Loss associated with subtractive change in health services: the case of centralization of cancer specialists in England
This article was originally published here
J Health Serv Res Policy. April 2022 26:13558196221082585. doi: 10.1177/13558196221082585. Online ahead of print.
OBJECTIVE: A major system change can be stressful for the personnel involved and can result in “subtractive change”, which is when part of the working 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 the 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 the activation or the obstruction of coping strategies associated with that loss.
METHODS: We analyzed 115 interviews with clinical, nursing and managerial staff in esophago-gastric, prostate/bladder and kidney cancer services in London and West Essex. Additionally, we used 134 hours of observational data and analysis of over 100 documents to contextualize and interpret the interview data. We conducted a thematic analysis based on the theory of stress coping and organizational change.
RESULTS: Staff perceived that during centralization, sites were devalued as sites lost surgical activity, skills, and experienced teams. Staff members felt that this loss had long-term implications, such as retaining high caliber staff, attracting interns, and maintaining self-reliance. Emotional repercussions for staff included a perceived loss of status and motivation. To mitigate these losses, the leaders of the centralization process have put in place some instrumental measures, such as joint contracts, surgical skills development opportunities and rotation of trainees. However, these measures have been undermined by uneven implementation and negative impacts on some people (eg increased workload or travel time). Relatively little emotional support was perceived to be offered. Leaders sometimes referred to negative emotional reactions to centralization as resistance, to be overcome through persuasion and appeals to the success of the new system.
CONCLUSIONS: Large-scale reorganizations are likely to elicit a high degree of emotion and perceptions of loss. Resources to foster adaptation and resilience must be made available to all organizations in the system as they go through major changes.