“Border Nut”

Medication or lifestyle intervention? The primary care physician and patient weigh the pros and cons. A personalized approach! Afterward, the doctor casually mentions that he has less and less time for personalized care. The conversation that follows reveals that his frustration stems from the size of the health center. Rather than being a doctor, he’s largely a coordinator. However, managing people isn’t his profession—nor does he enjoy it.

We quickly agree that the old family practice model—consisting of a doctor and an assistant—is no longer viable. The demand for primary healthcare has increased enormously, both in diversity and scope. To make the best use of the family doctor’s availability, others can take on part of that increased demand for healthcare. To receive the results of a blood test, the patient does not necessarily need to speak with the doctor personally—only if there is a problem. Furthermore, the demand for care is increasingly being met through self-care, supported by technology (apps from health insurers, etc.). At the other end of the spectrum, there is a growing need for specialized care nearby, under one roof, without the need for a referral to a more expensive hospital (so-called “secondary care”).

Five collaborating primary care physicians—in this example—with a staff of nurses and assistants to provide basic care on one side and a range of specialties on the other. The larger scale offers many benefits; the general practitioners learn more from each other than a single GP used to, it’s vastly more cost-effective, and many processes are streamlined so they don’t have to be reinvented repeatedly. But this entire healthcare offering must be properly managed. And that means this single general practitioner actually has less time for the patient, rather than more. With the added risk that he will eventually no longer know the patient—something that is essential for important care issues. No matter how informative the medical record may be, the experience within the doctor-patient relationship can be decisive. So scale does have its benefits. But there’s also a limit somewhere. The challenge is to find that limit—the sweet spot between too small and too large. Marginal utility.

Boundary utility is a universal issue in organizational theory. This is also the case, for example, with corporate staff functions. Many pyramid-structured corporations have large financial, risk, legal, and strategy staff functions. These keep the line units quite busy. Entire departments get involved in the business unit’s planning. By the time you’ve checked off all the boxes, the fiscal year is over. This doesn’t foster entrepreneurship; it breeds caution. And it creates a culture where people advance their careers by avoiding mistakes rather than by doing things well.

There’s also no doubt about the value of management: not having to reinvent the wheel everywhere, interchangeability, standards, learning from others’ experiences, and the assurance that the organization complies with laws and regulations—to name just a few. The goal is to take the pressure off the business. But the business becomes paralyzed as soon as too many indirect staff members get involved. An annual plan then belongs to everyone—and thus to no one.

Both examples show that there is a limit to the benefits of scaling up—a point where relief turns into a burden. How is that limit determined? Of course, you can calculate it using activity-based costing or by benchmarking staff-to-line ratios. Yet the definitive answer is often more qualitative in nature. This is partly because the experience and quality of the people involved are a determining factor. As well as—unfortunately—their self-interest and ego. Administrative and support departments tend to grow, entirely in line with their service-oriented nature. It is important that those involved recognize this and create some distance so they can step outside their own comfort zone.

Organizational developments sometimes follow a pendulum-like pattern over time. It is my assessment that the drive toward ever-larger scale will gradually begin to reverse. We are moving more toward “small and local”—a trend that AI will certainly accelerate. As a result, businesses will regain ownership of their operations, and primary care physicians will have more time to provide personalized care for important matters.