All is not as it appears.

12 08 2009

The recent gap in posting has been partly due to the large amount of work I have been putting into our degree assignment. This morning I (hope I) put the finishing touches to the wee beastie and popped it in a zip file. My paper is on “Engagement of clinicians and management in the NHS” and after considering the issue in terms of organisational structure, strategic planning and clinical leadership I do think I have some useful thoughts.

One of the principal causes of poor engagement is that, contrary to the Mintzberg classification of organisational structures, hospitals (or ours at least) are not being run as the professional bureaucracy that the clinicians expect but as a machine bureaucracy.

I appreciate that for some of my readers I might as well be speaking Polish but I am also encouraged that many people read this who are not approaching the topic from an in depth study of organisational taxonomy and yet show an interest and insight. I think it helps me to try and explain this (to myself) in different terms so I will try and do the same for you.

In a managed professional bureaucracy the “operating core” (clinicans) are the source of production and because of the specialised nature of what is produced (clinical care) the core have a large degree of autonomy, control over performance and are supported in this by the “strategic apex” (management).

A good example of a machine bureaucracy would be a factory with highly specialized, routine tasks; formalized procedures in the core; a proliferation of rules, regulations, and formalized communication throughout the organization.

Unfortunately, in the modern NHS the latter rings more bells than the former. Drives for performance, merged and centrally managed waiting lists, cross covering, out-sourcing, the lack of core professionals¬† influence or even be involvement in strategic planning, imposition of “guidelines” and “protocols” may be viewed as a move away from the autonomy and professionalism expected of a managed professional bureaucracy.

Bate proposes changing the culture of a hospital as the “experiment” of clinical directorates has failed. He may be right. What is sure is that the current structure is not as the operating core would like, nor as Mintzberg suggests it should be. Perhaps this partly explains the lack of engagement between clinicians and management.

crooked-house-poland

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2 responses

12 08 2009
anne marie cunningham

I’m just wondering if you have read the Innovator’s Prescription by Clay Christensen. He goes as far as to liken the future of medical education to that of training operatives in a Toyota factory.
Personally I am all for guidelines. I’m really surprised about how slowly some specialties change their practice despite good evidence that they could do so. And at the same time I would like a lot more discussion between clinicians on these guidelines,
Thanks for your post. Your experience makes me scared of starting another degree! I’m remember my Master’s dissertation all too well!
AM

12 08 2009
inseiffolliet

Haven’t read the book but will add it to the list.

I am not, per say, against guidelines. Their imposition from “on high” to regulate treatment does cause me concern because part of the drive is for efficiencies and cost protection NOT for excellence in individual patient care.

I was in discussion with an American Urologist once regarding the AAP Guidelines on the Management of Urinary Tract Infection in Children. He had been part of the panel and I asked (for me) a fairly erudite question. He laughed and said, “Actually, you are totally right, but you forget that “Guidelines” do not mean best practice. They are put together by a GOBSAT- a group of old boys sat around talking. What you end up with is a compromise, not the best. The difficult thing is agreeing on what the BEST actually is, because no-one actually knows.”

My writing issues shouldn’t scare you; all they show is how inefficient i have been AND how different social science is compared to what i studied previously. wait until the thesis!

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