27th November 2023
Relentlessly falling productivity (Part a).
Regulatory constraints.
I was in the midst of writing another blog on what is wrong with the NHS, happily highlighting a few of the many pointless tasks that get in the way of clinical work. But my attention kept being drawn to the more general issue of the widespread fall in productivity.
Here, from the report: ‘Is there really an NHS productivity crisis?’
It is certainly true that measuring productivity in the health service is wrought with difficulty. But in our view, the available evidence strongly points to the NHS – or, at the very least, NHS hospitals – having an ongoing productivity problem. 1
Productivity is by far the biggest problem the NHS faces. The one ring that binds them all. And it must be dealt with. If productivity continues to fall, the NHS will steadily become less and less efficient. Until … until what?
In truth, I am not entirely sure. Nor I suppose is anyone else. The NHS cannot just go bust like a commercial business. Mainly because it has a hundred and fifty billion pounds pumped into it every year (~$200Bn). Which means it is doomed to stumble on for years. Kept upright by massive infusions of money? Until …
One trend already picking up pace is that and more people are paying for private medical care. Either directly, or through health insurance. At some point in the future, we will end up with a fully established two-tier system. The rich getting good medical care, the poor … not so much.
Whilst people going private will relieve some pressure on the NHS, it won’t impact on the fundamental issue. Which is that the UK taxpayer is throwing ever more money at the NHS, whilst getting less and less in return.
Why is it happening? Are staff working less hard?
‘Fewer patients being treated per staff member should not be interpreted as NHS staff working less hard. Staff are not the only input into the system. The point is that if there are more staff, or staff are working more hours, but the system is providing less care, then something appears to be going wrong.’
There is no evidence here for the staff slacking. So, what is this something of which they speak.
To see if anyone else had any brilliant insights, I read a few different reports. Here is one from the Institute for Government (whatever this institute is, exactly). It was entitled: ‘The NHS productivity puzzle. Why has hospital activity not increased in line with funding and staffing?’
It droned on for sixty-two pages, before limping to three main conclusions. First, that we don’t have enough beds, so hospitals are running above capacity, which make them more inefficient. True.
Quite how much more inefficient was not entirely clear. But we certainly could do without running hospitals full to bursting point. Just to give one example of why this damages productivity. If a hospital is completely full, then planned operations will have to be postponed, even cancelled. Because there are no beds available for recovery. Fewer operations = decreased productivity.
Second conclusion. The NHS is losing too many experienced staff who can’t stand working in the NHS any longer (my words). Due to ‘staff burnout, low morale and pay concerns’ (their words). Experienced staff tend to get things done faster, and better. When you lose them, things slow down, get done worse, and cost more.
This is also true. So, you would think staff retention should be a ruthless focus – but it is not. Not even remotely. ‘You want to leave… well then leave. There’s the door. Bye! … and good bloody riddance.’ This, by the way, is the current NHS staff retention strategy.
Finally, the report concluded that the NHS is badly undermanaged … cough, splutter, strangled gasp of disbelief. Although the authors also discovered the following…
‘We found that hospitals that had more managers or spent more on management were not rated as having higher quality management in the staff survey, nor did they have better performance. The implication being the overall hospital performance is dictated by clinical actions and behaviour, while hospital management is focused on administrative tasks ensuring regulatory constraints are met. The number of managers in each hospital was largely determined by the administrative tasks that needed to be fulfilled, with the scope of management circumscribed to these well-defined tasks.’ 2
As with many such reports, it managed to contradict itself from one sentence to the next. In one section it claims that the NHS is undermanaged, but when the authors looked at hospitals that spend more on management, there was no difference in performance.
Anyway, apart from a couple of relatively minor issues, there was nothing much in either report here, or indeed anywhere else, to explain the widening productivity gap. Which is a common finding of such high-level reviews. Report writers very rarely bother to visit hospitals and speak to the staff, who might be able to enlighten them.
So, I thought I would have a go. I began by going back to basics, starting with two key facts.
Fact number one. There are far more clinical staff working in the NHS:
‘Hospitals had 15.8% more consultants, 24.6% more junior doctors, 19.5% more nurses and health visitors, and 18.5% more clinical support staff in January to July 2023 than in January to July 2019….’
Overall, around twenty per cent more clinical staff:
‘But in the first nine months of 2023, they had 4.3% fewer emergency admissions and 1.3% fewer non-emergency admissions than over the same period in 2019. They carried out 1.8% more outpatient appointments and 0.8% more treatments from the waiting list than in 2019. This means that the number of patients treated per staff member – one crude measure of productivity – has fallen substantially.’1
Fact number two. There has been no increase in clinical output.
Which means that in the last four to five years, productivity has fallen by around twenty per cent. If it keeps going down at this rate, in twenty years’ time, the NHS will be doing nothing at all.
By the way, clinical output means activities such as, seeing a patient in accident and emergency, or in the outpatient department. Or carrying out an operation, or doing a scan, and so on and so forth. Otherwise known as clinical activity. Consulting, scanning, diagnosing, treating, operating. Which is what hospitals, and GPs of course, are there to do.
Was there any evidence to be found in this second report that the staff were working twenty per cent less hard? Nope. My own observation is that clinical staff are working harder than ever. Work, work, busy, busy, chop, chop, bang, bang.
A view reinforced by the fact that healthcare workers are suffering a crisis of ‘burnout and low morale’ … and also taking far more sick leave. In addition, they are quitting, in droves. These are hardly strong indicators that the workers are all lounging about in cushy jobs.
Bringing these facts together, what we have is twenty per cent more staff, working just as hard, probably harder. Yet, they are creating no additional clinical outcomes. Where does this leave us?
