Told you so

"So how do we save money in this Alice in Wonderland pseudo-economy?" And answer came there none.
"Do more work; see more patients?" Er, no.
"See fewer patients?" No.
"See different patients by changing efficiencies?" Still no.
"Do work for free?" Sorry - still won't work.
All because the organisation that 'buys' from us doesn't have the money to pay the bills for what we do. So it doesn't. But it still expects the same level of work to be done and of course it will be done as no sane doctor will turn away a sick patient.
And there you have the internal market in an unpalatable, zany nutshell. Business principles in the ultimate non-business environment.

I was talking to my mother-in-law the other evening and she was reminiscing about the birth of her daughter, my wife, as parents tend to do on the occasion of their offspring's birthdays. She fondly remembered being in a large single room for a week - yes you read that right: a week - after the delivery, being pampered by the nurses and able to recover in peace. These days, after an uncomplicated delivery she would be sent home inside eight hours. Of course we no longer have the resources to do the former but it does not necessarily make the latter better.
Not everything that can be counted counts. And not everything that counts can be counted. Information is not knowledge.

Here comes the rain....

So after months of dyspeptic rumblings the machine that is the NHS is now due to vomit forth its response to the global economic recession. Healthcare spending will remain static so in real terms it will fall and something needs to give. Because of the ludicrous system of 'them and us' for primary and secondary care described below hospital Trusts are victim to not being paid or work already done and work still to come. One cannot turn a sick patient away from the door (not in this country anyway) so this situation will continue. Regardless of the amount of work commissioned the actual amount done will inevitably exceed it and, in contrast to virtually any other business model, the more we do the more we lose. Crazy?
Never mind that by cutting a swathe through the countless layers of ineffective middle management saving huge sums and improving efficiency. Never mind that the sums involved bear no resemblance to the market price for services in the private sector anyway. Never mind that cuts now will not only not help the current situation but bear grave dividends in the future. No - my major gripe is that when we meet with the bean counters next week to try and thrash out a plan their only agenda will be to cut salaries, lay off clinical staff and close wards.
I shall ask them only one question: "How do we save money in this Alice in Wonderland economy?" And you know what: they won't have a clue because they have no idea what is being counted anyway.

You get what you pay for

Time was, not everything was counted, catalogued and ticked. In the era before management consultancy and targets professionals were left to run their profession with minimal meddling. After all, they did know the most about it. And it worked well. A few bad apples made the headlines and the stifling, corporate, faceless culture moved in to transform a once beautiful vocation into a parcel of 'Programmed Activities'. And there is unlikely to be a way back.
Seven years ago the New Contract was introduced/imposed (delete as per personal view) on the hospital consultant body. Initially representing a basic pay rise along with the threat of no pay advancement for those that did not sign up, it was embraced by the majority. But now those carefully monitored and counted chickens are coming to roost. The working week was painstakingly divided into fractions with each Programmed Activity representing fours hours a week of work. There was initial managerial surprise at the amount of previously unpaid work that went on but after the usual acrimonious 'smoke and mirror' accounting (see below) the answer was usually 'ten'. Some managed eleven or twelve but the allocating depended more on negotiating capabilities than real work done.
Now, with the recession in full swing, there is a desire to cut these 'PAs'. But the expectation is that the previously done work will remain. In days gone by the consultant body would have tightened their belts and weighed in with a collective effort in the interests of professionalism but now, the goodwill having been long since eroded, there is the liklihood that it will take the attitude that - as with any other paid job - if one pays less one gets less work back from the employee. And services will suffer.
That's what comes from having one's cake and eating it. Ultimately they will regret destroying what had been and some lessons are hard to learn but necessary.
Oh woe, my beautiful profession.

Smoke and mirrors

I previously expressed the idea that the finances of the NHS, whilst obviously originating from a central government source, are then split, divided, hidden and generally massaged to distraction leaving no semblance of reason in the resultant mire.
Take this example - not at all unusual I'm sad to say. Consider a business case is written within a particular speciality for four new specialist services - A, B, C and D. All are proven technologies, some newer, some not so new but the team is agreed that to further the department these are essential steps. They collaborate to make the case to the Board to but into these advances. Technology A is a real money-spinner and would, within two years, not only pay for itself but also for the initially otherwise loss-making B, C and D (provided that the Primary Care Trust can fund it - see 'Divide and Conquer' below). The sums work out. The document gets passed through the legions of paper-pushers that inhabit the halls of administration but eventually the answer comes back: 'yes'.
So far so good. Arrangements are made to part-fund technology B from charitable sources and this is forthcoming. B, C and D all start up as they are more easily acquired and the services start later that year. There is small delay with Technology A as competitor quotes are evaluated but soon a decision is reached and the clinicians are happy and keen to proceed.
But.
But, but, but.
Suddenly the message percolates down from on high that the purchasing of this Technology A must wait until the new financial year as there is not enough money to invest in this during the current financial year. Meanwhile B, C, and D carry on regardless - providing a service but allegedly losing money. Money that was to have been covered by the income generated by A...
Could any private sector company run its business like this? Of course not. And there one sees the problem of an internal private market within a state funded system.
These are just numbers on someone's irrelevant spreadsheet but they carry more weight than clinical concerns.
If only it was as simple as looking through smoke and mirrors. Sadly it is the highest imaginable degree of obfuscation, the running of which costs as much as the service that it purports to underpin.
I would weep were I not so angry.

