Introducing innovation in a management development programme for a UK primary care organisation

Abstract

The aim of this paper is to examine the introduction of innovation as part of a management development programme at a primary care organisation, a legal form known as a Primary Care Trust (PCT), in the UK. The paper draws on experience of managing a successful management development programme for a PCT. The report of the case study analyses the key events that took place between 2008 and 2010, from direct observation, surveys, discussion and documentary evidence. The Northern PCT has partnerships with a number of educational providers to deliver their leadership and management development programmes. A close working relationship had developed and the programme is bespoke - hence it is current and of practical use to the UK's National Health Service (NHS). In addition, there are regular meetings, with module leaders gaining a firsthand understanding of the organisation's needs and aspirations. This has resulted in a very focused and personalised offering and a genuine involvement in the programme and individuals concerned. The research was conducted among a relatively small sample, and there is a lack of previous literature evidence to make significant comparisons. The paper identifies key implications for practitioners and educators in this area. This paper is one of few to investigate innovation and improvement in the NHS, and is unique in that it uses the lenses of a management development programme to explore this important, and under-researched, topic.

Reform of Healthcare

Edited by Helen Dickinson, Ross Millar and Michael West

Introduction

The National Health Service (NHS) is the largest employer in the UK, and since the late 1990s has gone through a period of unprecedented change in a wide range of areas. Reforms such as the NHS Plan ([13] Department of Health, 2000) have sought to help the NHS meet the needs of patients and improve health outcomes, whilst the establishment of NHS Foundation Trusts in 2004 gave financial freedoms and independent regulation to secondary providers of care. Recent developments have focused on improving quality ([15] Department of Health, 2009), with a drive for NHS organisations to become more cost effective through promoting innovation and improvement. This paper provides insight into this agenda through the introduction of innovation as part of a management development programme at a Primary Care Trust (PCT), a type of primary care organisation in the UK.

The management development programme was designed by a university business school (University A) in partnership with a PCT (Northern PCT) and was aimed at junior and middle managers, addressing the core skills required from the PCT, and allowing managers to gain credits towards a business-related degree. A few months into the programme, the PCT requested that innovation be introduced into the programme as a way of developing ideas of saving money, instilling a new way of thinking amongst staff and implementing a new policy from the Department of Health ([26] Maher, 2008). The paper tells the story of implementing policy into practice and begins with the policy context, an examination of the literature on innovation and improvement and an account of the management development programme. This is followed by an outline of the methodology used, findings and a discussion. The conclusion highlights the study's key contributions, and identifies some of the implications for future policy in the practice and reform of healthcare.

Policy context

The National Health Service was established in 1948 and has grown to become the world's largest publicly funded health service, born out of a long-held ideal that excellent health care should be available to all regardless of wealth. Since its establishment, the NHS has gone through a number of structural changes, which has meant that the way services are delivered is being constantly developed. At the time of writing, the NHS in England is divided into ten Strategic Health Authorities (SHAs) that oversee the delivery of services at a local level through the development of strategy and performance monitoring. They are the key link to the Department of Health (DoH), ensuring that national policy is incorporated in local health care planning. Within each SHA, the delivery of services is the responsibility of a variety of trusts. PCTs are responsible for planning and securing health services for improving the health of their local population. They are responsible for commissioning and funding primary and secondary care. There are some 151 PCTs across the UK and on average they serve a population size of a quarter of a million and are in most cases co-terminous with local authority (council) boundaries ([29] NHS, 2009). PCTs are responsible for assessing local health needs and providing a wide range of health services which include primary care services and community health services such as health visiting and district nursing. They are charged with ensuring that the local population is served by enough general practitioners (GPs) and are responsible for the provision of a range of health services such as dentists, walk-in centres, patient transport, pharmacies, opticians and integrating health and social care so the two systems work together.

The officer accountable for the PCT is the Chief Executive, who ensures that the PCT carries out its functions in such a way as to ensure the proper stewardship of public finances. These responsibilities include the propriety and regularity of the PCT's finances; keeping proper accounts along with prudent administration and avoidance of waste and the efficient and effective use of all resources. It is this last area that the paper will explore, along with the impact it has on introducing a management development programme within a PCT.

The cycle of reorganisation in primary care in England over the past decade has seen the establishment of Primary Care Groups, which evolved into 303 Primary Care Trusts (PCTs) in 2001, subsequently reduced to 158 in 2006 via a process of rationalisation, with many now serving larger geographical areas. The coalition government elected in 2010 is imposing the largest ever reduction in administration costs in the NHS, aiming to reduce these budgets by more than 45 per cent ([16] Department of Health, 2010). PCTs will be replaced by GP consortia, which will take over the role of health commissioning, and SHAs will be abolished. In terms of increasing NHS productivity and quality, the White Paper spells out the new agenda ([16] Department of Health, 2010, p. 47):

The existing Quality, Innovation, Productivity and Prevention (QIPP) initiative will continue with even greater urgency, but with a stronger focus on general practice leadership. The QIPP initiative is identifying how efficiencies can be driven and services redesigned to achieve the twin aims of improved quality and efficiency. Work has started on implementing what is required, for example by improving care for stroke patients, the "productive ward programme", increased self-care and the use of new technologies for people with long-term conditions.