There is only one possible conclusion. Which is the following. At least twenty per-cent of the work that clinical staff are doing is non-productive.
I suppose this is another statement of the bleeding obvious. But at least it does get us looking in the right direction, towards non-productive work. At which point the next obvious question arises. What is all this additional, non-productive work?
One clue is to be found in the report I quoted earlier, and two key statements that it contains.
Statement one: ‘hospital performance is dictated by clinical actions and behaviour.’
Statement two: ‘hospital management is focused on ‘administrative tasks’ ensuring regulatory constraints are met.
Here, I believe, we find ourselves looking directly into the heart of the problem. The underlying disease. The dichotomy, the split. The war within healthcare. Whatever you want to call it.
Which is that clinical staff do clinical work, and produce clinical outcomes, and therefore drive productivity. On the other hand, the primary role of management is to do something else. Namely, fulfil administrative tasks.
‘The number of managers in each hospital was largely determined by the administrative tasks that needed to be fulfilled, with the scope of management circumscribed to these well-defined tasks.’
As a manager might say, but never would. ‘You do clinical stuff; we will do management.’ And never the twain shall meet.
One of the first things people say to me, whenever a discussion turns to the NHS, is that there are far too many managers. ‘They don’t do anything. We should sack them all.’ Well … it certainly sounds tempting. The truth is that I have no idea if we have too many managers, or not enough managers, or just the right number.
What I can tell you is that, instead of having a tight focus on helping clinical staff do more productive work …
‘…hospital management is focused on administrative tasks ensuring regulatory constraints are met.’
And what is a regulatory constraint when it’s at home? Don’t you just hate language that means almost nothing, to almost everyone. A regulatory constraint is something that regulators insist has to be done before you can get round to all that pointless clinical stuff, like seeing a patient. Regulatory constraints, in turn, are met by the many and varied administrative tasks.
Where to start in attempting to explain how administrative tasks play out in the day-to-day life of any healthcare worker? On the basis that I know what I do best, I lay before you a few minor examples from my own work. I do realise each of them may seem trivial. With every additional task only adding a few minutes to each working day.
However … (exclamation mark) please bear in mind that I am only talking about one tiny area of medical practice, in one very small part of the NHS. Multiply this a thousand times, at least.
To begin.
In the GP Out of Hours department we used to have a locked drug box on the wall of a small side-room. It held a limited number of commonly prescribed medications. Having this stock meant that when the pharmacies were shut overnight, we could open the box, and hand out drugs directly to the patients. This saved them waiting till eight or nine the next morning to start treatment.
It used to be a pretty simple job. We wrote out a prescription, got the key to the box, opened it up, then handed the drugs to the patient. We left the prescription in the box to allow the used-up medications to be replaced.
There is now a behemoth of a multiple drawer thing in the department, that must have cost thousands. It looks a bit like those lockers where people can pick up on-line orders for Amazon. Somewhat smaller, yet vastly more complicated.
This locker has a touch-screen interface. It requires a smart card, two sets of key-codes – which keep changing, and no-one can remember what they are. A nurse must also accompany you, to ensure that … what? We don’t nick the drugs, I suppose. Locum doctors have no access to this locker and have to get another doctor to open it up.
This new, and vastly more complex system, adds about three to five minutes to the job in hand. Which, when you have fifteen minutes to see each patient, represents a very significant increase in time spent per patient. Up to thirty-three per cent.
Okay, yes, I can almost hear you thinking … trivial. Suck it up. Work a bit faster.
Here is another small thing from out of hours. In days gone by, when we went out on home visits, we plucked a handwritten prescription pad out of a drawer, then brought it back when we returned to base. Minus the scripts we had written.
Now, we can only take six scripts out with us, maximum. Not an entire pad – perish the thought. Once you have seen six patients you have to return to base to pick up more. And if you make a couple of mistakes, in writing out a couple of scripts, you can only see four patients before being dragged back to base. Which may be a half hour drive away, or more.
There is also an additional sign-out procedure for the prescriptions. On a good day this adds an extra couple of minutes. On a bad day, which is most days, we have to stand around and wait for the nurse to finish a phone consultation before they can countersign the book. Then the script prescriptions must be painstakingly counted out, with all serial numbers double checked. These must be matched up with the case numbers of the patients seen.
Sticking only to drug prescribing here. We have printers in each room for the electronic prescriptions we use at the base. At one time, if the paper for these electronic prescriptions ran out, we would pick a few new ones from boxes lying about the nurses’ room and load them back in the tray.
Now, the printable prescriptions are locked away, and the printer trays are also locked shut. Today, if you run out of paper for the printed prescriptions, which happens frequently, the task of re-filling the tray can take about ten minutes. Assuming the keys can be readily located.
Yes, yes, small additional tasks. Suck them up, see the patients faster. Make room in your day, lazy scum. But these few tasks add about half an hour to each working day, yes, I added them up. Thirty minutes out of each eight hours. You do the math(s).
In Japan they have a word for incremental improvements in the way work is done to improve quality and productivity. It is called Kaizen. Improvement in a gradual and methodical process. In the NHS we have anti-Kaizan. Anti-Kaizan means a reduction in productivity as a gradual and methodical process. Grinding, relentless.
My own term for this is ratchet world. It seems that almost every day, some new additional new regulatory constraint has been met .‘Click’, new task, goes the ratchet. The ratchet clicks ever tighter, the workload increases. Tomorrow ‘click.’ The next day. ’Click.’ Eventually all these clicks can no longer be sucked up. Inexorably they cut into real work.
