18 April 2009

Measurement madness

In case you haven't noticed managers think patient care is about ticking boxes. Box ticking seems to be the way of modern management. The medical students fail to clerk patients as they should so somebody gives them a sheet to get signed off. You can see why. Patients develop pressure sore so the nurses are given boxes to tick. You can see why. The nurses are so busy ticking boxes that patients may have to lie for hours in a wet bed. Which, of course, may cause pressure sores. So somebody introduces another box to tick. You can see why. It's what Dr Grumble refers to as puppet-string management. All the staff are controlled by somebody in an office who pulls the strings. No thinking is required at the coalface. The idea is that the intelligent worker can be replaced by people who do not need to think but just have to tick boxes. All the thinking is done by the manager. The concept seems to have come from manufacturing. Building a car can be reduced to a set of simple tasks. You do the task, the conveyor belt moves on and you do it again. Dr Grumble has yet to visit a ward that is like that.

Qualify as a doctor and you will find that there are more boxes to tick. Not just about the patients but about you. The managers, you see, need to prove you can do all the things you need to do. So they get somebody (it could be a nurse) to tick boxes to say that you are competent. Naively the managers think your job can be reduced to a set of competencies. You can see why. They are thinking about factory workers. By now you will find the boxes are computerised. Whoever set the system up thought that would be convenient . You can see why. It's office-based people who decide these things. But you try and find a computer that's free on a busy ward. The managers think each box-ticking exercise should take a minimum of 15 minutes. You can see why. But they forget that's 15 minutes each or half an hour of medical time. And they don't seem to realise that consultants do not even have a 10 minute break in some places.

By the time you get to Dr Grumble's stage and you are fully trained you will find that you still need to get boxes ticked. Dr Grumble used to go to on courses he wanted to go on. About things he needed to learn. Now there is pressure to do courses the managers want him to go on. You can see why. There is pulling and pushing from the managers. Dr Grumble might want to go to a conference but the managers will prevent him because the work is building up. You can see why. So Dr Grumble waves the unticked CPD boxes and tells them he has to go. You can see why.

It never used to be like this and the system worked. But that was in the days when managers told Dr Grumble off for over performing. Now they want him to work all the time. Even at weekends. They even offer Grumble extra money. Before he did it for nothing. The system is changing: some of it is good and some of it is bad. The pulling and pushing has been designed so that when the system is fully on a private footing the managers cannot make doctors work to the exclusion of ongoing training. It is the way you have to do things because the imperative for all organisations is to earn money and it is doctors, and not managers, who bring the money in. Managers are just an overhead. It's as well to realise that.

Any GP reading this will know about ticking boxes. That's how GPs seem to be paid these days. Some managers somewhere have decided that general practice is rather like a car plant and can be reduced to some set tasks that the population needs done and that all you need to do is get those idle GPs to do the tasks, tick the boxes and Bob's your uncle. You can see why. But is it sensible? GPs are highly computerised and they are rather good at ticking boxes. Most of their patients come their way quite often so it's quite easy to tick the boxes. That's why GPs got paid more than the government intended. They said they would. Or the BMA did. But the managers thought they knew better.

Now if you reduce general practice to a box-ticking exercise you can see that general practice is not a difficult job. You just find out what boxes need to be ticked and get somebody to tick them. Since no thinking is involved you could delegate this task to somebody who is not actually trained to be a GP and is not paid as much. Perhaps even somebody who is not actually a doctor. GPs wouldn't want to do this because they realise that their job is very much more than ticking boxes. But Big Business, with eyes just on the money, would see that ticking boxes could be done more cheaply and wouldn't be at all interested in the many unmeasurable thinking things a GP does for which there is no fee.