The PCT was under pressure to implement the QIPP initiative and the management development programme was a good example of how it could be embedded within the organization, thus closing the gap between policy and practice. It is within this turbulent context that the management development programme operated.

Innovation and improvement

This section explores the literature pertaining to innovation and improvement in the context of the management of the NHS. Generally, much of the seminal literature on innovation and continuous improvement relates to the private sector. There is research which specifically examines innovation in public services (e.g. [22] IDeA, 2005), including in services and health care organisations ([19] Greenhalgh et al. , 2004; [20] Greenhalgh and Bate, 2005), but this section draws good practice and knowledge from the wider innovation literature and applies it to the NHS. In this section we commence with an examination of what the concept of innovation means, and in particular link it to innovations and improvements within the managerial process. We make it clear throughout that innovation and improvement are not just about the development of world-class new technologies, products or services. Innovation and improvement are as much about making changes and improvements in the way in which things are done or managed, i.e. within the process or the "business model" (paradigm) by which the core service is delivered to the "customers" (in this case, patients) (cf. [40] Tidd et al. , 2005). The second part of this section focuses on the concept of continuous improvement and how this might be applied to managerial practices in the NHS. Thirdly, we consider the role of learning across the entire innovation and improvement process.

In the literature a distinction is made between invention, which is something new that is conceived or created, as opposed to innovation, which is about the application or putting into practice of an initiative which is then diffused ([24] Link, 2008; [28] Nelson, 1959; [34] Rosenberg, 1972; [36] Schumpeter, 1939; [42] Van de Ven, 1999), such as in service organisations including healthcare ([19] Greenhalgh et al. , 2004; [20] Greenhalgh and Bate, 2005). Therefore, innovation is "a process of turning opportunity into new ideas and putting these into widely used practice" ([40] Tidd et al. , 2005, p. 66). The practice of innovation is not, however, restricted to profit-making, private sector firms, since it can also apply to public sector health care organisations. Innovation can be further characterised or categorised in terms of products and services, processes, market positions or paradigms, i.e. business models ([41] Utterback, 2004) and, furthermore, along the lines of radical or incremental innovations. In this paper, we are considering innovation within managerial practice in the NHS, which is about incremental innovations, by continuous improvement, within the managerial process of delivering the core service of the NHS. In the next section, we examine the role of creativity and innovation in continuous improvement in the National Health Service.

Continuous improvement in the context of the NHS

It is thought that more creativity, stimulated by an innovation culture (i.e. an organisational culture which is innovative and creative; [11] Christensen and Raynor, 2003), coupled with appropriate incentive or reward mechanisms, should drive forward innovation and improvement within an organisation. Much research has considered the important role of cross-functional teams, which are highly important to the innovation performance of organisations (e.g. [25] Love and Roper, 2009). Similarly, a positive innovation culture ([11] Christensen and Raynor, 2003) assists the sharing of information within organisations. Therefore, it is thought to be important to involve employees within the innovation process (kaizen , as in Japanese companies), which is conceptualised as a cycle between knowledge, learning and innovations ([3] Bessant, 2003). For example, there is much documentation on how productivity and efficiency was increased in Japanese manufacturing companies through continuous improvement (CI) based on ideas from employees' suggestion boxes ([35] Schroeder and Robinson, 1991; [3] Bessant, 2003). Indeed, such authors identify a relationship between practising high involvement innovation and the performance of the firm as a result ([3] Bessant, 2003; [40] Tidd et al. , 2005). Furthermore, the literature suggests a clear link between CI and learning ([4] Bessant, 2006), as well as an important role for learning networks in the innovation process ([5] Bessant and Francis, 1999; [6] Bessant and Tsekouras, 2001; [7] Bessant et al. , 2003). Continuous quality improvement has been well documented in terms of clinical practice ([37] Shortell et al. , 1998), and healthcare more widely ([1] Berwick, 1989, [2] 1996), as well as the role of lean management methods ([8] Boaden, 2009; [9] Boaden et al. , 2008; [31] Proudlove et al. , 2008). Innovation and improvement in health care, and the NHS in particular, relies upon a particular culture of innovation which enables barriers to be overcome, and such innovation can be designed in a specific bespoke way for the NHS ([27] Maher and Plsek, 2009; [33] Rogers et al. , 2008).

In the context of the NHS generally and individual PCTs more specifically, it is clear that with the drive to improve the delivery of core health care services, the concepts of continuous improvement in managerial practice, by involving employees as well as managers, is one key means by which a successful approach to managerial innovation can be adapted to the NHS. In the next section, we consider the role of learning in innovation and improvement.

