British Journal of Management, Vol.

17, 139–151 (2006)

DOI: 10.1111/j.1467-8551.2005.00473.x

Re-Organizing Work Roles in Health Care:

Evidence from the Implementation of
Functional Flexibility
Terry Desombre*, Clare Kelliherw, Fraser Macfarlane* and
Mustafa Ozbilginz
*School of Management, University of Surrey, Guildford, GU2 7XH, UK, wCranfield School of Management,
Cranfield University, Cranfield, MK43 0AL, UK, zSchool of Business and Management, Queen Mary,
University of London, Mile End Road, London, El 4NS, UK
Corresponding author e-mail: t.desombre@surrey.ac.uk

Functional flexibility has been advocated as a mechanism for improving efficiency and
service quality and is, it is argued, especially appropriate to service environments. In
recent years the UK public health service has been subject to an ongoing programme of
reform, designed to modernize the way in which health services are provided. A central
feature of the reform involves breaking down traditional boundaries and the re-
organization of work roles. This article is concerned with examining the implementation
of functional flexibility in three health-care settings. Case-study data are presented,
focusing on the responses of employees and managers to initiatives to work more
flexibly. For managers the implementation achieved efficiency gains and improvements
to service quality, in spite of some resistance from employees. For employees the
outcomes were more mixed. There was evidence of ‘humanization’ through greater job
variety, challenge and access to training, but there were also costs in terms of
intensification, role confusion and stress. The implications of these findings both for
understanding the issues raised by the use of functional flexibility and for the
implementation of policies in the NHS involving job redesign are discussed.

Introduction the service is delivered. Many of these changes

This article is concerned with examining the
implementation of functional flexibility in three
health-care settings. Labour flexibility has been
advocated as a mechanism for improving orga-
nizational performance (Cordery, 1989; Crid-
land, 1997; Pinefield and Atkinson, 1988). The
re-organization of work and the redeployment of
staff associated with the implementation of
functional flexibility are likely to have significant
implications for the employees and managers
involved. To date there has been relatively little
empirical work examining how employees and
managers are affected. In recent years, health care
in the UK has been subject to an ongoing process
of change, designed to modernize the way that
have implications for the organization of work
and a number are specifically concerned with staff
working more flexibly. Few studies have exam-
ined the use of functional flexibility in health-care
contexts and as such there is a dearth of evidence
to inform the implementation of these changes.
The aim of this article, therefore, is twofold.
First, by reporting evidence from three case
studies we aim to make a contribution to
furthering understanding of the issues raised by
the implementation of functional flexibility.
Second, by considering the specific context of
the health-care environment we aim to shed some
light on the issues raised by the reforms currently
being undertaken in the UK National Health
Service (NHS) (Department of Health, 2001b).

