03 February 2010

Push-you-pull-you management

There was a time when a consultant in the NHS was a professional. He didn't really do what he was told to do because he wasn't actually told to do anything. He decided what needed to be done and did it. He decided how much training he needed and did it. He decided how much time he had to teach and he gave that amount of time. He decided what treatment his patients needed and he gave it. Perhaps some abused it. Most did not. Dr Grumble well remembers waiting in the car outside the NHS hospital while his father did a quick Sunday morning ward round. Nobody paid him. He just wanted to check that the patients he had operated on were all right. That was professionalism.

But that was yesterday. Now you are required to do set amounts of everything. A set amount of Sundays, a set amount of training and a set amount of teaching. These things are logged and measured. Some things are measured thoroughly, others are measured less thoroughly. You do exactly what the management require. It is like being a puppet on a string.

Being told what to do to at this level of detail does not make people happy. But there's no need to worry because happiness is another thing they measure. Dr Grumble will not give you the results of the happiness measures in his neck of the woods. That would not do. Suffice it to say that a lengthy document has now come out from the top management on how to improve staff morale. This is what Grumble calls push-you-pull-you management. They make the staff unhappy so the management alter course and try to make the staff more happy. It sort of oscillates.

This level of tight management control has now extended into clinical matters. Woe betide if you don't follow the latest treatment guidelines. Your performance is scored. It is put on a graph. It is compared with the performance of others. It seems reasonable in a way but the truth is that the guidelines are often decided on a show of hands at a meeting. Some change so rapidly that they just cannot be based on scientific advances. And finding the latest documents is time consuming. The whole thing is oppressive.

Last week Grumble had an email telling him to discharge patients as early as possible. Actually this is not quite what it said but that was the message. They don't like to actually tell you to discharge patients. Not yet anyway. This week Dr Grumble had an email saying that they were concerned about the number of readmissions. Patients are being sent home too early. Now isn't that a surprise? That's what happens with this sort of management. They push you one way and then pull you another. Sometimes you think that things would be OK if only they would leave you alone.


Anonymous said...

It is an inevitable consequence of big government. They hate professionals because they are a threat. Professionals think for themselves, whatever their field. They also know their subjects - and probably their limitations. Can't have that!

For parallels, look at Militant Medical Nurse, Inspector Gadget, Winston Smith 33 and so on. It is the same story. Even in the world of commerce, we now have 'facilitators' instead of managers. CPD (a universal joke) obstructs us from staying abreast of the game.

Most scary of all, we have integrity and (difficult to define) values being replaced by protocols, tick lists and rules. Once you've got rules, then you can find a way round them, as we have seen with the MPs. Integrity and spirit are more useful.

What you are seeing is just a small part of the whole world being dumbed down and turned into robots.


Hayley said...

You're not alone! I'm not even clinical and I get regular emails alerting me to the 'black' bed situation. Unfortunately, there seems to be an element of willful ignorance on the part of the management - if patients aren't being discharged maybe they're not yet ready for discharge. You don't need to be a doctor to twig on to that!

Mike said...

The increasing tendancy for management to control and dictate clinical practice has been going on for some time. How many of you have to prescibe according to a Trust Formulary, despite the fact that the legal ruling in the Herceptin case probably makes their enforcement on clinicians unlawful.
This is an area that the BMA should be strongly involved in, but aren't

Pondering Practitioner said...

It's what has turned me, and I'm sure others here, to writing. At least here we can unleash a creative side, whereas sadly there is no room left for this in medicine.

When I started as a medical student I remeber being told that medicine was both an art and a science - now I'm not quite sure what it is...?

Anonymous said...

Isn't this simply a consequence of being part of a salaried workforce? If consultants, like other professionals, were sel-employed and paid fees for the work they did they wouln't be subjected to top-down management.

Fuddled Medic said...

I'm probably being way to optimistic here but at the end of the day, no matter what people throw at doctors, we are still going to need and want people who can look at patients, weigh stuff up and make a clinical decision

trainer 1 said...

Here are a few other 'postcards from the edge' - true stories from NHS employees over the last few months.

In a large city teaching hospital all consultants are advised they must attend mandatory child protection training. An adult surgeon queries the appropriateness of this for his practice and is told consultants are 'responsible for the children of their patients'.

In another hospital a doctor opens their trust email. The medical director has emailed to instruct staff that they "must not discuss safety concerns regarding the swine flu vaccine with other members of staff or patients. The vacine has been shown to be safe!". She is pro-vaccination but finds the tone of this email strange.

At a different hospital all new junior doctors are told they must now attend a mandatory 'caring for the vulnerable' course. They will have to do a whole morning on this, as well as 'sensitivity training' and will probably repeat these courses in every hospital on their rotation.

