A strategic document as a tool for implementing change. Lessons from the merger creating the South-East Health region in Norway

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ContentslistsavailableatScienceDirect

Health Policy

j o u r n al ho me p ag e :w w w . e l s e v i e r . c o m / l o c a t e / h e a l t h p o l

A strategic document as a tool for implementing change.

Lessons from the merger creating the South-East Health region in Norway

Tarald Rohde

^a,∗

, Hans Torvatn

^b

aSINTEFTechnologyandSociety,DepartmentofHealth,Forskningsveien1,0314Oslo,Norway

bSINTEFTechnologyandSociety,WorkResearchSection,S.P.Andersensvei5,7465Trondheim,Norway

a rt i c l e i n f o

Articlehistory:

Received24November2016

Receivedinrevisedform20February2017 Accepted22February2017

Keywords:

Hospitals Healthregion Strategy Change Results Organisation

a b s t ra c t

In2007,theNorwegianParliamentdecidedtomergethetwolargesthealthregionsinthe country:theSouthandEastHealthRegionsbecametheSouth-EastHealthRegion(SEHR).

Initsresolution,theParliament formulatedstrongexpectationsforthemerger:these includedmoreeffectivehospitalservicesintheOslometropolitanarea,freeingperson- neltoworkinotherpartsofthecountry,andmakingtreatmentofpatientsmorecoherent.

TheParliamentaryresolutionprovidednospeciﬁcinstructionsregardinghowthisshould beachieved.

Inordertofulﬁltheseexpectations,thenewhealthregiondecidedtodevelopastrategy asitstoolforchange;achange“agent”.SINTEFwasengagedtoevaluatetheprocessandits results.Westudiedthestrategydesign,thetoolsthatemergedfromtheprocess,andwhich changeswereinducedbythestrategy.Theevaluationadoptedamultimethodapproach thatcombinedinterviews,documentanalysisand(re)analysisofexistingdata.Thelatter includedeconomicdata,performancedata,andworkenvironmentdatacollectedbythe South-EastHealthRegionitself.

SINTEFfoundalmostnoeffects,whetherpositiveornegative.Thisarticledescribeshow thestrategywasdevelopedanddiscusseswhyitfailedtomeettheexpectationsformulated intheParliamentaryresolution.

1. Background

The literature on hospital mergers revealsthat they seldomachievetheirgoals;moreoften,theyhaveaneg- ativeinﬂuence[1–4].“Politicalpressureformergersmay beirresistible,butaclearwayforwardandmoresupport areneededtopreventthemcausingmoreproblemsthan theysolve”[5].Themergingofthetwolargesthospitalsin Stockholm[6–8]hasmanysimilaritieswiththemergerwe

∗ Correspondingauthor.

E-mailaddresses:[email protected],[email protected] (T.Rohde),[email protected](H.Torvatn).

studied,andtheresultwasnotwhathadbeenexpected.

For stakeholders below thetop management, the ideas behindthemergerwerenotconvincing. Anotherstudy, fromDenmark,concludedthattheeffectofmerginghospi- talshadbeensmallorabsent[9].Thefewpositiveexamples hadtwothingsincommon:thehospitalswererelatively small,andthepurposeofthemergerswasclearlyspeciﬁed [10].

Against this background, the goals set for the new SEHRwereambiguous.IntheParliamentaryresolutionthe expectationswereformulatedasfollows[11]:

•Theoverallgovernanceandcoordinationofpatientﬂows shouldbeimproved

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•A more efﬁcientuse of resources ought to beimple- mented

•Increasedefﬁciencyshouldreduce hospitalpersonnel, makingthemavailabletootherpartsofthecountry;

•Improvementsshouldbemadeincoordinatingresearch andeducation.

Theseresultswereexpectedtoemergefromchanges implementedintheOslometropolitanarea.

The new management decided it was necessary to developastrategyasthe[main]tooltoachievethesegoals.

Basedonourstudyoftheformulatedstrategy,thisarti- clediscusseswhetherthestrategybecamean‘agentfor change’.Section4answersthefollowingquestions:

1)Didthestrategy concentrateonthetasks(changesin themetropolitanarea,governanceandcoordinationof patientﬂows,betterefﬁciency)givenbyParliamentand MinistryofHealthandCareServices?

