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On redisorganisation

On redisorganisation
Fantasy and reality
Missing the obvious

On redisorganisation


As soon as we abandon our own reason, and are content to rely upon authority, there is no end to our troubles. That is a quote from Bertrand Russell taken from a work called “An Outline of Intellectual Rubbish”. Bandolier hasn't read it in full, in part because philosophy makes what little brain we have hurt. But when it comes to managing organisations, a little brain goes a long way.

Or it should do. The golden rule that operates 99.99% of the time is that if it ain't broke, don't fix it. Most organisations ain't broke, but they always need tinkering with to make them run better. To tinker here means to upgrade, nurture, enhance, or develop rather than the several less positive dictionary definitions.

Understatement is the name of the game in management, together with recognising that every employee is a manager, making decisions crucial to the success of the firm, and giving them the tools to do a better job. Relying on big brother (authority) to make all the decisions results in an organisation of jobsworths, doomed to failure.

Healthcare around the world is undergoing massive reorganisation, often using organisational theories, but sometimes because reorganisation makes it look as if someone is doing something. A systematic review has looked for the evidence [1].

Fantasy and reality


Actually, this is not a systematic review, but a diatribe about continued, ongoing, pointless, redisorganisation, without a jot or tittle of evidence that any of it ever does any good, or has ever done any good. The evidence found was fantasised, but as the authors say, though their fantasies may well resemble other people's realities, that isn't their fault.

The most common reason for repeated reorganisations is that there isn't one. Trillions of dollars, more even than Bandolier's piggy bank, is spent each year on this activity, without much evidence of benefit. Success is measured in large consultancy fees.

Most people would rather die than think. Thinking about the many redisorganisations in healthcare would make most sensible people weep, which makes not thinking about it the preferable option. Read this paper, and make others read it too. If nothing else, it will make you laugh out loud at the utter folly of spending huge sums on reorganisation while missing the simple things that could make a difference. It might just jolt you back to reality, and make you think about what is happening around you. You won't like it, but much good medicine has a nasty taste.

And it is worth remembering the old axiom, that the trouble with the world is that the stupid are cocksure and the intelligent full of doubt.

Missing the obvious


There is a secret magic in numbers, and while some take great pleasure in prime or perfect numbers, Bandolier has a dread of small numbers. Small numbers in our world means that the random play of chance can blow chill and strong to bury the truth. The theme of limited evidence continues in this issue with a series of systematic reviews or studies which, however good, are limited by low numbers of events, with resulting uncertainty.

How we deal with that uncertainty is situation dependent. For instance, a finding that anti-TNF agents produce fewer cardiovascular events in rheumatoid arthritis is a good thing, fantastic for a condition with a higher rate than normal. Even though the numbers are small, we feel relaxed about it. But what if it were the other way around, and there were more? Think of the hype and headlines that would follow, even on the same limited numbers.

Natural history studies are rare as hens' teeth. One tries to chart spontaneous clearance of hepatitis C virus in a number of small studies. It raises as many, or more, questions than it answers, but it really demonstrates how variable doing nothing can be when numbers are small.

Reference:



  1. AD Oxman et al. A surrealistic mega-analysis of redisorganisation theories. Journal of the Royal Society of Medicine 2005 98: 563-568.

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