r 2005 British Academy of Management

140
Furthermore, by employing a case-study method
we respond to Bach’s (2000, p. 937) call for
‘workplace studies that explore the responses of
employers and employees to restructuring initia-
tives’ in the health sector.
The article will first present an overview of the
existing literature on the implementation of
functional flexibility, both in general and that,
albeit limited, which relates specifically to health
care. Second, the paper will present an overview
of the developments that are taking place in the
UK health-care system in order to provide a
context for this work. Third, we will report the
findings from three case studies on the imple-
mentation of functional flexibility in a variety of
health-care environments. Lastly, the findings
will be discussed and the broader implications for
the implementation of policy will be explored.
Background to Functional Flexibility
Flexibility in the management of labour emerged
as a central policy debate in the 1980s, largely
based around the model of the ‘flexible firm’
(Atkinson, 1984). Flexibility in the management of
labour is seen primarily as a mechanism for
managing labour more efficiently. Efficiency im-
provements are achieved by matching the supply
and demand for labour more closely. Flexibility
has been advocated as a means of accommodating
changes in the organizational environment (Cor-
dery, 1989; Cridland, 1997; Pinefield and Atkin-
son, 1988; Turner, 1999), since it assists in the
management of uncertainty (Bryson, 1999). Flex-
ibility is normally divided into three broad
categories, numerical, functional and pay flexibility
(Atkinson, 1984). Functional or internal flexibility
is where staff are redeployed across tasks to
accommodate variations in demand (Mutari and
Figart, 1997). In this article, we will only be
concerned with examining functional flexibility.
Functional flexibility can, it is argued,
‘lead to significant improvements in productivity, as
traditional production methods are replaced by
multi-skilled employees undertaking more varied
forms of work’. (Cridland, 1997).
In essence, greater efficiency in the management
of labour is achieved by the reduction of ‘idle
time’ and by the resulting intensification of work.
The notion of redeploying staff across areas of
T. Desombre, C. Kelliher, F. Macfarlane and M. Ozbilgin
work in line with demand rests on the assumption
that there will be variations in the nature of
demand for work tasks. If staff are fully occupied
all of the time, then there is little scope to
improve efficiency by the use of functional
flexibility. Variations in demand level can create
both periods of low activity for staff and bottle-
necks where they are unable to meet all demand.
Using multi-skilled staff in flexible ways allows
staff experiencing low levels of activity to be
redeployed to areas where demand for labour is
higher. Functional flexibility can be of particular
use where variations in demand are unpredict-
able, since response to unforeseen variations may
be easier and quicker with the redeployment of
existing staff, as opposed to hiring additional
staff. As a result, it has been argued that
functional flexibility has considerable application
to the provision of services, since the pattern of
activity is often determined by the incidence of
demand (Kelliher and Riley 2003). Yet, as Scott
and Cockrill (1997, p. 808) remark, much
previous discussion on functional flexibility has
focused on large manufacturing firms.
Functional flexibility can also contribute to the
enhancement of quality in relation to the provi-
sion of services by reducing the number of staff a
service user needs to have contact with, thereby
enabling a more holistic approach to be em-
ployed. For example, in the health-care environ-
ment the use of functional flexibility can allow the
provision of service to be rather more client or
user centred, as opposed to process or specialism
centred. Furthermore, if quality service is defined
as meeting or exceeding client needs, what is
required may only become clear when the service
is actually being performed. Such customization
of services may make it difficult to predict exact
labour requirements in advance. Functional
flexibility assists in the management of this
uncertainty, since staff can be redeployed accord-
ing to needs (Riley and Lockwood, 1997).
In spite of the proclaimed enthusiasm for the
use of functional flexibility, it is an area that has
not been subject to much research attention.
Whilst there is a rapidly accumulating body of
knowledge about numerical flexibility (see for
example, Casey, Keep and Mayhew, 1999; Syrett
and Lammiman, 1994), in comparison relatively
little is known about the use and practice of
functional flexibility. This may at least in part be
because UK employers have been relatively slow
Re-Organizing Work Roles in Health Care
to adopt functional flexibility, at least on a
formalized basis (Cully et al., 1999).
However, there is some literature that explores
the issues associated with implementation. The
implementation of functional flexibility relies
heavily on the multi-skilling of staff (Mutari
and Figart, 1997). If staff who are moved between
areas of work are to perform effectively, they
need to be equipped with the appropriate skills in
order to do so. Employees who are multi-tasked,
but not multi-skilled may not be able to perform
in a sufficiently effective way to make re-deploy-
ment worthwhile. In addition to having implica-
tions for training, there are implications for
recruitment standards, since the ability of em-
ployees to learn new skills and become multi-
skilled will influence the benefit an employer can
gain from the use of functional flexibility.
Bryson (1999) has identified a number of
impediments to the implementation of functional
flexibility. These include cost and availability of
the necessary training and the ability of an
organization to ‘spare’ employees for training in
new skills or skills maintenance. However Brus-
co, Johns and Reed (1998) argue that employees
do not need to reach full competence for benefit
to be gained. Their results show that limited
cross-training, to enable some what they term,
‘cross-utilization’ of staff, can result in significant
savings in staffing costs. In relation to sparing
staff for training, those organizations that have
most to gain in terms of efficiency, by use of
functional flexibility, are those that have fluctua-
tions in demand levels. Troughs or periods of low
demand may yield time for training, especially if
it is on-the-job training. Resistance on the part of
employees has been also cited as a potential
barrier to the use of functional flexibility (Car-
nall, 1982). Staff may respond negatively to
attempts to intensify their work, or to the
potential threat to job security posed by the use
of functional flexibility (Bryson, 1999). If the use
