Beyond ‘firefighting’ health inequalities in times of austerity: local authorities as ambidextrous organisations

Abstract

Aim:

This study takes a unique approach to understanding the implementation of a whole-system place-based strategy to improve health and reduce health inequalities, using ambidextrous organisational theory.

Methods:

The data consisted of the secondary analysis of 23 strategy documents in one local authority, and interviews (n = 22) with local decision-makers, front-line workers, and service users.

Results:

Our analysis highlights the tensions inherent in British Local Authorities (LAs), which in times of austerity have increasingly been expected to perform as financially self-sufficient, while meeting their health inequalities targets. Increasingly, LAs can be seen as being characterised by goal incoherence, with competing institutional logics. This leads them to exist in a paradoxical reality, leading to ambiguity and unease in the workforce, which can be reconciled through the generation of creative solutions.

Conclusion:

Organisations such as LAs can meet both of their social and financial performance ambitions by acknowledging, and working through, simultaneous strategic and operational needs, which capitalise on the potential of both exploration of new solutions and the exploitation of what already works well. Decision-makers need to see goals as not mutually exclusive, and instead engage in strategy discussions that lead to coordinated actions across the full range of ambitions. We highlight the potential contribution of the concept of ambidexterity to help LAs manage their competing priorities. It puts forward the concept of LAs as hybrid organisations with politically appointed boards and professional organisational units that intrinsically manoeuvre between mission and market orientation.

Introduction

In the UK, people from the most deprived areas can expect to live up to 19 years in poorer health than their wealthier counterparts. ¹ This situation is acutely felt in the North of England, where people have, on average, lower life expectancy, higher infant mortality, and higher rates of ‘deaths of despair’. ² This presents a particular challenge to Local Authorities (LAs), many of which have a dual challenge of health inequalities reduction targets to deliver on, and a reduced financial envelope. Indeed, since 2010 budget cuts have had the effect of further widening health inequalities, ³ with disadvantaged localities tending to be hit the hardest. ⁴ The UK government aims to reduce place-based inequalities, ⁵ leading to many LAs adopting improvements in housing and transport, for example, which has been shown to have some protective effects. ⁶ Partnership working involving third sector organisations, communities, and joint initiatives is thought to contribute to improvements, even if the evidence is as yet patchy.^7,8

This research took place in one LA in the Northeast of England, which developed an asset-based approach to tackle poverty and health inequalities. It is characterised by significant health inequalities, including a lower disposable income per household than the national average, ⁹ with 33.4% of children living in poverty (compared to 29% nationally in 2021), ¹⁰ and lower healthy life expectancy than the national average for both males (55.8 versus 61.5 nationally in 2021 to 23) and females (56.7 versus 60.3 nationally). ¹¹

Public finances have been under growing pressure, with rising demand for services, increasing austerity measures, and the end of pandemic-related support. In this context, the LA developed the Thrive Agenda, ¹² a place-based strategy to tackle health inequalities in financially constrained times. Thrive was designed to drive radical change in the way the LA make decisions, and work with local partners and communities. However, delivering change in these circumstances is difficult and the implementation of strategies such as Thrive can be slow and the evidence base supporting those efforts is currently underdeveloped. Organisational innovation and public health have traditionally been researched by distinct disciplines, which we uniquely bring together in this article.

While organisational ambidexterity has been introduced as a concept to help for-profit organisations reach their goals, ¹³ this has not yet been applied to public sector organisations with an aim to tackle enduring and deepening health inequalities. The purpose of this research was to understand the challenges faced in implementing Thrive and how ambidextrous organisational theory may support LAs going forward.

Aims, Objectives, And Research Questions

This study addressed the research questions:

1. How was Thrive implemented in practice?

2. Can ambidextrous organisational theory be used to understand how this implementation might have been optimised?

Methods

Data collection

Data collection consisted of a documentary analysis, interviews with key stakeholders, and secondary data analysis.

The LA website was searched for publicly available documents, which included any reference to the development and implementation of Thrive since its inception in 2017. Documents included the Thrive Agenda itself, the LA vision 2030, council and housing plans, asset management plans, and minutes from health and wellbeing board meetings. The documentary analysis informed selection of the service for data collection (Housing, because this was an area where implementation efforts were clear and could be used as a case study), and the development of data collection tools. In total, 23 documents were included.