2)Didthestrategycontributetochangesintheorganisa- tion?

a)Which organisational changes resulted from the strategyprocess?

b)Howdidorganisationalchangesaffecttheorganisa- tion?

c)Didthe strategy extendtothelower ranksof the organisation?

3)Didtheregionmeetthegoalsofthemerger,assetout byParliamentandMinistryofHealthandCareservices?

a)Was the overall governance and coordination of patientﬂowimproved?

b)Didefﬁciencyimprove?

c)Didthenumber ofemployeesinthemetropolitan areafall,tothebeneﬁtofotherpartsofthecountry?

d)Didresearchandeducationimprove?

2. Methods

Theevaluationadoptedamultimethodapproachthat combinedinterviews,documentanalysisand(re)analysis ofexistingdata.Thelatterincludedeconomicdata,perfor- mancedataandworkenvironmentdatacollectedbythe healthregionitself.

The document analysis covered all documents pre- sentedtotheboardoftheSouth-EastHealthRegionfromits establishmentin2007tothepresentationofthestrategyto thehospitaltrustsinJanuary/February2009,includingsup- portingdocuments.Fortheperiod2009–2012,document analysisconcentrated on documentsconcerningcentral hospitaltrusts.TheOfﬁceoftheAuditorGeneralofNorway auditedtheprocessconcerningtheOslohospitals,which alsobecamepartofthedocumentstudyoftheproject[12].

Theevaluationofeconomicdevelopmentandefficiency useddatafromtheResearchCouncilofNorway-financed project:“The effectsofDRG-basedfinancingonhospital performance:productivity,qualityandpatientselection”, which used accounting data from 2004 to2012 for all Norwegianhospitals.

The development of patient activity and quality in patienttreatmentwasstudiedusingregisterdatafromthe

NorwegianPatientRegister,whichincludespersonalised recordsofallhospitalvisits.

We interviewed top managers, managers in local departments,employeeswithoutmanagementresponsi- bility,unionrepresentativesandrepresentativesofpatient organisations.Intervieweesrepresentedbothhospitalsand departmentsthathadbeenhighlyinvolvedinthechange process, as well as unitsthat had not experienced any formal or practical change. Sixty-two individuals were interviewedthrough36individualandninegroupinter- views.

TheSEHRgathersannualdataonhowemployeesregard theirworkingconditions.Thesedatawereanalysedtosee whether,andhow,theprocesshadaffectedtheworking milieu.

Thefocushavebeentoinvestigatehowtheformulated strategyanswersthetasksandgoalssetbytheParliamen- taryresolutionandwhetherchangesafterapprovalofthe strategycouldbelinkedtothestrategy.

3. Theenvironmentalandhistoricalinﬂuenceson Norwegianhospitalservices

FollowingthetypologyestablishedbyBøhmetal.[13], healthcareinNorwaycanbeclassiﬁedasaNationalHealth Servicewithpublicactorsasserviceproviderssupported bystrongpublicfundingandregulation.Thecurrenthos- pitalsystemwasestablishedintheearlyseventiesbythe HospitalActof1969andtheParliamentaryresolutionthat describedNorway’sregionalisedhospitalsystem[14,15].

While all major actors are public, relationships among themhavechangedovertime.Thispaperfocusesonthe effects(andnon-effects)ontheserviceproviders,inthis casehospitals,ofamajorreorganisationinitiatedbyPar- liament.

SincetheHospitalActof1969,Norway’s19 counties haveownedthehospitalslocatedwithintheirrespective borders.Theonlyexceptionswereastatecancerhospital, theNationalHospital,which isownedbythestate,and a fewprivatenon-proﬁthospitals.Thecounties cooper- atedwithinﬁvedesignatedhospitalregions,eachhaving aregionaluniversityhospital.Regionalisationwasgradu- allystrengthened.In2002,allpublichospitalsbecamestate enterprises.Fiveregionalbodiesgovernedthehospitalsec- torasanextensionoftheMinistry’sauthority.Withthe Minister ofHealthactingasthenationalhospitalboard, Fig.1providesadescriptionofthehospitalsectortoday.

