Monday, 21 March 2011

Understanding averages


Over the last few years the ability to collect information from the regional centres has increased exponentially so that we can now reliably assess multiple aspects of their work from locally and nationally gathered minimum data-sets. Using these it is possible to assess performance based on indices such as profit, turnover and safety. This last area has been of especial focus recently due to a few well-documented cases in the media indicating short-comings in the processes followed by the staff.

An analysis of accident rates across all 10 UK regions show that safety is consistently high at over 95% but there is a variation from 95 to 99% - the average being 97%. Further details as to specifics of accidents in the under-performing regions is beyond the scope of this document but also considered unnecessary.

In line with modern statisitical thinking the proposal is to close the under-performing five centres so that only an above average service remains. The resulting cost savings need hardly be elaborated upon here.

The programme has been reviewed at senior management level and been assigned the title of: Consideration of Assessed Regional Departments: Insufficiently Average = Closed .

Thursday, 17 February 2011

The Point of Care?

The NHS has been in the news again with a stinging attack by the Health Service Ombudsman on the quality of care given to the elderly. However, this thinly veiled invective is based on only 10 cases (taken from 226 accepted for investigation). Ten cases, whilst each and every one deplorable, is not a sign of institutional failure in an organisation that employs 1.3m people. These are the 'bad apples' and the full weight of professional and federal law should be brought to bear on any involved in such neglect but it is the tiny minority. To tar the whole of the NHS with this brush is pure sensationalism and headline chasing.

That is not to say that standards have not slipped over the last 20 years with more emphasis on the pseudo-intellectualisation of nursing and the continued attempts to demean medicine from a profession to a job of work. The King's Fund's answer to this problem is to promote their "Point of Care" programme - designed to enable health professionals to reconnect with their patients despite the stresses of the modern workplace. Key amongst the initiatives is something called "Intentional rounding' (am I the only one who weeps in despair when he hears such meaningless patter?). Apparently this encourages nurses to go round the wards and visit their patients before they are called to help with something. This just used to be called 'nursing'. The very fact that a programme exists to encourage nurses to visit patients before they buzz for help is an indictment of their current training, not to say attitude.

Bad apples aside, most mistakes and cases of poor practice in the NHS are due to either laziness or the failure to carry out usually simple instructions. This in turn is a function of the deprofessionalisation of medicine and nursing caused by a loss of the values of the past in favour of the shallow ideals of today. To change this around requires a wholesale change in the education of student doctors and nurses from ground level up and a strong, respected leadership for them to aspire to. This cannot happen overnight an certainly requires more than an effete soundbite of a programme that amounts to an apologist for the lack of basic principles.

Wednesday, 16 February 2011

What would the AV mean for your health?

There has been much debate this week about the Alternate Vote system for future General Elections. The government will have a referendum on the matter where we all have our say. I do not wish to rehearse all the arguments for and against - these have been covered endlessly elsewhere - but simply to ask: "What effect, if any, would the introduction of AV have on our Health Service?"

Let us first consider the most basic fact. What would have happened to the make-up of parliament last May had alternate systems of voting been used? The above graph shows you the situation in all five of the proposed methods. A Coalition or minority government in each case with the Liberal Democrats (with possibly groups of minority/extremist parties in the case of full PR) as permanent kingmakers. Is this a good thing? Other European countries function perfectly well with successive coalitions and their health services have not necessarily suffered. The UK is however, in many respects, not Europe. Like it or not, policies that have encouraged us to emulate the Continent have not always worked - think 24-hour drinking/cafe culture.

Would the NHS, by then possibly with an independent NHS Board ostensibly outside direct political control, be much affected by changes in a government that had to accommodate more than one view? It is possible that future administrations might want to reverse this autonomy although it would be risky politically, given the degree of distrust that the public has for politicians tinkering with the service after the clumsy, shackling central target culture that characterised the Blair/Brown years. It is possible that future, more right wing governments might want to cut funding in favour of more involvement of the private sector (the seeds of this are starting right now). Having a centre-left balance might therefore not be a bad thing.

