The Reality Dysfunction: 1 (The Night's Dawn trilogy, 1)

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Riska E. The professional status of physicians in the Nordic countries. Milbank Q. 1988;66 Suppl 2:133–47. Academics have proposed a range of theories to explain and/or mitigate this common public hospital behavior. In the early 1990s, there was discussion among political scientists about path dependency as the source of institutional obduracy [ 11, 12] as well as the potential value of “big bang” as against “incrementalist” approaches to generate change [ 13]. The early 1990s also saw the rise of New Public Management theory, calling for private-sector-derived managerial strategies such as contracting out services [ 14] and “steering not rowing” in the organization of public sector service provision [ 15]. Public Administration theorists explored why contracting in public sector institutions, once introduced, was difficult to manage effectively [ 16]. More recently, ideas from complexity theory have been invoked [ 17], although these perhaps have more utility in explaining why organizational change is so difficult than they do in identifying strategies that might achieve it.

Degeling P. Mediating the cultural boundaries between medicine, nursing and management – the central challenge in hospital reform. Health Serv Manage Res. 2001;14:36–48. The first contextual limitation is the inherent and increasing complexity of delivering high quality, safe, and affordable modern inpatient care in a hospital setting and across organizational boundaries [ 32]. Then he had some advice for Biden. "When you’ve been in politics for 50 years, the first thing you’re supposed to learn is how to avoid an embarrassing question. That has to be lesson one.” Dahlgren G. Why public health services? Experiences from profit-driven health care reforms in Sweden. Int J Health Serv. 2014;44:507–24.Saltman RB, Busse R. Balancing regulation and entrepreneurialism in Europe’s health sector: theory and practice. In: Saltman RB, Busse R, Mossialos E, editors. Regulating Entrepreneurial Behavior in European Health Care Systems. Maidenhead, Berkshire: Open University Press; 2002. p. 3–52. Schwarzenegger said he understood that his role was to represent all Californians — not just Republicans and not just loyalists. What is required is a thorough reconstruction of the United Kingdom’s governance. One of the key figures in any future Labour government is a top civil servant who shortly after delivering her report Johnson’s “party-gate” scandals announced that she was moving to be chief of staff to the likely next prime minister, Keir Starmer. Her main task, which she has already begun planning, is an overhaul of structures, rights, and responsibilities of government departments. This is expected to be wide-ranging. On the clinical side, managers have sought to develop strategies that harness physicians to medical teams as a way to create better congruence between physician decisions and the best interests of the hospital they work in [ 58, 59]. As clinical data on individual performance has become more available, research has sought to determine the most effective way to improve physician performance. However, these internal management strategies have had relatively short half-lives, even shorter if the physician’s medical practice and salary are not tightly tied to the financial position of the hospital (either because the physician is in private practice on contract to a public hospital – as is often the case in The Netherlands – or if the physician is a public employee in a permanent post and thus insulated from most management rebuffs) [ 60– 62]. A key finding from research in this field is that physicians tend to dominate hospital decision-making procedures and constrain undesired institutional policies and practices regardless of the national health system and culture they operate within [ 50, 63– 65]. Operationally, physicians largely control the rate and pace of their workloads and the workflow of the rest of the organization, typically prevailing in conflicts with other staff groups [ 66].

This set of structural and contextual factors breaks out the core organizational constraints that confront decisions about change in public hospitals. These six dimensions delimit the de facto boundaries, lay down the practical parameters that both policymaking and management needs somehow to accommodate. Every proposal to alter institutional behavior, every new mechanism to improve quality and safety, to introduce more efficient financial programs, to alter daily staff service routines, even to change contracting partners for auxiliary services such as laundry or cleaning, all necessarily gets filtered through this six-way sieve before the outcome actually emerges at clinic or organization level. Young DW, Saltman RB. The Hospital Power Equilibrium: Physician Behavior and Cost Control. Baltimore: Johns Hopkins University Press; 1985.

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Alvarez A, Duran A. Spain. In: Saltman RB, Duran A, Dubois HFW, editors. Governing Public Hospitals: Recent Strategies and the Movement Toward Institutional Autonomy. Observatory Studies Series 25. Brussels: European Observatory on Health Systems and Policies; 2011. p. 241–60. Habicht T, Habicht J, Jesse M. Estonia. In: Saltman RB, Duran A, Dubois HWF, editors. Governing Public Hospitals: Recent Strategies and the Movement Toward Institutional Autonomy. Brussels: European Observatory on Health Systems and Policies; 2011. p. 141–62. Richard B. Saltman is Professor of Health Policy and Management at Emory University in Atlanta. He is a co-founder and associate director of research policy at the European Observatory on Health Systems and Policies, and since 2011 has been co-project director of the Swedish Forum for Health Policy. He holds a Ph.D in political science from Stanford University. Competing interests Rumbold BE, Smith JA, Hurst J, Charlesworth A, Clarke A. Improving productive efficiency in hospitals: findings from a review of the international evidence. Health Econ Policy Law. 2015;10(1):21–43.

Data sharing is not applicable to this article as no datasets were generated or analysed during the current study. Authors’ contributions Further, these three structural dimensions interact in an institutional environment defined by three restrictive context limitations, again two of which also affect private hospitals but all three of which compound the management dilemmas in public hospitals. The first contextual limitation is the inherent complexity of delivering high quality, safe, and affordable modern inpatient care in a hospital setting. The second contextual limitation is a set of specific market failures in public hospitals, which limit the scope of the standard financial incentives and reform measures. The third and last contextual limitation is the unique problem of generalized and localized anxiety , which accompanies the delivery of medical services, and which suffuses decision-making on the part of patients, medical staff, hospital management, and political actors alike. In short, contingency plans for governing in an all-consuming crisis of the kind that arrived with COVID-19 did not exist. But this was not only a matter of Johnson’s administrative incompetence. The British political system has for centuries been based on the so-called good chap theory of decent people playing by informal rules and doing their best. Regulations and structures are habitually dismissed, usually by the political right, as stiflingly un-British. At the apex of power, the relationship between the prime minister, his or her cabinet, and senior officials is blurred and subject to interpretation by each set of incumbents. Civil servants have a duty to political impartiality and to not making public statements, leaving them invariably to being blamed for government mistakes. Although these pressure points have always existed, morale is said now to be at an all-time low. Kingdon JW. Agendas, Alternatives and Public Policies. 2nd ed. Reading: Addison-Wesley Educational Publishers; 1995.How else to account for Johnson’s approach to the pandemic, painfully laid bare by several of his former advisors? In devastatingly deadpan evidence, the deputy head of the civil service, Helen MacNamara, said she struggled to think of a single day when Downing Street adhered to the emergency rules it had set, which many citizens were prosecuted for failing to follow. the conflict between expanding curative and primary care coverage areas as against staying within financial and budgetary limitations Porter ME, Teisberg EO. Redefining Health Care: Creating Value-Based Competition on Results. Boston: Harvard Business School Press; 2006.