of functional flexibility is effective, it will
inevitably mean an intensification of work, since
idle time will be reduced. Equally, as skills
become more widespread in an organization,
the reliance on any one or group of employees is
reduced and hence individual workers become
more dispensable.
Evidence on the outcomes of functional flex-
ibility for employees is mixed. Allan (1998)
identifies ‘costs’ for employees and presents
141
evidence of a negative impact on employee health
and wellbeing, leading to increased levels of
absence and a higher incidence of workplace
accidents. However, functional flexibility has also
been cited as a means of humanizing work.
Redeployment, it is argued, provides greater job
variety and may alleviate boredom. Equally, the
learning of new skills provides development
opportunities for employees (Cordery, 1989; Cross,
1986, 1991). Furthermore, Kahn (1999) found that
functional flexibility had a positive impact on
gender equality, by providing women with further
training and expanding their job tasks.
In addition to productivity gains, in organiza-
tional terms Michie and Sheehan-Quinn (2001)
found functional flexibility to be positively
correlated with innovation and creativity in UK
workplaces. Furthermore, Leveson (1996) argues
that functional flexibility may help to ‘build
bridges’ between different professional and occu-
pational groups, promoting dialogue between
people from different disciplines and groups.
Functional Flexibility in Health Care
Increasing resource pressures in health care have
meant that managers have sought ways of
managing labour more efficiently. Variations in
workflow patterns would suggest that there is
scope for functional flexibility to help achieve this
(Jones, 2001). However, there are a number of
specific impediments to implementation in the
health-care environment. Longstanding tradi-
tions of clearly demarcated occupational bound-
aries in health care (Bach, 2000; Wicks, 1998),
often supported by strong professional associa-
tions, might make redeployment difficult.
Equally, an increasing move towards specializa-
tion and the very nature of some work under-
taken may hinder the use of functional flexibility.
High levels of trade union membership and the
existence of established negotiation frameworks,
at least in the public sector, may also hamper the
implementation of functional flexibility. How-
ever, in a study of manual workers in the NHS,
Kahn (1999) concluded that union resistance to
such work re-structuring was limited in scope and
effectiveness. The Changing Workforce Pro-
gramme documentation identifies a number of
blocks to the new proposed ways of working in
the NHS, caused by factors such as anxiety,
142 T. Desombre, C. Kelliher, F. Macfarlane and M. Ozbilgin
territorial and protectionist behaviour and the
system of education and training for health
professionals (Secretary of State for Health,
2003).
Empirical work carried out by Appelbaum
et al. (2002) and O’Donnell (1995) examines the
implementation of functional flexibility amongst
health-care workers in Australia and in the USA
respectively. In both cases these studies focused
not on mainstream health-care professionals, but
on support or ancillary workers. Appelbaum et al.
observe that whilst hospitals are typically thought
of as employers of highly educated, technically
skilled staff, they also provide large numbers of
low-skill, low-wage jobs. O’Donnell’s study ex-
amined hotel services staff, where four previous
job classifications (cleaning, catering, ward assis-
tance and portering) had been amalgamated into
one generic role (patient services assistant).
Appelbaum et al. studied support service associ-
ates, who covered roles in housekeeping, food
service and transport of patients. The outcomes
for employees in both these studies were mixed.
The participants in O’Donnell’s study complained
on the one hand of excessive workloads and were
sceptical of being multi-skilled, since they did not
feel they had received adequate training, but on
the other had responded positively to the
increased range of work and also to the move to
be part of a ward-based team. In Appelbaum et
al.’s study employees reported an intensification
of work and in some cases resisted certain aspects
of the work (e.g. patient contact). However,
whilst overall employees in these new roles were
no more satisfied with their jobs, their intention to
quit had been reduced. The level of training
received and team involvement were found to
influence satisfaction levels.
Reform in the UK NHS
It is a particularly pertinent time to be examining
the implementation of functional flexibility in the
health-care environments, given the current cli-
mate of reform in the UK public health service. A
number of the policy initiatives currently in process
are specifically concerned with altering work roles,
in order to use labour more effectively and to
deliver services in a more patient-centred way.
From 1997 onwards, the newly elected labour
government in the UK set about a reform
programme based not only on increased funding,
but also on the principle of tying investment to
modernization of the management and organiza-
tion of the health service. This programme of
reform was set out in the NHS Plan (Department
of Health, 2001b). The NHS Plan stressed that it
was both a plan for investment in the NHS and
‘a plan for reform with far reaching conse-
quences’. Whilst the principles of the existing
NHS were commended, it was the practices that
were seen to be in need of reform. A central plank
of this reform was about redesigning health
services around patients. It was suggested that
one of the problems with the existing service was
that it was ‘old-fashioned demarcations between
staff and barriers between services’ (Department
of Health, 2001b, p. 10). Specifically in terms of
functional flexibility, the plan talked about
expanding the role of nurses and allocating
resources to fund the development of their skills.
More specifically, Securing our Future Health (the
Wanless Interim Report) argued that there was
scope for much of the work historically done by
doctors, to be undertaken by suitably trained
nurses (Wanless Interim Report, 2001). Simulta-
neous expansion of the role of health-care
assistants would be necessary to free up nurses
to take on new roles. Appelbaum et al. (2002)
report similar responses in the USA to cost
pressures in health care, with hospitals experi-
menting with the redesign of jobs. There has been
an increased interest in assessing flexible working
in the NHS, even though most studies have
focused on flexible shift patterns and not func-
tional flexibility. Arrowsmith and Sisson (2002)
looked at the decentralization of management
arrangements in the NHS from the 1990s
onwards. Their study indicated that while man-
agers sought to improve flexibility and reduce
