El valor de las crisis: crisis desestructurantes vs transformadoras

Responses to plans for PPEI within the transition period can be characterised by anxiety from PCT

commissioners and service user representatives about loss of relationships and GPs’ lack of experience in

PPEI, counterbalanced by some respondents (particularly CCG shadow board members and local authorities) seeing it as an opportunity for a more strategic approach and starting anew. However, our findings indicate that PPEI processes and impact were being affected in the case studies by varying degrees

of organisational amnesia.153_{As described in CS2 (see Chapter 5), an initiative underpinned by PPEI to}

transfer diabetes care from the acute to primary care sector was seen by PCT commissioners as likely to flounder during the transition phase. This was confirmed by service user representatives who felt that the focus on this initiative had been lost and communication from commissioners had ceased, a situation echoed in CS3 with the planned reconfiguration of diabetes services for the BME population.

In all our case studies, there was evidence that the speed of implementing the reforms153_{and the sharp}

focus on the CCG authorisation process resulted in a number of projects with PPEI being lost from the radar. This was further compounded by the accompanying downsizing and loss of PCT staff who had been leading these projects. In all case studies, our original PCT commissioners had moved onto other organisations, indicative of the career-jumping that is suggested as one of the characteristics of a reformed

public sector organisation.154_{Those staff who were still in post were working in great uncertainty about}

their future position, and were negotiating continually changing short-term roles.154_{In two of the three}

case studies, there was outsourcing of Communication and Engagement, with only one of our case studies retaining this in-house. This use of outside agencies may contribute to organisational amnesia by removing PPEI from the central radar. Observation of meetings indicated that major decisions were being made within a very short time frame (often as quickly as 24 hours), and supporting documentation was solely

electronic. This‘time compression’ and change in mode of record-keeping154_{inevitably made PPEI in the}

decision-making process more challenging. There was evidence that there was insufficient time for lay members of the shadow CCG boards to keep abreast and informed of changes, and, therefore, meaningful involvement was lost.

However, the move to the CCG structure was seen as an opportunity to be innovative and move away

from the former PPEI models. The relative freedom allowed by Equity and Excellence7_{to determine local}

CCG structures resulted in a variety of structures, again indicative of recent reforms of public sector

organisations.154_{While the PRUComm survey and EVOC case studies indicated the varied positioning of}

PPEI in these structures, our case studies also suggested that there was an ongoing tension between

representatives of the previous PPEI structures and of the new.153_{The innovators saw the previous model}

of LINks as failing to be a conduit to harder-to-reach groups, and for perpetuating a very narrow

representation. In CS1, this tension was openly acknowledged and addressed and there was evidence of a

concerted effort to maintain a balance between change and continuity.155_{However, in all case studies,}

continuity in terms of service user representation appeared to be outweighing change. Although more recently housed in different structures such as PRGs, the majority of our service user respondents remained unchanged during the EVOC project. At the start of the project, many had been LINks or service user group members, and all were committed to maintaining their local PPEI role. In many ways, they became the organisational memory and were able to refer back to PPEI initiatives that had been successful in the past. However, it was more of a challenge for them to have this memory acknowledged and listened to during the frenetic period of reorganisation. The resourced project lead in CS1 enabled some

groups and public involvement representatives. Nevertheless, this project lead was an outsider on a fixed contract and there was some evidence towards the end of the data collection period that the achievability of the PPEI strategy was being questioned. Within the other two case studies, the development of the

PPEI strategy was part of a shadow CCG board member’s workload, with an inevitable lack of focus

demonstrated by the comparatively late production of the PPEI strategy. It was also significant that both leads were relatively inexperienced in PPEI, and much of this work was done alongside outsourced PPEI resources (CS2) and complementary projects such as the Equality and Diversity Strategy (CS3). Having a key project running in tandem both informed and shaped the PPEI strategy, and affected the way PPEI was

understood in this case study.153_{The transition phase resulted in significant rehousing, with communication}

and engagement teams and PALS being outsourced or moved to provider trusts or CSUs. Containing PPEI within the overarching Communication and Engagement strategy made it vulnerable to being

overshadowed by the CCG’s organisational priorities around communication with staff and provider

services. Only one of the EVOC case studies had retained Communications and Engagement within the

CCG (CS1). There are questions of sustainability for the other case study sites– external organisations and

CSUs may be transitory.

Organisational memory is also stored through the norms and values of the organisational culture. In each of our case studies, the data suggested that PPEI could be mapped onto an intersecting continuum (Figure 10). The findings suggested a continuum of motivation for lay people to become involved ranging

from an individualistic perspective to collective.156_{Our respondents included service users whose}

involvement had been triggered by a personal health agenda, but more commonly were motivated to undertake PPEI from a volunteerism perspective. Narratives from commissioners and providers also indicated that organisations were undertaking PPEI because it underpinned the organisational ethos, and (rather than a simple alternative view) because it was a statutory requirement or externally

incentivised. During the transition period, there was evidence of some shift, albeit relatively subtle, on the continuum. This shift was influenced by the new structures, relationships within these structures and changes in key stakeholders in each case study. Interestingly, we could find evidence in only one of the case studies (CS1) of a shift towards an embedded ethos of PPEI. In the other two case studies, the sheer pressure of change was evoking PPEI strategies and responses more attuned to the top-down requirement of the reorganisation (see Figure 10).

Implementation of PPEI primarily based on a top-down requirement

Implementation of PPI primarily based on embedded ethos of organisation Involvement as a personal response to service needs INDIVIDUALISM PUBLIC PUBLIC ORGANISATION Involvement based on volunteerism COLLECTIVISM CS1 CS2 CS3

FIGURE 10 Continuum of PPEI.

Changing patterns and structures of patient and public