The organisational dynamics of integrating neurology services in an NHS hospital trust: A systems psychodynamic perspective

Background: The factors driving NHS integration are captured in the Neurology patient population, characterised by increased life expectancy, alongside high incidence of complex, degenerative, and long-term conditions. Organisational change is a requirement of integration, with the potential to undermine clinical care. Merger is introduced as an existing form of integration, where relational understanding has been subjugated. Literature Review: Research addressing professional views of organisational merger in NHS hospital trusts was systematically identified. A line of argument synthesis illustrates the distal influence of politics and place, borne out locally in assimilation, loss, and pragmatic progress. Aims: To explore what could be learned about a local integration from a psychodynamic method of observation, and to hypothesise unconscious aspects of integration relevant to wider UK health systems. Method: A philosophical and epistemological position consistent with the unconscious aspects of change in a public institution are set out in detail. This conceptual frame is operationalised into a three phase method of observation. Data generated from 6 in depth observations and reflective groups was analysed in line with reflective thematic analysis. Results: A rigid hierarchy underpinned anxiety at uncertain boundaries, indicating the task and structure of integration split off painful feelings. Systemic demands to quantify integration were hypothesised to obscure the painful task of caring for patients with degenerative conditions. These defensive structures also appeared liable to semi-sudden collapse, risking the sudden return and contagion of disavowed feelings. Conclusions: The capacity to flexibly contain painful feeling states is denatured by marketised competition and pressures to evidence quality. Associative forms of enquiry offer a means of integrating feeling states into the process of organisational change in the NHS. This form of knowledge is essential to integrate local systems, but is threatened by cycles of top down re-organisation, reverting power to the centre.