therapy team was the replacement of detailed, sectioned, message slips with new slips that carried the new logo and instructed the staff in basic telephone manners. This is hardly a great insult in itself but, when seen in the context of a service whose main problems clearly stem from a lack of resources and staff, in which 99% of complaints relate to excessive waiting times, seemed a bizarre and incomprehensible initiative. Conversations with staff members showed that they perceived such initiatives as alienating them from the process of change rather than facilitating it.
The result of all this was that the chief executive began to be perceived as an autocratic and threatening figure. Indeed, it is common knowledge that in his previous post in another local authority, he was known as "the butcher".
Reddin (1970) describes one of the functions of change as being to "allow the organization to meet reality." In this light we can see change as a necessary and positive phenomenon that allows a service to improve and to adapt to meet changing situations. However, Reddin emphasises the human element of change: "The greatest single factor in any change is human... personal value systems, informal relations, personal ambitions, preferred career routes and intellectual and emotional capacity."
Reddin goes on to criticise those who deride the human factor in change: "This is an inappropriate point of view as any change inevitably has human consequences which if ignored can lead to disaster." Reddin's Change-Reaction Checklist poses questions from the point of view of the workers, in order to help the manager to focus on the workers' subjective reaction to the way in which they perceive change to affect, or threaten to affect, their situation. If we apply this approach to the situation of the administrative workers involved in forming the duty team, we can begin to understand how the process of change has transformed them into change-resisters. Of particular interest are the questions: "How will my future with this company change?... How will my ability to predict the future change?... How will my status change?" To this can be added the question: How will my relationship with the organisation change?
The inclusion of three of the administration workers into the duty team is a part of the wider reorganisation of administration services across the department. Five hundred posts were to be deleted and 300 new posts created in their place. The new posts would be open for internal applicants, and workers already in posts would be invited to apply for the new posts. Workers from other teams and workplaces would be entitled to apply for the posts replacing those occupied by the OT team's administration workers. The administration workers were aware that they might be replaced by workers presently working elsewhere. This introduced an element of the unknown into the duty team's creation. Although the team's other members have been selected, three potential members of the team do not know whether they will be appointed, or if they will have jobs at all in a few weeks' time. It can be argued that in deleting 500 posts and inviting the affected workers to apply for 300 new posts the organisation is sending a message to the workers that can be interpreted as saying "You are here on sufferance. Your contribution to this organisation is not valued. Your future is insecure." The management required the workers to write a 500 word essay on their suitability for their posts. Such a task is not in any way representative of the work of an information and advice worker let alone a receptionist, a telephonist or a word processor operator. Thus the management is in effect saying "We neither understand nor wish to understand you." Given that the service manager and team leaders neither approve of nor understand the necessity for such a task, the organisation is saying "We do not value your line managers' opinions of you."
The overall effect of this is to create a feeling of being threatened and devalued. It is difficult to imagine how, given this situation, the administration workers can be positively involved in the process of creating a new duty team. Whatever the actions of the service manager, her efforts have been compromised by higher management. Whilst she can encourage the administration workers to feel valued by the team, she cannot alter the message that the organisation has delivered.
Nor does this process affect only the administration workers. When a section of the team has been treated in such a high handed manner, other team members will inevitably draw conclusions about the organisation's attitudes to themselves. Conversations with team members revealed a unanimous opinion that morale was at a low point.
This approach is in contrast to the approach to change described by Beer et al. (1990). They advocate six steps to effective change, three of which are:
The emphasis on joint analysis, shared commitment and consensus clearly aims to facilitate change through the involvement and incorporation of the parties to the change. Armstrong (1994) adds that "Resistance to change is inevitable if the individuals concerned feel that they are going to be worse off -- implicitly or explicitly." Resistance to change manifested itself in this case in demonstrations, lobbies and walkouts in which workers from the team demanded the sacking of the chief executive.
It seems inevitable therefore that, despite the best efforts of the service manager to facilitate the change process in the duty system, the wider change process will exert a negative effect. Both the administration members of the team and the fieldworkers are likely to have a damaged sense of identification with the organisation.
The local management of change shows a different approach. The service manager promoted a process that was characterised by openness, involvement and consultation. The plan was devised by the service manager in consultation with the Team Managers and Senior Practitioners. Having developed the initial idea, the proposal was put to the OTs and OTAs in service meetings where an open discussion could take place. The staff were made aware that feedback from these meetings would contribute to the decision-making process. The service manager presented proposals to the staff before final decisions were made. The ability to usefully express their views can be seen as an attempt to gain the staff's commitment to change. This was important as it was clear that the creation of the new duty team would have an impact on the roles of all team members. Those who formed the new fieldwork teams would no longer play a role in the duty system. Some expressed regret at this, as their duty work gave them a break from their allocated work and allowed them the opportunity of a different, more short term method of working. Others welcomed the removal of what they perceived as an interruption of their casework. Their relationship to other team members would also change. All staff members that the author talked to, however, were in favour of the changes, thinking that they would improve matters for both team and clients.
The involvement of the whole team in the decision-making and planning processes meant that the team as a whole could develop a sense of ownership of the change. It therefore helped reinforce the sense of being a team in the sense that they had a collective control over the organisation of their work.