costs, few NHS trusts fully embraced the employ-
ment freedoms associated with NHS trust status.
There were hopes that moving away from the
national approach to pay bargaining to a more
locally focused approach would free managers up
to focus on the needs of the service. McBride
(2003) describes the management pressures to
introduce more flexibility in working time. The
drivers for this are increased competition and
marketization, as well as the need to address the
work–life balance of staff.
Another form of flexibility has been seen in the
NHS Changing Workforce Programme initiative.
Re-Organizing Work Roles in Health Care
This was established to support implementation
of role redesign and to spread best practice in the
development of new roles. Role redesign could
involve developing new jobs that combine tasks
in new ways, expanding the scope of existing
jobs, possibly crossing traditional professional
boundaries. The Changing Workforce Pro-
gramme specifically identified examples of mov-
ing tasks up or down a traditional ladder;
expanding the breadth of jobs; increasing the
depth of jobs and the creation of new jobs that
combined tasks differently. At the same time as
this initiative to redesign work roles, a number of
human resource initiatives emanating from the
NHS Plan and designed to make the NHS a
better employer, were being implemented. These
included the Improving Working Lives standard,
designed to make the NHS a more attractive
place to work by helping staff achieve a healthy
work–life balance and providing personal and
professional development opportunities (Depart-
ment of Health, 2001a; Secretary of State for
Health, 1999). Equally, the Working Together
initiative was designed to improve the standard
of human resource management in the NHS
(Secretary of State for Health, 1999).
The UK government has also been trying to
reform the terms and conditions of service of staff
working in the NHS. Agenda for Change creates
common conditions for all NHS employees,
replacing dozens of different arrangements with
different groups, and tries to replace great
complexity with something simpler (UK Health
Departments, 1999). Smith (2003) argues that
these changes, combined with contract negotia-
tions, have caused a breakdown in trust between
employers and professionals within the NHS.
The problems associated with changes in the
terms and conditions of health-care staff were
identified by Leverment, Ackers and Preston
(1998), who described the need of any organiza-
tional change programme to acknowledge the
professional identity and unique identity of
health professionals. Included in this are the
problems of responsibility, accountability and
autonomy that are associated with professions.
They found that the more junior the nurse, the
more negative were the feelings towards the
organizational and job changes being proposed
in a particular NHS hospital process re-engineer-
ing study, although nurses, in general viewed the
process of multi-skilling more positively than the
143
other professions. Doctors in this study demon-
strated a more hostile approach to flexibility and
multi-skilling. This was not focused on the
dangers of de-skilling but on criticism of other
professions with which they worked, who might
be tempted to pass on extra responsibilities to
medical staff as a result of flexible working
arrangements and unclear working roles. Allen
(2000) has argued for more flexible training and
working within the medical profession, although
she acknowledges the challenges posed by doc-
tors delegating responsibility for patients to other
health-care staff. For this to happen, it is argued,
doctors need to feel secure that those patients are
going to be treated safely.
Methodology
The research reported here forms part of a wider
study designed to explore the implementation of
functional flexibility across a range of service
industries. The aim of the research was to
examine factors influencing the implementation
of functional flexibility. A case-study approach
was chosen in order to allow observation of
practices and process to be evaluated in context
(Robson, 1995). Case studies facilitate the collec-
tion of rich data and allow collection of data
from a number of different sources. The case
studies are workplace-based and are concerned
with the responses of employees and employers to
the redesign of work roles. In the context of the
current shift in the health sector to more devolved
management there is, as Bach (2000) notes, a
need for more workplace-based studies.
The case organizations for this study were
chosen to include environments where functional
flexibility was used with both professional and
non-professional staff. Two cases were based in
the UK public-sector health-care system and one
in the private sector. Whilst the majority of
health-care provision in the UK takes place in the
public sector, a private-sector case was included
for comparative purposes. Theoretically, at least,
private-sector health-care organizations are likely
to enjoy greater freedom to change the way in
which staff are managed, since they are not
constrained by government policy, or in the main
directly by national agreements with trade
unions. The third case study was undertaken in
a new NHS walk-in centre. These centres offer
144 T. Desombre, C. Kelliher, F. Macfarlane and M. Ozbilgin
access to a range of NHS services, including
health information, advice and treatment for a
range of minor illnesses (coughs, colds, infec-
tions) and minor injuries (strains, sprains, cuts).
They are staffed by experienced nurses, who have
adopted an extended role, and they are usually
open seven days a week, from early in the
morning until late in the evening. There have
been concerns, for example from The Royal
College of General Practitioners (1999) about
functional flexibility and quality issues around
clinical governance/patient safety because of the
extended roles of nurses. However, Grant et al.
(2002) have demonstrated that walk-in centres
perform adequately and safely compared with
general practices and the wider NHS.
All of the case-study organizations experienced
variable patterns of demand and had introduced
functional flexibility in an attempt to utilize staff
more efficiently. Building on existing studies we
sought data that would allow direct comparison
with international studies, but we also included a
case of professional staff in order to allow an
insight into the issues likely to be raised by the
current NHS reforms. Furthermore, given the
significance of professional identity in health care
(Seifert 1992), a comparison between professional
and non-professional groups was desirable.
Data were gathered by means of 18 semi-
structured interviews and access to organiza-
tional documentation. Interviews for these case
studies were conducted in early 2002 and were
carried out at the workplace and in working time.