Thehospitaltrustsadministertheindividualhospital unitswithinoneortwocounties.

In three of the regions (West, Mid and North), the regionalorganisationwasstraightforward,withaclearly identiﬁedandacceptedmajorhospitalastheregionalhos- pital.Therewererarelyseveralhospitalswithinthesame city,asNorwegiancitiestendtobetoosmall.

InOslo,thesituationwasdifferent.In2006,therewere fourpublichospitals,twoofwhichwereregionalhospi- tals.TheNationalHospitalwastheregionalhospitalforthe SouthregionandtheoldcountyhospitalofOslo,Ullevål hospital,wastheregionalhospitalfortheEastregion.Oslo citywaspartoftheEastregion.Thetwohospitalsare3km apart,andhaveahistoryofsomerivalryandconﬂicts.

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Fig.1.Norwegianhospitalorganisation.

Therewererepeateddiscussionsaboutpatientsbeing thevictimsofacompetencestrugglebetweenthesetwo universityhospitals[16].OneMinisterofHealthclaimed therewasaBerlinwallrunningthroughOslo,dividingthe hospitals[17].Tosolvethisproblem,in2007thegovern- mentdecidedtomergetheSouthandEastregions,creating by far the largest health region in Norway, the South- EastHealthRegion.TheMinistryofHealthandParliament assumed thatwiththesetwo hospitalslyingwithinthe sameregion,disputeswouldend.Theexpectationsarticu- latedintheParliamentaryresolutionwereprobablybased ontheworkofaprojectgroupestablishedbytheMinistry ofHealthandCareServices[16]forwhichMcKinseypro- videdthesecretariat,includedapaperthatclaimedthat mergingtheOslohospitalscouldfreeupalmostUSD100 millionayear[18].

4. Results

4.1. Didthestrategyconcentrateonthetaskssetby ParliamentandtheMinistry?

The Parliamentary resolution focused on the Oslo metropolitanarea,onpatientflowinthesomaticsector, efficientuseofemployees,andresearchactivity.Instead offollowingthisup,thestrategycoveredthewholeSEHR and allservices.It wasexpanded toinclude psychiatric and abuse services, para-medical services, laboratories andsupportservices,includinghospitalorderlyservices, catering,housekeeping,security,health&safety,laundry, managementofbuildingsandfacilities,financialdepart-

mentsandhumanresources.Allthetrustsandhospitalsin theregionwereinvolved,notonlythosesituatedwithin the metropolitan area. The main goals of the strategy weretomaketheservicesmoreequalandmoreavailable.

There wereno specific goals regarding efficiency, free- ingupofpersonnel,ora morecoherentpatientflowin themetropolitanarea.Anexceptionwasthechapterfor researchandeducation.Thattaskwasspecificallysetout intheresolution,andthestrategyformulatedspecificgoals forit.

4.2. Didthestrategycontributetochangesinthe organisation?

Thestrategydecidedtodividetheregionintosixhos- pital trusts, which should be large enough to provide treatmentfor80–90%oftheinhabitantsinitscatchment area,indicatingthat 10–20%wouldnormallyhavetogo outside of theareato seekmore specialisedcare. Each trustshouldhaveasinglemainareahospital,andanum- beroflocalhospitals.Followingthisdecision,thesmallest trust wasdissolved,its threehospital unitsweretrans- ferredtoneighbouringtrusts,correspondingtothecounty inwhichthehospitalswerelocated.Twocounties,Tele- markandVestfold,formallybecameonetrust,butthetwo hospitals,VestfoldhospitalandTelemarkhospitalmain- tained theirindependenceas hospital trusts.Originally, thecounty aroundOslowasonehospitalarea.Nowthe west side municipalitiesweremoved intoVestre Viken hospital trust, with their local hospital. The east side remainedahospital trust,andtwo districtswithinOslo

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became part of its responsibilities. The rest of Oslo remaineda hospitaltrust, and thefourpublichospitals weremergedintooneorganisationalunitunderthename ofOsloUniversityHospitalTrust(OUH).OUHthendecided todownsizeoneofthefourhospitalsandmoveitsservices totheformerUllevålHospitalandtheNationalHospital.

