Organizational health - Oxford Journals - Oxford University Press

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lump sum. I should perhaps have blown the whistle on their inefficiency, but I have colluded with it, on the feeble principle that I have a job to do and life is.
Q J Med 2006; 99:883–884 doi:10.1093/qjmed/hcl122

Coda Organizational health A couple of years ago, I had three part time jobs in different parts of the National Health Service, and I also had three dictating machines. For some reason, dictating machines have never become standardized, and since the NHS isn’t very standardized either, I needed a different type of machine for each job. By an odd coincidence, all three machines happened to break down at around the same time, so I put in requests for a replacement in each of my workplaces. What happened next was instructive. In workplace A, my secretary gave me a new machine immediately: she had kept one in reserve for such an eventuality. In workplace B, I had to fill in the appropriate requisition form and get it signed by my line manager there. I then had to give the form to my secretary, who got it signed by her own manager. Finally, two or three weeks later, I got a new machine. In workplace C, everyone in the office went into a flat spin in response to my request, because nobody was quite sure who was responsible for ordering a replacement, or which budget it should come from. After several months, a new machine had still not arrived. Shortly after that, the problem became academic anyway since I left that organization. I didn’t resign solely for want of a dictating machine, of course, but it could stand as a symbol for all the reasons why I did actually leave. Working in several different parts of the NHS is eye-opening. The range and variety of organizational cultures is staggering. The saga of the dictating machines is one of many examples I could give. Other examples are a matter of common observation, such as the institutionalized rudeness of receptionists in one hospital, compared with the thoughtfulness and patience of their colleagues in another. What is fascinating is that each institution always has a perfectly good set of explanations to account for the way it behaves. Thus, in the case of the dictating machines, it was obvious to everyone in workplace A that doctors needed to have a functioning machine at all times, and also

that it was appropriate for secretaries to anticipate this. In workplace B, this was obvious to a certain degree, but it was even more obvious that you always needed to follow the proprieties in making sure that everything was accounted for. As for workplace C, the prevailing narrative was that providing health care was a very complicated enterprise that was forever throwing up unexpected demands, and these would inevitably take time to sort out. One did one’s best, of course, but there were always other priorities to attend to, and trivial things like dictating machines would sometimes have to wait. And wait. In theory, people like me who work in more than one institution should be able to challenge poor or unacceptable systems where we come across them, and to point towards more intelligent models of working. Yet I am struck by how difficult it is to do this. Time and again, I find myself falling in with established cultures of obfuscation or inertia, and I don’t dare to question the plausible narratives that always sustain them. To give a flagrant example, I am currently organizing the same training courses for a number of different NHS trusts. Some of the trusts have agreed to give me ‘carte blanche’ to organize recruitment for the courses. In other trusts, I have tamely agreed to attend endless meetings to discuss who should come on the courses, simply because ‘that’s the way we do things here’. In one particular trust, I have discovered that the personnel records and communication systems are so pathetic that I have helped them to find an independent third party to take over the course management for a lump sum. I should perhaps have blown the whistle on their inefficiency, but I have colluded with it, on the feeble principle that I have a job to do and life is too short. Curiously, I not only find myself behaving differently within each organization that I encounter but I also become, almost literally, a different person in each. In a well-functioning work culture, I experience myself as a thoroughly competent and

The Author 2006. Published by Oxford University Press on behalf of the Association of Physicians. All rights reserved. For Permissions, please email: [email protected]

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884 conscientious senior professional. In more defensive or troubled workplaces, I feel and display a whole variety of other attributes, including aggression, passivity or sullenness. Not long ago, I had the experience of chairing a meeting confidently in a national agency on one particular day, and then sitting on a local committee later that week in another institution, where I was treated like a truculent adolescent. I duly behaved like one. I am lucky enough to spend enough of each week in healthy institutions, and so I am pretty sure that my more delinquent side only emerges in response to a certain kind of organizational pathology.

Coda However, I realize that there must be very many workers in the NHS who do not have any such touchstone. Inevitably, they are drawn into the systemic problems around them, and their personalities come to express and perpetuate the same problems. It must take an unusual independence of spirit to recognize and resist this process. And I suspect it will take more than targets, star ratings and points systems to transform the kind of organizational culture that cannot provide a doctor with a dictating machine. John Launer