Published: 07/06/2002, Volume II2, No. 5808 Page 28 29

Reengineering Health Care By Terry McNulty and Ewan Ferlie

Publisher: Oxford University Press. ISBN: 0199240841. 402 pages.£50 (hardback).

The question of how to achieve a step change in NHS performance has taken on added urgency in the light of the sustained funding increases announced in the Budget.

With the public and politicians impatient to see the additional money achieve results, what are the prospects for achieving a transformation in performance, and what evidence is there to help those involved in this task? This book contains some important clues.

It tells the story of Leicester Royal Infirmary's application of business process re-engineering in the 1990s.

Their initiative sought to bring about organisational transformation but achieved far less.Service change occurred, but the impact of reengineering was uneven and its application in a healthcare setting problematic.

Of particular importance was the finding that re-engineering had a limited effect in a hospital with many of the characteristics favourable to this kind of approach.

At the book's heart are accounts of the experience redesigning services in different specialties.Examples include accident and emergency, gynaecology, orthopaedics and ear, nose and throat.

The authors then use the research literature both to locate their empirical data and to explain the results.

A central theme here is the powerful role of doctors in professional bureaucracies like hospitals, and the clash that often occurs when managerial initiatives seek to alter professional practices.

It was for this reason that the original approach adopted at the LRI was adjusted to allow different specialties to take their own approach and secure greater clinical commitment.

However, and more surprisingly, the authors note that doctors and middle managers at the specialty level collaborated to resist changes promoted from above.

The authors'work suggests that the more ambitious claims made for current efforts to achieve a breakthrough in NHS performance should be treated cautiously.This is especially given the gap that often exists between the rhetoric surrounding organisational change and the hard reality of implementation. It does not mean that bringing about change in hospitals and primary care is impossible.

Rather, it requires effective managerial and clinical leadership, skills in project management, and an understanding of the nature of professional cultures and how they can be changed.

Above all, achieving change involves slow, painstaking work with clinical teams who may be resistant to attempts by non-clinicians to shape what they do.

The corollary is that reforms to clinical practices that are driven from outside are likely to have both a limited and a superficial impact.

As the authors put it: 'A quasi-Leninist emphasis on charismatic leadership from healthcare managers as the vanguard of the salariat is too thin and fragile a base for organisational transformation.'

Substitute politicians or regulators for managers in this quote and the warning from this analysis in the current context is clear.

Reengineering Health Care is an important addition to the theory and practice of health policy and management.

My only reservation is that in displaying their academic credentials, the authors often resort to a theoretical approach that may deter busy practitioners from discovering the core findings.

This book is a must-read for students and teachers, but a jargon-free summary would ensure it reaches the wide audience it deserves.