This is a long essay. Sorry.
Once it was the case that clinicians decided how to run their service and managers facilitated; now doctors find ways to meet management targets set by the managers (or politicians). What surprises me is how the new generation of doctors do not seem to have a problem with this; they obey like sheep. My failure to persuade colleagues that they must stand up was one of the reasons I left the NHS early.
Ponder for a moment, and recall what I said earlier. How long is the average senior doctor in a single place? And how long is a manager? (And to that add – how long is a politician?) So where resides the institutional memory?
No doubt it will be said that as a geriatric with a bus pass I am the last person to be pontificating, as times have changed, I am an old stick-in-the-mud, poor old chap can’t keep up with the times etc. But you should remember – I was young once and I don’t think I have changed greatly, except that when I pontificate I do so from a position of experience.
How many times have the keen and thrusting new generation come up to me and my fellow old farts with a new plan to save the NHS? Reform, modernisation, I have seen it all before. I am likely to say gently that we tried that 25 years ago, and it didn’t work then, and I am not clear what has changed that will make it work now.
It’s not always the managers’ fault. Sometimes they are driven by political pressures but doctors must be prepared to embrace change if it’s good, but be equally prepared to resist it if it isn’t. And, as I have said before, that requires doctors to step outside the evidence-based culture of clinical practice and consider finances, common sense and history.
Consider the plan. Be prepared to raise Cain if you have not been consulted at the right time. Do a proper SWOT analysis on it if you must. Look for unforeseen consequences. Think of the cost of doing it compared to the cost of not doing it. Check it hasn’t been tried before somewhere, and failed. Have your arguments ready marshalled for the showdown. Be prepared to concede if you have missed a trick but be prepared to enlist support from without if you cannot find any flaws in your own argument.
Let’s look at some global and parochial examples.
The Lancashire/Cumbria ISTC debacle
While I was President of the British Society for Rheumatology (2006-8) a grand design was developed in the north-west of England to construct a series of independent sector treatment centres for musculoskeletal services (ie orthopaedics, rheumatology, physiotherapy etc. A detailed proposal was drawn up showing where these new centres would be, and indicating how much more convenient they would be to a large part of the population.
There had been no consultation with people providing the existing services in District General Hospitals. Cain was therefore raised. It became apparent on careful review of the plan that it would be funded by a transfer of work from existing centres to the new ones – there was no new money that would allow both to co-exist. So the SWOT revealed an unforeseen consequence. A quick calculation indicated that the existing centres would lose so much elective work that one-third to one-half would have to close as they would be uneconomic. This had a further knock-on effect as emergency services would immediately be threatened. On this basis, although the new centres would provide better elective access to some of the population, the loss of existing centres would mean that other parts would have worse access.
The local consultants enlisted the support of colleagues nationwide, and of their local MPs. Backed up by a firm medical opinion, the trade unions started to kick up. The plan was abandoned. As the government had paid a private company on the basis that it would be the preferred bidder a considerable sum of money was irretrievably lost.
If only they had consulted with the locals, and worked with them instead of behind their backs…
Choose & Book
The rheumatologists in SE London were approached by the clinical lead for the Choose and Book project to be briefed on its introduction. We looked at the system and realised that, while it had been extensively consulted on at the consumer end (ie with GPs) it had not been consulted on at all with the providers of outpatient services (ie the consultants). So we wrote our own analysis pointing out all the likely difficulties and flaws, and duly turned up for the meeting. The team were quite taken aback by our negativity. When challenged on why they had not sought specialists’ advice they retorted that there were too many specialist organisations to consult. The meeting ended with dissatisfaction on both sides. A month or so later the Royal Colleges and specialist societies were circulated with a request for their input to the provider side of the scheme…
In fact there has been widespread dissatisfaction with the system on all levels. Getting the first available appointment may be good in some ways, but may lead to the division of care between hospitals and there is risk in that. Anyway, the waiting time may be a poor indicator of quality. Consider the following fable.