In parallel with this, there is no longer any free time, for anyone. No moment for a chat and a cup of coffee. No time for bonding and creating a team. No fun, no joy left in work. Everyone is just head down, working harder and harder. In some A&E departments, doctors are being followed around by clipboard wielding managers, ensuring that they don’t dare to stop working. No cup of tea for you, scum.
Can I, as a doctor, announce. ‘I am not doing any of this crap, it is a waste of bloody time, and it is stopping me from seeing patients.’ No, I cannot. Because regulatory constraints take precedence over everything else. Absolute priority number one.
If you fail to meet a few regulatory constraints then, when the Care Quality Commission comes to visit – knives sharpened – you will FAIL your inspection. You will be MARKED DOWN. Your hospital trust will be deemed INADEQUATE!
There will be shame and public humiliation. The chief executive will have his head placed on a spike outside the hospital … maybe not quite. But failed inspections in other areas, such as schools, have recently led to suicides.
Unsurprisingly therefore, regulatory constraints are what managers relentlessly focus on. It is also what they demand that clinical staff focus on. So, I, like everyone else, sigh gently and get on with it. Do these endless additional administrative tasks make me happy in my work? Have a wild guess on that one.
Of course, it is not the managers who do the vast bulk of actual additional work. This is almost entirely done by clinical staff. It is the clinical staff filling in forms, and completing audits, and ticking drug boxes, and checking every patient for bed sores – no matter what age. Which means that ‘Administrative tasks’ are what clinical staff spend much of their time doing. The job of managers is to ensure that all regulatory constraints are met. Or else.
Although I do remember listening to the chief executive of a hospital trust on the radio saying that she employed eight people just to put together all the reports and audits that were demanded of her by the organisations above. This managerial workforce, alone, was costing her hospital trust two million pounds a year. Two million pounds worth of pure unadulterated productivity … not.
Winding back the ratchet I could write a hundred pages, a thousand pages, on all the additional paperwork, the additional forms, the clicks on the ratchet that have been introduced over the last few years. Instead, I give you a picture of Dr Gordon Caldwell, who is an A&E consultant. In this picture he is demonstrating the paperwork that has to be filled in when a patient arrives at the department. He is using his body as an indicator of scale. He is not dead.
These are the forms that now have to be completed to admit one patient in Accident and Emergency. He wrote an article about it all entitled ‘The NHS is drowning in paperwork.’ 3
Once again, I hasten to add that this is not the fault of hospital managers. They are simply following the orders handed down to them by others. And who, exactly, are these others?
They are the regulatory bodies that sit above the hospitals, controlling their every action. And there are a hell of a lot of them, churning out regulatory constraint after regulatory constraint. How many? Here from a report in the British Medical Journal:
‘We found that in total, more than 126 organisations are engaged in safety related regulatory activities in the NHS.’ 4
Here are the names of but a few. The Care Quality Commission (CQC), and NHSE (NHS England) and the Integrated Care Boards (ICBs) and NICE (The National Institute for Health and Care Excellence). The four horsemen of the apocalypse, as I like to think of them.
These bodies carry greater power and influence than most others. But each and every one of those one hundred and twenty-six is eternally busy, thinking up new regulatory constraints. New targets to be met, regulations that MUST be fulfilled. Administrative task after administrative task, my precious.
All of these tasks have one thing in common, and only one thing.
The all take time away from clinical work. They all reduce productivity. Every single one of them. These are the ‘anti-Kaizan’ jobs. Ratchet click after ratchet click.
Are they all necessary?
Would the NHS fall over sideways if we just stopped doing some of them, or all of them? Next time I will look at the rationale for the introduction of these million new anti-Kaizan jobs that are dragging the NHS – and social care – to their knees.
1: https://ifs.org.uk/articles/there-really-nhs-productivity-crisis
2: https://www.instituteforgovernment.org.uk/sites/default/files/2023-06/nhs-productivity-puzzle_0.pdf
3: https://www.spectator.co.uk/article/the-nhs-is-drowning-in-paperwork/
Dr. Malcolm Kendrick 
thank you
But the NHS has 107 management consultant firms to advise it on strategy, productivity etc. Surely they know the answer to the conundrum.
https://www.consultancy.uk/news/18095/nhs-selects-107-consultancies-for-management-consultancy-framework
wordpress has gone mad again with yet another ‘improvement[‘!
Yes, Web developers and App coders are as big a pain in the ass as are the administrators and QOF police in the NHS.
I am so pleased that you have posted another article to your blog. It has been more than five weeks since your last. If Mr Justice Nicklin has yet to declare a final ruling then we are all on tenterhooks. Once it is ready and submitted then Matthew Nicklin would do well to be made aware of an evidential statement currently under preparation and due to be submitted to the UK Covid-19 Public Inquiry. This has been in preparation since May 2020 and is neither perfect nor finished even now.
These representations argue the case that enfeeblement of interfacial water can enfeeble specific mechanisms upon which the innate immune system is based. These mechanisms include dendritic type actions along with the actions of methyl transferase’s. Peculiarly I only became familiar with the affairs of interfacial water and interfacial water stress after ruminating upon the content of What Causes Heart Disease Part 66.
So that you so much for all your efforts over the years.
When I was a GP ( twenty years ago) I remember my friend who was a Consultant Ophthalmologist, who specialised in eye cancer surgery, telling me that she wasn’t allowed to diagnose a patient with cataracts and list them for operation but instead had to send them to a community optician for them to diagnose them!
Drugs for out-of-hours use locked away? When my father was a GP (qualified Aberdeen 1944, retired 1986) the common drugs were kept in the boot of his car. Today’s regulators would have kittens.
Excellent. I know exactly how you feel.