Threetrustsdidnotexperienceanyorganisationalchange.

Onenewtrust,coveringTelemarkandVestfoldcounties, existed only on paper; the two hospitals carried onas before.Theaimofserving80–90%ofinhabitantswithin agivenarea(trust)wasidenticaltotherealitybeforethe strategybegantotakeshape.

4.3. Didorganisationalchangesleadtootherchanges?

Protagonistswhoworkwithstrategicformulation all agreeononeessentialaspectoftheprocess:management mustembracethestrategy.Throughourinterviews,the onlywholeheartedsupportforthestrategycamefromthe CEOwhostartedtheprocess.Otherrespondentswereless supportive.TheCEO’sﬁrsthandwaseagertopointoutall themodiﬁcationsassociatedwiththegoals.TheCEOofone trustsaidthat“thevisions(ofthestrategy)couldsupportany organizationalstructure”[19].

SomeoftheimportantdecisionstakenbythenewOUH boardwereonlyimplementedbecausethechairusedhis castingvote[20].Thecurrent CEOofOUS hasexplicitly statedthatheneverreadtheSEHRstrategy[21].Employ- eesat lowerlevelsintheorganisationclaimed thatkey decisionsweretakenbeforetheywereinvitedtopartici- pate.Itisimportanttomentionthatno-oneinterviewed actuallyopposedstrategyandcentralgoalsassuch.The medicalmanagersofthetrustsinparticularregardedthe qualitygoalsasasupportinperformingtheirduties,but theydidnotconnectthemwiththestrategy.Theyrelated thegoalstotheannualcommissionfromtheMinistryand bytheMinisterofHealth’sownpublicpronouncementsin newspapersandontelevision/radio.Wefoundlittledirect oppositiontothestrategybut norwasthereanystrong support;ratherwe registeredindifferenceanda lackof knowledgeofwhatthestrategyactuallywas.Theformal changesdidnotleadtoanyobservablechangeinhowthe trustsperformed.

4.4. Implicationsforthelowerreachesofthe organisation

Wewereeagertoseeifthestrategyaffectedtheemploy- eesintermsofhowmuchtheywereaffectedbythestrategy intheirday-to-daywork.ThemergingoftheOslohospitals inparticularwaswidelydiscussedinpublic[22].

Beforethemergerin2007,bothhealthregionsassessed theworkenvironmentofalltheiremployeesannually.The questionnairesemployedwerebasedonwell-knownpsy- chosocialtheoriessuchastheDemand–Controlmodelof Karasek[23]andquestionnairessuchasQPSNordic[24].

Theyemployedstaffwhowerespecialistsonthesemeth- odsand who carried out validation analysis,as wellas assistingingatheringandinterpretingthedata.However, therewerebothmajorandminordifferencesbetweenthe healthregionsregardingwhatinformationtheyrequested.

Therefore, following the merger, the new region har- monisedtheworkenvironmentsurvey.Thisprocesstooka year,andin2009,nosurveyswerecarriedout.Thesurvey in2010didnotincludethenewOsloUniversityHospital, duetoitsrecentmerger.However,sixindicesweredevel- oped,basedontwotofouritemseach.Thesewereidentical in allunitsfrom2008until2013.Belowwedisplaythe scoresintheperiod2008–2013forthesesixindices(Fig.2).

We normalised the work environment indices and rankedthemfrom0to100,whereinallcasesahigherscore indicatesabetterresult.Whatisimportanthereisnotthe exactscoreforeachindex,butratherthestabilityofthe situationasawhole.Therearereallynodifferencesover theyearswhenlookingatthewholehealthregion.This top-levelpicturecouldmaskdifferencesatlowerlevels;

theworkenvironmentofsomeunitscouldhaveworsened whileothersmighthaveimprovedasaresultofthesame changes.Toassessthis,weanalysedwhathappenedatunit level,fairlylowinthehierarchy.Therecouldbefivelevels frombottomleveltotop.Thetotalnumberofemployees intheSEHRiscloseto80,000.Therewereseveralthousand identifiableindividualunits,inwhichasignificantpercent- ageexperiencedchangeannually.However,whenwetook the2011–2013asasample,wewereabletocompareall unitswithinSEHRon72itemsin15indices.