Pestonjee Bomonjee sat under a palm tree, wearing his hat, from which the rays of the sun were reflected in more-than-oriental splendour. Beside him was the cooking stove but, O Best-Beloved, I wouldn’t ask about that if I were you. Word of the cake-crumbs had got about, and them that could sort out thieving rhinoceroses were in demand. So it was no surprise when a little old man appeared from the Almost Undoctored Exterior (which abuts on the islands of Tobacco, Sago and Tapioca, and the promontories of Salmonella), and stood before him, and bowed ‘scrutiatingly deep.
“Oh Sage,” quoth he, and pitiful it was to hear the tremble in his voice, “Oh Sage, I am needful of your superior advice on a matter of the Utmost Importance. My water is stopped up, and something must be done.”
“Might I assume that this is not a problem of the mains supply to your accommodation that has been obstructed on account of an overloaded articulated lorry squashing the main, or more likely of you not paying your water rate?” said P.B., “but that of which you complain is a personal affliction caused by the benign enlargement of the prostate gland and resulting in Hesitance, Penitence and Dribbling?” And, on a sign of assent, he continued: “Why, then, you must find a urologist (or a general surgeon if you are less particular) to whom you may submit yourself for surgery.”
The old man nodded gravely. “I have myself reached the same conclusion,” he said, and added rapidly, “That itself is not the problem. But I have been told that there are many who will perform the operation, yet I may wait for years before it can be done. I have consulted the Great Wise Minister, K, Neth Clariq, second only in the land to Queen Tat Cha, and he said (or at least he has written on a White Paper that this is what will come to pass) that I must travel to the Uttermost Ends of the Earth to find him that has the Shortest Waiting List. He has told me that my personal physician, Dr Geepi, will herself conduct the search using a Fabulous Machine, which some call a Computer.”
Pestonjee Bomonjee, whose face had darkened at the mention of K. Neth Clariq, was silent for a moment. Then he smiled, kindly.
“Pay no attention to the words of Clariq.” he said. “I advise you to seek out the surgeon with the longest waiting list, and apply to him (or her) for attention.”
But why should this be?” exclaimed the Pensioner. “Your advice makes no sense! If the operation is required, it must be done with all haste!”
“That is but one of the factors involved in your case;” said P.B., “there are others. In the Old Days your Doctor Geepi would have sent you to the surgeon whose bedside manner was politest, whose scar was neatest, whose postoperative complication rate was lowest, and whose hospital was cleanest. Naturally, then, the waiting list will be long. The surgeon that might hack you about, let you bleed pints postoperatively, and discharge you with wound abscess will no doubt be well known as a butcher, and no-one will send him patients. Naturally, then his waiting list will be short. If you are that desperate then take Slasher Harry with alacrity, but blame not me if you end up in trouble.”
The old man nodded. “I understand and can see what you say is true. But why should Clariq not see this?”
“He might,” said P.B., “when he needs what you need. But he is ignorant of the First Law of Audit. Facts may be Facts, but there is always more than one explanation for why the facts are Just-So.”
“Clariq that dictates and cuts the docs’ rates makes dreadful mistakes.”
And there was a great deal more in that than you might think.
