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Int J Qual Health Care. 2010 Feb; 22(1): 1–2.
Published online 2009 Dec 1. doi:  10.1093/intqhc/mzp055
PMCID: PMC2803010

What makes the health system tick?

Jeffrey Braithwaite
Australian Institute of Health Innovation,
Centre for Clinical Governance Research,
Faculty of Medicine, University of New South Wales,
Randwick, NSW,
E-mail: ua.ude.wsnu@etiawhtiarb.j
Johanna I. Westbrook
Health Informatics Research and Evaluation Unit,
Faculty of Health Sciences, The University of Sydney,
Sydney, NSW,
E-mail: ua.ude.dysu@koorbtsew.j

Between Gesellschaft and Gemeinschaft the difference literally is only four characters, but conceptually they are a world apart, as students of sociology (and the Germans) know. For the health care sector, it is a distinction worth appreciating if we want to deliver better quality, safer care.

Gesellschaft denotes that official, impersonal web of organizational structures, hierarchies, departmental divisions, policies and procedures which govern human interactions and relationships in big, complex bureaucracies, such as modern hospitals and health care systems. Gemeinschaft refers to that other defining web of human interactions built on emotional, personal bonds, which are often overlooked in the perpetual requirements to fall into line with the official, formal frameworks of our lives.

This vital distinction was conceived by sociologist Ferdinand Tönnies in the late 19th century to explore the breakdown of the natural, personal ties of rural communities as industrialization re-organized German society, re-casting individuals as functional units in a modern economy [1]. In today's NHS, and many other health systems, a parallel gulf persists. There is a relentless focus on the formal organizational structures and prescribed roles of health care professionals and comparative ignorance of the sociologically deep and psychologically rich networks which make people—including clinicians—tick. While substantial amounts of time, energy and resources go into scrutinizing and fine-tuning the former (there is a large industry devoted to ‘restructuring’) there are extraordinary opportunities to improve health care outcomes by tapping into the Gemeinschaft.

Intuitively, we recognize the intersections between the formal hierarchies we work within and the socially fulfilling networks any profession throws up. It is widely accepted that social inclusion amongst professional communities can make for happier workers which, in turn, enhances organizational success [24]. Satisfying work in social–professional networks [58] has been credited with a long list of positive outcomes from employee retention [9], safer workplaces for staff [10, 11] and patients [12] and professional motivation [13] through to organizational resilience [14]. Most clinicians have felt the productive buzz of inclusiveness and social cohesion at work. Puzzlingly, public health professionals have long known about the healthy impact of interconnected communities [15]. But we have mostly neglected systematically applying the principles to the organization of clinical practices despite confronting evidence of high suicide rates [16] and poor mental health [17] indicating that social and organizational support networks often fail health professionals [18].

Interest in social–professional networks has grown rapidly in other complex industries such as aviation [19], manufacturing [20], finance [21], education [22] and the military [23]. In health, we talk a lot about clinical teams [24], re-invigorated professionalism [25] and more recently inter-disciplinary practices [26]. Yet there is a paucity of empirical evidence to underscore the many anecdotal benefits, or to identify potential disadvantages such as elitism in professional cliques. Nor is there a convincing model for the systematic evaluation of clinical networks to answer a core question: how can we enable groups of clinicians to work together more effectively, right across the board, not just in sporadic instances?

It is far easier for policy-makers to argue for a restructuring of the formal system than it is for researchers to secure funding to determine whether and how the camaraderie of a professional team contributes to the success of delicate surgical procedures or chronic, complex medical care, and to apply that knowledge widely. Tönnies described Gemeinschaft as having an ‘immeasurable influence on the human soul’. The challenge is to establish how naturally occurring personal interactions at work—between friends, respected colleagues or multi-disciplinary clinical communities—have measurable influences on staff wellbeing, health care delivery and patient outcomes. This must go beyond mere topical arguments in favour of teamwork [27].

Most of us think that it must be the case that there is a positive relationship between collaborative clinical networks and good patient outcomes. But there are problems. One is that a definitive study that looks at this has never been done. Another is that productive teams cannot readily be orchestrated; otherwise we would just do it. They can be built over time, and the received wisdom is that we need good leadership, encouragement and investments in support structures. However, even these strategies will not work on every occasion. No one had discovered a one-size-fits-all recipe for success. The alternative is not tenable, however—to intensify the bureaucratic responses, and risk estranging clinicians further.

At stake is an understanding of the relative contribution of both the formal bureaucracy (and what it contributes) and the web of professional bonds (and what they contribute) to the care of patients. In other words, it is about time we figured out, especially in the case of the latter, how the health care metronome really ticks.


Our work is supported under Australian Research Council's Discovery Projects funding scheme [project number DP0986493]. Ethics approval is granted by the University of New South Wales’ Human Research Ethics Committee, application number 09085.


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Articles from International Journal for Quality in Health Care are provided here courtesy of Oxford University Press
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