Learning

[12] Cohen and Levinthal (1990) focused upon external communication and learning, whereas we consider the importance of both modes of internal and external learning, in the new forms of organisation which include extended stakeholder networks comprising external consultants etc. Their key contribution was absorptive capacity (AC) which they describe as:

The ability to exploit external knowledge is thus a critical component of innovative capabilities. We argue that the ability to evaluate and utilize outside knowledge is largely a function of the level of prior related knowledge. [...] These abilities collectively constitute what we call a firm's "absorptive capacity" ([12] Cohen and Levinthal, 1990, p. 128).

It is clear that learning has a critical role in the innovation process, whether in terms of absorptive capacity of external knowledge ([12] Cohen and Levinthal, 1990), or of learning by doing or "learning-before-doing". Whilst much of the literature does focus upon the firm-level innovation and learning, i.e. the "organisational learning" where it is implicit that individuals have a key role within this process, but they are often subsumed or collapsed into this economic notion of a "firm", "business" or "company".

Contextualising innovation from an NHS and public services perspective

A key question emerging from the above literature in the context of the NHS is, "So what?". Clearly, though, it is important to understand what innovation actually is and why it applies to the PCT which is the subject of the next section of this paper. We have argued that innovation in managerial practice is important to the NHS because it facilitates the better delivery of its public service remit and its core healthcare services. Improving efficiency and performance is enshrined in a number of governmental policies and documents (e.g. relating to improving quality; [15] Department of Health, 2009). Linked to improving and innovating in managerial practice to achieve this end is the concept of continuous improvement (CI). While CI most famously relates to kaizen and other techniques adopted in world-class Japanese manufacturing, we argue that it also has relevance to improving and innovating within NHS managerial practice. That is, therefore, where learning comes in, particularly the ability of PCTs to absorb external knowledge ([12] Cohen and Levinthal, 1990) and a management development programme is perhaps one way of facilitating such approaches. Thus, in the next section we present our case study in order to link the above literature to actual on-the-ground, practical interventions for facilitating innovation and improvement through the learning process within the NHS in order to achieve change and to improve the quality and performance of the organisation.

Management development programme

The management development programme is part of the Northern PCT's "Learning in the Workplace Programme" (LITWP). LITWP is a unique partnership approach between Northern PCT and the School of Health and Social Care at University A to provide bespoke training and education opportunities for both commissioning and clinical staff across the organisation. LITWP provides academic accredited programmes delivered in the workplace, which are tailored to meet organisational needs. The Northern PCT developed an in-house learning directory based on the organisational mission of world class commissioning. World-class commissioning for PCTs ([14] Department of Health, 2007) requires them to develop the knowledge, skills, behaviours and characteristics that underpin effective commissioning which come under 11 organisational competencies:

locally lead the NHS;

work with community partners;

engage with public and patients;

collaborate with clinicians;

manage knowledge and assess needs;

prioritise investment;

stimulate the market;

promote improvement and innovation;

secure procurement skills;

manage local health system; and

make sound financial investments.

The directory covered four specific areas:

world class leaders;

world class management development;

lean management methods; and

technical world class commissioning skills.

The management development programme is delivered through LITWP via the Business School at University A.

University A is a post-1992 university with nearly 28,000 students, 60 per cent of whom are part-time. It offers a range of vocational and academic programmes and has developed a reputation as one of the leading universities for employer engagement. The Northern PCT was established in 2006, serves a population of nearly 500,000, and is based across five sites. The PCT corporate improvement strategy provides the vision for the management development programme and the following section highlights the links to organisational improvement:

All staff have a role in supporting change and leading improvement [...] It is the vision of the PCT corporate improvement team that the first step in delivering the transformational change programme [...] is to build the capacity and capability of staff so that they understand the methods of improvement and are able to apply them in their every day work (Internal Document 1[1] ).

As part of a major investment in staff development and training, University A was approached by the Northern PCT in late 2008 to develop and deliver a series of management development programmes. The development of bespoke learning for staff at all levels across the organisation was a key element of the organisation's change programme and intent to become "the most forward thinking commissioning organisation in the NHS [...] well placed to deliver better health and well-being, care and value for all" (Internal Document 1).

The vision of the Northern PCT corporate improvement strategy was that the first step in delivering the transformational change programme was to build the capacity and capability of staff so that they understood the methods of improvement and were able to apply them in their everyday work. In short, the move to change culture through the planned creation of a learning organisation resulted in a training needs analysis exercise; a substantial learning directory document; and a systematic approach to the implementation and evaluation of organisation wide staff development.

While practical considerations had to be taken into account in terms of the programme delivery, the main emphasis in terms of programme consideration and discussion was ensuring a move towards and understanding of the PCT statement of intent: "moving the emphasis from spending on services to investing PCT funds to secure the maximum improvement in health and well-being outcomes from the available resources" (Internal Document 1). In other words, material would need to be developed to draw on the vision, core values and corporate behaviour and aspirations of the Northern PCT.

