Worth a second look Shaping strategic change: making change in large organizations Barbara Allen, Graeme Currie Warwick Business School, University of Warwick, Coventry, UK † Pettigrew A, Ferlie E, McKee L. Shaping strategic change: making change in large organizations. The case of the National Health Service. London: Sage, 1992 At the time of publication, Andrew Pettigrew and col- leagues’ book received wide acclaim as a balanced and rich contribution to the study of strategic change. Eighteen years since publication, it remains a relevant analysis of how new processes and environmental factors impact on health care, and how strategic change is dependent on locale, fiscal situation, struc- tures, politics, and people. It can help illuminate current issues in the commissioning landscape in the English NHS outlined in the recent White Paper. 1 Pettigrew and colleagues highlight that much research on organizational change is ahistorical, apro- cessual and acontextual. They advocate longitudinal and historical accounts of strategic change, with an emphasis upon action, as well as structure, and the com- peting versions of change held by various actors. Through a comparative case analysis of a limited number of in-depth cases, they examine the interplay of the context, the process and the content of change, at the system level within the English NHS, and seek to explain the differential achievement of change objec- tives. A central concept within this processual analysis, which foreshadows more recent interest in institutional work, is that of legitimacy. ‘If one sees major change pro- cesses at least partially as a contest about ideas and rationalities between individuals and groups, then the mechanisms used to legitimate and de-legitimate par- ticular ideas or broader ideologies are crucial.’ They also stress the need to explore how context is a product of action and vice-versa. Finally, they note that outer and inner context of change are linked, so that we need to consider how exogenous factors interact with, and are mediated by endogenous factors. They emphasize that features of inner and outer context should not be seen discretely but that they represent a highly inter-correlated combination, which taken together may raise energy levels around change in ways that are highly location specific. Through their analysis, they identify eight features of outer and inner context for change in health care, as follows: quality and coherence of policy; availability of key people leading change; intensity and scale of long- term environmental pressure; supportive organiz- ational culture; effective managerial-clinical relations; co-operative inter-organizational networks; simplicity and clarity of goals and priorities; fit between the change agenda and locale. We now re-visit each of the eight factors for organizational receptivity to change as a framework for illustrating how the commissioning agenda in the health (and fundamentally interdepen- dent social care sector) may emerge, and how this book remains a text of contemporary relevance. Quality and coherence of ‘policy’ In the case of commissioning, current policies state: ‘[t]he government will devolve power and responsibility for commissioning services to the healthcare professionals closest to patients: GPs and their practice teams working in consortia.’ 1 Although there remains little detail and much remains out to consultation, processes of commit- ment-building and buy-in from interest groups are underway, allowing, in Pettigrew and colleagues’ terms, groups to be ‘scripted in’ rather than ‘scripted out’. The lack of detail on realistic financial frameworks and tran- sition process is worrying, as receptivity in this case may depend on marrying strategic ambition with operational realities. There is no doubt that process components have not been worked out to any extent and somehow the top-down approach needs to marry up with the bottom-up work that now needs to be done. Availability of key people leading change The leaders of commissioning change are drawn inevi- tably from two sources, one being the Primary Care Barbara Allen PhD, Assistant Professor of Public Management and Policy; Graeme Currie PhD, Professor of Public Management, Warwick Business School, University of Warwick, Coventry, CV4 7AL, UK. Correspondence to: Graeme.Currie@wbs.ac.uk 184 J Health Serv Res Policy Vol 16 No 3 July 2011 DOI: 10.1258/jhsrp.2011.010184