Loss of personal autonomy and erosion of professionalism

Lack of recognition by senior management for the work of the units, lack of steer from the government or match between political, managerial and unit agendas, low profiles for endoscopy, and factional discord between different professional groups led to disillusionment, particularly among senior GI physicians and surgeons. Individual autonomy was also eroded, whereby notions of professionalism are linked to an individual's ability to make informed decisions that can impact on modernisation: ‘clinical autonomy has gone’ (FG3.3). This led to a dispirited workforce feeling undervalued: ‘we are now … seen as employees rather than professionals’. (FG3.5):If you want my Damascus moment, it was when somebody came back from a meeting sitting alongside a hospital administrator who said that consultants, as far as managers are concerned, are really on the level of a store manager. (FG3.2)

Low morale left professionals feeling disengaged and less likely to be flexible in adapting to change or taking on board new approaches to working: ‘there is an attitude of suspicion’(FG1.1). Understaffed units and staff deskilling were of particular concern, both for nurses and consultants. Thus, while expansion was helpful, units appeared to be running without their full complement of staff with no major drives to recruit additional staff. In addition, greater staff specialisation, for example, differences between GI physicians and surgeons, suggested the loss of the professional ‘all-rounder’, with people working in different specialisations working according to their own individual agendas and little clarity regarding who should be taking on which tasks:I would like to see a Welsh health strategy that decides what's being done and where, so it actually happens, with enough people to do it sufficiently specialised and not everybody trying to do everything everywhere. (FG4.2)

Nurses are particularly demoralised, spending less time caring for patients and more time doing paperwork: ‘Nurse morale is really low and if they don't do something they'll all be leaving’ (FG1.4).

Low morale and low-team spirit can be countered, to a certain extent, by strong medical and nurse leadership, with a few motivated individuals making a difference and pulling everyone together. However, this sense of integration and belonging in the face of adversity was also described as the ‘sinking ship’ mentality, having the negative effect of bringing everybody down: ‘People stick together because there is only one life raft’ (FG4.2).

Lack of senior management understanding

Lack of senior management understanding of the work of the units and the needs of its members and lack of appropriate management systems to underpin the work of units was an overarching theme across both English and Welsh focus groups. Units could not make long-lasting changes to service organisation and delivery, while decisions around unit change and changes to the process of care delivery were taken by ill-informed management with no scientific or clinical expertise. This was exacerbated by a lack of funding, particularly in Wales, and extensive resource deficit that left a deflated workforce with little sense of professional status. Participants perceived management as favouring government-driven targets within a top–down managerial environment. In Wales in particular, there was a conflict of interests between groups of professionals, such as surgical and medical specialists, and discordance around the use of space and resources: ‘I think historically, if you look at the way endoscopy services sit in most Trusts, they don't sit very easily in one service group’ (FG4.4).

Conflicting interests between staff and management were noted, and senior management was seen as out of touch, reactionary and not to be trusted: ‘management have their own agenda in terms of fulfilling their local delivery plans’ (FG4.4). Moreover, new target-driven political and managerial directives engendered bureaucracy and legislation, creating extensive paperwork and adding to the work of staff, especially nurses.

There were difficulties convincing senior managers of the importance of endoscopy and many layers of red tape. If management were supportive, then change was effected, but this was often only the case in crisis management: ‘This is a reactionary, entirety management when crises arise’ (FG4.1). Management was highly distrusted, and management systems were noted as being ‘an enormous and complex labyrinth’ (FG4.2). Middle managers were perceived as pressurised by senior managers to reach targets, and clinicians wanted to bring about change without targets attached. Lack of communication between clinicians and managers furthered this sense of frustration and futility. To overcome these hurdles, decisions were often made irrespective of the medical evidence, patient need or the immediacy of the problem:In practical treatment the changes we want to bring have to be evidence-based. I cannot suddenly go and do something to a patient, which I think is right, irrespective of what the data shows. But changes are applied to us through the political and management system and there is no evidence. (FG3.1)

Barriers and facilitators to meaningful change

Groups discussed the reduction in waiting times as the main facilitator for change, alongside ‘pooled lists’ and ‘flexible staff working arrangements': ‘our waiting list has dropped a lot’’ (FG3.4). However, this was not discussed in terms of better patient care or enhanced quality of care. Indeed, patient outcomes such as greater patient satisfaction with services, patient-centred care or changes for the good of the patient were predominantly absent from focus group discussion, at odds with the weight of discussion that concentrated on service re-evaluation towards performance-related goals and targets. Reduced waiting times were considered in accordance with the need to meet government targets for improved service provision and as something easily measured. This created ‘a depressed atmosphere’ and ‘distressing times’ (FG3.1) and led to healthcare services that were unable to cater to even the most basic of patient needs. It was also mentioned that the implementation of the new consultant contract led to a decrease in working hours and consequently the quality of patient care that could be offered had fallen.

English focus group participants were keen to express their support for the modernisation of endoscopy units, the improvement of services through change and the innovation of service delivery.

Beside reduction in waiting times, other facilitators for change included fast tracking of patients, more nurse endoscopists, new guidelines for referral and management of endoscopies, ‘prep’ nurses and more specialist staff. Longer waiting lists were also, paradoxically, seen as a facilitator for change, encouraging the generation of new resources and acting as an impetus for the fulfilment of waiting list targets.

Barriers to change related to lack of senior management support and understanding, lack of funds and the slow speed with which change was occurring: ‘It's not change that is the problem it's the rate of change’ (FG1.3). Exacerbated by managerial decision-making bereft of unit input, focus group participants talked at length about lack of funding, lack of leadership, poor skill mix and the difficulties different specialties had sharing endoscopy facilities. At that time, the absence of a National Service Framework for gastroenterology, poor-quality information at the point of referral from general practitioners regarding prioritisation of patients and lack of interest at an executive level did little to enhance a sense of self-worth. Endoscopy units were not recognised for their cutting edge work and consequently were not at the top of the Trusts' lists of priority areas for funding. This was linked to managerial inertia: ‘endoscopy as an area was never effectively managed’ (FG2.1). In Wales, lack of support from external sources such as the Welsh Assembly government was an additional problem.

Differences between English and Welsh units

Focus group participants in Wales emphasised the high level of camaraderie across units, close unit links and strongly supportive nursing teams: ‘We do work well together’ (FG2.1). However, Welsh units were seen as lagging behind their English counterparts regarding: resource availability, government and Trust support, good management, colorectal screening and technical development. The changes made in English units, as a result of the work of the National Health Service Modernisation Agency, were described in predominantly positive terms, but similar changes in Wales were at a much slower pace:We are lagging behind—the waiting times in England are much better than in Wales. Colorectal cancer screening we are lagging probably two years behind, and some of the technological developments, again we are lagging behind. (FG3.6)

However, this had its advantages, as Welsh units could learn from their English counterparts and could take care not to repeat their mistakes. No major differences were mentioned regarding clinical outcomes; indeed, Welsh units were seen as on a par with their English counterparts, learning from their experiences: ‘We have been fortunate; various GI meeting speakers from these kinds of organisations came to Wales and presented case work’ (FG3.3). Nevertheless, there was still a strong sense that Welsh units lacked recognition among the wider healthcare community for the excellent work they were doing and the changes they had already made towards an improved service. Lack of recognition led to a great deal of scepticism that funding and other resources would be made available from external sources.