Interpreting and managing risk in a machine bureaucracy: Professional decision-making in NHS Direct

Abstract

Since the early 1990s there has been an active movement towards scientific – bureaucratic medicine which incorporates accumulated biomedical research evidence with the use of algorithmic rules in order to specify clinical action and reduce variation in practice. Health professionals' claims to authority, for identifying and managing risk, are increasingly being challenged through the imposition of bureaucratic devices to control their professional behaviour. This paper examines the extent to which professional decision making is constrained in an organization that is characterized by the generation and application of rules for encoding knowledge and for monitoring compliance in order to ensure unified and predictable behaviour and outputs; a machine bureaucracy. Thirty nurse advisors in one NHS Direct site were interviewed, observation of the call centres and analysis of routine monitoring data were also carried out. The data revealed that respondents' behaviour was deceptive, giving the appearance of being controlled and standardized but in reality representing that of a professional working autonomously. By casting the encoded knowledge as a source of risk, respondents were able to invoke the use of professional judgement to manage the risks it posed. Informal risk management strategies and a focus on individual rather than organizational needs enabled respondents to subvert managerial control.