Organisational behaviour in health care

The research agenda

Edited by Annabelle L Mark and Sue DopsonMacmillan Business 274 pages£45

Many academics are tiring of policy analysis and are now showing much more interest in how people in the NHS behave. This book, based on a symposium at Middlesex University, offers a variety of insights. I recommend that you choose what is likely to interest you most; it is not a book for continuous reading.

Rosemary Stewart - organisational doyenne - reminds us that research must be feasible, useful and understandable. It helps, say the editors, to understand the difference between organisational behaviour - the study of the character and processes of individuals - and organisational analysis, which is the study of whole organisations.

Several contributors acknowledge not only the complexity of NHS organisations but also the different perspectives we can adopt to try to understand what is going on. Sandra Dawson lists five: industrial, scientific, professional, public and political.

Small wonder, says Peter Spurgeon, that this leads to instability, which in turn vitiates the ability of organisations to innovate. To be proactive, managers need a more supportive environment.

Several chapters accept that research has not always kept in touch with the realities of everyday life in the NHS and is in danger of being ignored. Useful, then, are discussions of the involvement of consumers and of the behaviour of doctors, nurses and professions supplementary to medicine.

Lynn Ashburner and Katherine Birch note that nurse influence in primary care development is likely to be limited if doctors keep their dominant position. But GPs may be less than effective if allowed to burn out in mid career. Virginia Morley and colleagues describe a scheme to avoid this.

The discussion as to whether doctors can be effective managers continues, and Lorna McKee suggests that there are three distinct ways of working: traditionalist, managerial and power sharing. In the Netherlands, doctors and managers collaborate to deal with external agencies, policy-makers and insurers, say Ong and Schepers. But in both studies doubts still remain that involving doctors in management has become embedded in the system.

Annabelle Mark shows how the professions supplementary to medicine might be rescued from their present plight - fragmented and professionally under attack. If they formed what she calls 'virtual networks' they could innovate free from domination by others and bureaucratic constraints.

Whatever the framework, leadership is still required. Beverly Alimo Metcalfe is persuasive in her account of transformational - as opposed to transactional - leadership and the process of 360-degree feedback which can encourage this approach. But don't forget the middle managers, says Graham Currie. They are not just implementers but can keep senior management in touch with reality.

Louise Fitzgerald and former colleagues from Warwick have here and elsewhere reminded us that evidence is not all that it seems, and they use clinical case studies to prove the point. Another note of realism is made by Frank Blackler, who says that tension deriving from conflicting priorities is 'a driving force', not something to be avoided.

Collaboration is a characteristic of today's NHS, but it needs to be understood better. It is not only a means of working but also a statement of values, says Steve Cropper.

If all this seems a little detached from patient care, John ovretveit reminds us that managers make influential long-term decisions, which can have a profound effect.

This is the ultimate message of the book. Only if we understand more about how research can help NHS staff to provide effective care will things get better.

Andrew Wall

Visiting senior fellow, Birmingham University health services management centre.