Data, data, don’t compare a rosy apple with a pear; the new and follow-up game
The funding system of Payment by Results (PbR – perhaps more aptly termed payment by activity) has been responsible for the development of a new game. My local Primary Care Trust sent down an instruction (not a request, mind) that my department reduced its follow-up appointments because the ratio of new to follow-ups was too high (we averaged 1:4.2 and they wanted 1:2.1). We refused and they sought a meeting to discuss the issue. We were informed that we “had to” reduce our follow-ups because our ratio was much higher than the comparator hospital – which was not in fact far away. We had done some homework and identified that our casemix was substantially different from theirs, largely because we had a back pain triage service that creamed off a large percentage of patients who would by the nature of things be seen only once and then in the main sent on to physiotherapy. The other hospital counted all such patients under rheumatology. Inflammatory joint disease required ongoing specialist review (as it turned out, later NICE guidelines underpinned this). We pointed out that if we discharged the numbers needed we would have to discharge over two-thirds of our rheumatoid arthritis patients. Would the GPs be happy to monitor their disease-modifying therapy? What about review of biologics patients? What would happen to emergency flare-ups? Our own Trust managers were quite happy that we should discharge patients, on the basis that they would have to be re-referred and then attract a new patient rather than a follow-up tariff. We thought that was, simply, stupid. We also thought our GP colleagues would agree, not least because of all the time they would waste making the re-referrals (of course, under C&B there was no guarantee they would see the same consultant or even be able to get the patients back to the same hospital).
We had not at this stage raised the casemix issue; its time had come. I suggested that we did not need to discharge our follow-up rheumatoid arthritis patients at all; there was another way of reducing our new:follow-up ratio which would actually make it better than the comparator hospital. Interest was immediate. I explained the casemix difference and said that if we included under rheumatology all the back pain patients going through our (physiotherapy led) triage service we would add another 1500 new appointments to the caseload – but of course these would all be charged under Payment by Results and add an overall cost to the PCT budget of nearly £250,000.
No further interest was taken in trying to reduce our follow-ups. At least at first. Another attempt has just been made (and there is an intention to reduce new patients also, which will of course require an even larger reduction in follow-ups to achieve the magic ratio – there is a new manager on the PCT block (and all ours changed after major reorganisation), so the institutional memory on both sides has been lost. This time round the required ratio is 1:1.88. This was, it transpires, signed up to by our Trust! Indeed the Chief Executive indicated to me that he would look unfavourably on me if I do not obey. I must not do work for which the Trust will not be paid. I was told that the responsibility for my patients lies with the GP, not me. I might add that he promulgated quality as the first priority of our service. Here we go again!
I actually tried to find out where this new to follow-up nonsense had come from. Rather like Athene springing fully armed from the breast of Zeus it appears to have been a thought process with the Department of Health (based, of course, on surgery, which is what so many department-wallahs seem to think hospitals are exclusively for) and then sent out as a policy document. It is predicated on the assumption that once a patient is discharged from follow-up they will never need to be seen again. It also suggests that all hospitals should aspire to achieving the 25th centile. So – if we all do, then the mean moves, so we all have to reduce further, ad infinitum et ad absurdum. I think it was Estelle Morris who famously said, while Education Secretary, that it was a disgrace that half the population were below average intelligence but this has been variously attributed to Lyndon B Johnson and George W Bush among others. It would help if the top team understood statistics (in case you don’t, just recall that the mean is the midpoint of a population so by definition half are above and half below). But then, as my good friend Wolfgang Gaissmeyer points out, even medics don’t understand statistics. A test for you. What percentage is one in a thousand? Most people come up with 0.01%. Wrong.
Perhaps common sense will prevail, but why does it take such effort? Following on from my 2008 audit a large chunk of the Midlands decided to do something similar, and over a dozen units repeated our work. They found an average ration of 1:4.9 and, like us, found that casemix differences were the main determinant of whether a unit was above or below the mean. However when one hears of managers suggesting that improvements must be made so that less than 30% will be below the mean you do wonder whether any of them have even a GCSE in elementary maths (just in case you have already forgotten what I wrote in the last paragraph, the mean is halfway so 50% will be below and 50% above – always! And so, moving everyone closer to the end centiles alters the mean, and thus the centile points, and off we go again).
What might be sensible (and interesting) is if the managers made an investigation into both ends of the normal distribution to discover why some ratios were as low as they are as well as why some are so high. With all the pressure to stop GP referrals, and threats of extreme sanction if GPs over-refer, I think an investigation should be made into why some under-refer. Patients are more at risk from that than from being sent to hospital too quickly.