Interviews were undertaken with LA senior leaders (n = 2), front-line staff (n = 8), and service users (n = 7). Recruitment was undertaken through a convenience and snowballing approach, building on the authors’ extensive local networks. The data collection was significantly disrupted by the pandemic, undertaken mostly online, and was completed in February 2022. The pandemic represented a moment of crisis management, which interrupted our ability to collect data. However, as inequalities were deepened by COVID and the public purse did not expand, it increased the salience and timeliness of our study. The secondary data consisted of cleaned, anonymised transcripts from practitioners in the same LA, from a previous study (n = 15). Recruitment had been undertaken through a snowballing approach from within the council and partner organisations. The aim was to co-construct an understanding of the local area as a system that could learn and adapt to external challenging circumstances. This, while not specifically focused on Thrive, added detail and richness to our primary data collection.

Data analysis

The documentary analysis focused on the development and implementation of Thrive. Documents included the Thrive Agenda, the LA vision 2030, council and housing plans, asset management plans, and minutes from health and wellbeing board meetings. Documentary analysis began in 2019 and continued during the pause to qualitative data collection (March 2020–2021), informing selection of the service for data collection (Housing) and the development of data collection tools.

Interviews were recorded and transcribed verbatim. Participants have been allocated a unique identifier using a code for either Interviews with Key Stakeholders (IKS) or Secondary Data Analysis (SDA) followed by a number allocated to each individual to protect the anonymity of participants.

An inductive approach to thematic analysis was used in the first instance, leading to the identification of two overarching themes: relationism and transactionalism. A second layer of analysis was subsequently undertaken, applying ambidextrous organisational theory ¹⁴ in a deductive process, which is presented in this article.

Ambidextrous organisational theory

Organisational theorists have adopted ambidexterity, the skill of being able to use both hands, as a metaphor to describe the way in which organisations work. ¹⁴ Ambidexterity refers to an organisation’s ability to enact both exploitation of current processes and procedures and exploration of novel solutions. Organisations that operate ambidextrously are most likely to succeed in achieving their own goals, competitive advantage, survival, and resilience, particularly in times of economic or political crises.^15,16

However, organisations can find it challenging to manage the trade-offs between exploitation and exploration. ¹⁷ Research has shown that the characteristics most likely to lead to successful ambidexterity are organisational structure, culture and context, organisational capabilities, resources, and individual- and team-related factors ¹⁵ (see Figure 1). Organisations can find it challenging to manage the trade-offs between the often-competing demands of exploitation and exploration. ¹⁷

Figure 1

Enablers and outcomes of ambidexterity (Adapted from Smara & Bogatyreva). ¹⁵

The purpose of this article is to map ongoing implementation of Thrive against this framework (Figure 1) to show where there are pockets of ambidexterity and where there are areas for further work, taking into consideration the barriers and challenges posed by working in times of austerity.

Findings

Individual and team mechanisms

Ambidexterity has been described ¹⁵ to be manifested at both individual and collective levels through shared responsibility, trust, collaborative working, joint decision-making, open discussion, and knowledge, skills, and experience within the team. Within this, ambidexterous leadership is key.

There was clear evidence that the senior leadership team were keen to develop transformative ways of working, promoting open discussion and innovative thinking and ‘clearing blockages’ (IKS2) that prevented change. A ‘distributed leadership model’ (IKS1) was encouraged in which ‘all staff, including frontline workers are empowered and enabled to make decisions without having to run them by [the CEO]’ (IKS1). This was underpinned by a culture of trust and bravery. While staff felt they were empowered and working more closely with senior leaders, it was acknowledged that ‘a lot of the old hierarchical thinking and fear of acting without permission from above remained’ (SDA3), somewhat limiting the success of these strategies. It was still felt that the ‘people at the top of the ladder have both the power and the voice without necessarily having a full understanding of what was occurring on the ground’ (SDA3).

