Box 1.

Impact of merger on service delivery and development

Acute trust (merger of constituent trusts A and B)

Negative aspects of merger

• Proposed changes to services in pathology, accident and emergency, and maternity departments still not implemented and delays continue, two years after the merger

• Most respondents from outside the trusts had looked forward to a fusion of the constituent trusts' strengths (of the experience of trust A's clinicians with trust B's management credentials); they were disappointed by the lack of progress, and they felt the merger had a negative effect on trust B's services and the morale of its staff

• “Policy changes regarding protocols and integrated care pathways are being implemented here—something that has been occurring in trust B for years. The nurses have said that this is what they want. It obviously takes time to filter through” (senior nurse, obstetrics and gynaecology)

• “It is difficult to transfer good practice because of the underlying distrust and prejudice toward the other [trust], and because people haven't themselves changed. There persists a difference between specialties and services. Clinicians talk of other clinicians (from the other trust) as if they are part of a different organisation and a unified organisational identity varies from service to service” (primary care group representative)

Community trust I (merger of constituent trusts C, D, and E*)

Negative aspects

• Impatience over delays in implementing actions after service reviews and an awareness of bureaucratic barriers to change in the larger, merged organisations are increasing. In community trust I, a proposed review of paediatric treatments had not been completed two years after the merger; this increased the review period to over 12 months

Positive aspects

• After initial resistance, the professional supervision and development policy introduced across the community trust was felt to enhance service delivery: “Now, for me as a manager [staff appraisal] helps me focus on certain areas, it's a useful process . . . The staff appreciate it, most find it helpful. We set both team and personal objectives” (borough manager, community trust I)

Community trust II (merger of constituent trusts F, G, and H*)

Negative aspects

• Delays in appointment of middle managers held up development of intermediate care services

Positive aspects

• The merger resulted in some sharing of good practices across constituent trusts: “There have been some positive things—there's been sharing of good practice. The staff might not support this, but some have been swapped about—our associate directors for this patch [a jobshare] came from [trust G] and brought different models—it's been good cross fertilisation” (primary care group representative)

Mental health trust (brought together mental health services from four trusts: J, K, L, and M*)

Negative aspects

• The process of merger distracts senior managers considerably from patient care: “The costs of restructuring are very hidden but very colossal. The negative impact of merging is that time and attention of senior people gets drawn away—on looking on policies, budgets, etc. We were disrupted by efforts to try and merge our information systems and find new headquarters. There is an incredible disruption to the patient focus agenda. You become more business oriented and it steers agenda away from patient care” (director of operations, mental health trust)

Positive aspects

• The merger achieved coterminosity with local authorities, which facilitated greater integration with social services: “The creation of directorates allowed for the focus on boroughs, it opened up the integration with social services, without any problems, and it allows us to become even larger” (executive board member, mental health trust)

• The merger facilitated the development of some smaller services: “[The merger] pulled together many experienced and good clinicians who previously did not have a dedicated management. They had been left to fight with adult mental health services for resources and for support. It brought together child and adolescent mental health services and helped us gain an identity as a service, with a stronger voice with purchasers and enabled the share of good working practices” (service manager, mental health trust)

• Merger has some benefits for service delivery: “The transfer of patients [across psychiatric intensive care units] is much easier now, as we are a larger organisation. This has taken pressure off hospital beds, and it has brought specialists together. We still do referrals, but the process is less complicated as it's mostly internally done” (senior manager, mental health trust)

*These mergers were complex reconfigurations whereby constituent trusts' services were amalgamated into more than one merged trust.