Background

The health service is increasingly looking to the manufacturing sector for ideas to improve its processes.1 2 3 The BMJ, for example, has published articles drawing on lean thinking, the theory of constraints, and six sigma.4 5 Within the NHS, the Modernisation Agency and, subsequently, the Institute for Innovation and Improvement have championed this way of thinking about the delivery of health care. Their work, and that of Don Berwick and others at the US Institute of Healthcare Improvement, has resulted in the identification of common systems failures in the healthcare setting and provided clear, detailed prescriptions for overcoming such failures.6 7 8

Although this approach has resulted in real improvements to patient care, it tends to focus attention away from some of the most distinctive features of health care. Drawing on both health economics and medical sociology, we highlight some of these features by comparing a hospital and a bottling factory. Hospitals are similar to bottling factories in that they are built around a set of interconnected processes, and if these processes do not run smoothly, or if they are poorly coordinated as a system, the organisation will …