The Department of Health (DH) is responsible for one of the largest estates in Europe. In this capacity, the DH produce and disseminate estates-related Standards & Guidance (S&G) to provide support to the briefing and design processes for new, and refurbishment projects in old healthcare buildings. The estate is made up of a variety of buildings, many ageing and in need of extensive refurbishment or replacement. It is therefore important to the stakeholders in the procurement and provision of healthcare environments that the DH S&G provide them with the information and data they need at the relevant time in the process to enable them to design and construct healthcare facilities that are safe and fit-for-purpose. Policy changes over the past 20 30 years have had a profound effect upon the estate. The estate was seen to be in need of modernisation, but Government lacked the extensive funding necessary to achieve anything like the extent of redevelopment required. The introduction of private sector funding to achieve this resulted in a major shift in the ownership of the estate, and latterly the regulation of the estate, both private sector and National Health Service (NHS). The NHS Constitution, introduced in 2009, was the first Government document explicitly to recognise the estate and the importance of it being fit-for-purpose. This research seeks to establish the importance of the DH S&G, and their benefits and dis-benefits to stakeholders using them, including organisations and individuals from the private and public sectors. The groups have differing roles and priorities and the research seeks to establish how these affect their requirements for S&G, how effectively the S&G meet those requirements and how they contribute to the overall provision of healthcare environments. Moreover, hospital accommodation has been proven to have an effect on the patients and staff, therefore, the provision of useful and helpful S&G could be seen to have an indirect influence on patient outcomes, and also on providing a pleasant and efficient environment for staff. The research has identified three major strands: Policy; the DH S&G themselves; and what is important to users about them and any benefits or dis-benefits incurred. Policy is viewed as the driver for the need for DH S&G. The changing political environment, amongst many other factors, affects how the S&G have been operationalized. This study of the application of DH S&G aims to establish how users view the benefits and dis-benefits and their effects on the healthcare environment. Research in the construction industry sector spans the scientific and social worlds, and the methodology is deductive research orientated, exploiting a range of data. Qualitative and quantitative data have been collected through open interviews with known experts and an on-line survey of the stakeholders using the S&G from private and public sector organisations involved with the provision of healthcare accommodation. Reference to the DH S&G and related unpublished DH documents traces their development and examines their content. The results have been mapped to the stakeholder categories (Designers, Service Users, Estates and Facilities Managers, Contractors and the DH/NHS), thus enabling comparisons to be made between each group, and between the public and private sectors. Analysis of the data identified the characteristics users found to be of importance and of benefit or dis-benefit. On balance, it was clear that the DH S&G are beneficial, but not universally. Of prime importance to its users is the DH endorsement of the S&G and its independence from commercial influences. However, the classification of the DH S&G, defined as best practice is often regarded and applied as mandatory. The content of the S&G varies in its scope, content and characteristics, being perceived as incomplete, inconsistent and out-of-date. Taking all these factors, therefore there is a danger that the DH S&G may contribute to healthcare buildings being unfit-for-purpose or out-of-date.

This thesis examines a middle manager’s response to strategic directives on integrated care in a National Health Service (NHS) organisation and the development of an awareness of prejudice that acknowledges its relationship to the process of understanding. The research focuses on an integration of two community NHS trusts and an NHS hospital trust into one integrated care organisation (ICO). A change programme was initiated and promulgated on an assumption that integrating the three organisations would facilitate integrated care. However, despite the use of organisational change approaches (such as communication plans and systematic approaches to staff engagement), implementing the strategy directives in practice remained problematic. What emerged during the integration process was resistance to change and a clear division in the different ways of working in the community NHS trusts versus the community and hospital trusts – differences that became apparent from the prejudices of individuals and staff groups. The proposition is that prejudice is an important aspect of relationships whose significance in processes of change is often overlooked. I argue that prejudice is a phenomenon that emerges in the processes of particularisation, which I describe as an ongoing exploration and negotiation in our day-to-day activities of relating to one another. Our pejorative understanding of the term ‘prejudice’ has overshadowed more subtle connotations, which I propose are unhelpful in understanding change in organisations. However, I suggest a different way of thinking about prejudice – namely as a process that should be acknowledged as a characteristic of human beings relating to one another, which has the potential to generate and enhance understanding. The research is a narrative-based inquiry and describes critical incidents during the integration process of the three organisations and focusing on interactions between key staff members within the organisation. In paying attention to our ongoing relationships, there has been a growing awareness of disconnection from traditional management practices, which advocate systematic approaches and staff engagement techniques that are designed to encourage cooperation and reduce resistance to proposed change. This thesis challenges assumptions surrounding prejudice and how middle managers traditionally manage organisational change in practice in their attempts to apply deterministic approaches (which assume a linear causality) to control and influence human behaviour. I have taken into consideration a hermeneutic perspective on prejudice, drawing on the work of Hans Georg Gadamer, and have argued from the viewpoint of the theory of complex responsive processes. This offers an alternative way of thinking about management as social processes that are emergent in our daily interactions with one another, that are not based on linear causality, or on locating leadership and management with individuals. It provides a way of taking seriously the relationships between individuals by paying attention to what emerges from the interplay of our expectations and intentions. This leads to a different way of thinking about the relationship between prejudice and strategic directives, which I argue are not fixed instructions but unpredictable articulations of our gestures and responses that emanate from social interaction and continually iterate our thinking over time. This paradoxically influences how we make generalisations and particularise them in reflecting on and revising our expectation of meaning I suggest that it is not possible to predetermine a strategic outcome; and that traditional management practice, which locates change with individuals – and reduces aspects of organisational life, such as resistance, into a problem to be fixed – obscures our capacity to understand the processes of organisational change in the context of a much wider social phenomenon. I therefore conclude that my original and significant contribution to the theory of complex responsive processes and to practice is encouraging a different way of thinking about prejudice – as a process that can be productive and generate understanding, when considered as encompassing our expectations of meaning, linked to our own self-interests. This then opens up possibilities for transforming ourselves in relation to others – and, through this process, to transform the organisations in which we work.