I am 12 days out from a total hip replacement. Apart from waiting 15 months my hospital experience was exemplary. Couldn’t fault anything (except maybe the sandwiches). However, on admission, I was astonished to see the ‘booklet’ my admitting sister was completing on my behalf. In a short while, she was followed by my anaesthetist and consultant who expertly flicked back and to in the same booklet, asking me the same questions and countersigning everything. Sister didn’t complain and neither did the doctors who were all full of positive cheerfulness. But what a complete waste of highly skilled and important time!! Sister told me that ‘it’s all going on here (nod towards computer) next year, and then we will need training etc etc…’
I’m not surprised they feel they are drowning in paperwork and whoever decrees this incessant record keeping is necessary needs to be the first to go!
I think the collapse is by design, and the only thing to be taken from the NHS is patient data.
Oh dear, WordPress has changed the format againwith funny blue lines round the text. Perhaps some poor delinquent was refused mental treatment.
It’s most likely the same here in the US with Obamacare…and making sure the inpatient forms capture your pronouns correctly.
I don’t think it’s just Obamacare. I’m on Medicare. Yesterday I had a regular checkup with my oncologist. Part of the checkin procedure involved the receptionist handing me an 8 1/2 x 11 sheet of paper full of text, from which I was expected to choose my preferred pronouns. She didn’t seem surprised when I immediately slid it back to her with a disgusted face and the comment “What you see is what I am”.
Incidentally, prior to my appointment, I had filled out all the usual medical history, etc. forms online, one part of which was my preferred-pronouns-and-gender-self-identification, among other things. This seems to be a waste of time, because no one ever appears to look at it, instead asking me all the same questions during the actual appointment.
Right on the nail – thank you.
This is not the exclusive specialty of the NHS. It’s similar in Poland.
Reading your blog for the first time, so entertaining and at the same time infuriating!
I think I just had a firsthand experience with the results of the A&e paper work:
Two weeks ago we phoned 111 due to sudden onset of severe abdominal pain. It took 2 hours for a doctor to phone back and order an ambulance. After 6 hours we had a call, that they had to send a taxi as no ambulance was available. About one hour later, I arrived at A&E and was seen almost immediately by a triage nurse 😲🥳, just to be told it would take about 7 hours to see a doctor 😐. There were about 8 patients in the waiting room. 14 hours after onset of the symptoms, the doctor suspected appendicitis and finally things got rolling.
It turned out it wasn’t, but thinking it could have been, such a delay could have resulted in a bad outcome.
I always think, doctors and nurses (and other staff) should be the first to be consulted and their opinion asked about what they think would be an improvement. They are the ones that know best. And surgeries and wards should have more autonomy without micro management.
Recently I buggered my knee.. I knew I had as it was the same injury type I’d had on the other knee a couple of years earlier. No point in seeing GP asked just refer me to the physio so I went straight to physio. I got a telephone appointment a week later. He agreed that a telephone appointment wasn’t ideal anc arranged to see me in a week or so. When I saw him he agreed with my initial diagnosis and said I’d need to see a surgeon but before I could I’d have to see the physio at the hospital. After several weeks I got to see him but his ticket for x ray had expired and he couldn’t authorise, nor could anyone else. Anyhow, eventually got the x ray and he agreed with my initial diagnosis but he’d like to leave it three months to see if it got better, then try steroids and if that didn’t work refer me to surgeon. The surgeon wait would six months and he’d order an MRI. That’s non urgent so I’d wait months thrn get back on the surgeon wait list to confirm original diagnosis anc thrn book surgery. About 2 1/2 years for a torn knee that needed trimming and flushing. So I rang the surgeon, who done my knee, saw him the next week and got fixed 3 days later in exchange for £3000. Back at work pdq. What about the poor people who haven’t got £3000.
Frightening.
‘Hospitals had 15.8% more consultants, 24.6% more junior doctors, 19.5% more nurses and health visitors, and 18.5% more clinical support staff in January to July 2023 than in January to July 2019
It would take years of planning and training to get so many suitably qualified staff ready to take up their positions from the UK population, that or hoover them up from the third world.
I wonder which was done?
You haven’t mentioned the brilliant electronic health record, meant to make records more accessible and comprehensive, but merely makes creating them more cumbersome.
And don’t those computer health records lend credence to the illusion that all care can be fitted into an algorithm so that – say – one of the many managers could figure out the solution to the problem – given enough time?
Back in the 1990s I became self-employed and made a living writing mostly about computers and software. At several of the big conferences where I spoke, conducted seminars, and chaired sessions, the vague plans to “computerise” the NHS became one of the staple case studies. I vividly remember how expert after expert related how the politicians and senior managers were sure it was a brilliant idea, and how – as work got closer and closer to the coal face where actual software had to be written and used – it gradually became clear that it was virtually impossible. Partly because of the mounting prospective costs and complexity, but mostly because of snags in the intrinsic nature of software – which point-haired bosses and politicians have never been able to understand.
A classic interview question put to aspiring programmers is about the problem of writing a single routine (and, perhaps, database) to handle all possible combinations of personal name, title, and address. The absolutely ignorant assume it’s easy. The inexperienced suspect that it’s not so easy. While the fully expert know that it’s actually impossible. There are so many combinations and possibilities that no one can write foolproof rules for every case. Setting out to try is the IT industry’s form of madness (well, one of the many).
One amusing example I saw in a newspaper decades ago was a letter addressed to:
Mr Prince,
Charles Buckingham Palace,
London.
Luckily the experienced and intelligent postman managed to deliver it to Buckingham palace for the attention of Prince Charles.
Bureaucracy has become a cancer on the NHS.
“Why is it happening? Are staff working less hard?”
