Lindblom, L. (1959)
The science of muddling through, Public Administration Review, Vol. 19,
Pp 79-88
Somewhere I have the paper....
Simon, H(1960) The new science of management of decisions New York, Harpers.
I like Mr Simon's idea of 'bounded rationality' very much.
He is still a rationalist but acknowledges its limitations
He argues that managers could only be rational within boundaries imposed by
resource availability, experience and knowledge of the range of options
available for action. He was on the slippery slope to abandoning positivist
thinking in management but didn't quite get there :-)
Alasdair
On 26/5/02 8:44 am, "Paul Robinson" <[log in to unmask]> wrote:
> Alasdair,
>
> Lindblom sounds interesting. What is the source: I'd like to read some.
>
> His analysis sounds to be political rather than MBA management 'science'.
>
> Suits the era I suppose.
>
> Paul
>
> Paul Robinson
> General Practitioner, Scarborough
> GP Consultant Sowerby Centre, Newcastle
> Hon. Senior Clinical Lecturer, Leeds
>
> -----Original Message-----
> From: Complexity and chaos theories applied to primary medical and social
> care [mailto:[log in to unmask]]On Behalf Of
> [log in to unmask]
> Sent: 25 May 2002 08:50
> To: [log in to unmask]
> Subject: Re: co-operative inquiry- talking money
>
> Great points David. My only addition is that we are not
> Muddling along on our own in this instance but muddling along
> Together.
>
>
> Lindblom described muddling through in 1959. He observed in state sector
> organisations that in complex situations it is not possible to identify all
> the objectives of different groups of people affected by an issue, so
> policies are chosen directly. The means and the ends are thus chosen
> simultaneously. In these circumstances, you canıt judge a policy according
> to whether it achieves a given end, but only according to whether it is
> desirable or not..
>
>
>
> I am interested to know what constitutes a group
> For muddling communally. How do we contain muddle
> Anxiety and whose desires do we listen to?
> In our muddle :-)
>
> Alasdair
>
>
>
> Just wondering also if muggles can protect against muddle
> [grinning]
>
>
>
>
>
>
>
>
>
>
>
> On 24/5/02 3:37 pm, "St Thomas Medical Group Research Unit"
> <[log in to unmask]> wrote:
>
>> I wanted to reflect a little on what was going on here.
>>
>> We are talking about informing patients of resource allocations. As
>> scarcity is a pervasive feature of all public health care systems you are
>> beginning to expose the concept of rationing (who gets what and inevitably
>> who goes without, and how the decision is made) and not just cost
>> effectiveness (relating the costs and consequences of different
> intervention
>> options)
>>
>> Historically, rationing was carried out implicitly, mainly by doctors who
>> adopted a strategy of delay, denial and dilution. It has been argued that
>> this process accommodated the hetrogenicity of patients and the
> ambiguities
>> and paradoxes of values and objectives that are inherent in the NHS. It
> also
>> reduced the disutility that was associated with the denial of care.
>>
>> For a number of reasons this system was thought to be unsatisfactory.
> Enter
>> explicit rationing, with health economists in the vanguard preaching
>> technical/rational solutions to resource problems. This involves making
>> explicit your objectives and values and deciding between known courses of
>> action in terms of their costs and consequences. Needless to say, wherever
>> rational rationing has been tried across the world, the whole thing has
>> ended in tears!
>>
>> But the can of worms has been opened. The current focus is on a
> transparent
>> process involving all stakeholders which takes into account many factors
>> and we still get into all sorts of muddles. (Eg the recent beta interferon
>> debacle). I actually see rationing as an emergent phenomena in a complex
>> adaptive system but that is a story for another day.
>>
>> I am not sure where that leaves this interesting enquiry but a few
> practical
>> thoughts:
>>
>> Firstly, costing exercises in the NHS are notoriously inaccurate and the
>> answer to the question "what does something cost?" is invariably "it all
>> depends".
>> Secondly, the purpose of your enquiry seems to be part of deciding whether
>> the NHS gives value for money. What does this mean? Health economists
> stress
>> that the cost should not stand alone but always be related to the benefits
>> that they incur. How do we assess the value of a GP consultation or
>> treatment for cancer? What do we/the patient/the government mean by value?
>> (health economists look at value in terms of what you are prepared to
> forgo)
>> Thirdly, a more accurate reflection of costs is not a financial estimate
>> but the opportunity cost - the next best opportunity foregone. So for
>> example, a GP consultation doesn't cost £52 but is seen in terms of three
>> lost nurse appointments.
>> Fourthly, like Paul, I was interested that having set the enquiry you were
>> very keen to limit the agenda. The fact that some poor punter was paying
>> £6.70 for a prescription that was worth 25p was deemed not suitable for
> the
>> emergent enquiry!
>>
>> I am not sure where all this rambling on is going, but it may offer some
>> input into teasing out the reasons for your enquiry. Is it to tell
> patients
>> how lucky they really are? To help them decide whether they would like
> more
>> money spent on the NHS or making the railways safer? Raising questions
> about
>> the best way of delivering health care? Or just exposing the fact that the
>> whole thing is extremely complex, no one can really understand the whole
>> picture and it is just much better if we muddle through pragmatically and
>> keep the whole thing under wraps as much as possible!
>>
>> ----- Original Message -----
>> From: Paul Hodgkin <[log in to unmask]>
>> To: <[log in to unmask]>
>> Sent: Monday, May 20, 2002 9:50 PM
>> Subject: co-operative inquiry- talking money
>>
>>
>>> At the last Tufton co-operative inquiry meeting I said I would explore
>>> increasing feedback loops with patients in the form of giving them
>>> information about the costs of health care. So far I have:
>>> * tried telling people the cost of the drugs when they appear on the EMIS
>>> screen as I prescribe them. This gets a variety of reactions - most often
>>> 'why are you telling me this?' but is hard to do. Also I tend to
>> concentrate
>>> on only the most expensive drugs... the cheaper ones are less interesting
>>> (whatever that means) and anyway I find I dont want to get into a
>> discussion
>>> about whether OTC would be cheaper for them. Although perhaps this might
>> be
>>> the most appropriate thing from their point of view?
>>> * since it was hard to remember/get myself to give patients this
>> information
>>> (why?) I have now moved on to thinking about giving the enclosed
>>> questionnaire out. It is avowedly 'political' in the sense that it is
>> about
>>> portraying a particular view of health care - and as such is an
>> interesting
>>> surfacing of these dimensions in the consultation. When I suggested to
> the
>>> practice that we give these out to patients in the waiting room, they
>>> refused: it was 'research' and hence needed ethical approval. And it was
>>> also 'unethical to force this sort of information on patients' - both
>>> understandable points of view - but quite extraordinary in any wider
>>> international context of health care (where NOT discussing costs of care
>>> would surely be both unprofessional and unethical). These reactions
>>> reinforce for me how money is truly the last taboo in British medicine;
>> and
>>> how just beneath the surface lies a whole realm of anxieties about money
>> and
>>> medicine that Balint never dreamt of. As a kick to the complex system of
>> the
>>> practice it has certainly helped me explore things. I shall pursue this
>>> more....
>>> I would be interested in any other reactions that people on the list have
>>> and whether any body else has tried this sort of thing - or gets the same
>>> reaction.
>>> All the best
>>> Paul
>>> Paul Hodgkin
>>> Primary Care Futures
>>> 7 Edgebrook Rd,
>>> Sheffield, S7 1SA
>>> 0114 258 6337/07946463698
>>> [log in to unmask]
>>>
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