But overall, the NHS at 63 years of age, has a central place in the heart of the nation who will therefore not tolerate its dismantling and politicians do it at their peril. There will always be stories of mishaps - disasters even - as there will be in any health service in the world but underneath we know that we have it good. So good. As many people as live on these islands enjoying largely free and comprehensive healthcare remain uninsured in the USA.

So whilst the political landscape may change in other respects the NHS will remain relatively immune to changes in the voting system. So in the referendum, vote whichever way your conscience tells you. You'll still have a health service, free at the point of care.

Paul helps set up a new service

Despite the rumblings of discontent that the new methods of administration had brought, work continued apace. The Ferraris were driven out to executives for the weekend; the removals vans could barely keep up with demand; the estate cars towed caravans until their drivers nearly broke down with exhaustion; the bulldozer cleared the way for everyone to go to work each day.

Despite all this the drivers continued to think up new ways of improving the business. It was quite clear that demand for the caravan-towing arm of the operation was mushrooming and the current quota of drivers and vehicles could not really cope. They knew of a colleague who was just finishing a short-term contract with a rival company nearby and they wondered whether he could be persuaded to join them and help increase their capacity. They took the proposal to Paul.

Much to their surprise Paul was in favour of the idea and approved it without much hesitation. He authorized the new post. As to the work that he was to do, he merely had said: "Just get it up and running through the usual channels."

That was two months ago. Setting up this additional activity had not been as easy as they had initially hoped. Paul's 'usual channels' - ones he had created alongside all the other new initiatives - were not entirely straightforward. After the visit to his office the drivers had gone to see the Vehicle Bookings Clerk to arrange for bookings for the new driver to start. She was keen to help but explained that she needed to run the idea past her supervisor, who was away that week.

When this lady returned, she seemed quite amenable to the scheme but felt that it still needed approval form the Vehicle Bookings Manager. This person only worked on Thursdays and Fridays and no one could deputize for her but the Bookings Supervisor thought that time would not be wasted as she could "run the idea past the Section Service Transformation Lead".

This young man, Norbert, in turn thought long and hard about the plan and asked whether executive agreement had been sought for the post of the new driver. The other drivers were by now becoming a touch exasperated and replied that they would hardly be trying to set up more bookings if they hadn't secured this rather obvious first step to start with. Norbert thought he had better check with his Section Operations Manager, who in turn asked Paul. Paul remembered that he had acquiesced and sent a message to the head of the 'General Performance - Car Concern' group to chivvy things along as he was noticing the increase in delays from booking to delivery of the cars and this had led to some heated discussions with the head of the Sedan and Hatchback Agency.

When the Vehicle Bookings Manager returned she saw this correspondence and acted quickly. First she enquired whether this was an new service they were offering or the extension of an old one.

"For heavens sake, Mabel!" chorused the drivers. "You know it is the extension of the caravan-towing service. You come and pester us to take more of these bookings on almost every week because there are so many! Now can you please just set up the booking facility?"

"You need a code," objected Mabel tartly.

"And how do we get one of those?"

"You need to fill out this form," she replied triumphantly, handing over a thick wad of papers.

And so the drivers sat down to fill out the form, answering questions that had been sorted out at the very start of this process but trying nonetheless to keep their patience. Proudly they gave the completed result to Mabel later that day.

"Can you get a code now and start booking?" they asked hopefully.

"Codes are issued by the Vehicle Bookings Manager," she replied. "She's on a Communications Course but will be back next week."

And Paul looked on from his office on the top floor, and smiled, and felt a deep wave of satisfaction wash over him as he regarded his kingdom, where everything was proceeding like clockwork.

If you think this tale is far fetched, just try setting up a clinic for a new colleague in today's NHS.