As with most of the afflictions of civilisation, the problems are ancient and the solutions have been known for ages. Trouble is, it isn’t in the interests of those who matter to fix them.
For a start, we have Pournelle’s Law of Bureaucracy:
“In any bureaucracy, the people devoted to the benefit of the bureaucracy itself always get in control and those dedicated to the goals the bureaucracy is supposed to accomplish have less and less influence, and sometimes are eliminated entirely”.
From everything Dr Kendrick writes, that is the obvious diagnosis. And the prognosis is that it will get steadily worse until all useful activity has ceased.
As I see it, there are two possible ways of approaching a cure. The first is that it is the managers and administrators who are causing the trouble, but (as Dr Kendrick emphasises) they are only obeying the regulators. Who are presumably empowered by Parliament. So the thing would be to start at the top and get rid of as many of the regulators and regulations as possible. Unfortunately, since the UK is not a democracy (actually it never was, not even close) it’s doubtful whether any number of mere citizens can influence, let alone direct, the government. There is simply no connection between you and me and Dr Kendrick on the one hand and Whitehall and Westminster on the other.
The second approach is to diagnose gigantism. Politicians, civil servants, and managers tend to think that efficiency can be increased by scaling everything up. As you would expect, in this as in everything they are diametrically wrong. Efficiency in any real meaningful sense is to be found in scaling down. Back to cottage hospitals if necessary. There should be a celing on the maximum size and complexity of a hospital, to be approached only if absolutely essential.
I still believe that if, by magic, all the managers, administrators, and regulators were to vanish, the doctors, nurses, and technicians would carry on treating and curing patients – probably much faster and more effectively, and in a much more pleasant atmosphere.
Yes. Yet it does not seem to avoid medical mistakes. Gordon Caldwell is retired now and I am hoping he will write a memoire. This was in mind when I sprung an inguinal hernia in 2018. It was summer and when I checked the waiting time for NHS treatment it was 4 months. For many reasons: support at home for a few weeks post op, thinking that end of year would be a bad time because getting a cough would be bad news, one of my friends had a similar op a few years previously on the NHS where the surgeon said this was his first such surgery with gauze (and it didn’t work & needed a repeat that would have been costly for me), I decided to pay for a private job. The surgeon I remember from the NHS hospital. It was £2000 well spent. One of my sons dropped me off and collected me just 4 hours later, surprised that I could walk out and sit in his car. Five years later still fully fixed and never a pain. The killer comment was in the chat with the surgeon – there’s just too much paper work in the NHS, that’s why he had set up full time with a private clinic – got more done with more time off.
Five years later,the waiting time to have the initial outpatient appointment is 6 months. My husband has just had his hernia dealt with privately. The cost was 50% higher than 5 years ago, but I could not imagine his having to go through pain and distress indefinitely.
Folk might care to look at my book “Mad Medicine: Myths, Maxims and Mayhem in the National Health Service”. If you double the number of hospital doctors but leave the bed numbers and theatre slots the same then individual productivity will go down. Funny these reports don’t seem to understand this. When I was working I was told to reduce my outpatient numbers and not overbook emergencies because the hospital wasn’t being paid for work over contracted numbers. That was 15 years ago. Plus ca change.
Agreed. Were I in charge of things I would always build in spare hospital wards for minor incremental cost. In periods when they were not needed they could help in rotation for deep cleaning of wards and would be available at busy times to take people off those waiting ambulances. The accounting system is daft, higher productivity reduces unit cost. Prompt treatment will usually mean less treatment, less cost, and a faster return to economic life for the patient.
Robert….
What you’re talking sense…
Who allowed you in the room…. 🙂 🙂 🙂
Initiative and personal responsibility clearly not wanted, only blind obedience and conformity no matter how stupid.
As you say, anti-kaizen.
Tyranny of the form design Tim…
And the question is…
Who authorised the design of the form?
eric the red. Is that it? Can I type now? Has wordpress been using the same consultants as the NHS?
Is this a new paragraph?
Paperwork is good. It is being eliminated from Queensland hospitals, and this is bad. No longer is there a clipboard hanging from a patient’s bed. If you want to know what’s going on you need to log into a computer. This is probably why they keep asking you for your name all the time. They haven’t got a bloody clue who the patients are any more. And if the system crashes …..
The best question in this situation is not “why do we do this”, but “what would happen if we didn’t do it”? Like Neil Orr did in 1980, asking “what would happen if the surgeons didn’t wear masks in surgery?” The answer was that NOT wearing masks decreased infection rates by 50-66%. Or looking at it the other way, wearing masks increased the risk of patient infection by 100% to 200%.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2493952/pdf/annrcse01509-0009.pdf
The problem really lies with the doctors and nurses, to be honest. These people are so untrustworthy. Unreliable. Prone to dispensing aspirin without ensuring that every pill is accounted for. Diagnosing galloping dandruff without clearly indicating the diagnosis and prognosis. They need to be Head and Shoulders above all else with the treatment. If spending million quid spent on saving 50 aspirin isn’t a critical priority I don’t know what is.
See, unproductiveness isn’t necessarily a corollary of inefficiency. Inefficiency can increase productivity. Wasting a bit of stuff (a few pills, some flour, cutting oil, detergent) to save time is good.
And then, of course, there’s Yes Minister.
https://www.youtube.com/watch?v=JAk448volww
Yes Minister 👍 is becoming more applicable all the time
I believe you suggested Yes Minister before – and as a result, my husband and I binge-watched it – and were torn between laughing hysterically and being dismayed at how prescient it was. Also sorry to see it end. Truly prophetic and not in a good way. Perhaps the pols in Washington were taking notes?
