The Reality Dysfunction: 1 (The Night's Dawn trilogy, 1)

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When do appropriate professional interests and caution evolve into inappropriate resistance to change?

Weber M. The Theory of Social and Economic Organization. Translated by Talcott Parsons. New York: Free Press; 1947. reprinted Simon and Schuster, New York, 2009.Managers have the anxiety that comes from the limited control that they can wield in a professional organization, often combined with high levels of external pressure to perform and a political context that tends to denigrate their role and limit their scope of action. In turn, politicians are frequently in the same position and are held accountable for a system they cannot control and which they will not be associated with for long enough to change. The fact that they may not even have formal responsibility for the way that care is delivered is not a protection from blame. The experience of trying to reform health systems and the subsequent career trajectories of those that do suggests that their anxiety may be justified. Both political and managerial anxiety seep into the clinical system as attempts are made to create assurance and exercise control. Hwang J, Christensen CM. Disruptive innovation in health care delivery: a framework for business-model innovation. Health Aff. 2008;27(5):1329–35. Dahlgren G. Why public health services? Experiences from profit-driven health care reforms in Sweden. Int J Health Serv. 2014;44:507–24.

It also is important to recognize that the 3 + 3 framework is not a formula for discovering what organizational theorists sometimes derisively refer to as “magic bullets”. Instead it is a call to apply the basic core lessons of traditional hands-on, shop-floor-level management. Among other elements, this approach will mean accepting different management styles and approaches in different institutions, indeed in different parts of the same institution. Operational flexibility, not centralized standardization, will need to become the policy watchword. Importantly, the political role in public hospitals will need to fade further, while the managerial role will necessarily grow in prominence. the conflict between expanding curative and primary care coverage areas as against staying within financial and budgetary limitations Taken together, these theories add up to a clear if somewhat inchoate set of explanations for why normally functioning organizations – including both public and privately operated hospitals – present structural barriers to efficient functioning and introduce seemingly inexorable perverse consequences. Helpful comments from the journal’s three reviewers and Ruth Thorlby at the Nuffield Trust are greatly appreciated. FundingDomberger S, Jenson P. Contracting out by the Public Sector: Theory, evidence, prospects. Oxf Rev Econ Policy. 1997;13(4):67–78. Chinitz D, Wismar M, Le Pen C. Governance and (self) regulation in social health insurance systems. In: Saltman RB, Busse R, Figueras J, editors. Social Health Insurance Systems in Western Europe. Berkshire: Open University press/McGraw-Hill Education; 2004. p. 155–70. Data sharing is not applicable to this article as no datasets were generated or analysed during the current study. Authors’ contributions Hunter DJ. The slow lingering death of the English NHS; Comment on ‘Who killed the English National Health Service’. Int J Health Policy Manag. 2016;5(1):55–7. Hospitals are hard organizations to change. Publicly owned and operated hospitals even more so. In many countries, both managers and staff anticipate, despite constant calls for improvements in efficiency, quality, and responsiveness, that little will be different tomorrow or next year. Similarly, politicians, seeking to outflank these intra-institutional expectations, have learned to introduce major reforms early in their term to maximize what leverage they have over public hospital managers and staff.