There is of course a serious side to this farce. On the one hand we have PCTs suborned into taking out block contracts with private suppliers that are then underused (like the MRI scanning contract referred to earlier). On the other they refuse to pay for NHS provision that is not only necessary but is best practice according to national guidelines. If consultants have heavily overbooked clinics (like me) do we really have an interest in seeing people unnecessarily? But cutting hospital outpatients will effectively lose us large chunks of profitable business (unless, of course, we are not paid for it). Thus it is not only in the patients’ worst interests to be discharged but it is actually in the hospital’s worst financial interests not to challenge the figures! Unless, of course, they return as new patients and are charged as such – wondrous effect on the ratio, but increasing the cost to the PCT by at least 40%!
What amazes me is that some consultants are actually putting down on their CVs how they have succeeded in these aims, and appear proud of it.
There is yet another twist to this. Although we are being “ordered” to see less new patients our clinics are full (through Choose & Book referrals from out-of-area) and even over-full because a large number of local GPs are not using C&B on the basis that (1) they want their patient to see a particular consultant and (2) the patient actually agrees that their GP’s advice is reasonable and is prepared to wait. I had one such recently; every page contained a header in capitals saying “Dr Bamji only”. But there is a “breach” target for new referrals. It doesn’t matter how many thousands come through the letterbox but we have to see them in 6 weeks or the hospital is fined. So we run extra clinics (for which we might personally get paid extra – cheaper than the fine) to see the patients that the GPs want us to see. But the PCT then says we are seeing too many and refuses to pay the hospital.
Of course the PCT had got partly wise to this, and so forced GPs to submit to a vetting system for referrals. It’s as if they are not trusted. What happens if they are browbeaten into not making a referral and something goes wrong may be a matter for the courts.
But where is patient choice in all this? I had lots who, when I suggested discharge, expressed both horror and fear – horror that there will be no-one who has time to listen to them and fear that their GP will be unable to look after them properly.
Managers lose their heads when targets, however mad, are threatened with breaches. One of our neurologists, a long-term locum, left recently. The secretary, who happened also to be mine, was ordered to cancel all the follow-up appointments – but continue with the new ones. She very reasonably pointed out that many of the follow-ups were awaiting the results of tests done after the initial consultation, and they would get very agitated if they were suddenly told that no-one was going to let them know if they had a brain tumour, MS, motor neurone disease or whatever else they feared. This cut no ice. Is this mad, or what? It’s time to abandon the “target” of new to follow-up ratios for the lunacy that it is.
It amazes me that, if a specialist sees a patient and decides they need to see another, that they are being inhibited or even prevented from making a direct referral but are being ordered to send the patient back to their GP for them to make the second referral. This demeans the specialist, wastes everybody’s time and is I think an arrogant and conceited view. The specialist may be far better placed to refer on appropriately (especially as they know who they would be happy to be referred to, or more importantly whom they would not wish to see, which is expressed in the fable above). Forbidding the practice is childish, petty power-play and completely contrary to patients’ interests. It also adds to GP workload, quite unnecessarily. However, as the irritation was minor, I played along. When it was least inappropriate. Which was not often.
Contracts and PAs
Our managers decided to make everybody’s contracts the same. PAs are Professional Activities, in case you didn’t know.
Pity this did not take into account the fact that some of us see twice as many patients as others (so earning the Trust twice as much income, assuming the PCT actually pays). We had a splendid calculating program which worked out our sessional time to the second decimal place. In fact it made even more explicit that most consultants actually put in more time than they are paid for. So cutting sessions (which could mean a pay cut of 20% for some) should produce an immediate response of “Which clinical commitment shall we drop?” This will not increase productivity, which is another aim of government.
My rehabilitation unit was built for a 3 district population with 20 beds, but with the perennial shortfalls only 14 could be staffed. Periodically there were pressures from the acute hospital to use our empty beds as an overflow. To avoid major problems for our own patients we set strict criteria for use – no significant infection (C.Diff or MRSA), no dementia (the unit has automatic doors which lead to the hospital back road, which is a bus route) and no incontinence (disabled folk who cannot see very well will either trip on the wet patch or scoot gaily through on their wheelchairs and spread it about a bit).
