Waste not, harm not: The moral case for efficiency and productivity in healthcare (part 1)

Summary

This is the first of three articles in which Professor Clive Deadman argues that driving modernisation and productivity improvements in clinical care is a moral necessity. It examines why unwelcome change is so difficult to implement and considers solutions for our NHS. It contains extracts from the recently published ‘Risk, opportunity & performance: The art of taking worthwhile risks'.

Content

Medicine and healthcare: One of the oldest professions

The noble art of nursing, wound care and nutrition has been successfully providing healthcare since ancient times. Acute care and pharmacy has a much patchier record of success. Until recently, physicians—and even quack doctors—treated their patients in almost any imaginable fashion. In 1612, Prince Henry Stuart of England died of typhoid. His well-meant but chaotic treatment was ineffective. Physicians knew nothing about the disease. In his final hours, they tied ‘split pigeons’ and other broken poultry to his head and feet.

Modern progress at last

Modern pharmacy, acute clinical care and health prevention now have increasingly successful outcomes. This is a major achievement as everything about medicine is complex. Most drugs are types of poisons, and many clinical decisions must make difficult choices to incur some risk to prevent or treat a greater harm.

A study of 650 global business leaders, many of whom have led businesses and sat on boards in multiple industries, has revealed medicine has one of the highest levels of ‘un-managed complexity’ of all human activities.[1] Let me explain what is meant by ‘un-managed complexity’.

Un-managed complexity

The challenge when we allocate funding or are managing value and performance in any activity is having the information you need to make a good decision. And towering minds, such as J R Galbraith[2] and H Simon,[3] have studied this and shown this is harder than it looks. This is because in business there are two ‘worlds’ that need to be managed. These are the:

• Physical world: Where goods are manufactured and delivered, patients are treated, our employees get paid and live their lives.
• Virtual world: This is where activity is administered. Records are kept of stock, debtors, clinical outcomes, waiting lists, and the type and location of equipment.

The eternal challenge is to ensure the ‘virtual’ world contains sufficiently accurate records of what an activity did, does and will own, create, treat, prescribe and sell. If information is poor the business is not ‘transparent’ and managers and democratic stakeholders are unable to see and manage value well. Such a business has a high level of ‘un-managed complexity’. Delegation within clear and enforceable boundaries drives performance. Delegation without such boundaries is abdication. Because these businesses are difficult to supervise, frontline staff must choose to be efficient and effective for the organisation to perform well and serve society. Will they do this if it means giving up funding or excess pay so it can be better spent elsewhere?

In complex industries, identifying value is especially challenging for business and political leaders. The Chair of the board and CEO may have huge authority, but they will also experience the greatest separation from the day-to-day information, which decision making needs. The distinguishing feature of much of medicine, and especially acute medicine, is that it is difficult for the virtual world to accurately describe the fine choices and judgments that clinical specialists make daily. Even clinical directors (in my view the most difficult of all jobs in any industry), find it unbelievably challenging to supervise the activities of colleagues who may be leading specialists and have sole possession of much of the information about patients, their care and their symptoms.

But we do have lots of information about healthcare safety and productivity

In all well organised healthcare systems there are large amounts of management and patient care information. But we must ask ourselves what is the value of it all?

In the UK in 2013, the Francis Report published its conclusions on failings at the Mid Staffordshire NHS Foundation Trust. The public enquiry was triggered by reports of hundreds, possibly thousands, of unnecessary patient deaths. Undoubtedly a scandal had occurred. The investigation revealed numerous examples of failures and unacceptable care, which inspectors, regulators and managers had not previously identified. However, with access to the best experts, a forensic and well-funded scrutiny of patient mortality figures, the review was unable to come to any conclusions about patient mortality.[4] We have to ask ourselves, if the most important and simple piece of information (i.e., in a closely supervised hospital how many patients are dying unnecessarily) is unreliable, then what is the use and value of all the other much more complex and less vital management information that is reported?

There are many other examples. In the UK in 2016, Lord Carter of Coles undertook a review of NHS cost-effectiveness. He found variations (sometimes 5–10 fold) in different hospitals’ running costs, procurement prices and infection rates.[5] It is hard to dispute the validity of the conclusions, but trying to implement change and reallocate funding between wards, care pathways, and even between hospitals, proved incredibly difficult. Local managers and clinicians (perhaps sometimes but certainly not always with merit) argued higher costs or poorer patient outcomes were caused by external factors, such as their ability to treat high acuity patients, workforce skills gaps, or higher levels of obesity, smoking, social depravation and certain cultural/ethnic groups in the local population. It is extremely rare that any improvement has no cost and only leads to welcome improvement.

It is difficult to make changes if it might be unsafe to do so. Information is only of value if it can be used to show that change, which may be uncomfortable or unwelcome, is necessary and fair.

Why is this so important now?

With very few exceptions, almost all countries are now experiencing the highest levels of peacetime sovereign debt and taxation. Lower economic growth rates and population aging are creating a toxic situation. If medicine is to maintain society’s trust while funding for other services is being curtailed, we must demonstrate that it is efficient and effective. Where we cannot do so, we must find better ways to drive modernisation and improvement. And it will be difficult and will require the leadership and ideas of our greatest clinical leaders. If we don’t decide our own future, someone else may decide it for us. And that might not be a pleasant experience.

In my next article, I will look at how other industries have done this, explore the challenges facing our NHS and question if there are any ideas of value for us. In the final article, I will explore possible solutions for our NHS.

References

1. Deadman C. Risk, Opportunity & Performance: The Art of Taking Worthwhile Risks. Troubador: 2025.
2. Galbraith JR. Organisational Design: An information processing view. Interfaces 1974; Volume 4, No 3.
3. Simon H. Administrative Behaviour. The Free Press, 1987; 4th edition: p118-119. ISBN 0-684-83582-7.
4. UK Parliament/Commons Library. The Francis Report (Report of the Mid-Staffordshire NHS Foundation Trust public inquiry) and the Government’s response: 2013.
5. UK Government. Operational productivity and performance in English NHS acute hospitals: unwarranted variations: February 2016.

Blogs in the 'Waste not, harm not' series:

• Part 1
• Part 2 
• Part 3

About the Author

After starting work as an engineer in Africa, Clive spent 9 years in private equity/corporate finance and then 20 years with United Utilities and Electricity Northwest.

In recent years Clive has worked as and Chair, Audit & Risk Chair and Non-executive Director for a range of organisations, including the NHS and several social housing providers. He is continually researching and writing and is a Professor of Water and Energy at Cranfield University.