Housing teams were encouraged to work more collaboratively with the public health team and health and wellbeing board. This was seen as a ‘meaningful and tangible way of recognising the health impacts of housing, and way of working that would support improving health outcomes and reducing health inequalities in the area’ (IKS5). It was, however, recognised that these new ways of working came with increased levels of complexity, uncertainty, and risk with retraining and upskilling of staff seen as a priority. A need for joined-up working with other teams, such as income and revenue (rents), planning, and homelessness, was also identified, with one participant stating:

One department doesn’t even communicate with the other, where they should be working together. Every eviction costs money, there are not just the eviction costs but the property sitting empty, cleaning costs, court costs, and the cost of finding another suitable tenant, and then the person who was evicted will be housed by the homeless team meaning those costs have largely been for nothing. (IKS7)

Some innovation pilots were initiated to facilitate exploration and preventive work. One of those consisted of contacting residents with council tax or rent arrears to ask what help they needed, instead of initiating a legal recovery route. For the vast majority of those involved, life had just become too difficult to manage, but they were keen to engage and work towards clearing arrears. At the time of data collection, further innovation pilots were in the development stages, such as looking at how the ‘three strikes and you are out’ issue, in which people missing three appointments are discharged from services, could be addressed.

Collaborative working was also highlighted as a key area for development for person-centred service delivery that prevents people from ‘bouncing around or dropping out of the system’. It was acknowledged that there are some pockets of good partnership working with shared decision-making and risk management but also that this was down to ‘individually brokered relationships rather than anything structural’ with successful change often ‘hamstrung by policies, procedures, and risk averseness’ (SDA7). Fear of blame was a strong theme within the data, which mitigates against individuals’ ability to foster innovative practice (exploration).

Organisational culture

Typically, organisations have a culture which is either exploitative or explorative. ¹⁵ Exploitative culture values management processes such as control, discipline, accuracy, and performance monitoring, while explorative culture values diversity, creativity, flexibility, and risk-taking. To successfully manage competing demands, organisations must create a culture in which a balance can be sustained. A shared vision to guide action from the strategic to the practice level is considered the key driver of ambidexterity, supporting engagement of all staff in organisational goals. Beliefs, values, and behaviours are shaped by the organisational culture and vice versa, in a process of collaborative development. ¹⁵

There was a commitment to work collaboratively to develop person-centred service models that address multiple and complex issues, sharing data and pooling budgets to increase targeted integrated programmes for individuals and communities most in need. The documentary analysis identified a clear strategic goal to innovate and increase the efficiency and effectiveness of existing services.

Despite this, commissioning still tended to be siloed, undermining strategic aims and leading to duplication across the system. One participant shared their frustrations around siloed working. ‘We’re caught in a cyclical narrative of saying we should collaborate, making tentative first steps, then attacking each other, withdrawing, keeping distance, and reinforcing the siloes’ (SDAP1). Further stating:

We need to find the people who are prepared to be blunt and advocate for the need for real change. We need to be having the difficult conversations. Instead, we keep getting stuck in the sticky middle and reverting to our safe zones. We need to disrupt this cycle. (SDAP1)

Issues with this siloed way of working were identified by many participants, with dual diagnoses (mental health and addiction), and (re)traumatisation of both clients and staff highlighted as concerns. There was a strong feeling that ‘no one service can go it alone if we want to see everyone in [area] thrive’ that ‘one size does not fit all’ (IKS 7) and that support offers should be individually tailored. Sharing information, learning, and supporting each other rather than acting competitively were seen as key to success and are indeed aligned to the idea of exploration; however, competitive funding models and paternalistic attitudes towards the community voluntary sector (VCS) were seen as barriers to successful collaboration, with complexity, time, resource, and spaces for discussions considered as challenges.

A move from a culture of performance management focusing on attendance and completion rates (exploitation) to a person centred, partnership approach in which services have autonomy, ownership, and freedom to respond to challenges creatively, offers ‘bespoke by default’ (IKS2) and performance is measured on impact for people (exploration) was seen as the best way to improve health and reduce inequalities locally.

