Intended for healthcare professionals


What’s the difference between a hospital and a bottling factory?

BMJ 2009; 339 doi: (Published 20 July 2009) Cite this as: BMJ 2009;339:b2727
  1. A Morton, lecturer1,
  2. J Cornwell, director, point of care programme2
  1. 1Operational Research Group, Department of Management, London School of Economics and Political Science, London WC2A 2AE
  2. 2King’s Fund, London W1G 0AN
  1. Correspondence to: A Morton a.morton{at}
  • Accepted 30 May 2009

Efficient processes are essential to good and cost effective care. But health services need to look beyond manufacturing for models, argue A Morton and J Cornwell

Various commentators have argued for interventions to improve processes in the delivery of health care by drawing attention to experience and practice in other industries—for example, airlines or vehicle manufacturing. A common and natural objection to this line of argument is that health care is different, and so the potential to learn from other sectors is limited. We have sympathy with both claim and counterclaim and explore in this article some features of health care that distinguish it from other industries.


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 …

View Full Text

Log in

Log in through your institution


* For online subscription