Of course, all this has already gone way too far and whether we are talking about the competencies of young doctors or the hoops GPs have to jump through, frankly, it is all unstoppable. But like Iona Heath, Dr Grumble calls for restraint. Below is what Iona says in the current BMJ:

The quality and outcomes framework purports to measure clinical quality at the level of the individual, or rather at the level of a standardised individual of its own creation, and organisational quality at the level of the primary care practice. Take the case of a single patient with hypertension. However, she also has bronchiectasis after many years of smoking and has just had cancer of the oesophagus diagnosed. She has a child with severe learning difficulties and she is fearful, not only for herself but also about what will happen to her child. She is married and the relationship is difficult. Her sister has lung cancer and is already very ill. The sister’s children have problems and children of their own, and this is only the beginning of a story which becomes richer and richer the more that it is told. It is a story with multiple components, each of which interacts with the others unpredictably. Each of the components has a history that affects the interaction, and each has the capacity to affect the patient’s blood pressure and to support or undermine the treatment that is prescribed for her. To what extent does the achievement of a blood pressure of less than 150/90 mm Hg assess the quality of this patient’s care? Could it be that some of the apparently poor adherence to guidelines in primary health care is not a sign of poor quality but rather a sign that the indicators of quality are not yet adequate? There will surely come a point when we need to restrain our contemporary obsession with measurement. There will perhaps always be some essential components of care which verge on the ineffable and whose subtlety and effectiveness could be destroyed by the very attempt to measure them.


Cockroach Catcher said...

This is what Lord Laming said in his report on Baby P.:
The report said that social workers’ professional practice and judgment were being compromised by an 'over-complicated, lengthy and tick-box assessment and recording system' which failed to therefore respond properly to individual cases."

Many NHS Trust CEOs are ex-social workers and nurses with very few doctors. What has happened? Will anyone actually see sense? I know many friends' children who just qualified as doctors are going to A/NZ.

The Cockroach Catcher

Anonymous said...

Some old sayings are wise and true, such as the old arabic (?) one I heard.

"You do not make the camel heavier by weighing it"

Unfortunately there is so much emphasis on weighing (testing, box-ticking, reviewing etc) that there is not enough time to take care of the patient, teach the children or use professional expertise to assess an individual case.

Politicians do not always know best. In fact, politicians NEVER know best. They are simply not qualified to pass an opinion on almost anything. I wish they would just butt out.

Nutty said...

When I saw my GP for my annual assessment this year, he worked his way through a computer programme. I became more and more incredulous. There were only four questions relating to my physical health - weight, blood pressure, smoking & drinking. There were no questions relating to whether I felt unwell or was in any pain. There were questions about things like when I last saw my psychiatrist and whether I have a care plan, but none about my current mental state.

So at the end of it, my NHS records show whether I own my own house and whether I am in debt, but not whether I am well or ill.


Trainer 1 said...

I agree with Dr Grumble that management, administration and "governance" require paper trails and other evidence to demonstrate their worth to their own monitors. Some say that we are being deliberately 'swamped' to destabilise us and undermine the NHS and Trainer 1 is starting think these peple have a point.

Unfortunately there is also something more fundamental going on here.

The ticking of boxes, the acquisition of portfolios, the certification of 'skills', the mindless parroting of pre-determined dogma at interviews, the attendance at prescribed courses on 'management' and 'training' and their necessity to progress or maintain ones undergraduate or postgraduate career eventually has an affect on the participant.

It is not just a means to an end but an end in itself.

This tick-box culture is a classic 'token economy'. This is called 'operant conditioning'. It, remarkably, does not really originate in educational theory, but in 'behavioural theory' or 'behaviourism'. Trainer 1 knows that Dr Grumble will look up all these terms so won't go into them further.

'Behaviourists' have a rather dim view of humanity and the concept of individualism.

Why 'condition' the medical profession? Why 'train' us to jump through hoops to get boxes ticked? We are important but surely not that important. So why then the special treatment?

Well in fact this type of behaviourism is a societal phenomenon and has underpinned the mainstream educational establishment for some time.

Why, and how, would one establish a trans-generational agenda of that kind? One that people instinctively feel is unstoppable, and hence don't resist? One that smacks more of social control than education?

Trainer 1 said...

Dr Grumble should also read this (via pubmed). The section on 'staff training' will sound familiar.


Dr Grumble said...

Thank you Trainer1.

Once again you have set Dr Grumble thinking. He may even do a post on this topic.