In ordertodeterminewhetherthestrategyhad par- ticularlyinﬂuencedcertaindepartmentsorhospitals,we selected a number of hospitals that had experienced changesandothersthathadnot.WithinOUH,somedepart- mentsmergedbeforethestrategyprocessstarted,while otherswerestronglyinﬂuencedbytheprocess.

Wefoundnounitwhoseworkenvironmentsystemati- callydeterioratedorimproved.Overall,theconclusionwas straightforward;themergerdidnotaffectworkingenvi- ronmentswithinSEHR.

OUHsupplementedtheannualquestionnairedescribed abovewithquestionsabouthowemployeesassessedthe mergingofOslo’shospitals.Lessthan30%believedthatthe intentionbehindthemergershasbeenfulﬁlled.Threeyears afterthemerger,onlybetween40and50%saidyestothe samequestion.Despitethislowlevelofbelief,70–80%of OUHstaffrespondedthattheyenjoyedworkingintheir department,andthispercentagewasconstantthroughthe periodstudied.Comparinganswersovertimeforeachunit and differences between theunits,we found nodiffer- encesandnochangesrelatedtothestrategyprocess.On mostof thetopics,suchasjobsatisfaction and motiva- tion,thepositiveanswersratedfrom75%to88%,which mustberegardedashighscore.Thelowestscoreswere forself-assessment,whichrated46%andworkloadwith 63%.

Anunexpectedﬁndingwasthelargenumberoforgan- isationalchangesthatweretakingplaceindependentlyof thestrategicprocess.Everyyear,anumberofunitswould disappearandnewunitsappear(Table1).Organisational changeisthenormalsituation,whetherstrategicprocesses arebeingimplementedornot.Ahuswasadaptingtoacom- pletelynewhospitalbuildingintheperiod,asisreﬂectedin thetable.Eventhemoststablehospitaltrustshadchanges rangingfrom6to24percentineachofthesethreeyears.

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Fig.2.WorkenvironmentscoreinSEHRfrom2008–2013;entirehealthregion.Indexscorenormalisedfrom0to100(max).

Table1

Numberoforganisationalchanges2011–2013.“Ended”referstounitscloseddownand“New”tounitscreatedinthecourseofthisperiod;percentage relatestothebaselineeachyear.

2010 2011 2012 2013

Baseline New Ended Baseline New Ended Baseline New Ended Baseline

Ahus 238 12% 37% 179 54% 51% 183 9% 50% 108

OUH NA NA NA 1031 3% 7% 992 4% 10% 928

HospitaltrustofTelemark 244 7% 9% 239 14% 13% 242 1% 4% 236

HospitaltrustofVestfold 229 10% 4% 242 9% 10% 239 4% 3% 241

HospitaltrustofVestreViken 337 15% 8% 359 11% 13% 350 2% 4% 341

4.5. Didtheregionmeetthegoalsforthemergerssetby ParliamentandMinistryofHealthandCareServices?

Thegoalsforthemergerwerebetterefﬁciency,better patientcoordinationofpatientﬂowandbetterresultsin theareaofresearchandeducation.

In orderto studythedevelopmentof economicefﬁ- ciencyweanalysedtheproductivityofsomatichospitals for the period 2004–12. We analysed the effect of the mergerbylookingathowdevelopmentsinSEHRhadbeen, compared to theotherregions in theperiods 2007–12, 2008–12 and 2009–12 [25]. Data envelopment analysis (DEA)wasusedtogetherwithbootstrappingtoestimate conﬁdenceintervals[26].Bothconstantandvariablereturn toscalewereused[27].Wefoundnosystematicdifferences (Fig.3).

OnespeciﬁcgoalthatwassetoutintheParliamentary resolutionwastoreducethenumberofhospitalperson- nelin themetropolitan areasothat theycouldbecome available to other parts of thecountry. The result was theopposite.ThenumberofemployeesinOUHandAhus increasedby1700from2010to2013.