Through general discussion, it was also implied that the Northern PCT wanted to use the visual ramifications that cultural change through learning would offer. For instance, they would create a common-language and teams across departments and sections - thus breaking down barriers; creating greater common understanding, appreciation and recognition of the corporate message and its relevance on an individual and team basis, clear messaging and communication; and being seen to be recognising employee need and making the necessary provision. It was also deemed important that, whilst the modules needed to be informative and meet PCT and university regulations and standards, they needed to be fun and practical - including aspects which had immediate relevance and could be easily transferred to the workplace.

In summary, University A aimed to develop and deliver programmes at both a foundation and intermediate level. Foundation level was aimed at those staff in a junior management position or those who did not have any formal management qualifications. Foundation level would ensure all staff had a basic understanding of the organisational approach to management development. Learning at the intermediate level would be designed for managers in more senior management positions and would further develop key skills and confidence. The modules would be delivered at NHS premises and have a clear workplace focus thus allowing healthcare professionals to gain immediate benefit. To date, two foundation level programmes had been delivered, with a third in progress and the intermediate level programme pilot commenced in April 2010. Initially, three modules were identified as meeting these needs at the foundation level:

Personal and team effectiveness;

Managing and developing people; and

Organisational communication.

Discussion and practical constraints resulted in the first two modules only going forward with a commitment to embed organisational communication as a core skill throughout the teaching, learning and assessment in the other two level four modules (see Figure 1 [Figure omitted. See Article Image.] for full programme details).

Each module was to be delivered over two days including pre-and post-course work and appropriate assessments. Experience of this approach has proved successful in delivering leadership and management education to a range of professionals from foundation through to Master's level, and in recent years University A has gained extensive experience of delivering core modules in a master class format using experienced academics and/or senior practitioners, following its successful corporate development programmes. In addition to academic staff input, it was agreed that staff from the Northern PCT would be invited where appropriate to deliver sessions on policies and procedures. As well as the master class of two days of face-to-face teaching, the modules were delivered and communication kept open between academics and delegates through the use of a virtual learning environment (VLE). All delegates on the programme accessed the University VLE via their own "Learning in the Workplace" web site. At the time of the commencement of the programme, 530 people were employed by the PCT, of which 150 were deemed to be in need of, or it was recognised that they would benefit from, the management development learning programme. The foundation level was deemed to be mandatory, and would therefore eventually include all junior or middle managers who had had no previous experience of higher education, or formalised, management study. In total, 46 employees were enrolled on one of four cohorts (three at the foundation level, one pilot group at the intermediate level). Staff attending the programme were selected from across the organisation, as Table I [Figure omitted. See Article Image.] demonstrates. There was no strategic plan for the order in which staff attended or were invited to join specific cohorts. Ultimately, it was felt that attendance would be beneficial to the organisation and to have staff from different sections use the training to build new networks and contacts. In essence, staff self-selected themselves for course places (and the recruitment across different areas of the PCT are set out in Table I [Figure omitted. See Article Image.]). It had been anticipated that a minimum of a further cohort at the foundation level and two at the intermediate level would have commenced before December 2010 and recruitment had already begun before the decision was taken to terminate the programme.

There are many other examples of management development programmes in the health care context, too numerous to analyse and discuss here; however, for a review see [30] Peck and Dickinson (2010), who cite examples of "enquiry-based learning", role plays, and simulations, as well as their own programme. As discussed in the next section, the rationale behind the embedding of the programme in the specific organisational context was that it would be tailored and customised to the PCT rather than being generic. It is important to deliver programmes that are reasonably bespoke and, therefore, have greater potential impact upon the participants because they are relevant to the organisation and are thus genuinely embedded in the work life of the participants.

Methodology

The methodology adopted for this study draws on the authors' experience of running a successful management development programme for a PCT. The report of the case study covers the key events that took place between 2008 and 2010, from direct observation, surveys, discussion and documentary evidence. The evidence draws on the "Corporate Improvement Strategy, Organisational Behaviours" document and minutes from project team meetings (Internal Documents 1-3). The project design and methodology used draws on the case study approach ([44] Yin, 1994; [21] Hartley, 2004), which has as one of its major strengths the ability to deal with a full variety of evidence beyond what might be available in the conventional historical study and is particularly useful in exploring contemporary issues. The paper builds on previous studies documenting the concept of partnership between employers and education providers within the NHS and other sectors using the case study approach (see [23] Keithley and Redman, 1997; [38] Smith, 2000; [10] Borwankar and Velamari, 2009).

