Intended for healthcare professionals

Rapid response to:

Analysis And Comment

Steadying the NHS

BMJ 2006; 333 doi: (Published 27 July 2006) Cite this as: BMJ 2006;333:254

Rapid Response:

NHS - a failure of integration and differentiation

Tony Watson advocated a model describing the nature and tasks of
management.[1] The external and internal view of an organization should be
balanced. Integration should facilitate differentiation through a
continual assessment of the Structure Strategy and Control systems of the
organization. Heavy top down management from government to board level,
however is focusing all the attention on externally imposed targets.
Little thought is given to the internal needs of the organisation.
Indeed, integration is overbearing and the drive for standardisation is
stifling the differentiation.

Henry Mintzberg identifies four almost opposing forces in a hospital
that Degeling attributes to ?colonization ?.[2] Process thinking is alien to
the Doctor, Manager, Nurse and Patient who are conditioned to a system
that likewise does not facilitate collaborative and systems thinking.

Tony Watson?s model as applied to the NHS and the hospital is less
than balanced. External focus overshadows the internal needs of the
individual, team and organization. Control through stifling integration
fails to allow for the differentiation concomitant with socio-
technological advancement. Our Health Care has inherited structures,
strategies and control systems that fundamentally have not been reviewed
since inception and the culure and meaning of our work is lost.

Marx coined the term alienation - it is an apt term to apply to the
highly skilled and dedicated workforce of the NHS. There is a lack of
pride in workmanship as the workforce, as described in Demmings work,[3] is
,'bruised battered, denigated and demoralised by the target driven culture
promalgated by automatons and beaurocrats. We are suffering from the
'structuration' described by Giddens.

Lastly, I believe it is becoming an oxymoron to refer to our health
care institutions as TRUSTS - do we really TRUST our staff!

Competing interests:
None declared

1 Watson T. Organising and managing work. Prentice Hall, Financial Times, 2002.

2 Mintzberg H. Managing care and cure- up and down and in and out. Health Services Management Research 2002;15(3):193.

3 Deming WE. Out of crisis. MIT, 1982.

Competing interests: No competing interests

30 August 2006
David John O'Regan
Consultant Cardiothoracic Surgeon
Leeds General Infirmary LS1 3EX