Large scale models and large scale thinking: The case of the health services

The delivery of health services represents one of the most daunting challenges confronting contemporary management. The complexity of the issues involved suggests that health service policy makers seeking to allocate scarce resources would find the opportunities offered by large scale modelling attractive. However, the application of such models to strategic management of the health services has not been a success in the UK. This paper seeks to explain the failure by describing three important initiatives in the UK National Health Service that have occurred over a period of 20 years. The first is the deployment of the large scale 'balance of care' model, which was developed in the 1970s, and sought to allocate local government and health service resources between competing claims. The second is the performance indicator initiative of the 1980s, which concentrated on the measurement of a large number of processes and outcomes in the health sector. The third is the 'internal market' reform of the 1990s. These developments were informed, respectively, by the disciplines of operational research, accountancy and economics. Alternatively, they can be thought of as representing the planning, bureaucratic and market views of management. The paper argues that the traditional OR approach fails not because its model is an inadequate representation of reality, but because it does not acknowledge the priorities of the manager or politician who must take responsibility for implementing the model's findings. The overriding concerns of the accountable person are likely to be securing control and avoiding blame, rather than the pursuit of either allocative or managerial efficiency. In this respect, the models of accountants and economists are more attractive to managers and politicians.