Monday, 7 February 2011

Paul makes sense of economics

It was a fine summer's day. Paul sat by the open window and gazed at the activity outside. Presently he heard two of his workers - one driver and one of the fuel pump attendants - in conversation.
"Hey, Billy!" called the driver. "Can you give me a hand with this roof-rack. I need to remove it from the car before the next trip and it's a bit stuck."
"Sure thing Jack," replied Billy. And they set to work.
Paul was incensed.
How was Billy going to account for this time. He was not working on his designated tasks - he would doubtless be late for something. And Jack - he was being paid for work not all of which he would have done himself. It made him seethe with anger.
He got to work with pen and paper and by the evening he had come up with a plan. The very next day he called all the workers together for a meeting.

"It has come to my attention that tasks within the company are being performed by random personnel," he began. The drivers and washers and pump attendants and all the other workers looked nonplussed.
"Work is being performed by personnel outside of their usual occupation, which will have downstream knock-on effects on productivity."

The staff looked mystified.

"To combat this I am from today introducing a new system whereby individual groups can both sell their services to other groups and purchase others within the company. The drivers' grouping will be known as the 'General Performance - Car Concern'; the fuel pump attendants and washers will form the 'Forward Taskings' group; the management in this building who oversee and regulate all the work will be known as the 'Sedan and Hatchback Agency'. All will have budgets for which they will be accountable and from which they need to purchase services from other groups. They may of course attempt to turn a profit - either by also offering their services elsewhere, or by looking for services that are cheaper outside and thus saving money. This degree of competition will, I am sure, drive up the quality of what we do."

The staff looked mystified.

"How on earth is that going to make us more efficient, Paul?" they asked. "For a start it'll take half our day just to manage all this new paperwork."

"Ah!" countered Paul, pleased that he had an answer to this. "We will employ new people to do this for you. The 'Profitable Car Traders' will work with you to achieve maximum profits."

"Surely this just adds to the expense, Paul? These extra layers of bureaucracy won't make us work any better."

"Oh, I think they will." smiled Paul knowingly. "Once you have your individual budgets to safeguard you will understand the meaning of efficient, cost-effective and accountable work. Competition with the outside world is no bad thing."

"Maybe not," argued the workers. "But we have fuel pumps and washers here on site. Why would we go anywhere else? For a start it would take us miles out of our way and so increase the time spent on a job."

"Other companies can now tender for providing these services more cheaply. Once you see you are saving money you'll change your minds."

The staff looked mystified. "Saving what money, Paul? This all comes from the over-arching budget of the company. There's no real money behind this initiative - only numbers on a spreadsheet, accounted for in a different way."

"Wait and see," said Paul, and got up and left.

And so the drivers and washers and fuel-pump attendants all convened into their nominated groups and started to buy and sell services to each other, though did not notice much difference in the way they worked, other than there was a lot more paperwork.

The Profitable Car Traders closely monitored the number of interactions between the General Performance - Car Concern and the Forward Taskings groups and the Sedan and Hatchback Agency set targets for the maximum allowable number of these interactions. At the end of the year there was very little change in the number of journeys the drivers had undertaken or the way in which the company was perceived by the outside world but there was a large amount of data on how this had come about.

And the drivers noticed that as attentions were now so focussed on the flurry of paperwork that pervaded the buildings no one really gave much thought to the customers anymore.