A well-known university, not a million miles from Johannesburg, South Africa, School of Public Management [sic], uses (or used) ‘Yes, Minister’ as part of the teaching course. Draw your own conclusions.
Worth mentioning over investigation. This seems to be produced by the twin evils of protocol driven medicine and fear of litigation. I have recently retired after a few months short of 40 years working for the NHS. By the end I was definitely one of the older experienced doctors and I investigated much less. The younger ones called it cutting corners, I called it knowing the difference between what is possible and what is likely. Will it change your management? I used to ask. If not, don’t do it. I also encouraged those I was training to take their own bloods there and then in the room, rather than send them out to make an appointment with the nurse. Not only did it save the patient time, the investigations were done sooner, and, most importantly, because I had to write all the bloody forms, and label the bottles, I thought twice before doing the investigation in the first place.When you see how many investigation results GPs have to see during one working day, most of which are normal, or worse than that, almost normal, making you wonder whether you can ignore it, you understand why they have less time for patients. And the irony is that I don’t think that this safety first protocol driven approach is more effective. Important result pass unnoticed in a sea of normals.
I wonder if AI in the not too distant future will improve things ? Or make them worse ?
And who decides on the criteria that AI solutions may suggest?
Answers on a postcard…
If you remember postcards…
There is no mention of the NHS strikes in this assessment. Surely those have had an effect on productivity.
Sounds like a common thing, I retired from nursing 11 years ago, oh my the paperwork and computer work and meetings, only a third of my time for cliental. Can’t imagine anything has improved either and this was community mental health Queensland Australia.
“…this was community mental health…”
How frightfully ironic! The terminally confused leading the outright nuts.
Heard on a respected news chanel that in private medicine
And, changing subjects, what of the glycocalyx in C19 Dr K? Sorry! https://wmcresearch.substack.com/p/underscoring-sars-cov-2-and-sped?utm_source=post-email-title&publication_id=770713&post_id=139212295&utm_campaign=email-post-title&isFreemail=true&r=tb182&utm_medium=email
Where is the political lobby to remove all this crazy unnecessary clutter?
I think you mean the political lobby not to do valuable favours for rich and powerful companies and their owners, and thus to assure your own failure in politics.
A tiny group at all times.
Two points: first if you set a target that becomes the BEST you get and second: if the driving force is cash (budgets) quality suffers — put judgement and quality at the top of the list………………
A good piece Malcolm. I can’t help but look back to 1981 when I started work at a DGH in Lancashire. In A&E there was a cupboard containing board games for the staff for when it was quiet!!
Thank you Malcolm….a very insightful and no doubt accurate commentary of a state run, non-profit organisation that is over laden with extremely expensive directorates. When any “company” is using boards or commissions of highly paid advisors, the one thing they are extremely adept at is providing constant directives, whereby they are justifying their existence. One wonders if on a Monday morning the “Chair” admonishes the group that there are not enough “ideas” this week to push through. If in any doubt let’s see if suggesting re-painting the wards chimney pot red helps to stabilise anxiety. 🙄🙄🙄 I’m afraid that life at all levels has become change for the sake of change whether needed or not: the use of IT in itself has become in-efficient in a lot of ways and over complicated in situation that only really require a pad and pencil. IE…your medicine locker. By the way…have you had a descion from the courts regarding your case ?
wishing you the best in appreciation.
No decision yet. I have decided the longer the judge takes, the more it is we get the decision we want.
I certainly hope so….🤞
Maybe. However in many ‘political’ cases the process is the punishment. Delay hurts you, not them.
Some years ago I had the opportunity to experience the different approaches to hernia repair in the Netherlands and the US. In Holland I had a 4 inch groin incision in the morning and crawled to a taxi the next morning, Following 3 weeks recuperation I returned to work albeit there was a further 3 weeks until complete recovery.`in the US for the same repair, I arranged an appointment directly with the surgeon, for a Friday morning. I had a 1 inch incision and left the hospital after a 1 hour recovery period. Apart from a brief vomit on the way home I made a rapid recovery and returned to work on the Monday morning. In the first instance I lost 3 weeks working time, it could have been 6, and in the second I lost no time since I recovered over the weekend.I am sure that the hospitals concerned would not have taken into account the impact of the procedure on my time outside the hospital. So the real productivity difference between the procedures was a factor 20/40 to 1. This was of course related to surgical techniques but there are ,as Dr Kendrick suggests, many other obstacles to improvement in the UK systems.
More recently I had an appointment to investigate a suspicious “freckle”in my eye. After an appointment at a local hospital I was referred to a consultant at a specialist centre. So far so good. At my appointment the previous examinations were repeated despite the originals being available on line. Maybe the weren’t good enough.It was then decided that I should have a biopsy of the problem eye. To do this would require another appointment. A 2 hour train journey and an overnight stay. I asked, “why don’t you do all that today?” This was not an impertinent question. This hospital clearly had all the expertise to do the biopsy but the system required another appointment, another 3 or 4 ( or more)weeks delay. Since there were 17 people waiting their appointments so no change was possible.
Dr Kendrick mentions kaizen. the system of continuous improvement and elimination of waste. Queuing is waste. It doesn’t matter whether it is inside the hospital or outside. There are probably thousands of industrial engineers in the UK who could analyse the processes within hospitals to streamline processes and eliminate waste. Such an analysis is not rocket science but it is painstaking and time consuming. It requires the participation of the front line staff unencumbered by hierarchy or redundant processes, or by restrictive practises or management diktats. It cannot be done top down. This should not be a question of who or what is to blame for current inadequacies. Merely a process to effect improvement.
