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J R Soc Med. 2007 February; 100(2): 78–80.
PMCID: PMC1790999

Health care participants' dualism: are new sub-species evolving?

Humans are distinctive primates behaviourally, yet are also uncannily like chimpanzees. Both evolved for survival in places such as the forbidding African savannah and are thus good at sustaining themselves through activities such as resource foraging and socio-political navigating.1 Amongst humans, this can be observed in both hunter-gatherer and modern technological habitats. Life can be tough in each setting. To get more resources and succeed politically, many humans strive to move from being one of the troops to a place of power—the classic alpha male or socially predominant female.

This is especially noticeable amongst that most interesting of cultural groups, the health reformers, who by definition have climbed up the primate hierarchy to a position of authority. These are ministers for health, heads of health departments or private hospital chains, chief executives of trusts, directorate leaders, and others in senior policy and management ranks. They can be contrasted with the staff who occupy posts with little formal influence. We have come variously to call these ‘workers’, ‘clinicians’ and ‘the shop floor’.

It is eerily as if there are two emerging, recently evolved, sub-species. Homo commandus controlus and Homo extremus flexibilitus, while often co-inhabitants of the health environment and externally similar to each other, display contrasting cognitions and behaviours. Exposing and understanding these two sub-species, we argue, is important in determining whether and how the health system works. Early identification of the sub-species in situ will allow participants to understand events and reduce fall out damage to themselves. Personal and sub-group survival is, after all, the name of the game in heavily threatening environments.


H. commandus controlus is a zealous health reformer with a mechanistic, linear perception of the world, in which organizational life is characterized in tangible, cause and effect terms. The logic for controlus is that there is, or should be, a direct correspondence between stipulated change measures and responses at the coal face. Those in authority should specify the system requirements and the policy changes to be made; those below should carry these out through modifications to their practice. The lens H. commandus controlus uses to regard the health system is structural—and the task to reform it flows naturally from this.

In the minds of these thinkers, reform measures should be bureaucratic, top down and modelled on the military:

  • stipulate the roles and goals of the troops;
  • set milestones, targets and indicators;
  • benchmark performances against others;
  • train people hard;
  • extract maximum economic value for the efforts expended.

Staff are chess pieces to be moved around to suit predefined purposes.

Evolution has taught controlus that the health system is an input-process-output machine. As such, the mechanisms needed for reform are measures such as restructuring, separating purchaser from provider, adherence to guidelines and pathways, and insisting on evidence-based practice. Doubt rarely manifests in the evolved controlus mind, and noise in the system (disagreements, multiple stakeholders requiring or demanding a voice, errors or alternative perspectives) are not countenanced—they are to be variously ignored, sidelined or squashed.

We have all met the type. He or she is the most recent health sector incarnation of Baroness Thatcher. Cabinet ministers, captains of industry and agency chiefs are overrepresented in this sub-species.


Homo extremus flexibilitus' behavioural patterns reveal a qualitatively different mindset. This is a sub-species which believes that the world is continuously uncertain. Health system characteristics are seen as emergent, fragile, indefinite, fragmented and at times chaotic. In this person's belief system, not only is there no 1:1 translation of cause into effect, it is unhelpful to even think in such terms. Health sector behaviour ebbs and flows, and changes are not enacted unproblematically, but are always contested. Everything has to be negotiated, and the bureaucracy navigated, to get things done.

The lens through which flexibilitus views the system is cultural, not structural—each organization and institution, every service and team, exhibits unique behavioural attributes. These thinkers do not have dogmatic answers because they are aware of and deal with so much ambiguity in their work. And in the subterranean depths of their psyches they do not think anyone else does or should have such answers, despite often encountering the bravado, and apparent sure-footedness, of controlus.

When flexibilitus sniffs at the health system he or she sees staff configured in complicated clinical networks in order to deliver care to complex and chronic patient groups and conditions. Reform measures should be bottom up, and liberating for those providing services—and they should involve the troops who do the actual work. The task of those in influential positions is to induce collaboration, discuss issues with other stakeholders, aim for optimum involvement, provide resources to the workers and hammer out, through dialogue, a preferred direction which the majority will accept. Flexibilitus is prepared for most agreements to be tentative, until the next wave of reform. No central nervous system is in control and, whenever someone tries to dominate, their ascendancy will be shortlived—and will have been unwarranted anyway. Individual rights, especially of lower order participants in the system, are paramount. This is labelled ‘clinical autonomy’, and jealously-guarded.

Again, stereotyping this group is seductive. The political rank-and-file, public health colleagues, psychiatrists or community doctors and, perhaps, researchers are disproportionately found in this category, but the cohort of all clinicians world-wide seemingly make up the sub-species.


Decades ago, Burns and Stalker,2 two early organizational theorists, distinguished between mechanical and organic companies. They did not go far enough, and left unrecognized the fact that a more apposite duality applies not to organizations but to people's thoughts and behavioural profiles. We suggest the stresses and strains of the NHS3 and other health system4 reforms have exposed much more clearly than in previous eras the international nature of these polarized mind-frames. They can be readily seen if you travel within or across the modern health sectors. The two thinking modes are not pathological, but perfectly normal. For instance, they are not classifiable in the Diagnostic and Statistical Manual of Mental Disorders,5 but they are tribal. Network patterns suggest that individuals cluster within their sub-species. Research has not determined whether this is normal kinship-grouping tendencies, preferential mating behaviours or some form of underlying incompatibility syndrome across the subspecies.