Sunday, 6 February 2011

Big Society? No - Big Responsibility

Well, it never really looked like living, did it? The last week has witnessed several pre-terminal gasps from Mr Cameron's Big Idea. Charities leaders are lambasting the public sector cuts that are severing the lifeline that should have fed the initiative and a flagship council withdraws from the programme citing, again, cuts.
The fundamental flaw with the Prime Minister's idea is that although the British public are by and large very keen and able volunteers there is a vast difference between helping to run something and running it. This he has failed to grasp. The financial, legal and moral implications of taking on ultimate responsibility for an enterprise, be it library, school or local swimming pool, is a world away from donating even large amounts of time to it. And so it is that the Big Society will die a rapid death, unmourned by most, leaving the Coalition's flagship ideological legacy in tatters.
What implications this will have for the Health Service remains to be seen. Whilst I am sure that not even in his wildest dreams did Mr Cameron envisage local people clubbing together to run a 'failing' hospital (I am crossing my fingers here) there may yet be knock-on effects with respect to GP commissioning. This other half-misguided policy leaves GPs holding much of the NHS budget to purchase care for the patients (purchasing care, you will notice, that is also given by themselves). Who gets a, for example, physiotherapy contract is no longer a given but groups could tender bids just as in the world of business. Whilst clearly these sort of bids are outside the general level of Big Society thinking it is not hard to shift the ideology up a level and expect suitably qualified groups of independent specialists in this field or that to make bids for fragments of contracts for a myriad of services.
The more fragmentation that goes on, the less smooth the patient's journey from one medical staging post to the next. Those with chronic diseases will be proportionally more affected as they need more 'fragments' of care.
The death of the Big Society, its own highly suitable acronym, might help limit the amount of this breaking up of our national treasure that can go on. Perhaps there is after all a silver lining.

Tuesday, 1 February 2011

Red Dolphin's response to the Health Reforms (2): Quis custodiet ipsos custodes?

The idea of de-politicising the NHS if of course attractive. Removing it from the short-termism of the past, with politicians creating sub-5-year milestones that enable them to massage the data into their re-electability is clearly not a sensible way to form strategy for a country's health service, where the term of a parliament is but the blink of an eye. Under the new reforms Monitor, the independent Foundation Trust regulator, will be given far more powers. It behoves us therefore to scrutinize this body closely and ask: is it able to perform this extraordinarily delicate and vital task, and also - who guards the guards?
Remember that this watchdog had the responsibility to ensure that all Trusts are able to stand firmly on their own financial feet but under the new Bill it receives a far wider mandate to include licensing providers, price setting, promoting competition and supporting service continuity. This is from it's own website.
But wait one moment. 'Promoting competition' and 'supporting service continuity'? Is it just me or is that a contradiction in terms. Let us just imagine for a moment...
Let us say that a hospital is offering a diagnostic service that is an integral part of a pathway for patients with a variety of conditions. The result is fed into the body of knowledge that is accumulating on the patient and reviewed in a specialist clinic or multi-disciplinary team meeting. Now consider that a private consortium - hospital, independent diagnostic centre or consortium of private providers - offers to undercut the tariff that the hospital charges for this test and wins a contract to perform a fixed number of these per year. However, being outside the organisation the results are not so easily available; they may not find their way to the patient record in time, or at all. The patient's treatment is delayed; the test might even need to be repeated. A pessimistic scenario? Not at all: a regular occurrence since the introduction of the Independent Sector Treatment Centres some years ago.
So how does one square the circle of promoting this competition yet supporting service continuity? Clearly having some experienced medical input into these decisions would help identify such retrograde steps. But one look at the Board and Senior Management Team of Monitor reveals a local government officer, three management consultants, a venture capitalist, two accountants, a lawyer, an HR professional and an administrator at the top table. Not a medic in sight.
So who guards the guards?
No one who might know anything useful.

Monday, 31 January 2011

Red Dolphin's response to the Health Reforms (1)

Posted on the King's Fund website:

"The new reforms have missed an opportunity and the elephant in the room remains. The entirely artificial division of 'providers' (largely meaning secondary care) and 'commissioners' (also of course providers in primary care) serves no one and simply fosters the old antagonisms.
Patients of course are not concerned with these politically driven boundaries when it comes to rapid, effective and joined up treatment. They simply want to see the correct health care professional with minimum wait. Applying free market principles in a closed market has not worked but the ideology continues to be pressed.
Whilst we welcome the abolition of SHAs and PCTs as mountains of needless bureaucracy we are concerned that, at least the latter, will be replaced by something very similar under a different name.
The much needed simplification of the administration of the Health Service is still a long way off."