Interviewees were drawn from across the organi-
zational hierarchy. In all cases interviews were
conducted with employees who were subject to
functional flexibility (ranging from 33–50% of
the population), the line managers responsible for
managing the process and those responsible for
developing the policy. The interviews were audio
taped. Each case was written up individually and
analysed using thematic content analysis and
categorization techniques. A summary of each
case is presented below.
Case 1
This case is based on an NHS Trust in London
providing outpatient clinics dealing with a range
of mental health services for psychological,
emotional and personality problems. Since the
establishment of the Trust in 1994 staff in support
services had been subject to functional flexibility.
Six full-time ancillary staff were employed in this
area, they were all multi-skilled and deployed
across the areas of cleaning, portering and
gardening. Staff were scheduled in a rigid way,
but were likely to work across more than one
area in the course of a shift. For example, the
cleaning rota was worked out in advance, but in
practice the cleaning duties might go on all day,
or staff might be called upon to undertake
portering duties, such as setting out chairs in a
lecture theatre or delivering packages to the
clinics.
The need for flexibility was made clear to staff
at the recruitment stage and the managers
reported that they had encountered little resis-
tance from staff to working across a range of
tasks. The Director of Human Resources com-
mented,
‘We’ve never really had staff since 1994 that didn’t
take to functional flexibility, because many have
come from backgrounds where they have been
expected to work across a range of tasks. When we
need staff we mostly get introductions from existing
staff from their network of family and friends.
Therefore explaining the process and expectations
is easy; many already know a great deal about the
job.’ (Director of Human Resources)
It was acknowledged that this kind of re-
organization might have been more difficult prior
to trust status, since many of the former staff
were very conscious of job demarcations. A
number of these staff had, however, taken early
retirement prior to the move to trust status.
Staff were offered training of both a generic
and specific nature. The generic training covered
areas such as basic computer skills, understand-
ing the NHS and dealing with stress. The specific
training dealt with job-related skills, such as the
British Institute of Cleaning Science courses.
Supervisors were responsible for on-the-job
training. Staff started off by learning one role
and when they reached the required standard and
felt confident in that role, they were introduced to
the next area. It was felt important to give staff
plenty of time to develop their skills in each area
before going on to the next.
The introduction of functional flexibility was
largely cost-driven, and enabled a reduction in
the number of staff working in support services.
The use of a more flexible approach to deploy-
Re-Organizing Work Roles in Health Care
ment was seen as a means of rostering staff more
efficiently and also enabled holidays and sickness
to be covered more easily. The Central Services
Manager indicated that,
‘Payroll costs would have risen dramatically if
portering and cleaning staff were not multi-skilled,
the old system of having bespoke jobs meant that
some people were definitely under-employed at
times during the day, while at others, the porters
were over stretched.’ (Central Services Manager)
For the Trust, this way of deploying staff enabled
them to cover slack periods with fewer staff. The
Director of Human Resources explained,
‘We try and train them up to work in different parts
of the business because it allows us to have fewer
members of staff on at any particular period of
time.’ (Director of Human Resources)
Functional flexibility was also seen as way of
providing development opportunities, even
though a fairly small number of staff were
employed in the support services area. Managers
believed that this training, coupled with greater
job variety, had had a positive impact on both
recruitment and retention of staff.
Staff indicated that the job variety and training
were welcome and indicated that there was a
stronger sense of teamwork as a result. However,
staff also indicated that it could make the job rather
more stressful. One member of staff remarked,
‘We start at 7.00 in the morning and the cleaning bit
is easy. However, it can get a bit tiring. You’re
running about all over the place, delivering
packages and setting out chairs. You sort of get
confused about what you were doing before you
were sent on the errand.’ (Staff member)
Case 2
This case is based on one hospital situated in the
UK Midlands, which is part of a private health-
care organization. The hospital provides general
and acute care. There are 39 in-patients beds
and the hospital also provides a range of
outpatient services. Functional flexibility was
introduced when the private health-care organi-
zation took over the hospital, which had pre-
viously been a convent hospital. A new post of
Care Support Worker (CSW) was created, which
amalgamated the previous roles of nursing
auxiliary, ward clerk and medical records admin-
istration. At the time of the research there were
145
six CSWs in the nursing department, all of whom
were subject to functional flexibility. Four of the
CSW had been employed by the convent hospital
prior to the takeover by the private health-care
organization.
In practice each of the three separate roles
continued to exist. However, all CSW were
trained in each of these roles and were expected
to be able to undertake each one. Significantly,
unlike the previous arrangements where there
were specific uniforms for each role, one uniform
was introduced for CSW irrespective of the work
they were undertaking. Staff were rostered to
work in each of the roles for a one- or two-week
period at a time, which in effect amounted to a
system of job rotation. In addition to this
planned movement, staff were redeployed on a
short-term basis to cover absences or unforeseen
changes in workload. There was also some
evidence of informal movements taking place
on a short-term basis. One member of staff
reported that, since they worked as a team, if one
area was particularly busy, they would ‘help each
other out’ by moving from one area to another
on an informal basis.
When the private health-care organization
took over, the new job of CSW was advertised
and existing employees were invited to apply. At
the recruitment stage the need to be flexible was
stressed to staff, and following appointment some
training was given to prepare staff for the roles
they were not familiar with. Staff recruited since
the changeover had a training period of approxi-
mately three months on-the-job training, spend-