An important element of the management development programme was the investment in time and resources, on both sides, from key personnel. The role of University A was largely to listen, familiarise itself with the PCT documentation, language and to help interpret and translate its vision to produce world class commissioning via world class managers into learning needs which were deliverable and yet would meet the PCT's organisational strategy and objectives. A small, but illuminating example of this in practice was the use by the Northern PCT to describe specific, measurable, attainable, relevant and time-bound (SMART) objectives ([17] Doran, 1981) as "clear" objectives. All teaching and learning material was able to be altered to reflect this preferred use of wording. It was agreed that there would be a pilot cohort for all stages of the programme, and that feedback would be sought on a regular basis from delegates, module tutors and other staff involved in course delivery.

Initially, the objective of gathering research data was not so much about the formal evaluation of the programme, but to inform future developments. Each stage of the programme was run as a pilot, so that research needed to be carried out and carefully considered to ensure that it was meeting the needs and expectations of both the organisation and individuals, and where necessary modifications could be made. It was also seen to be crucial that there was "delegate buy-in", and that their views were not only listened to but that they could be seen to be visibly taken into account, in terms of decision-making and further development. Largely, therefore, the organic nature of the programme meant that initial questions were deliberately kept open to allow for as wide a variety of possible personal responses to be captured.

Before each programme, delegates were asked about their expectations and concerns. After each element, all delegates were asked about the aspects they had most enjoyed and found most useful, the aspects they had least enjoyed and found least useful, and their own suggestions for future inclusion. With a few exceptions, responses were received from all delegates after every programme event. The results from these initial open questionnaires were transcribed and used as a starting point to extend the dialogue either between the programme leader, or the leader of the Learning in the Workplace Programme, their own working teams, and the participants. It was the close working relationship between these individuals, including regular and recorded meetings with detailed action plans, which resulted in such thorough programme evaluation documents - more a consequence of the nature in which the programme evolved, rather than a driving factor. However, the close consideration and development of the programme meant that it was highlighted on a number of occasions as an example of "real" workplace learning and, in particular, through the NHS was chosen for more formal evaluation by the Centre for Health and Social Evaluation (CHASE), an independent research centre based at University A, whom it commissioned to review the programme as part of their overall evaluation of the Learning in the Workplace staff investment. A key feature of the programme was to involve employees from within the Northern PCT and make sure they felt ownership for the future development of the programme (as ownership was important to an embedded programme, rather than a generic approach) - feedback to delegates was important. It was made clear that all comments raised by delegates would be considered and the options for integrating their ideas discussed. Action points were raised to address all matters of concern and everyone was aware that the programme worked to self-improve continuously.

The main focus of delegate suggestions was practically based - around enrolment, registration, use of the virtual learning environment, parking and catering. In time, these moved on to elements of assessment, and the programme worked towards not only making practical aspects of assessment easier to grasp within the learning in the workplace situation. Close consultation and familiarisation with the way in which both organisations worked was beneficial to help the programme develop in line with the rapidly changing and demanding political agenda, and all the internal issues that brought with it. From the inception of the programme to its demise, a number of major changes had to be taken into account to meet externally driven demand. The most obvious of these during the course of the programme was QIPP (an initiative to facilitate quality and efficiency, as discussed earlier). Within the space of two months, it became apparent the organisation would have to find 30 per cent management savings and the focus of the programme needed to change to reflect this.

With the change of government, however, the impact upon delegates was much more direct, with changes to the intermediate level programme being made module by module to respond to increasing demands and pressures and to ensure that the very real elements of dealing with rapidly changing external priorities were embedded into case studies and presentations as well. One academic tutor commented: "It was an eye opening experience to recognise the direct and rapid impact of the new government in this ever changing world". Again, a close working relationship and investment in personal time was crucial in delivering results. Time was spent with delegates to hear their views on the direct changes affecting them and to look for practical ways in which learning from the programme could be put to good use both in the short and longer term. Time, too, was taken with university personnel to explain the sector changes to them and in one instance a key academic tutor was invited to attend an internal training course within the Northern PCT on business commissioning in order to fully understand the organisational approach and language. At all stages, and on all modules, all personnel and individual academic tutors went out of their way to check their ideas, use of material and even assessment wording, was a good fit for the Northern PCT and to work closely to ensure learning outcomes were linked back to organisational objectives. As one academic tutor clarified:

... my task is to help them [the delegates] translate these general objectives and strategies and make them work in reality in their day to day jobs.

In short, communication and understanding were key elements throughout the course of the programme, the programme was evaluated and acted upon at every stage, and the close co-operation and partnership approach of all concerned cannot be underestimated. It is imperative to remember that the gathering of information at each and every stage of the programme was primarily to inform and develop the module material and programme format for future cohorts and deliveries. Indeed, only weeks before the decision to suspend the programme, plans were being made to open up recruitment for new cohorts at each level, and so the post-programme feedback that was being sought was intended to further enhance future deliveries rather than provide an end-summary of a completed project. The rapid demise of the programme in many ways gave perhaps more gravitas to the collected comments and research than had originally been intended. Given the limitations of the data and analysis, a key issue (which is also relevant to the "independence" of evaluations and conflicts of interest in research) concerns reflexivity. Since some of the authors developed and delivered the programme, but were joined by other independent authors - who were not involved in the development and delivery of the programme - this approach ensured a significant degree of independence and, therefore, mitigated the risk of reflexivity.

