Curing the NHS
I have vague memories of an advertising slogan which ran something like: 鈥淲e鈥檇 rather sell 鈥榚m than count 鈥榚m."
It was a plug for one of those semi-permanent sales which seem such a salient feature in contemporary commerce. However, it came to mind when I glanced at the Howat Report into Executive spending priorities.
You know, the report 鈥渟uppressed鈥 by the previous administration but published under the glad new dawn that is John Swinney.
I say 鈥済lanced鈥 advisedly. I freely confess I have yet to study the report in detail - although I will. It may be a character flaw but I am always happier ploughing through financial papers than absorbing the stilted, over-blown prose that characterises most political speeches.
Anyway, Howat drew an initial glance - and I was struck, once again, by the inability of bean-counters to cope with the Leviathan that is the NHS.
Howat agrees with Audit Scotland that 鈥渋t remains difficult to assess whether the NHS in Scotland is delivering value for money鈥. Is it perhaps beyond difficult? Is it philosophically impossible?
Further, is it possible that improving the audit capacity may actually hinder or distort the small matter of catering for patients? Has this already happened through the obsession with targets? Did this oblige clinicians to pursue objectives which departed from medical decisions they would otherwise have taken?
More, how do you measure 鈥渟uccess鈥 in such a value-laden sector as health care? Yes, you can count how many enter hospital - and how many live or die. But how do you assess the quality of care received, the experience which contributed to well-being - or left them feeling worse, psychologically, than when they entered? In particular, how do you do this in such a vast organisation?
Should we perhaps abandon the search for a perfect audit experience - and, instead, rely on less precise but perhaps more valuable measurement tools such as surveys of patient opinion?
As the clinician might say, we鈥檇 rather cure 鈥榚m than count 鈥榚m.
I'm 
Comments
Four and a half hours waiting in A&E (Hairmyres, 2006) to be seen for a broken bone - not acceptable under any measure of counting. Lets get that sorted out!
I think it's possible to do both. In terms of hard data it should be around number of people requiring treatment, when they get it and whether it was successful. But patient perception surveys are also very important - how did they feel they were treated, did they get the service they expected, do they feel better etc. But these then need to be acted on - not left to gather dust.
EG
I totally agree that the government has brought in far too much target management. It's stopping people doing their jobs properly because they are trying to meet targets(police, parking enforcers and teachers are 3 that spring to mind as well as the NHS). The trouble is, how do you avoid this when everyone is so fond of statistics these days?
When I have needed the NHS, it has been there for me, and I've no complaints. Anyone who doesn't appreciate it should try living in America for a while.
Of course, there's always room for improvement, but at present it suffers from constant meddling by political pen-pushers and bean counters and the perception that everything can be cured by
A satisfied customer,
ed
There's a wonderful device which sorts good service from bad service and requires no management from the centre. It's called "The Market". Many may be surprised to learn that it is already being used to allocate most of the resources in our economy. If a business is rubbish, it closes. Why, oh why can't we have a market mechanism in the NHS?
Ed, expectation is always measured against the investment put in. It is not about whether we have an NHS or not (i.e. Americans obviously have a different system).
With the millions of pounds put into the NHS by this disastrous Labour government, people are justified in feeling let down when the care is not good enough. Perhaps like football, when you go see part-timers in the 3rd division you dont expect a showpiece game, however when you watch the likes of Chelsea you expect quality since they have spent huge amounts of money on their "product"
The bit that hurts is that it is our money being wasted not Abramovich's!
For our family, the NHS has been absolutely wonderful. Time and time again over the years its dedicated professionals have come up with life-saving solutions for our son who has had ongoing severe and complex health problems since he was very small and which have required continuous expensive multiple treatments. Thanks to their expertise, dedication and often heroic efforts he has grown up into a happily independent 21 year old with a job and a flat).
The NHS is as jewel without price.
No, performance assessment is essential where vast amounts of public money is being spent by individuals who are not the public face of the NHS.
We cannot accept that the NHS is delivering value for money from those that have an interest in their efforts and performance being positively presented; 鈥渢rust me I鈥檓 a doctor鈥 is not good enough.
The only time I have needed to access NHS 24 was to report, an individual suffering shortness of breath and pain when breathing, four times I was informed this was only flu and four times the patient was informed 鈥渋t is only flu.鈥
This resulted it an emergency admission the next day with14 days as an inpatient for pneumonia, the attending doctor stating 鈥測ou were lucky.鈥
When I received the recordings requested under the Data Protection act there was not one reference to 鈥榝lu;鈥 it took three months for the recordings to be supplied, when I claimed that the tapes had been edited I was carefully answered by in the following manner, 鈥渢he person who copied these onto the tape did not edit them.鈥
The old adage of 鈥渄octors bury their mistakes remains true.鈥
Having worked in the NHS on both side of the border the biggest problem in the NHS is that there is no agreed definition of 'quality'.