ing three to four weeks in each of the three areas.
From a managerial perspective, the use of
multi-skilled staff was seen as a solution to
managing variations in workload. It was the
ability to move staff at short notice that was seen
as the real benefit of using staff more flexibly.
However, the senior sister who ran the scheme
also indicated that she felt flexibility was about
quality, since if people take on several roles then
patients see fewer faces and it makes their
experience of being in hospital more personal.
It was acknowledged that there had been some
confusion in the wider hospital community about
what the role of the CSW actually involved, and
as a result the CSWs could end up being the
hospital ‘dogsbodies’, and that this was stressful
for the staff concerned. As a result, she felt that
there was a need to have a clear system in place
146
system to govern the way in which flexible, multi-
skilled were managed.
There were a number of different views
expressed by staff about their experiences of
flexibility. In the main, staff indicated that they
welcomed greater job variety. One CSW indicated
that she now found the job more challenging, but
that made the job was more appealing to her than
when she previously just did the work of a nursing
auxiliary. Another CSW reported that initially the
job was very tiring, because there was a lot to
learn, but that ‘now it is brilliant’. There was
general agreement that this was ‘a very busy job’.
Although staff generally felt that flexibility was
a good idea in principle, in terms of being able to
cover absences and the way in which it helped to
build the team, there was some concern expressed
over how it worked in practice. There was a
feeling that moving between jobs meant that
there was a lack of ownership of tasks, and as a
result not all tasks were completed as effectively
as others. Equally, as changes were made it was
not so easy for all staff to keep up to date. As a
result, they did not always remember what had to
be done when they returned to work in an area.
One CSW commented, ‘you have to put the right
head on for the right job’ and that on the first day
back in a department, you needed to concentrate
in order to avoid mistakes. They indicated that
this was especially so if they had just swapped a
shift for one day.
The view was also expressed by a minority that
the workforce would be happier if they were
allocated to the areas that they liked best and felt
comfortable with, rather than being forced to
move between different roles. A CSW remarked,
‘If someone is good at a job, you should keep them
there . . . it is when they divert into others that they
don’t know where they are and things do tend to be
forgotten.’ (CSW)
One member of staff had reacted negatively to
working flexibly and had been on stress leave
following its introduction. This member of staff
did not enjoy participating in the administration
aspect of the role, preferring to work with
patients.
The ‘one size fits all’ approach to the manage-
ment of functional flexibility and divergent
reactions to its implementation were evident both
in the above remark and also in accounts of other
participants.
T. Desombre, C. Kelliher, F. Macfarlane and M. Ozbilgin
Case 3
This case was based on a ‘walk-in centre’
operated by a NHS Community and Mental
Health Trust located in the Southeast of Eng-
land. At the time the case study was conducted,
the walk-in centre had been in operation for a
period of 18 months. The aim of the walk-in
centre was to provide open access and planned
care to clients. As a result, staff in this environ-
ment needed to be able to treat anyone who
walked in, whether they had a minor injury or
health problem. At very least, they were expected
to provide a baseline assessment of the client,
which could be passed on to a specialist. The
walk-in centre was staffed by four full-time and
eight part-time nurses.
In order to treat the range of conditions they
could be faced with, nursing staff needed to be
multi-skilled. Historically in this Trust nurses
who worked in A&E were trained and experi-
enced in dealing with minor injuries. Those in
district nursing were trained and experienced in
dealing with minor health problems. Rarely had
there been an overlap in the skills practised.
When the walk-in centre was set up the centre
management were keen to avoid a situation
where someone coming in for treatment could
only be seen by a nurse with a particular
background. This need to cover both injuries
and health problems was detailed in the job
descriptions and person specifications for the
nurses employed in the walk-in centre. In order to
ensure that any nurse could deal with a patient
who walked in, recruits were provided with
training in those areas in which they were lacking
skills and experience. To support this, when the
scheduling of staff for each shift was undertaken
an attempt was made to balance the experience of
the staff, so that they could learn from one
another. The centre management saw both the
need for formal training and for staff to
cooperate and learn from each other as essential
to the success of this type of operation.
The centre management indicated that for this
type of operation having flexible staff enabled
greater efficiency. The very essence of a walk-in
centre means that the nature of skills required for
any one period of time is hard to predict and as a
result the ability to deploy staff over a broader
range of tasks than is traditionally the case can
result in a closer match between the supply and
Re-Organizing Work Roles in Health Care
Table 1. Reported aspects of functional flexibility in three case studies
Reasons for Staff New or
implementation group existing staff
Case 1 Reducing staff numbers Auxiliary New and existing
Case 2 Efficiency Support New and existing staff
Quality
Case 3 Efficiency Nurses Existing staff
demand for labour. This resulted in the need for
different, more-flexible professionals. In this
particular case, enhanced efficiency had not
resulted in a reduction in staff numbers, because
since the opening of the centre there had been a
continued increase in demand for the type of
services offered. Whilst training costs were higher
in this type of operation, respondents felt that
these were offset by the efficiencies achieved
(although evidence for this was not put forward).
Furthermore, labour turnover problems had not
been experienced. All of the staff who had been
recruited when the centre opened 18 months
previously were still in post. The manager also
indicated that the commitment to training and
learning through teamwork had a positive impact
on recruitment and that they had not encoun-
tered resistance to this way of working.
Staff also indicated positive outcomes. There
was general agreement that this way of working
allowed them to gain wider skills and build up
their confidence in using them by dealing with a