Findings

The programme aimed to create a non-threatening, friendly, student-centred learning environment. This was commented upon universally across all days and is perhaps reflective of the amount of personal investment from all members of the delivery team in allowing time to get to know and understand the organisation and its aims thoroughly at each stage of the programme.

Importantly, feedback from the PCT was positive. In particular, they commented upon the good working relationship between University A and themselves and specifically that delegates were "engaged and active in the process" - "there is a 'buzz' about the programme". Commenting on the success of the programme, a senior manager from the PCT said:

What makes this programme unique is that the academic content of the programme has been woven into the PCT ways of working [...] The management development programme has been a huge success in the PCT [...] From the original concept of an NHS based programme for managers, it has evolved into a truly bespoke management development programme that has embraced the learning in the workplace concept, and enthused the students.

There were some very valuable comments too from delegates about the opportunity afforded to them:

- "This is the first time I have been given the opportunity for management training".

- "This is the first time an employer has invested in my personal development".

- "I'm excited by the learning process; it will increase my self-management and multi-tasking skills".

The review by the Centre for Health and Social Evaluation summarised the impact on working practice under six key areas:

increased confidence;

having a theoretical baseline;

improved networks;

a better understanding of people;

improved communication skills; and

effected change in relationships with their own managers.

This direct impact won recognition at the highest level of the organisation, with the following comment from the Chief Executive of the Northern PCT:

The success of the [management development] programme has been evident through the personal development and increase in confidence of the students involved. This has given rise to increased productivity which has ultimately impacted on commission improved healthcare.

Another key feature, and one that was crucial to the success of the programme, was that there was felt to have been a good mix of practical and theoretical work, and that this could be applied to their work situations:

- "Good application [...] especially to NHS".

- "I found out a lot of information I can transfer into my day to day work".

There were also some positive comments from delegates on the group dynamics in an overall debrief at the end of the programme and it was apparent that there was a real feeling of "being a group" - one that a number of delegates were keen to keep going informally, and through organising future group meetings on a more formal basis. Inevitably, there were some "teething" issues to be addressed, which were around practical implementation such as enrolment, registration and the virtual learning environment (VLE). These problems were largely down to the limited amount of time before the start of the programme and limited administrative support.

The second delivery of the management development programme (foundation level) took place between September and November 2009. The group consisted of 13 delegates (one delegate transferred from cohort 1). As with cohort 1, the overall feedback from the groups about the modules, induction, insights discovery day and the workplace seminar was generally positive. One of the key features of the second cohort was that feedback from the pilot cohort was taken into account and programme changes both practically and in terms of the overall ethos were implemented in full. These included everything from the decision not to provide lunch on training days (with the exception of the induction and workplace seminar days), to changes made to the topic for the workplace seminar to reflect the innovation and improvement agenda ([26] Maher, 2008).

This ability and willingness to monitor and evaluate and act on feedback within a short timescale has been one of the keys to the success of the relationship with the PCT and the programme itself. Changes to the second delivery were in making more productive use of the induction session to really help delegates reflect and consider why they had enrolled on the programme, why their place had been supported and what their expectations and concerns might be. Whilst the responses perhaps held few surprises, it set the tone that their opinions were valued and listened to, and of course gave an opportunity for any issues to be addressed before the group left for the day.

Again, feedback for both accredited modules was positive and the quality of the in-course presentations and work was high. Delegates in particular commented on how much they had enjoyed the days; that they had found the alternate use of practical and fun activities alongside theory useful, that they had been comprehensive; and that they were given very practical ideas which they were able to take back to the workplace and apply.

Innovative features of the programme

Following the earlier discussion of innovation in public services ([22] IDeA, 2005) and the NHS in particular ([1] Berwick, 1989, [2] 1996; [8] Boaden, 2009; [9] Boaden et al. , 2008; [19] Greenhalgh et al. , 2004; [20] Greenhalgh and Bate, 2005; [27] Maher and Plsek, 2009; [31] Proudlove et al. , 2008; [33] Rogers et al. , 2008; [37] Shortell et al. , 1998), the programme has produced some innovative features for corporate programmes at University A and allowed the PCT to take advantage of the flexibility and innovative learning processes to create a bespoke programme to meet their strategic needs going forward. These innovative features are outlined below.

Insights Discovery profiling

Insights Discovery is a personality profiling tool that identifies the uniqueness of each individual and highlights individual strengths and weaknesses both on a personal and team level. Insights Discovery was the profiling tool of preference used by the PCT.