Wednesday, 26 January 2011

Paul takes charge of training

They were busy times for the company. The drivers could barely keep up with the number of requests for their services. Most of their assignments passed off satisfactorily but sometimes they wished they had different vehicles for certain jobs. Even more than this they wished they could learn to drive their current ones in new and different ways in order to achieve more. But these extra expenses were hard to come by as there was a recession and there was little money for career advancement and the acquisition of new skills. The drivers found this sad but got on with their work, complaining but little.

Paul too had been thinking about training. He had been on a management study day and saw that many coloured bar charts could be produced analysing the number of course modules employees had attended. These in turn curried favour with the executives who liked to feel that they were providing a good learning environment as this in turn ticked many legal regulatory boxes.

Thus it was that he sat down and thought of the many areas that could be addressed by such a training programme. After several days of chewing his pen he came up with an extensive list. He composed a memo to all the drivers informing them of this splendid new opportunity to advance their knowledge and advised them that once they had attended all these modules they would only need to update their knowledge once a year. Topics included 'Keeping Fuel in Your Vehicle', 'Opening and Shutting Car Doors - the Risks and Benefits', 'Car Washing', 'The Importance of Servicing', 'Vehicle Identification', 'What to do in a Breakdown', ' Talking to your Passengers', 'Tyre Care', and many more.

  "But Paul," cried the drivers as if with one voice when they saw this catalogue. "Apart from the 'What to do in a Breakdown' one, these are all useless. We know this stuff anyway and it is very patronising of you to think that we need to go on a course to learn how to shut a door. What we wanted was the chance to go on courses to learn how to drive in the snow, or change a fan-belt on the road, or how to load a removals van correctly. Not how to wash a car, which we do every week anyway."

Paul looked annoyed. All his efforts on their behalf were being spurned.

  "And another thing, Paul," they said. "Doing all these learning exercises will take lots of time - time that we could otherwise be working. We are barely keeping up with customer demand as it is."

Paul looked annoyed. He needed those bar charts.

  "It's not negotiable," he retorted. "It is a part of company policy that you do these and your annual increase in wages depends on their successful completion. We will lay on days when all work is cancelled and you can attend these lectures."

  "But Paul, that will increase delays for our customers even more though," cried the drivers.

Paul looked annoyed. He hadn't thought of that.

  "We will also pay you extra to do some weekend and evening work to clear any backlog," he replied, pleased at this idea. How generous he was!

The drivers shook their heads sadly. "But Paul. That's a huge extra cost to the company. If you let us go on the courses we wanted to go on, instead of these, we would do it in our own time. Some of this extra money could be spent on the course fees instead. That way you wouldn't lose any work and we would all get better at our jobs."

But Paul simply looked annoyed. "It's compulsory," he said. And walked off.

Monday, 24 January 2011

Listen to those who know

One morning Paul walked into the office through the car park where the majority the company's fleet of vehicles was kept. He looked at all the different models and types but was most taken by the row of red Ferraris. It was a picture of this row that appeared on the company's advertisements as they were the top of the range.
'We need to get more of these,' he thought to himself as he passed the other rows of less photogenic vans, estate cars and fuel-efficient Smart cars. And he called his managers together in his office.

None of them had ever driven a Ferrari, nor indeed any of the other cars that the company owned, and rarely met the drivers who did. Nonetheless they made plans for changing the make-up of the fleet and energetically wrote business cases to this effect.

On his way to another such planning meeting Paul bumped into one of the drivers in the corridor and casually mentioned this plan to him. The driver was aghast.

'But Paul,' he said. 'The Ferraris are only hired by young executives for weekend jaunts. They don't make up a very large part of the business. Most of what we do is long-distance driving of both people and goods. A Ferrari wouldn't be much use there. The biggest growth area we are seeing is people wanting to hire cars to tow caravans.'

Paul remained obstinate.

'They are our top of the range. We need to get as many people as possible to use them as quickly as possible. We can only do this by having more of them.'

The driver looked incredulous. 'But Paul. The Ferraris are the most expensive vehicle for the firm to run. They cost more to buy, to maintain and to fuel. Why use them for anything other than their specific tasks?'