wider range of problems. Staff indicated that the
environment in the centre was supportive and
that as a result of team working they were able to
provide a good service to the public. However,
staff did acknowledge that work had been
intensified. One nurse commented,
‘Before in A&E I used to see 8 patients a day and
now I see up to 30 patients a day with a vast
amount of different problems.’ (Nurse)
Equally, some staff reported that they experienced
stress if they felt they were required to work in an
area they did not feel competent in dealing with.
Discussion
Although functional flexibility in the different
case organizations operated in slightly different
147
Resistance Negative outcomes Positive outcomes
for staff for staff
Little Intensification of work Job variety
Some Stress Job variety
Intensification of work Challenge
Role confusion
None Stress Learning new skills
Intensification of work
ways, some general observations can be made.
Table 1 summarizes the findings according to a
number of dimensions. In all cases, functional
flexibility had been introduced as a response to
short-term variations in demand levels and
sometimes specifically to accommodate unfore-
seen occurrences. Commonly, it was identified
that functional flexibility was a way of attempting
to balance the budget. It was considered that
multi-skilled employees could plug gaps within
the service by effectively ‘robbing from Peter to
pay Paul’, either in a planned way, or in response
to a crisis. Whilst efficiency was a primary
motivation for implementing functional flexibility
in all of the cases, there were also other
motivations relating to both the nature and
quality of service provided and to the opportu-
nities for employee development, especially where
they might otherwise be limited. This last factor
was seen as especially important where the
organization was competing with non-health care
employers for staff.
Previous research has identified the difficulties
associated with implementing functional flexibil-
ity in professionalized health-care organizations
(Allen, 2000; Arrowsmith and Sisson, 2002;
Leverment, Ackerson and Preston, 1998; Smith,
2003). These case studies indicated that func-
tional flexibility does work and that it is accepted
by the majority of staff, although it is not without
its difficulties. This study did not examine this
type of flexibility in a medical setting and so it is
not possible to address the concerns described by
Leverment, Ackerson and Preston (1998) and
Smith (2003) about the difficulties faced by
doctors in ‘re-engineered’ organizations.
The study did not find significant staff resis-
tance to the implementation of flexible working
practices as predicted in the literature (Bryson,
1999; Carnall, 1982; Cordery, 1989). The three
cases demonstrated the importance of clear
148 T. Desombre, C. Kelliher, F. Macfarlane and M. Ozbilgin
communication about flexible processes to staff
at the recruitment stage and in most cases this
was made explicit in job descriptions. There was
evidence that the notion of working across
functional areas appeared to be attractive to
employees, although the case studies do show
that some of those already employed were
reluctant to alter their working patterns. How-
ever, given that in these cases the introduction of
functional flexibility was part of a wider change
process, and that new staff were involved in
addition to existing staff, this may have amelio-
rated the effect. It is interesting to observe that
the implementation was not noticeably easier in
the private-sector case. Even though it might be
considered that private-sector managers would
have greater freedom to re-arrange the organiza-
tion of work, it was here that the greatest
evidence of resistance occurred. However, it
may be that it was not so much the freedom of
the private sector, but rather as Kahn (1999)
argues that union resistance to such re-structur-
ing is limited in scope and effectiveness.
In line with the work of O’Donnell and
Appelbaum et al., we found mixed outcomes
for staff (Appelbaum et al., 2002; O’Donnell
1995). There was evidence of ‘humanization’ of
work as predicted by Cordery and Cross (Cor-
dery, 1989; Cross, 1986, 1991). Staff responded
positively to the increase in job variety, to the
new challenges presented and the opportunities
to learn and practise new skills. Being able to
practise a wider range of skills based on their
original professional training was seen as espe-
cially attractive by the nursing staff. The cases do
highlight the concerns of taking on more tasks at
the same level of skill, which could be seen as
multi-skilling, whereas in reality, it is the
intensification of work. Leverment, Ackers and
Preston (1998) address this issue in looking a
business process re-engineering within the NHS.
They highlight the fears of many staff that the
promotion of functional flexibility may in fact
just be another way of loading the newly defined
roles with extra tasks. This was particularly
prevalent in Case 1, which looked at functional
flexibility in a support staff team. There were
concerns from the staff that this was a way to get
more work out of a smaller team, although this
view was not shared by management.
Across the cases examined in this study there
was also evidence of intensification of work and
of increased levels of stress. The intensification of
work manifests itself in both quantitative and
qualitative forms (French, Caplan and Van
Harrison, 1984). In a quantitative sense employ-
ees reported that they had more to do in the
course of a working shift. Qualitatively, employ-
ees reported increased difficulty and complexity
in their work. This involved not only taking on a
broader range of tasks and keeping up to date
across the different areas, but also handling the
short-term movements between different areas of
activity. There were also some fears expressed
about ownership of tasks when they were
redeployed. Stress levels were reported to have
increased as a result of this intensification, but
only in one case did we find evidence of sickness
absence as a result of this.
Working across professional boundaries also
raises the issue of identity and belonging. Once an
employee becomes multi-skilled it begins to raise
questions such as what their job is, who am I
today, a clerical worker or a health-care assis-
tant? This did not emerge as a major factor in
these cases, partly because the implementation of
functional flexibility did not level a significant
challenge to the traditional professional demar-
cations that the health-care workers are accus-
tomed to. At a deeper level though, what makes
functional flexibility problematic is the under-
pinning assumption that workers are infinitely
expandable in terms of their skills and abilities,
and the ways in which these may be deployed.
The insight from these three cases highlights that