Within University A there were no staff accredited to deliver this particular diagnostic tool. Rather than just buy in expertise as an "add-on", a decision was taken to explore funding avenues to support representatives from both organisations to train internally as accredited trainers. Such a move, as well as creating opportunities for both organisations to work more closely together and develop an understanding of individual work preferences, would also allow the team to consider Insights Discovery in a more holistic way for potential future use. By having accredited trainers within the organisation, opportunities for accessible, workplace follow up would be increased; the tool is potentially valuable for continuing professional development and personal development planning. In this way, it can be embedded into organisational language and culture with greater consistency and reinforcement.

Workplace seminars

In addition to the training days and academic modules, the programme team developed the idea of workplace seminars. The thinking was to create earmarked time for delegates to be encouraged to engage with the taught programme and relate it directly back to workplace issues. The time would also create opportunities and flexibility for the programme team to make adaptations and address specific material or issues as and when they arose. In the first pilot group, it was decided to run the day with key PCT personnel discussing departmental and organisational policy and practice. Areas addressed included the corporate development agenda, workforce agenda, HR and organisational development and training and development. In addition, one to one tutorials were offered to all.

In the intervening period between the first and second cohorts, the innovation and improvement agenda ([15] Department of Health, 2009) became imminent and the decision was taken for the second cohort to use the time to introduce key messages from this agenda and begin involving delegates in considering ways in which they might help or contribute to future planning. A group "brain-storming" session around the changing NHS agenda was planned which would focus on an article in The Guardian ([18] Edwards, 2009) in which Nigel Edwards, NHS Confederation Policy Director, discussed how the NHS could make £20bn in savings, advocating "removing waste, duplication, unnecessary steps and delay". There was some very positive feedback from this session - some around the benefits of the group meeting and generally considering work and roles from different people's perspectives.

There was obviously variation in the quantity of information or involvement individuals had with the innovation and improvement agenda, but several interesting comments were made:

- "I think that the organisation doesn't take the time or doesn't have the time to speak to the staff actually at the 'coal face' who may be able to point out wastage or areas for improvement that never get raised otherwise".

- "Very interesting, lots of ideas, but will they be used?".

- "Enjoyable and brought the QIPP agenda home".

- "I feel that the group came up with some good ideas and had a lot of suggestions which would aid our trust to save money".

As everyone is based in different places, it is difficult to coordinate, but the workplace seminar has proved to be a good opportunity for the group(s) to come together for support, to network and for fruitful discussion.

Discussion

The Northern PCT has partnerships with a number of educational providers to deliver their leadership and management development programmes. This programme is unique because of the critical factor to its development - the close working relationship that had developed and the bespoke nature of the programme making it current and of practical use to the NHS. Regular meetings and discussions had taken place since the inception of the programme. This mode of working had been extended to all module leaders and, as new modules have been introduced, module leaders had been encouraged to talk to and visit the Learning In The Workplace team to gain a first-hand understanding of the organisation's needs and aspirations. This has resulted in a very focused and personalised offering and a genuine involvement in the programme and individuals concerned.

Among the successful areas for other NHS organisations to note was that the University and PCT were able to offer a work-based learning approach thus making it easier to target healthcare professionals. The programme has helped to address organisational development issues, such as the introduction of the innovation and improvement agenda ([15] Department of Health, 2009) and the embedding of corporate values. It has helped to raise the profile of management development across the organisation and demonstrated the commitment of the organisation to staff development. The partnership between the university and the PCT had started to deliver a bespoke solution to what had become a longstanding and complex training issue.

There have been a number of problems that arose from the partnership; for example, a shifting agenda driven largely by government policy on the NHS, which made trying to accommodate changes in the programme at short notice difficult. The PCT has been subject to a number of organisational changes and subsequent shifts in priorities, which has meant the cancellation of cohort 4 at the foundation level and pushing back the start of the intermediate level of the programme. This has meant that the programme team at the university had to regularly reschedule the programme, which caused problems with staffing. In July 2010 the Northern PCT informed the university business school that they could no longer continue with the management development programme, due to a major management cost-saving exercise. The programme would end in December 2010. This means that further research will not be possible on this particular programme, but the model of knowledge transfer outlined in this paper and, in particular, the practical interventions for facilitating innovation and improvement may have possible applications in sectors outside the NHS. Even though this was a relatively small study, it is possible to see shifts in practice as a result of attending the management development programme. The shared understandings, dialogue and ownership by the programme delegates of the modules and emerging policies are clear evidence of the implementation of policy in the practice and reform of healthcare.

On reflection too, with the demise of the programme, there was a feeling within University A that the model created was potentially unsustainable in terms of the heavy investment in resources to meet the needs of such a relatively small group of people.

This raises a number of issues for future programme development, particularly in an age where economies of scale are being carefully scrutinised.

The close working relationship between the partners involved was a key factor in anticipating, developing and being able to deliver a programme that reflected the rapidly changing environment within which the NHS worked and met very specific requirements.

It is a conundrum; to be truly work-based and employer focused, management programmes such as the one described need to build in significant levels of time and human resources to gain thorough knowledge of the different organisational cultures, drivers and needs with which they plan to work. It is difficult to conclude in the current climate whether or not this is a realistic ambition and further research and consideration of the issues raised would be necessary.