Having tried to help by explaining that the internationally agreed definition (ISO 9000) is that quality is the ability to meet patients needs and expectations (note not wants).
Clinicians tend to respond that you can't measure health quality in that way because doctors are the only ones that know what a patient needs (missing the point of service delivery completely) and the NHS management see quality as defined by ISO 9000 a process that could hold them accountable for service.
So what they have done is spend a fortune re-inventing the wheel and creating a whole series of mini-quangos of which NICE is a good example of ineffective assessment of patients' needs and expectations.
An everyday example of the NHS failing to meet the needs and expectations are the unclean wards.
As for the bloke who waited four and half hours the failure may not have been the length of wait - there could have been a more serious case - but failure to inform him of the delay and why. The NHS failed to meet his need or expectation and that is poor quality of service and care.
Can I be the first geek to point out that the quote Ed attributed to Caius Petronius existed nowhere in print unitl the 20th century and is almost certainly widly wrongly attributed?
And it's Gaius, not Caius.
Sorry!
>Is it philosophically impossible?
Yes, it is, because so much depends on context and one's own mental outlook.
I have seen the NHS excel when my son needed emergency treatment.
And I have seen NHS staff use eBay for personal shopping for long periods while at work.
Like any large organisation there are first-class, talented and dedicated people along with the usual proportion of numpties and slackers. (Much as you have accurately observed being the case at Holyrood.)
the basic idea is to keep fit, but the NHS is excellent if you're suffering from brucelosis, distemper or hard pad.
(with apologies to Scotland the What)
I agree that it is time that we moved into the "post-performance-indicator" age - the sooner the better.
As for the "quote" by Cauis Petronius, I'm afraid that is a fake that has been appearing in business management books, newspapers etc since 1970. Nice though it is, it isn't true. If you can prove otherwise there are some Classics specialists who would love to hear from you.
The problem here is that the NHS funds will always be limited. I am sure the NHS could spend the entire GDP of the nation, and spend every penny well and to the benefit of patient health, and still be able to spend more.
Therefore, whatever the budget level, the NHS has to have some way of measuring the benefits of its services, and rationing its services so that the greatest overall benefit is provided.
To not do so will not make more money available - it will mean less benefit is provided.
I think that NICE, aiming to be independent of the NHS and the politicians, is a great approach for achieving this.
#1 just think, in three years time with Monklands downgrading to level 2 hospital, the projected 30-40% of cases it can no longer treat will end up at Wishaw and Hairmyres. Even with investment in community casualty units (only open 9-5 in most cases) and out-of-hours care for minor injuries. A fair whack of the emergency admissions deemed untreatable at Monklands are going to end up at the other two Lanarkshire hospitals. Putting strain on already overstretched hospitals and with the supposed increase in beds being less than Monklands has which mostly is like a branch of Pizza Hut on a saturday night - queuing at the door for a bed. Lets see what the SNP do in relation to their promise of the retention of a full A+E at Monklands (along with the retention of all inpatint services too!)
Also as I would like a job in a coronary care unit (I'm a nurse), it would mean I could get a job in Monklands which is only five minutes down the road! Instead of working in Glasgow Royal, a.k.a. Stabb Inn.
In England a GP has set up a web site called Patient Opinion that allows people who have used the NHS to leave their comments. Users can then search the web site to see what service is like in a hospital.
Perhaps Brian can ask one of his colleagues to do some more research and see if he can help us get patient opinion rolled out to Scotland
Health care, like many other parts of the public sector, have been afflicted by "Managerialsm" in recent years, an approach shared by New Labour and Tory alike. It is based, believe it or not, on the principles of "scientific management" that were discredited many years ago!
It assumes that statistical measures should be imposed and used as a basis for targets. But the targets are usually only very crude surrogates for what we should care about. Hence, health care becomes about measuring waiting times, the percentage of beds filled etc. It assumes chasing these targets is a good substitute for assessing if people are getting better. It does not measure health impact directly at all. Then what happens is clinicians are expected to chase these targets, rather than being solely concerned about providing the best health care. It undermines the basis of clinical professionalism, and places the wrong demands on clinicians.
I want to see more demands on clinicians, but the demands I want, are on two fronts. First to treat patients to the highest of standards, and secondly to continuously develop and strengthen clinical standards. To do this would mean throwing out entirely "managerialism" and introducing a more professional (but at the same time much easier and more rational) approach. For example, I would argue that the key is to develop professional "communities of practice" at local levels, with a focus on critical professional engagement with one another, aimed at improving health care. The politicians should step back from their obsessions with surrogate measurement, and encourage the development of such communities of practice. The key is to do our collective best to improve peoples health.