in its present form the functional flexibility model
fails to recognize and value individual differences.
Combining functional flexibility with recognition
of individual differences in the workplace requires
a reconsideration of issues of identity and
belonging in the context of flexibility initiatives.
Managerially, the need to determine lines of
responsibility, and in some cases accountability,
was an essential part of this change management
process. This agrees with the concerns expressed
by Leverment (1999) about the possible confu-
sion about accountability, autonomy and respon-
sibility. The studies demonstrate that whilst it is
important to detail the role responsibilities of a
flexible worker, it is equally important to make
clear the boundaries of flexible working, in other
words what the flexible employee is not respon-
sible for. It is therefore important to write as well
as espouse the detail of the formal job descrip-
Re-Organizing Work Roles in Health Care
tion. This is important not only for the employee
to know their role, but also for others in the
organization to know what can be expected of
these employees. Alongside this, the cases suggest
the need for clear guidelines concerning appro-
priate working practices and what to do when
areas of responsibility become clouded or ambig-
uous. All of the case studies show the importance
of an appropriate psychological contract to allow
functional flexibility to be practised. This is not a
panacea for its acceptance and in some cases
there were examples of staff who were not willing
to embrace it. However, the case studies demon-
strate the need for employees to understand the
approach of organizations to functional flexibil-
ity, and the need for training and structures to
support a different way of working.
In spite of the cost and availability of training
being cited in the literature as potential impedi-
ments to the implementation of functional flex-
ibility (see for example Bryson, 1999), this was
not a major issue in these cases. In general staff
had been well prepared to take on their new and
additional tasks, with adequate training and time
to get to grips with each of the different areas of
activity. Only in the walk-in centre case was the
availability of training mentioned by some
respondents to be an issue, and this was largely
because they were moving outside the normal
divisions of nursing work. That training did not
act as a barrier in these cases may well be
explained by the central role of training in health-
care organizations and an awareness of the
potential risks associated with not carrying out
adequate training (Secretary of State for Health,
1999). Generally, whilst it was acknowledged that
this way of operating meant higher training costs,
this was considered to be offset by the efficiency
gains. This point was argued by the managers in
Case 3, the walk-in centre, although no evidence
was put forward to support this. Indeed research
by Salisbury et al. (2002) indicates that because
consultations in walk-in centres are relatively
lengthy, provision of care is not necessary more
economical that in traditional settings. This case
does indicate that it is possible to implement
functional flexibility in a professional setting with
the support of clinical staff.
These findings shed light on the implementation
of functional flexibility in a variety of professional
and non-professional health-care settings. These
case organizations had all achieved positive
149
results as a result of introducing functional
flexibility, which in itself sounds an optimistic
note for wider implementation in the health-care
environment. The implementation in these cases,
whilst not entirely without difficulties, appears to
be have relatively problem-free, although this
does need to be seen in the context of wider
changes of which these initiatives were a part.
However, the issues that were raised as concerns
both by the staff and managers involved indicate
some factors that are likely to be relevant to
wider implementation. The qualitative intensifi-
cation of work, especially that brought by short-
term movements and the concerns over possible
lack of ownership of tasks are areas of potential
vulnerability. This may be in part by alleviated by
the increased use of protocols. Equally, questions
are raised over the breadth of flexibility that is
appropriate and desirable in a health-care envir-
onment. These findings have demonstrated that
this is relevant not only to notions of occupa-
tional identity, but also to how workers are
perceived by the wider community. Where rede-
sign of work roles erodes demarcations between
professions with strong traditions of occupa-
tional identity, the issue of external perception
may be as significant an issue as the perceptions
of those involved.
There are of course a number of limitations
associated with the findings of this study. First,
given that a case-study method was employed,
the extent to which these findings are general-
izable may be limited. Furthermore, given that
the cases selected were what might be considered
to be outside of mainstream health-care work, it
is hard to assess the applicability of these findings
to other health-care work. However, the case
studies nevertheless generate rich insights into
contextual circumstances and dynamics of job
redesign at workplace level.
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Re-Organizing Work Roles in Health Care 151

Professor Terry Desombre is Professor of Health Care Management and Deputy Head of the School
of Management at University of Surrey. Prior to this he worked in the NHS, holding clinical and
Board level posts. His most recent research interests include ethnicity in health policy and improving
partnership working between health and social care.

Dr Clare Kelliher is senior lecturer in strategic HRM at Cranfield School of Management, Cranfield
University. Her principal research interests lie in flexible working, employee relations in the service
sector and managing change in the public sector.

Dr Fraser Macfarlane is a lecturer in health-care management in the School of Management,

University of Surrey. He has an MBA from the London Business School and has recently completed
his PhD looking at how research activity develops in general practice. His research interests include
the diffusion and spread of innovations in service-sector organizations and the development of
innovative behaviour in health-care professionals.

Dr Mustafa Ozbilgin is a Senior Lecturer in Employment Relations at Queen Mary College,

University of London. His research focuses on equality and diversity management from comparative
perspectives. He has previously worked at the University of Surrey and the University of
Hertfordshire and held visiting fellowships at CEPS-INSTEAD (Luxembourg), Cornell University
(ILR) and the Japan Institute for Labour Training and Policy (JILPT).