Conclusions and implications

One of the novel contributions of this paper relates to the effectiveness of the innovative management development programme in terms of it being developed closely with the employer (the primary care organisation or PCT) and the university. In addition, given that there are countless management development programmes for healthcare with a variety of pedagogical approaches ([30] Peck and Dickinson, 2010), it is important to differentiate this programme from other approaches. There have been concerns in other research about the unwillingness of employers to engage in work-based programmes ([32] Reeve and Gallacher, 2005; [39] Smith and Preece, 2009). This is most clearly demonstrated by the close employer-university linkages and, indeed, the bespoke nature of the programme and its embeddedness within the organisational context - and, therefore, the "ownership" that results from this unique characteristic of the programme, rather than a generic approach which ignores the organisation and is thus less impactful upon employees because of a lack of relevance to their work life and organisational context. This programme, however, provides evidence of greater relevance because of its embedded and bespoke nature.

An additional contribution of the paper is that it enhances our understanding of innovation within management development within the public services in the UK, i.e. specifically the healthcare sector, the primary care organisation, in this case. Clearly, the most pertinent innovation literature that is relevant to our study is that of continuous improvement ([35] Schroeder and Robinson, 1991; [3] Bessant, 2003), especially as previously implemented in healthcare (e.g. [1] Berwick, 1989, [2] 1996; [8] Boaden, 2009; [9] Boaden et al. , 2008; [31] Proudlove et al. , 2008; [37] Shortell et al. , 1998), and also high-involvement innovation ([3] Bessant, 2003; [40] Tidd et al. , 2005), with the relationship between CI and learning ([4] Bessant, 2006). Whilst such prior research has tended to focus upon CI, high-involvement (or employee involvement) innovation in relation to products and processes within the manufacturing sector, it does have relevance to services and, therefore, to the public services. When we consider the ways in which the management of the public services, in this case health care, can be improved, then involving employees directly in the development of programmes that improve their management capacity is itself one of the most effective means by which managerial processes can be enhanced. This, therefore, answers the "So what?" question that we posed in the literature review. Delivering the NHS's public service remit and its core healthcare services better, as enshrined in policy (e.g. [15] Department of Health, 2009), through learning and continuous improvement, is thus a key facilitator of such improvement.

Throughout the paper, we have identified what is novel about the management development programme - i.e. the ownership, embeddedness and involvement of both employees and the employer, and consequently the bespoke nature of the programme - which we would argue makes it pedagogically robust and relevant to the primary care organisation. In addition, our study has provided insight, using the lenses of a management development programme, to explore and add knowledge on an important, and under-researched, topic.

The earlier review of the literature highlighted a limited range of research on innovation in public services (with an exception being [22] IDeA, 2005) and health care ([1] Berwick, 1989, [2] 1996; [8] Boaden, 2009; [9] Boaden et al. , 2008; [19] Greenhalgh et al. , 2004; [20] Greenhalgh and Bate, 2005; [27] Maher and Plsek, 2009; [31] Proudlove et al. , 2008; [33] Rogers et al. , 2008; [37] Shortell et al. , 1998), as well as the core service being delivered to the "customers" (in this case, patients) (cf. [40] Tidd et al. , 2005) and the need for a positive innovation culture ([11] Christensen and Raynor, 2003). In addition, it highlighted the concept of continuous improvement (CI) based upon ideas from employees' suggestion boxes ([35] Schroeder and Robinson, 1991; [3] Bessant, 2003), as well as the use of external knowledge and absorptive capacity ([12] Cohen and Levinthal, 1990) - the learning perspective. It is clear from our review that the management development programme could contribute to all of these aspects; for example, through bringing in external knowledge and expertise to improve the managerial competence and innovativeness of NHS managers, and also by encouraging a more innovative culture. However, as there appears to be a key research gap more widely on the issue of continuous improvement and innovation in the NHS (with key exceptions including the studies cited), our paper has limitations in the extent to which it can relate our findings to extant research. However, it does highlight a need to conduct future, deeper research into this research question. The case study demonstrates how a partnership of this nature can provide a way forward for NHS organisations to deal with their staff training needs and embed current policy developments in improving organisational performance.

The authors wish to thank Dr Helen Dickinson (the Editor) and another editor for very helpful comments on earlier drafts of this paper. In addition, the authors thank the participants of the programme, their employers, and other colleagues for their input into the research process. All errors and omissions remain the authors' own.

Footnote

1. Internal document 1, "Corporate improvement strategy", confidential; Internal document 2, "NHS final clinical compact and behaviours", confidential; Internal document 3, "Management development pogramme: project team minutes and related papers", confidential.

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Appendix

Corresponding author

Paul J. Smith can be contacted at: [email protected]

  

Illustration

Figure 1: University programme

  

Table I: Job roles of delegates