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August 11, 2009
The NHS is coming under increasing scrutiny, and the issues around its funding once again making front page news. There are some recurring statistics: productivity in the NHS has fallen by 4% despite a large cash injection from 1997 onwards.
But what does this mean? There is an increasing drive for doctors in training to have formal management qualifications. With this in mind, what does a 4% increase in productivity actually mean? Does every doctor do 4% less work? Are patients likely to get only 96% of the treatment that’s should be given to them? More importantly if a trainee inside the organisation, with an interest in management has little idea of how the numbers are derived, and what they mean to the average medical clinic, A&E department or on call surgical list, then there is a problem.
The most telling argument was a rule mentioned in passing to me by a colleague. It doubles follows a principle which despite my ‘intelligent’ Google searching, I cannot find…It goes like this: once you turn a marker of performance into a target, that marker of performance ceases to accurately reflect performance.
When applying this to the NHS you get a simple, understandable concept. Consider the Emergency department 4 hour wait. It is likely that departments that were seeing, treating, discharging or transferring patients within 4 hours of their arrival in that department were good A&E departments, better than the ‘norm’. Where is the evidence for this? Common sense and expert opinion!
Once the 4 hours becomes a target, then hospitals managers will be ‘forced’ to hit those targets. If that means renaming a bay in A&E as an inpatient observation ward then so be it. If it means treatments being delayed, then so be it. Its increasingly common for junior doctors to be faced with management policies at their inductions, and the potential repercussions of not fulfilling specific targets set. Its more likely that they will be turning away from the NEJM to the other publications (for example form the Medical Defence Organisations like the Medical Protection Society) that produce survival advice for newly qualified doctors in changing times.
The difficulty is introducing the kind of lean management principles reported in the late 1990s by the American Academics that sought to find out why Japanese Car manufacturers like Toyota could produce and import cars to the US for less money than their American counterparts.
It is the challenge of meaningfully measuring and quantifying management performance in the NHS that is the challenge. Getting from line staff (like myself) to understand the concepts of productivity is critical, as is giving departments this sort of information.
If the focus shifts to lean and efficient management processes, then the numbers behind the targets will follow. The measurement of markers of productivity needs to be more transparent to staff, patients, and contributors to the NHS budget (British taxpayers) to allow them as voters to make informed decisions surrounding healthcare policy.