Selection of the therapists for the new duty team was on a voluntaristic basis. Therapists who preferred short term casework and the challenge of crisis intervention volunteered for the posts and were included in the team without having to undergo a selection process.
Of the two approaches to management of change, it can be seen that the wider organisational change promoted resistance because of its top-down, autocratic style. The local management of change, on the other hand, emphasised involvement and consultation and succeeded in gaining co-operation from those involved.
It is difficult to pinpoint the precise mechanisms through which change management will affect staff performance. It is likely, however, that disenchantment with the wider process of change will result in changes in staff turnover and possibly difficulties in recruitment. Vanstone (1995) argues that practitioners need to feel supported in order to function optimally and provide a good service. Job insecurity and the feeling of being unappreciated by the organisation act to undermine this feeling of support, thus impacting negatively on staff performance.
Lambert (1993) claims that management behaviour that is inconsistent with the desired culture of the organisation inhibits change. The culture of a social services department is focused around providing a fair, egalitarian, high quality, caring service. Authoritarian behaviour by management that shows little regard for the welfare of the team members is a stark contrast with the desired culture of the organisation. Lambert also cites Maslow's theory of needs as a way of understanding organisations, and, with more validity, individuals within organisations. This provides a useful method to explain the need of workers for job security, and thus the security of their ability to acquire the necessities of life, as a prerequisite for their achieving "self-actualisation" as a committed member of a team.
This is an important point, as teamwork is vital in the running of an occupational therapy service, hence the ubiquity of the word. Almost every therapist works as part of a 'team', although the congruence between the concept and the reality varies from one team to the next. Katzenbach and Smith (1993) portray the strength of teams in relation to skills, accountability and commitment. Teams allow a sharing of skills so that the different skills of team members can contribute to the solution of a problem. They encourage commitment to the project, as team members feel a responsibility to one another to achieve the team's objectives. They foster accountability as the roles of team members, ideally, should give a clear indication of their respective areas of responsibility, and provide a common standard for performance. The occupational therapy team, however, is split. The therapists and assistants are part of a team integrated under the management of the service manager. The administration staff on the other hand are part of a wider administrative structure that is being 'rationalised'. The consequence is that the service manager has little say over their inclusion in the team and the coherence of the team is damaged.
The new system of organisation of duty work can be seen to be an improvement on the previous system. A dedicated duty team will facilitate efficiency, continuity and consistency of approach in dealing with cases awaiting allocation. Liaison with other services is likely to improve while disruption to the allocated casework is likely to be minimised. The possible disadvantage is a division of therapists into caseworkers and duty workers, with duty workers having the more stressful part of the job. This has been minimised by the selection of workers who prefer short term work and value the challenge of intervening in crisis situations where a fast response is necessary. The implication, therefore is that dedicated duty teams should, in theory, be more efficient and productive.
The two processes of change involved in the setting up of the new team are very different in their approach and their facilitation of change and the formation of a successful team. The wider process of reorganising the department's administration team has had a negative effect on morale, primarily of the administration workers but also of the therapists. Its high-handed approach has fostered a sense of job insecurity and damaged the relationship between the workers and the organisation. This is likely to damage efficiency, productivity, staff retention and the quality of the service received by clients.
The local process of change on the other hand displays some positive features of consultation, involvement and openness. Team members have been involved in the planning of the new team and have had ample opportunity to influence the process and to air their fears and apprehensions about change. Thus the process has not encouraged workers to resent and resist change, but to help promote and shape the changes.
The balance between the positive and negative management approaches to change has yet to find its equilibrium as the processes have not yet been fully worked out. It is already clear, however, that the exercise will not be as successful as it could have been had the processes of change been better managed at departmental and organisational level. It appears therefore that higher management is at fault. Further research may be required to determine whether the use of higher management techniques from the private sector is appropriate for local councils and particularly for social services departments. It is also necessary to consider whether organisational cultures in private and public sectors necessitate different managerial cultures.
Anonymous (1997) A climate of fear. Printed in an unnamed personnel trade publication, circulated, unreferenced, to workers. Reference anonymous to preserve confidentiality.
Armstrong M (1994) Improving Organisational Effectiveness. London: Kogan Page.
Beer M, Eisenstat R and Spector B (1990): Why change programs don't produce change. Harvard Business Review 1990, November - December. Cited in Armstrong M (1994) Improving Organisational Effectiveness. London: Kogan Page.
Borough (1996) Community Care Plan 1996-7. Incomplete reference to preserve confidentiality.
Katzenbach JR and Smith DK (1993) The wisdom of teams: creating the high-performance organisation. Boston, Massachusetts: Harvard Business School Press.
Lambert T (1993) Key management tools. London: Pitman publishing.
Occupational Therapy Service (1997) Service Improvement Plan. Incomplete reference to preserve confidentiality.
Reddin, WJ (1970) Managerial Effectiveness, McGraw-Hill, New York
Vanstone M (1995) Managerialism and the ethics of management. In Hugman R and Smith D (Eds.) Ethical Issues in Social Work. London: Routlege.
This article is an adaptation of an essay submitted in the course of a postgraduate diploma in occupational therapy, 1997.
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Last updated: 1997
Author: Mike Griffin (OT Student)
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