This is not to suggest that all of the issues can be addressed with Kaizan. However it is clear that there are many front line inefficiencies that can be addressed in this way. While others can be referred upwards for alternative solutions.
I could go on, but I must apologise for this lengthy response. Nevertheless it is clear that the NHS is a brownfield site that has been ignored while politicians pontificate and the rest of the industrial world takes all of these improvement processes for granted.
Although I’m against privatisation, my question is why can the private sector respond and deliver healthcare in a timely manner ?
It cannot just be the money. Do they have to jump through the same administrative hoops ? If not, why not ?
The NHS in it’s current incarnation, IMO, cannot survive. And the tories will be very happy, and richer, with that outcome.
“Although I’m against privatisation, my question is why can the private sector respond and deliver healthcare in a timely manner ?”
But is that true? Does the private sector deliver the goods? I think it depends on what sector of a privatised health industry that you’re looking at. Certainly, the NHS has been deliberately carved up, with the most profitable areas privatised and allegedly in competition with the NHS equivilent eg, hearing. And certainly, judging by the number, size and location of newly opened private clinics that have opened here in London, very profitable but what about things like eye care? Is the private sector doing a better job (definitley not cheaper) than the NHS?
“Does the private sector deliver the goods?”
Yes, there can be no doubt about that. The investors and managers are thoroughly pleased with the performance of their money.
You write: “The investors and managers are thoroughly pleased with the performance of their money.”
Okay, the shareholders are laughing all the way to the bank but what about the patients?
Re. Eye Care. The NHS, in my area, outsources eye care (Cataracts, Laser Surgery) to private clinics. So they are using NHS funds to pay the private sector to do NHS work . Good for the patients but bad for the NHS !
It’s the same NHS staff. The more demand the more they outsource themselves
It’s ironic that, when the NHS was launched, its proponents expected that after high initial demand while the punters got themselves fixed up, demand would slacken off because everyone would be healthy.
Further comment would be superfluous.
It makes the NHS sound like a job creation scheme with a few extras attached. By the way WordPress has gone mad with its text entry and formatting so I hope this is readable when it appears on the screen.
Why put a WordPress editorial ‘feature’ (block editing) on a public-facing Website? Because the programmers think its ‘neat?’ I’ve been using WordPress for 13 years and watched it deteriorate, driven by who knows what? Megalomania? Move to Substack Dr Kedrick before it’s too late?
I am happy to say that I have found, in the past couple of days since I first noticed this disimprovement, that I can still manage by simply typing away as in the past and ignoring all the new “features”.
As for the motives, first of all there are lots of highly experienced professional programmers jostling to get their work seen by the public. Presumably they can’t be prevented from doing so indefinitely.
Also, from the quality of the average article online (let alone comments) – Dr Kendrick’s magnificent blog and its highly literate readers apart, naturally – I suspect that the resources of the English language do not satisfy their ambition. They need all sorts of special fonts and clever effects to express themselves fully.
But really, who knows? These things are sent by God, and we must make of them whatever we can.
“It makes the NHS sound like a job creation scheme with a few extras attached”.
One doesn’t have to be too cynical to see the whole of government in that light.
Albert Jay Nock, a very fine American writer of about a century past, was fairly clear about it. Just think how much progress the state has made since then!
“The State claims and exercises the monopoly of crime . . . . It forbids private murder, but itself organizes murder on a colossal scale. It punishes private theft, but itself lays unscrupulous hands on anything it wants, whether the property of citizen or alien”.
“Taking the State wherever found, striking into its history at any point, one sees no way to differentiate the activities of its founders, administrators and beneficiaries from those of a professional-criminal class”.
The issues you describe are not faults they are ‘features’. The NHS is working exactly as (currently) intended. If these problems were mere “incompetence” then you would expect to see occasional errors that would be to or in the staff and the patients favour; these do not happen.
I personally know of two men who were separately admitted to hospital. On the day after admission they received visitors from their family, were sat up in bed, conscious and with their full faculties intact. Both told their families “Don’t you worry about me, I’m going nowhere (I.e. they were not at deaths door). On the third day they were dead.
Now would that be all those features as designed by the 117 consulting companies the NHS onboarded in 2018….
Asking for a friend…🤔
I have noticed that the nearer the coal face you get the harder the staff are working but the waiting lists still get bigger. Thank you for this explanation.
For the want of a nail a shoe was lost, for the want of a shoe a horse was lost, etc., etc. Small compounding additions can lead to devastating consequences. I spent many years in Med device/Pharma (US) watching a similar thing happen where the regulatory aspects began and then completely overran the production/quality (clinical) aspects of the work being done. This was before the regulatory agencies became lapdogs of the companies. Now I am happily retired from the whole mess and can sit back and observe without being involved. I feel badly for the personnel who are caught in the downward spiral as there is not an easy answer to cure bureaucracy from any endeavor. It is a persistent disease.
Bureaucracy = Power…
Power is a disease…
I am a 79 year old member of my local church. It is mandated that I take part in a Safeguarding course, I need to aware of data protection, I have a DBS (or whatever it’s called now), it is recommended that I take a diversity and inclusion course, I have a hygiene certificate to work in the kitchen that has to be resat every 3 years. I feel your pain Dr Kendrick 😵💫
They seem to spend a lot of time trying to eliminate ‘women’ from the NHS
After 32 years of military medical service around the World and 15 years as CEO of an NHS Ambulance Trust the faults of the NHS are routed in its history. It was never designed but came from the takeover of existing public and private hospitals throughout UK to cope with the expected mss casualties as a result of strategic bombing. It was called the Emergency Medical Services (see Medical History of WW2 – Civilian Medical Services). Patients would receive free hospital treatment if injured or made ill due to enemy action. Primary care remained separate from the EMS and has never become fully part of the NHS except for funding and pensions. By 1948 most patients received free hospital treatment and the EMS was renamed the NHS which provided free access to primary care and subsidised prescription drugs.