Are you labouring, or feeling anguished, under a reform process, locally or nationally, with which you disagree? Do you feel uncomfortable with the measures being undertaken by your chief of service, chief executive officer or the Secretary of State? Or are you unhappy with the take-up of your reform initiatives, and displeased that staff are not moving quickly enough in response to your managerial strategies or policy moves? Chances are your own fundamental controlus or flexibilitus outlook is incommensurate with theirs. Perhaps the seeds of conflict, or the key to many health system misunderstandings, may be a result of these fundamentally different evolved tendencies.

At a practical level, recognizing with which subspecies you are dealing may help in selecting the most effective strategies. H. commandus controlus responds well to facts and figures but is likely to make decisions with little consultation which may, therefore, not be well-informed. H. extremus flexibilitus seeks interesting work, to be provided with resources and technology, and to be left alone to do it. However, the greatest challenge with this species is to ensure its voice is heard and it is not marginalized in the bigger power game unfolding over its head.


We have two tests of your type. Our first test is relatively simple. Think about yourself—which are you? Perhaps you are a swaggering controlus, found brachiating high in the organizational rafters, or an anxious flexibilitus, frequently averting eyes when encountering authority figures, displaying a perpetual fear-grin? If either of these describes you, you are an extreme example of one of the two types. Our second test, suggested by the alcoholic's anonymous credo, is what you will do about it if you do recognize that you are one or the other. Evolution may hard-wire behaviour but humans have culture and the intelligence to modify or overcome relatively fixed characteristics.

For now it is sufficient to speculate that you, and others in the system, might fall into one of these groups, depending on the mix of evolved genes, social learning, personality and predilection. Weighing up our collective familiarity with healthcare personnel through experience and our research,6-9 we do seem to observe the H. commandus controlus type is more frequently found at the top of the tree, dispensing reform from on high, and H. extremus flexibilitus is mostly seen in the subordinate, less powerful positions, being expected to exhibit ever more professional elasticity. Particularly dextrous flexibilitus individuals may exercise unexpected posturing manoeuvres, and move up the layers of course; and this could be a consequence of rapidly evolved or learned mental suppleness in this sub-species. The effects of these developments are yet to be investigated and mapped out.


Some may object to our dichotomy, and be sceptical about whether we have indeed detected the emergence of new sub-species, the consequence of naturally selected characteristics, or even that we have postulated correctly two clearly identifiable groups. Yet do not the alpha authoritarian figure and the subservient others manifest across many species10 including trout,11 hermit crabs12 and wolves,13 and especially other primates, such as the silverback gorilla?14

It is not beyond the realms of the possible to suggest that this duality is a primary feature of the architecture of the human mind. We could hypothesize that there are more thinking types (H. incompetus? H. technologici drivenus? H. disengagii?), but Occam's razor favours simpler explanations over complex ones, and these two categories explain a large proportion of the health system organization. We will leave our evolved dichotomous sub-species hypothesis to future researchers.

However, we offer some advice. Have you formulated strategies to help you cope with the other exemplar types? To be forewarned is to be forearmed. You cannot readily change naturally selected characteristics which become hard-wired, of course, but whichever sub-species you belong to, you can learn how to navigate socially within your own group, and sometimes even outflank those in the other group. There is anecdotal evidence that some have befriended members of the other species, and a few have even swapped allegiances. Indeed, you and the great apes are evolved with great potential for this, along with capacity to forage for resources, politically manoeuvre and survive in the savannah... and the Trust.


Competing interests None declared.


1. Braithwaite J. Hunter-gatherer human nature and health system safety: an evolutionary cleft stick? Int J Qual Health Care 2005;17: 541-5 [PubMed]
2. Burns T, Stalker G. The Management of Innovation. London: Tavistock, 1961
3. Dixon J. Reforming the NHS in England. BMJ 2005;331: 852
4. Pruitt SD, Epping-Jordan JE. Preparing the 21st century global healthcare workforce. BMJ 2005;330: 637-9 [PMC free article] [PubMed]
5. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th edn. Washington, DC: American Psychiatric Association, 2000
6. Braithwaite J. An empirically-based model for clinician-managers' behavioural routines. J Health Organ Management 2004;18: 240-61 [PubMed]
7. Braithwaite J, Finnegan T, Graham E, Degeling P, Hindle D, Westbrook M. How important are safety and quality for clinician-managers? Qualitative evidence from triangulated studies. Clin Governance: An Int J 2004;9: 34-41
8. Braithwaite J, Westbrook M. A survey of staff attitudes and comparative managerial and non-managerial views in a clinical directorate. Health Serv Management Res 2004;17: 141-66 [PubMed]
9. Iedema R, Degeling P, Braithwaite J, White L. ‘It's an interesting conversation I'm hearing’: the doctor as manager. Organ Stud 2004;25: 15-34
10. Lawrence PR, Nohria N. Driven: How Human Nature Shapes Our Choices. San Francisco: Jossey-Bass, 2002
11. Beaugrand JP, Caron J, Comeau L. Social organization of small heterosexual groups of green swordtails (Xiphophorus helleri, Pisces, Poeciliidae) under conditions of captivity. Behaviour 1984;91: 24-60
12. Gherardi F, Atema J. Memory of social partners in hermit crab dominance. Ethology 2005;111: 271-85
13. Mech LD. Alpha status, dominance, and division of labor in wolf packs. Canadian J Zoology 1999;77: 1196-203
14. Read DW. Change in the form of evolution: transition from primate to hominid forms of social organization. J Math Sociol 2005;29: 91-114

Articles from Journal of the Royal Society of Medicine are provided here courtesy of Royal Society of Medicine Press