Paul remained obstinate.

'It is good publicity if people know that we are associated with high profile, high performance vehicles like these'.

'But Paul,' the driver persisted. 'Getting a Ferrari to pull a caravan is not only inefficient practice but it will damage the car if it goes on for any length of time. Not only is there no need to use such a car but it can be positively damaging.'

Paul remained obstinate. He had had an idea and he was determined to see it through, evidence notwithstanding. 'We'll call it the initiative SPECIAL International Superior Transport Service - or SPECIAL-ISTS for short.'

The driver shook his head sadly and wondered why his opinion counted for so little.

Wednesday, 12 January 2011

A tale for our times

Once upon a time there was a man named Paul. He ran a company that hired out vehicles with drivers for a whole variety of different tasks. On the whole the outfit worked well with all the drivers working very hard at their assignments, which were many and varied. But Paul, who had never driven a vehicle, began to feel as if he was being cheated by the drivers and started to think of ways to monitor them. The drivers, who were an honest bunch, were unaware of this and in any case often met up to see how they could do better as they liked their work and were seen by most outsiders as being good at it.

However Paul's suspicions grew and grew until finally he decided to perform checks on the performance of his staff. Sadly, not understanding the work they did, he was unsure what to measure or how to interpret what he did measure or even whether the methods he used to measure things were at all valid. Undeterred however, he set up a complex system that he hoped would calculate the number of miles each driver with his vehicle had driven each month. He argued that as all the vehicles would have to fill up with petrol frequently, monitoring this would be useful and so he managed to put some very expensive sensors in place in the surrounding petrol stations. These would then send him data every time one of his vehicles filled up. He realised that the amount of petrol used depended on a number of variables including the engine size, the type of journey, the condition of the vehicle and the way it was driven so he calculated complicated formulae to factor this in. From these equations he derived his estimates as to how far each vehicle had gone in the last month.

He was shocked. There was a huge variation. Some drivers seemed to be working far harder than others; some appeared to be doing next to nothing and must surely be losing him money. Still he did not ask the drivers as to why this might be but went to lots of meetings with other managers in the company and between them they made even more complex formulae to interpret the data by aportioning it in different ways. Finally though, they decided to meet with the drivers to explain the system to them.

"But Paul!" they said. "If you wanted to know how far we drive why didn't you just look at the milometer instead of setting up this complex arrangement? We do it ourselves every month anyway so we could have just given you the data."
Paul looked a little embarrassed but said nothing.
"Sometimes," they continued "we fill up in far away petrol stations that don't have your monitoring systems so you aren't even capturing all the data."

But Paul wasn't listening.

"And Paul," they said. "Not all our vehicles are the same. Many of them do other tasks as well as simply going from A to B. Just measuring the distance they have driven won't tell you much about what we do."

But Paul wasn't listening.

"Look at Vehicle number Seven," he said, pointing at the spreadsheet. "Last month it only drove three miles, whereas Vehicle Number Two managed over two thousand kilometers."

Ignoring the disparity in units the drivers replied: "But Paul! Vehicle Number Seven is a bulldozer. It can't go very far and in any case its main task is to flatten out the route between the depot and the main road every day. That track is in such bad repair that if the bulldozer didn't flatten it out every day none of the other vehicles could even leave base, never mind do all their work."

But Paul wasn't listening.

"And Vehicle Number Two is a removal van. Of course it clocks up long distances. What you should be measuring is how successful it is at transporting furniture and how much it breaks, or how happy the customers are with the service."

But Paul wasn't listening.

He was dreaming of rolling out his system to all the other branches of the company. He would call it Paul's Longitudinal Investigative Car Survey. Or PLICS for short.

It made no sense but might make his name in the management world.

And the drivers wondered how much all this had cost and whether that money could have been better spent on improving their vehicles or the road, and they wept to see such ineptness all around them but carried on doing what they did very well anyway, much as they had done before.