If A&E and the Out of Hours Service could get shot of the eejits that use it as a substitute for their own General Practice (and to be honest, as a substitute for common sense!), there would be far less waiting times for us to treat those who are seriously ill. A&E/OoH is not staffed to cater for anyone who fancies dropping in because they can't get hold of their GP. Why do these people attend? Are they stupid? Or are we just stupid for putting up with them? We want to see you if there is something wrong with you, not because you've had a cough for two weeks and you can't sleep at 3 in the morning! Go away, use your common sense and leave the emergency services for people that actually need it,
As an aside, the people who tend to complain loudest and longest, are usually those with whom there is very little wrong with. The next one to tell me that he pays my wages and I better pull the finger out - although not usually in such polite terms! - is really going to get it!!
We all love to complain about parts of the NHS when changes or decisions affect us, and then to praise it (occassionaly) when people provide the care, support and medical miracles that we expect.
Surely though, the time has come for us all to take more responsibility for ourselves. The NHS budgets would not be under so much pressure if the majority of us took a bit more regular, gentle exercise; drank a few less glasses of wine; lost a couple of stones; spent a bit more time with our elderly relatives and friends; took time to listen to other people; and avoided the relentless "expect it now" consumerism that drives so many of us to a stressful cycle of debt and overwork.
Scotland prides itself on its sense of community. A bit more caring for ourselves and for others might lessen our need for expensive health care, and improve our mental health and wellbeing into the bargain.
(and yes, I need to take my own advice)
we are so lucky in this country to have a free 24 access to health care, and all the professionals of whom I am one deserve a huge praise for their efforts most go the extra mile staying late and foregoing breaks keeping up to date and develpoing always done on our own time. many other countries are jealous of the level of service we as the public recieve however this service is not without cost.
to the person who waited 4 1/2 hrs for a broken bone did it occur that the reason for this wait may be for dealing with others who were critically ill at this time rather than the staff had all popped to mcdonalds or such like.
I agree however much needs to change we should develop our nurses and clinicians to lead and manage our service rather than a huge number of senior managers from retail sectors who care nothing for patients satisfaction or the time it takes to explain and help a patient understand their illness journey.
more emphasis needs to be placed on promoting health rather than the crisis management of ill health when it is too late and enable people to care for relevant illness independantly with help and support rather than the brush off patients can often feel they are recieving.
a little thought into access, should primary care be more than 9-5 in the days where we are all strongly encouraged to work and therefore cannot access our gp if required.
while we are at it seeking help when ill from a gp is no good when the appointment is two weeks on tuesday.
there are no easy answers hospitals and training nurses and doctors costs money which is of course limited and spending must justify the means. however when and who will have the courage to reward our nurses financially for their critical and challanging job inline with others in the public sector such as police firemen and teachers and then maybe recruitment and retention may be addressed because at this time as a mother of two children I would not recommend nursing to any youth as the professional recognition is not there and we are very much taken for granted and if this continues we will continue to leave in our droves
Its obvious.....survey the patients....but I suspect that, that is too dangerous, both for the clinicians and the administrators
A basic cure for the NHS would be to ensure everyone washed their hands with hot water and soap. These 'modern' gels are not getting rid of the superbugs acquired in hospitals and the next generation of chemical handwashes will take the skin off hands - believe me. I am one who contracted the new superbug clostridium difficile when in a local hospital for a small examination. Fortunately I was reasonably fit at the time and four months later I am still struggling to get back to swimming even 6 lengths at my gym. Our hospitals are filthy. We could save billions taking cleaning of NHS properties back under governmental control (where there is at least some form of accountability) and ensuring hands are washed. Our prisoners enjoy far better safety than our hospital patients. In Switzerland nobody is permitted to enter a hospital unless basic hygiene is adhered to - all entry is electronically controlled. We really must get back to basics and stop throwing all this money at salaries and high-tech equipment. The cost of treating superbug patients far outweighs any benefit from such purchases.
The whole point about taking the temperature of service quality is to enable change. Change needs to be local, and prompt.
The devil is always in the detail, and the detail is almost always local.
What the NHS needs is local empowerment, and local feedback, producing local decisions that produce meaningful change at the local level.
The longer change takes, and the further away it is from the locus of feedback the less meaning it has. Eventually it reaches the ethereal halls of Westminster where it is good for nothing except sound-bites, back-biting, and posturing.
Give back power to the local practitioners and we will see real and dramatic advances.
Matthew (10),
Thanks for the correction, but do you disagree with the observation about the nature of reorganisation?
厂濒谩颈苍迟别
ed
Ed,
The quote's good (I'm a civil servant and I live this every day), I was sad when I first found out it was a fake too!
Like your website too.
Matthew.