The NHS was never designed to meet the needs of the population it served nor the demands placed upon it. It has developed to meet its own demands first before the public it serves. This highlighted by the linking of acute Hospitals with private hospitals for this who can pay to jump the queue and to increase Consultants income. Although Patients require hospital admissions forecastable numbers 168 hours a week most Acute hospitals are only fully manned for some 30 hours a week. Getting access to a GP usually takes a number of days thus emergency primary patients ring for an ambulance or make their own way to the nearest A&E.
As a patient I want quick access to an accurate diagnosis, effective treatment and an understanding of the cause of my condition and how to prevent recurrence. I can get the first two if I bypass my GP but I have never the latter two requirements.
I knew that it would be necessary to reorganise the Ambulance Trust, I headed, to meet the patients requirements for quick response and to clinically reduce emergency conditions. This we achieve by matching emergency demand by hour of the year and prioritising the location of our ambulances. We employed Doctors with emergency care experience who produced clinical protocols, online advice to paramedics and out of hours primary care to reduce unnecessary transports to A&E. Volunteers were encouraged to establish Community First Responder for their local area and were trained and equiped to provide emergency life support level care. All non-emergency ambulances and staff were similarly trained up to ELS level care. For 10 years Staffordshire had the best survivors from cardiac arrest proportionate to population , the fastest response to emergency calls and with productivity improving by some 50% we became the most cost effective Ambulance Trust. No more that 6 paramedics left to join other Ambulance Trusts during those 15 years an indication of staff satisfaction.
What was the NHS view of these achievements:
a. To disband the Trust in July 2006 and amalgamate it into a regional ambulance service for the West Midlands. Cream into milk produce more milk.)
b. Call in the CQC to try and prove that the performance claimed was inaccurate and that the services provided to patients ws unsafe. They failed but still decided that services provided were risky.
c. Today in Staffordshire you may wait hours for an emergency ambulance and remain in that ambulance for hours on arrival at hospital A&Es. Cost have increased, clinical care has severely deteriorated, community first responder groups have been reduced in numbers and capability, many staff have eft or are looking forward to retirement.
This is just one small example of what is wrong with the NHS. Reorganising to meet the patients requirements is not welcomed. Average is preferred to excellence. In the real world of private business failure to meet the customers requirements is not survivable unless you are the monopoly provider. In the UK the NHS is the only monopoly provider of free health care. It will become larger and more expensive each year but will not meet the public’s requirements. Thus more of the public will opt for private healthcare.
If all the money wasted on outside consultants (non medical), diversity officers, useless commissions, boards etc. etc. was lumped together, it would just about cover my electricity bill – which is so outrageously extortionate due to another ill-thought-out shambles conceived by morons totally out of touch with me, who I consider an example of an ordinary, increasingly badly off (cash and health) citizen. What a mess. My sympathies doctor.
They are not morons and they are not incompetent – as George Carlin famously said “It’s never going to get any better, don’t look for it, be happy with what you’ve got. Because the owners of this country don’t want that. I’m talking about the REAL owners, now. The REAL owners, the BIG WEALTHY business interests that control things and make all the important decisions — forget the politicians. The politicians are put there to give you the idea that you have freedom of choice. YOU DON’T. You have no choice. You have OWNERS. They OWN YOU. They own EVERYTHING. […] the game is rigged, the tables are tilted”
You can find the George Carlin routine on YouTube or you can search for a transcript of it by using. the search term: “the game is rigged”
Do the clinical staff have no say at all in the running of the hospital – are they really so supine that they are unable to say ‘this is not working, it must change’ and then make it change?
All critical thinking and/or questioning was disallowed during the pandemic so now perhaps it comes down to the fact that they really CAN’T think any more. Perhaps we just need to face the fact that the WHO is going to take over next year, so no one will bear any responsibility for anything once that happens. Ho Hum…
Vivien I don’t know who has a say in running hospitals as I’ve not worked in the NHS.
But I have suspicions that the clinical staff are not, repeat not supine but are working in a system designed to comply with protocol medicine…
If others know please enlighten me…
So the real questions are…
1. Who designs these protocols?
2. For whose benefit? Clinically I mean
3. For whose benefit? Monetarily I mean
My gut feeling…
Follow the money… Simples
Supine was quite a tough word I agree. I apologise – but where can any kind of change come from if not from the clinical staff – God knows the administrative staff aren’t going to change their gravy train…. as you say, follow the money…
Here is a related, ‘heart-on-your-sleeve’ Facebook post by Aseem Malhotra about the 5-year anniversary of his mother’s passing ‘due to NHS Cuts’.
https://www.facebook.com/aseem.malhotra.98
I totally agree with what you have said Dr Kendrick. I recently had to attend the children’s hospital with my granddaughter who had broken her little finger. I was astounded by the amount of forms the doctors’, nurses and anaesthetists had to fill in, it was utterly ridiculous. Luckily, they did not have to operate and took about twenty minutes to manipulate it back into place. They probably spent longer than that filling in the forms ! My daughter in law had to repeatedly answer the same questions for the various forms numerous times. Though I have to say, the staff were wonderful. At every point they were so helpful and caring. But for the life of me I really do not understand why they had to fill in so many forms. What a waste of their precious time.
Lorrie Pearson
Perhaps benefit/harm analysis should be applied to management & admin tasks.
Maybe more admin prevents more iatrogenic damage.