Reviews Soundings

Scaling up

BMJ 2002; 325 doi: (Published 21 September 2002) Cite this as: BMJ 2002;325:665
  1. Trisha Greenhalgh, professor of primary health care
  1. University College London

    Regular readers of this column will know that I am convalescing from surgery. Under threat of splitting my stitches, I have agreed to do no strenuous sport, no unloading of shopping trolleys, and no gadding about the country giving lectures for 120 days.

    My search for interim sedentary pursuits recently led me—don't laugh—to discover the joys of jigsaw puzzles. The family (to its eternal credit) embraced my new hobby with enthusiasm, and we initially spent many a happy hour gathered round the dining table completing some rustic scene or other, gradually progressing from the sort you can complete on a tea tray to a 4000 piece blockbuster only obtainable by mail order through Nerds Direct.

    I can now tell you a thing or two about managing the production team for such an enterprise. Firstly, divide the pieces into seven or eight piles corresponding to grass, sky, buildings, and so on, and allocate a person to each. Ensure that each gets on with his or her own bloc, subcontracting smaller blocs to additional helpers if available. The boundary between blocs must be negotiated by the respective leaders of each bloc, and should be seamless from the viewer's perspective.

    Initially, this arrangement worked extremely well, and we were amazed at the pace of progress once we had introduced role allocation, ground rules, and a strict division of labour. But in recent weeks the project has gone pear shaped. The sky expert was the first to abandon his post, on the grounds of intractable boredom. Even though he had responsibility for several varieties of clouds, he apparently felt that his work was less fulfilling than that of the tree expert or the flower expert. The rest of us pulled together in his absence, and recruited a string of temps who lacked commitment and demanded frequent coffee breaks. The original core team members have now begun to experience stress symptoms, claiming they've lost commitment to the big picture.

    Increasingly, I try to identify the critical point at which a small, fun initiative became an incongruous unfinished jungle occupying what used to be our social space.

    As with jigsaw puzzles, so with hospitals, primary care groups, academic departments. Perhaps the cure for our collective anomie is to acknowledge the downside of economies of scale.

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