Studyingactivityandquality,wecomparedthedevel- opmentofthemostcommonparameters;inpatients,day patients and outpatients, bed days and length of stay.

Norway registers a set of quality parameters both for somaticandpsychiatriccare,suchasnumberofcorridor

patients,infectionrates,waitinglengthsbeforetreatment, etc.,whichweanalysed.Inthecourseoftheperiod,the performanceoftheregionaltrustsmovedclosertoeach other.In2013waitingtimeswere70–75days,outpatients visitsper1000inhabitantswere900,7%ofoperationswere postponedand infectionrates were5%.Fig.4 describes thenumbersofpatientsinthefourregionsintheperiod analysed.

Wealsostudiedhowtheregionworkedwithdifferent nationalprojectsthatweretryingtoimprovethequality oftreatment.Theresultsweresimilartotheproductiv- itystudy.Thedevelopmentdidnotdivergefromthetime beforethestrategyprocessorwiththedevelopmentinthe otherhealthregions.

Thelong-termgoalfortheSouth-EastHealthregionis toputﬁvepercentofitsbudgetintoresearch.Intheperiod afterthestrategyprocess,itreached2.8%,whichwasabove thegoalforthatperiod.Comparedtootherhealthregions, pointsforscientiﬁcpublicationsdisplayedapositivedevel- opment.Theregion’sshareofpointsrosefrom59.6to62.6%

ofthetotalforallfourNorwegianhealthregions.

5. Discussion

5.1. Theproﬁleofthestrategy

The ﬁnal strategy document [28] describes all the positive goals for the regions’ patient treatment, the

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Fig.3. Averagelevelofproductivityineachhealthregion,model:constantreturntoscale,andoutpatientactivitymeasuredasnumberofconsultations, bootstrappedestimatewith95%conﬁdenceinterval.

Fig.4. Patientsper1000inhabitantsperhealthregion2008–2013.

Source:SAMDATA.

involvementofemployeesandasustainableeconomicper- formance,butthereisnoanalysisofwheretheregionis performingbelowexpectedstandardsandwhereitisper- formingabovethem.Documentsandreportsleadingtothe ﬁnaldocumentneitherdiscussnoranalysethesetopics.An earlydocumentstatedthatthestrategyshould“concen- trateonimplementationratherthaninvestigation”[29].It isprobablycorrecttosaythatitfailedinbothrespects.The demandingcharacterofmergerswasunderestimated.The statementbyCharlesworth,chiefeconomistoftheNufﬁeld Centre,isrepresentativeofthedocumentedexperiences.

“Merginghealthcareorganisationsshouldbeviewedwith

caution, unless there are clearand demonstrable bene- ﬁts to patient services” [30]. In 2013the Competitions CommissioninNHSinEnglandblockedamergerbetween Bournemouthhospitalsbecausetheycouldnotproveany gainforpatients[31].Thestrategytookacautiousstand resultinginfewand weakchanges.Makingthestrategy covering‘everything’itevadedthehardtasks.Itwasgen- eralandnotatoolforchange.

Thenotionofthe“Berlin wall”runningthroughOslo wasprobablytheonestatementthatmoststronglylead tothemerger,andinourinterviews[32]quiteafewper- sonsexpressedtheviewthatcooperationbetweentheOslo

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hospitalsneededtobebetter.Inspiteofthis,neitherthe MinistryofHealthandCareServicesnortheSEHRinves- tigatedwheretheproblemswereconcentratedandhow many patients wereinvolved. Such a study could have broughtthemclosertothedesiredchange.

TheParliamentaryresolutionisclearonspecifyingeffi- ciencygoals, and in ourintroductory meeting withthe SEHRmanagementthiseconomicargumentwasstatedby theCEOasanimportantpartofourmandate[33].Thatwas thelasttimeinourstudythatanyhigh-rankingofficialused economicgainasanargumentforthemerger.Onecentral personintheMinistry’sprojectgroupthathadsuggested themerger,toldusthatherconcernwasthatitcouldcost morethanexpected;shehadneverbelievedinanyeco- nomicgain[34].Thatcontrastedwiththereport[35]she had deliveredin 2004,which statedthateconomicgain wasanimportantgoal.Thisdenialofhavingeconomiceffi- ciencyexpectationsforthemergercamesomeyearsafter themergerwasareality,withthebenefitofhindsight.How strongthebeliefwasbeforethemergerwedonotknow, buttheCEOofthenewregionstated:“Myopinionis,and hasalwaysbeenthatwhenParliamenthasissuedaclearly expresseddirective,thenwecarryitthrough”[36].Bymak- ingthestrategysowide-rangingandgeneral,it became possibletomoveawayfromtheoriginalspecificgoals.The regionalmanagementactedasOleBerg[37]statesbureau- cratsdo;“Theywill alwayslookbackward notforward.