So what's in a name?

It has bothered me for a long while now - so long that I cannot remember exactly when the 'Personnel' department became 'Human Resources'.
Just stop and think about it for a moment. Human resources. How cold is that? But a very accurate reflection of how the system is designed to treat the employees. There is very little compassion to be gleaned out of those two words and it is not a coincidence that over these last years staffgeneral disgruntlement is on the up.
Doubtless a legion of management consultants was drafted in to think up this title - and paid handsomely - but ask yourself whether you would go to a store that was billed as an 'Essential Nutrient Vendor' or see a film called 'Mobile Images and Sound'. And if you were working in that store or making that film how long before you became disenchanted with your core business and gave off less than your best?
I'm betting not so long.

Snail mail? Fail mail

Although it is a large organisation and everyone is aspiring towards a paperless office the reality is that much paper correspondence still goes on these days. From GP referral letters to clinical queries to cheques that are sent in as payment for one thing or another. It is this latter that has been occupying me this last week although the frequent going astray of post relating to important clinical issues is arguably more important and certainly can have more of a serious consequence for the patient - as always unwittingly caught up in this calamity.
Whilst no paper system is perfect (well, no system of any sort is perfect but that's another matter) the error rate of post going astray is extraordinary. No private sector organisation would tolerate it - it could not sustain such a poor public image. Here, in the shielded environment of the state sector, the onus appears to be on the recipient to ensure his mail arrives and the slovenly internal mail system trundles along in its own inimitable, blundering way with no ability for retribution.
It is one of those instances that makes for, on the face of it, a powerful argument for private sector solutions and in this instance - an entirely non-clinical service - that might be the better solution. But the mistake is to try and recreate that solution across the board. The filthy lucre mars good medical practice - look States-side for proof, if you doubt this. Look at our own Independent Sector Treatment Centres.
The genius of the inception of the NHS in 1948 was to remove the two systems (the money and the care) from each other to the benfit of each side. Now the gap is shrinking to the detriment of both although the politicians try to make us believe that this is all 'progress'.
A system of checks ('performance management' is, I think the jargon) is of course necessary but this depends on good motivation. The simpler the system the more likely it is to work and sadly the middle management that runs thie infra-structure is bloated, out-of-touch and ineffctive. 'Performance management' does not seem to apply to them. Their number has doubled in the last decade yet their output has become more and more impotent.
Were the clinical staff to run the various services that underpin the smooth running of the organisation there would be no room for the slovenliness that loses post as regularly as happens now. It is because they are motivated by a vocation. There is no vocation for management.
'Delivering' services, targets and deadlines are a part of the management-speak culture that pervades the country. That the only things that can really be delivered are the post and the milk does not cross their buzz-word polluted minds. Doubtless there lie in a drawer somewhere voluminous files on the departmental structure of the mailroom and flow-charts outlining the 'process'. Employee appraisals may well figure in this file too and probably countless standing orders and records of staff updates.
But can they deliver my mail? Can they hell.

Open letter to the President

Dear Mr Obama,

I've been following your efforts to introduce healthcare legislation into the United States with interest. It is of course high time for an aspiring first world country to have this but I realise that several of your predecessors have tried and failed. I wish you better luck.
Being fortunate enough to live in a country where the ABC of resuscitation is not 'American Express, Barclaycard, Chargecard' you may suppose that I am about to be smug. Not at all. Indeed it is precisely because I am a cog for the third largest employer in the world that I know the system's strengths and flaws. I can appreciate how incredible is this National Health Service of ours but also I can see its shortcomings and write to urge you, if successful in your initial efforts, not to make these mistakes on your side of the pond.
Currently healthcare in your country is a huge business like any other private sector venture. The sea-change that you have to make is that a state sector service no longer follows the same business principles and that the more it tries to do so the more ineffectual it becomes. Let your traditional managers run the show and you will probably be worse off than now for not only will the system fail but it will not provide the niches of excellence that you currently do have.
Here is an area where all the key personnel by definition have started on the shop floor and worked their way up. Consultants (attending physicians to you) and senior nursing staff were not born, but made. These people know more about the nuts and bolts of what is required than any health service manager fresh from grad school.
Whilst you will of course need some checks and balances to ensure equity and fair play, please try and keep the system structure simple. The more convoluted layers of management and regulation you put in place the more clogged the whole becomes.
And don't, whatever you do, try and recreate a mini-economy within your health service: the internal market is a distraction and a failure here with no easy way out.
For both good and bad: look over here and watch, and learn.
Best of luck!
Yours sincerely.