Pride and Joy

Alex Knight



Level of TOC knowledge acquired:

Intermediate and Introductory


316 pages

Designed for:

Academics, Consultants, Implementers and Managers


Operations/Production, Strategy and Tactics, Change Management/Buy-In and Ever-flourishing




Buffer Management and Strategy & Tactic Tree


English and French





Written as a business novel about a struggling hospital, Pride and Joy 
takes the reader through a journey of discovery into why good people with good intent struggle to achieve a breakthrough in performance. It offers a practical way to address the core problem of our health systems and achieve high-quality, patient-centered affordable care for all.

The first third focuses on answering the questions, \\\\\\\'Why is there a need for change?\\\\\\\' and \\\\\\\'What to change?\\\\\\\' The analysis is based upon the typical situation found at a local level.

The middle third of the book applies the Theory of Constraints (TOC) to the hospital\\\\\\\'s major streams of care and links in the healthcare chain. The Theory of Constraints was invented by Dr Eliyahu M. Goldratt and is best known through his book, The Goal. TOC is based on the belief of inherent simplicity—that in any goal-oriented system there are only ever a few places that have the power to affect the performance of the whole system: the weakest link(s)/constraint(s). In Pride and Joy the TOC principles have been adapted to fit the healthcare environment and through logical derivation the reader sees how the ideas are practical, common sense and can be implemented in a short timescale to achieve unprecedented results.

The final part of the book demonstrates how a nation can safely, and in an affordable envelope, achieve a breakthrough in performance at a national level and provides a working hypothesis for a global solution that involves a change in mindset of all stakeholders in the chain.

Health Systems Around the World are facing the Perfect Storm

Healthcare systems appear complex. Each patient requires the efforts of many different resources—both people and equipment—before they are clinically fit to go home or move to the next stage of their healthcare journey. The most common response to this seeming complexity is to divide the system into parts and manage and measure each part in an attempt to improve the whole. Such an approach may have an impact when the number of system variables are relatively small and the variability within each dimension is relatively small. However, our health systems are an example where almost the opposite extreme is true: we face the perfect storm.

Alex Knight
BSc, MBA, CEng

Alex has worked around the world alongside many great leaders in health, social care, for-profit and not-for-profit organisations. His consulting, lecturing and coaching work has shown him, first-hand, the joys and struggles people face in their endeavours to improve their services and businesses.

Alex's work is guided by the scientific approach and the principles underpinning the Theory of Constraints (TOC); a belief that inherent simplicity exists: in any goal-oriented system there are only ever a few places that have the power to affect the performance of the whole system—the system's constraint(s).  

Alex was fortunate to be mentored by Dr Eliyahu M. Goldratt, the inventor of the Theory of Constraints. Their friendship lasted almost three decades and included a period when Alex was the first chief executive of Goldratt Consulting Ltd, where he helped to steer the organisation through its formative years. Alex is recognised as one of the world's leading authorities on TOC. He led the introduction of the first ever Masters in Theory of Constraints at Nottingham and Trent Business School; a programme that continues to run and is the only Masters programme in TOC in the world.  He is also a board member of the Theory of Constraints International Certification Organisation and the Goldratt Foundation. 

Prior to his role in Goldratt Consulting, Alex was the managing director of Ashridge Consulting, which is part of the Ashridge business school, and was a board director of the business school. While at Ashridge Alex taught on many strategic and operational programmes and consulted at a strategic level to a wide range of organisations. During his time at Ashridge Alex investigated many different consulting approaches and advocates a few that he believes help people to see the world anew.

Alex is a founding partner of QFI; an organisation committed to applying the scientific approach and Theory of Constraints to seemingly intractable problems—problems that are limiting the organisation's performance. This often requires Alex to take the principles of TOC and invent new, practical and robust solutions.  Most recently Alex has applied this thinking to the integration of healthcare, in particular to community-based healthcare. He is also exploring healthcare at a national and a global level—analysing the seemingly intractable problems. 

Pride and Joy is an extraordinary book in the way it communicates actionable insights about the inherent simplicity in apparently complex human systems such as healthcare organisations. Taking the form of a very readable novel it describes how focusing on patient flow brings significant improvement in health outcomes without exhausting finite resources or compromising quality of care. As a customer and financier (through tax) of the UK healthcare system I sincerely hope the message in this book will be absorbed and acted upon by political, clinical and operational leaders.

John Murphy
Vice President of a major global industrial company


Pride and Joy has the potential of doing to healthcare what Goldratt’s The Goal did to manufacturing and supply chain.  Alex describes the environment and crisis situations where they could take place in the US, UK, Australia, Canada, etc. The problems are universal. The situation is complex and impossible to many BUT as anyone in TOC knows, the more complex the situation the simpler the solution.  Alex proves this to be correct.  Once you read each solution; your response should be: That’s brilliant!  You end up making this statement a number of times throughout the book. In my opinion, this book may provide the solution to implementing universal healthcare without bankrupting the country for the US.

James F. Cox III
Professor Emeritus, University of Georgia


This is a must read for politicians, policy makers, clinicians and managers. It tells the story of how healthcare systems can be managed in a sustainable way with the patient at the centre of decision making.

Dr Mike Williams


Patients should only stay in hospital as long as they need to. This is central to the quality of care. Read this book - it will change your view of how to manage patient flow in a hospital. It can transform the way we deliver care and steer us away from the downward spiral of poor quality, poor performance and inefficiency.

Jeffrey Worrall
Portfolio Director

NHS Trust Development Authority 

Derby office



Chapter One - Helter-skelter
Chapter Two - Never... again
Chapter Three - Money
Chapter Four - Stevie
Chapter Five - Crocodiles
Chapter Six - Ever-fluorishing
Chapter Seven - Be Linda
Chapter Eight - Murphy
Chapter Nine - One more roll
Chapter Ten - Looking in the mirror
Chapter Eleven - An unrefusable offer
Chapter Twelve - Sorcery or science?
Chapter Thirteen- Setting the rhythm
Chapter Fourteen - Pride
Chapter Fifteen- And
Chapter Sixteen- Joy
Chapter Seventeen- Scrambled eggs
Chapter Eightteen- Showtime
Chapter Nineteen - Reflections
Chapter Twenty - Strategy and tactics
Chapter Twentyone - Brotherhood
Chapter Twentytwo - Butterfly
Chapter Twentythree - Yes, but...
Chapter Twentyfour - Yes, Minister