Heorsheisinsearchforprecedencyanddoesnottryto estimatesubstantialconsequences.”

If the merger had met Parliament’s expectations, it wouldhavebeenunprecedentedintheNorwegianhistory ofhospitalsandalmostindirectcontrasttoexperiences with hospital mergers internationally [38–42]. In par- ticular, there were nopreviousexamples in Norway of achieving a reduction of personnel. Attempts to make hospitalsmore efﬁcientoftenleadtopolitical and pub- licdebate.Therefore,itshouldbenosurprisethatactive supportforsuchanattemptwasweak,evenwithinthe Ministryinducingthemerger.AnoptionfortheSEHRman- agementcouldhavebeentodiscussmorecloselywiththeir principal(theMinistry)whatwasarealisticgoalforeco- nomicgains,and whattimespan wouldbenecessaryto reachthem?

Incontrasttosuchanapproach,thestrategyendedup withgoalsveryclosetothoseformulatedforNorwegian hospitalservicesthroughthecommissiondeliveredbythe MinistryofHealtheveryyear.Thedifferencesweresome- what cosmetic.While the aimof theNorwegian health servicesistobeequaland accessible,themain goalfor thenewstrategywastobemoreequalandmoreaccessible.

Thestrategyformulatedthevirtuesthatshouldpervadethe services,butnotspeciﬁcgoalstobemet.TheSEHRman- agementnowcallsthestrategyareformofdirection[43], butnodirectionwaspointedout;thereformwasrathera visionofgoodintentions.

5.2. Organisationalchanges

Theorganisationalchangeswereformalandnotcon- nectedtoanyspeciﬁcdesiredchange.Intheinterviewwith thenewCEOofSEHRin2013,hestatedthatifonething

fromthestrategyprocesswouldsurvive,itwouldbethe creationofhospitalareas[20].Thatwasthenewnamefor thetrusts.AsdiscussedinSection4,thepracticalchanges wereformal,andthemissionformulatedforthenewhos- pitalareas (trusts) didnotchange. Thegreatest change occurredintheOslohospitalarea(trust). Thefourpub- lichospitalsmerged,appointingoneCEO.However,that wasthewhole,theappointmentofanewCEO.Neitherthis newCEOnoranyoftheotherCEOsofthetrustsweregiven speciﬁcordersregardingfulﬁlmentofthestrategicgoals.

Fordecades,theMinistryhadbeentroubledbystoriesof non-cooperationbetweenthetwolargesthospitalsinOslo.

Duringalltheseyears, theheadofallNorwegianhospi- talshadbeentheMinister.Inourinvestigationwehave foundnodiscussionofhowa merger,ﬁrstof theSouth andtheEastregionandthenoftheOslohospitalscould changethissituation.Thechiefmanager,theMinisterof Health,wasthesame.Themanagementatthenexttwolev- elsbelowwaschanged.TheCEOsweregivennonewtools touse,eitherformaloreconomic.Theresultsweremea- gre.TheﬁrstCEOofOsloUniversityHospitalhadbeenpart oftheMinistryprojectgroupthatproposedthemergerof thetworegions.Afteronlyafewmonthsinthechair,she becamethemostarticulateandpowerfulcounterpartto theSEHRmanagement.Sheresignedaftertwoyears.The SEHRmanagementdidnotensurethattheCEOoftheby farlargesthospitaltrustbecameasupporterofthestrategy.

AsdescribedintheSection4,thestrategyhadlittleactive supportevenintheinnercirclesoftopmanagement.