Too many people are powerless against a system that just tries to churn out ‘results’. So many of these people don’t want to rock the boat so they just do what they’re told, but the system is entirely overlooking things like friends, community and the importance of social connections. There is damage being done by a system aimed at ‘efficiency’ and that acts as though a roof over their heads is all that matters. (SDA2)

Organisational capabilities and resources

In turbulent environments such as that caused by austerity, organisations face major challenges in balancing the need to exploit existing capabilities and the search for new ones. Idea generation, horizon scanning and asset management, decision-making, and opportunity seizing, the ability to shift and reconfigure services dynamically, organisational resilience, human resources, and underpinning infrastructure and IT systems are identified here as being key to innovative organisational ambidexterity. ¹⁵

Thrive was proposed as a framework to drive all decision-making, moving away from ‘salami slicing’ efficiency approaches to managing budget cuts in which services are trimmed and reduced and thresholds tightened, towards more strategic thinking about how to do better with less available resource. A core strategic aim of Thrive was to liberate thinking so that regardless of job title, everyone in the organisation is focused on helping people to thrive.

There was a strategic recognition that the current system is weakest where it needs to be strongest. For example, current ways of commissioning, monitoring, and evaluating services mean that the most vulnerable individuals are left navigating a complicated system, often leading to them obtaining help late or not at all. This has not been helped, it was stated, by an external policy environment which often fails to understand the underpinning causes of multiple and complex needs, often blaming poor behaviour rather than broader determinants of health. Current ways of working were described by one participant as ‘how much of what I do can I do to you’ (SDA9) as a way of personalising services. Operating hours was highlighted by one VCS organisation as a significant challenge. ‘Our service runs 7 am to 8 pm seven days a week, but the LA is 9 am to 5 pm five days a week. People’s problems don’t just stop because its 5 pm you know? They have lives you know and can’t always come when you want them to come, you have to be flexible enough to accommodate that’ (IKS7).

Flexibility resulting from COVID-19 was seen as a strength, with more staff working from home increasing their agility and responsiveness through online communications, at the same time as reducing operational costs. This led to creative thinking around digital service provisions in the future. However, resident participants felt that a move to digitised services had made dealings with the LA impersonal and left them with no known person to turn to when issues arose.

Some front-line workers felt like there were too many conversations that were not translated into action. It was felt that better engagement with frontline workers, learning from their ‘up-to-date sensing of change as it happens’ (SDA9) would help inform service delivery and translate knowledge and motivation into tangible action. Knowledge of the system, organisation, and local population was recognised as an asset, with those able to span boundaries, know the pushes and pulls of the system, speak a common language across providers, and able to remove blockages key to driving meaningful action. However, it was also recognised that this can mean staff absences or staff leaving can have a negative impact on success.

Ambidexterity support systems

Smara and Bogatyreva ¹⁵ identified several support systems that help to successfully manage organisational ambidexterity. This includes the development of management control systems (belief systems, boundary systems, diagnostic systems, and interactive systems). Interactive systems explore threats and opportunities in the external environment, while diagnostic systems are responsible for tracking organisational outcomes and triggering internal management processes. Boundary systems prevent strategically undesirable outcomes, and belief systems are concerned with organisational values and behaviours. The greatest external threat to successful implementation of Thrive was austerity, with an LA commissioner stating: ‘Until the end of austerity, we are just firefighting in different forms’.

One senior leader stated:

Innovation is difficult in the current context. It can be hard to find the space to think when you are over-stretched, it is difficult to have conversations with providers when you are having to cut their services, and it can be hard to implement new ways of working when all available resources (and those of your potential partners) are tied up in the face of increased demand and fewer resources. (IKS1)

At the time of this study, COVID-19 was a considerable external threat, with increased demand for services, staff pressures and ill health, and a need for completely new ways of working adding to financial pressures. While this was undeniably a difficult time, temporary reductions in ‘red tape’ and an increased willingness to collaborate united by a common enemy, saw the system overcome some of the challenges to effective collaboration and ensure that people received the support they needed when they needed it. With the Thrive agenda, the LA has a clearly stated strategic intention to invest locally, supporting services already doing good work, and developing solutions that build on assets, skills, and creativity using collective strength to unlock new potential.

However, participants identified challenges around information sharing even among services within the LA, budgets and financing, and staff fear and negative attitudes. A lack of compassion or compassion fatigue, limited understanding of trauma and people with multiple and complex needs, and a need for training throughout the workforce were highlighted as key issues. To reduce fear among staff and increase autonomous decision-making the LA implemented a ‘get out of jail free card scheme’ (IKS2) in which staff were encouraged to do what needed to be done to support their client, providing they broke no laws and caused no harm. While this was successful in alleviating some stress, impacts were small with staff falling back to usual ways of working very quickly.