You can guess what came next. As pressures grew, protocols went out of the window, so we ended up on one occasion with 12 medical patients of whom all were in one or more ways in breach of our rules.
When this happened I made a fuss; it often seemed to occur when my unit manager was off duty, or at weekends. On one occasion I forbad the bed manager to admit a medical patient, not least as one of my seriously disturbed and depressed patients, who we had only just got settled in a side-room, was going to be moved out of it. The following morning I arrived to find the medical patient ensconced.
Now much of the time we could cope – except that it was rare for all the extra staff needed for the 6 beds to turn up, so the permanent staff ran around at double speed (if bank and agency staff did appear, we were subsequently accused of overspending). But ignoring the clinical rules has itself become a rule.
As a result we had to cancel some of our booked admissions. One such was Mrs Smith, an MS patient who was already in a state because she had just buried her best friend. The dog had been boarded out (cost £140) with a couple who had changed their holiday dates to oblige. Mrs Smith sat on the unit all day hoping one of the medical patients who was supposed to go home actually did, but they didn’t. She was offered a night on an acute ward, but previous experience of care led her to turn this down, so at 8pm she went home. The ambulance crew kindly drew her curtains. The next day she was stuck. She couldn’t open the curtains, her telephone was not within reach and so she couldn’t contact her family who, thinking she was on the Unit, had gone away.
Need I say more?
Actually, I need. A year and a month after I retired my erstwhile Unit Manager informed me that the Unit – a purpose-built unit, designed for (and partly by) heavily disabled patients – was to be moved to an ordinary, unconverted ward so the space could be used for something else. I suppose you could argue that in the last 25 years all the other units that worked like ours had gradually been closed down, and that ours was an anachronism. However, it had provided substantial care and support, on both an in- and outpatient basis, to well over 300 patients. Of course it was expensive; looking after severely dependent people is staff-intensive, but to run “standard” ward levels was impossible. If a heavy quadriplegic patient requires three people to move them you cannot have just two nurses, and if all your patients are in wheelchairs then they need lots of room to move about. When I started, the Unit was in an unconverted ward and we got moved out to our new premises precisely because the old ones were inadequate.
The wheel turns. Once again pennies come before patients. The large numbers of severely disabled folk we looked after included patients with multiple sclerosis, spinal cord injuries (who had often been discharged from the big centres with no backup, so couldn’t cope) and young patients with muscular dystrophy. It was thus ironic that a report appeared the same week of the closure decrying the lack of support for disabled children entering adulthood. That was one of the things we did, and now it has gone.
 Bamji AN. How the NHS waiting list got its length. Hospital Doctor, 6/4/89. Read this in 2014 and you will wonder at its acute relevance. You are correct to identify the tale derives from “How the Rhinoceros got his Skin” by Kipling. I have a soft spot for it, not least as my great-grandfather was hakim to the Maharajah of Baroda, whom Kipling would have encountered. That his name was Pestonji Bamji (of which Bomonjee is an alternative spelling) may thus be more than coincidence.
 A much condensed version of this (I think it was Mark Twain who apologised for the length of a letter on the basis that he had not had time to write a shorter one) is Bamji A. We should scrap targets for outpatient follow-up ratios. BMJ 2011; 342: c7450. Actually I learned, at the end of 2012, that the target had been abandoned “because it didn’t make any sense”. Fancy that.
 Following reorganisation of the reorganisation that created the South London Healthcare Trust (and failed), my unit has now been closed. The senior staff have been relocated to a major teaching centre which is taking over one of the constituent hospitals – not mine – and intends to open a similar unit in it. So a purpose-built unit will be replaced, four miles down the road, by another, although I suspect it will be less purpose-built. Such is NHS progress.