5.3. Reachingouttothelowerlevelsoftheorganisation

Ourﬁndingsgiveapictureofanorganisationwherethe differentunitsaresomewhatindependentofchangesin thelayersabove.Thereisavastliteraturedescribinghow medicalcaremarketsdifferfromstandardmarkets[44], andthismaybereﬂectedinhowtheorganisationreactsto reorganisation.Degelingetal.describehowdoctors,and evenmedicalmanagers,werecharacterisedasindividual- istic,non-hierarchicalandpatient-centred,incontrastto managerswhowerehierarchicalandsystematicallyteam- centred[45],i.e.“...,themedicalstaffandadministration arelockedinanoncooperativeoligopoly-typegame”[46].

Aprojectthatinterviewed30 cliniciansbecomingman- agersinthemiddleandﬁrst-lineofahospital,revealsthat theyweremostlyappointedbyfellowcolleagues,oftenthe formerleaderoftheunit[47].Thisprojectunderpinsthe descriptionthatthelowerunitsofahospitalarelargely independentofhigherlevels.Ifastrategyistoreachout tothispartofthehospital,itmustbetranslatedintolocal settings,makingitrelevanttothem[48].

Thisseparationofthelowerandhigherlevelsofhospi- talstaffisaccentuatedbyourunintentionalﬁndingofall thechangesthatweretakingplace,independentlyofthe centralinitiatives.Inthissettingofconstantchangeatlocal level,whywouldamergeroftwohealthregions,atavery differentorganisationallevel,matter?Fortheindividual respondentthelocalchangeswereprobably“bigger”and morerelevantthantheoverallmerger.

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532 T.Rohde,H.Torvatn/HealthPolicy121(2017)525–533 5.4. Meetingthegoals

Withnonewgoalsfortheactivityandwithnonewfor- mulatedmissionforthetrusts’CEOs,itisnotsurprisingthat economic performance and proﬁleof patient treatment havedevelopedsimilarlytootherhealthregions.Further- more,therearenosignsofanydropinactivityoreconomic performanceeither,norofanynegativedevelopmentinthe workenvironment.Thisiscontrarytosomeinternational experiences[42,49].

Thepartofthestrategyconcerningresearchandedu- cationwastheonlyonethatexpressedaspeciﬁcsituation fromwhichtodevelopandtocomparewithotherregions.

Thesegoalswerenotnew,butwereunderpinnedandmade moredemandingthroughthestrategyprocess.Duringthe periodunderstudy,thissituationdidactuallymovecloser tothegoalsexpressed.

6. Conclusions

Thereisalargeliteratureontheproblemsthatoften followmergers.ThisknowledgewasavailabletotheSEHR management,butwefoundnoindicationthatitwasdis- cussedorused.Astrategyshouldbemorethanavisionof goodpractice.AccordingtoMagretta,Porterclaimsthat

“...strategy requiresa tailoredvaluechain,and thatis oftenforgotten”[50].Thatwasthe case withtheSEHR strategy. It didnot describeeither a starting oran end point.Insteadofprioritisingwhattoachieveandgatherthe organisationaroundthetasks,someformalchangesinthe responsibilitiesofthetrustswereimplemented,andthe Oslohospitalsweregivenasingleleader.“...management toolshavetakentheplaceofstrategy”[51].

Afterstudyingthestrategyprocessanditsimplemen- tationinSEHR,wewouldsumuptheseessentialpointsfor astrategytoachievechanges:

•It must establish objective goals that cannot be met withinexistingmodesofoperation.

•Itmustdescribehowthenewmodelwillhelptorealise thegoalsexpressed.

•Theremustbeasigniﬁcantwillingnesstoprioritiseand maketrade-offs.

•Theresourcesandtimeneededtoachievefundamental changesmustnotbeunderestimated.

•Inordertoreachouttoallemployees,thepoliciesmust bedescribedintermsthatarerelevanttotheirdailyactiv- ities.

•Theremustbestrongpositivesupportfromthemanage- ment.

Conﬂictofintereststatement

Thereisnoconﬂictofinterestconnectedtothisarticle.

Acknowledgements

NootherinstitutionsthanSINTEFhavebeeninvolvedin thisarticle.

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