Externally, funding models which encourage innovation (exploration) but provide little support for ongoing successful work (exploitation) were highlighted as a threat. There was a concern that good ideas that have proven successful would be disregarded purely because they are not seen as innovative enough to attract funding. On the other hand, some felt that the LA needed to get better at recognising when something is not working and trying something new instead of continuing to do the same thing because it is what has always been done.

Discussion

The concept of ambidexterity offers a language to help understand how organisations such as LAs can best achieve their stated objectives in challenging political, financial, and social contexts. This study highlights clear tensions between exploitation of existing mechanisms and exploration of new practice. While this tension and the need for organisations to foster both mechanisms simultaneously is well rehearsed for private entreprises, it is much less so for LAs. We argue here that the ideas and components of ambidexterity not only apply well to the context of LAs, which typically are broader and more complex organisations with multiple strategic goals, but that they offer a framework through which to think how to maximise their potential within restrained financial envelopes.

The data highlighted a strategic intent to balance exploitation with exploration with pockets of excellence, some of which had been unlocked by the pandemic, which was hampered by more traditional, siloed, ways of working. Despite a drive for innovation, financial pressures, increasing needs, and a fractured system in which information sharing was not facilitated led to a fall back to siloed ways of working which stifled innovation.

A devolved model of leadership, in which staff across the system are supported to make bold decisions, demonstrate autonomy, and take personal responsibility for action was evident. Trusting relationships and communication were considered two key mechanisms of supporting innovative action; however, despite this, participants felt they had no real voice in the system and struggled to trust that there would be no negative consequences to failed experiments.

Our analysis highlights the tensions inherent in British LAs, which in times of austerity have to be financially self-sufficient, while meeting their health inequalities targets, which echoes other studies. ¹⁸ Increasingly, LAs can be seen as experiencing goal incoherence, with competing institutional logics leading, typically, to a degree of ambiguity and unease in the workforce, ¹⁹ which can be reconciled through the generation of creative solutions. ²⁰ Our analysis suggests that this is possible, but tensions, and the need for trade-offs, need to be acknowledged. ²¹ Maine et al. ¹⁸ demonstrate that a sustainable engagement in ambidextrous ways of working leads to improved social performance. As large organisations, LAs need to acknowledge the simultaneous needs for financial sustainability and social gains, and the parallel need for equal drivers for exploration and exploitation. Our data show that when exploration was encouraged, this was often at the expense of exploitation of assets and practices already existing in the community. There were attempts at innovation, such as the ‘get out of jail’ card, but this tended to be short-lived. Embedding this kind of scheme in the organisation, and fostering a culture of continuous learning at all levels of the system would help. Organisations such as LAs need to acknowledge, and work through, simultaneous strategic and operational needs, which capitalise on the potential of both exploration and exploitation functions. Decision-makers need to see goals as not mutually exclusive, and instead engage in discussions on strategy that lead to coordinated actions across the full range of ambitions. This study contributes by highlighting the potential of the concept of ambidexterity to help LAs manage their competing priorities. It puts forward the concept of LAs as hybrid organisations with politically appointed boards and professional organisational units that intrinsically manoeuvre between mission and market orientation.

Strengths and limitations

Data were only collected from one LA within a specific region with a distinct profile of needs, inequalities, and services. Furthermore, fine grained detail was only collected from one specific service, housing. Therefore, to better understand the level of ambidexterity across the system, further data would be needed from a wider range of services. It should also be noted that data were collected during and immediately following the COVID-19 pandemic, which may have influenced ways of working.

Recommendations for policy and practice

Findings from this study showed clear areas of strength and weakness in working ambidextrously and finding balance between exploitation and exploration, between core business and implementation of new strategies. Based on these findings, we suggest that using ambidextrous organisational theory could support LAs to meet their health inequalities targets in time of austerity. Incorporating ambidextrous organisational theory into strategy documentation and providing staff training to understand and apply the theory would support future ways of working.

Areas for future research

Future research is needed to better understand how ambidexterity theory can be applied in LAs, where it is beneficial and where it is not, what changes as a result of applying the theory and how this impacts on outcome measures such as financial performance, innovative performance, service user experiences, and longer-term health and inequalities.