Meanwhile a large deanery rolls out 360 appraisals, not for trainees....but for the educational supervisors of the trainees. There will doubtless be 360 appraisals of the people who supervise the educational supervisers. It won't be long before we see the first course in 'training the trainers to train the trainers".

In a different, large teaching hospital a consultant anaesthetist arrives after a weekend off to find that all the supplies cupboards have been fitted with very expensive fingerprint scanners. He is so incredulous he actually photographs the scanners because when he relates this story to others people don't believe him. He wonders how the NHS can afford such pointless equipment. You don't have to have your fingerprints uploaded of course......but then you have to remember a 14 digit security code. Unsurprisingly people opt for the biometric option. The anaesthetist asks a theatre sister if she also finds this intrusive and is told "I have nothing to hide...do you?".

This same hospital is clearly at the vanguard of this type of inititiative as it has already installed swipe card scanners to check out and deposit theatre scrubs. The consultant is told that the hospital plans to have RFID chips in hospital ID cards within 2 years. This will be very helpful as if you get lost HR will be able to tell you exactly where you are. Hopefully there will also be CBD checkpoints throughout the hospital so you can prove you are not a criminal on a half-hourly basis just by swiping your card. If you keep losing your card you might even decide to have your RFID chip implanted (after all your cat didn't mind being chipped).

Meanwhile, in Whitehall, grand plans are laid to aggregate all citizen data (health records, credit, criminal records, social services) within the 'Inititate Systems Identity Hub" (true - I kid you not Grumble). It seems there is always enough money for another database.

This, sadly, is how beaureaucratic dictatorships work. You don't enforce obedience at gun point, you do it with endless checks, traces, monitoring, surveillance, production of 'papers' and pointless training. People end up paranoid, fearful and confused about everything....except the central idea that they are no longer in charge of their own lives. There is a pervasive sense that a database manager somewhere can terminate your livelihood at the click of a button.

Trainer 1 hopes this madness will end soon.

Nurse Anne said...

They were pushing me to get an unwell patient discharged the other day. He was not ready and would have gone home to an empty house all alone. They wanted me to harass the doctor about discharging the guy. It would take a week or two to get social services into the guys home and I really did not want to send him there.

One of my other patients deteriorated and I had to special him until he went to ICU. Ha I thought. I can use the fact that I am tied up with this poorly patient as an excuse for not working on and sorting out the discharge for the other guy.

When I came back from transporting my other patient to ITU they bed managers had booked an ambulance and just sent the other guy home.

For two hours prior I was tied up with the critical patient. I had not done a discharge plan, or called the district nurse, or given him his lunchtime meds, or made sure that he was clean, got confirmation from the consultant that he could go etc. I never send people until I do those things. They just sent him home behind my back.

Instead of getting my 15 other patients their meds that were overdue I ran to the phone and called the district nurse for this guy. I called social services.

Social services gave me hell because they need 2 separate forms , one on admission and one 12 hours prior to discharge filled in and faxed to them before thye will allocate care manager and sort care. And it has to be done while the patient is still in hospital. Don't know if they will see him and sort out care and if they do it will take over a week to get "rapid response" in.

All in all I spent over an hour on the phone trying to get someone to take care of this guy. I had already not seen my other patients for over 2 hours because of the ITU guy. I think it was more like 3 hours in total. I did worng there, I should have just worried about my other patients who were on the ward and taken care of them first but I was really worried about this guy being home on his on.

Pisses me off.

But just so you know, they will force the patient out behind the nurse and doctors back, before we have sorted their discharge stuff out.

Nurse Anne said...

"What you are seeing is just a small part of the whole world being dumbed down and turned into robots.


I agree with you 100%. And I think that both parties have the same agenda, they are presenting it to people differently. But it is the same agenda underneath all the rhetoric.

Dr Grumble said...

I'm probably being way to optimistic here but at the end of the day, no matter what people throw at doctors, we are still going to need and want people who can look at patients, weigh stuff up and make a clinical decision

This is, of course, the case but the managers genuinely seem to think otherwise. They honestly seem to think that the management of a patient can be preordained from a piece of paper or a web site. In other words you read off from the diagnosis which antibiotic to give and Bob's your uncle. No concept of the variety and complexity of the cases we see and certainly no concept of the grey case where the diagnosis is in doubt so there is nothing to read off from.

I have just been redoing our operational policy. I haven't looked at it since it was last written two years ago. Things have changed so we have changed what we do. The paperwork catches up later. There is useful paper and paper for managers.

They want us to work like they do at Toyota. Everybody does things exactly the same way. This means that if there is a faulty part used in Tokyo it will also be used in Derbyshire and the world over. If it goes wrong it's a disaster. But there are savings as well as drawbacks to this approach. I have often wondered whether all of us using the same antibiotics has contributed to antibiotic resistance.

Julie said...

Confucius he say;

Privateers out! Keep our NHS public!

(Well, it probably doesn't say that, but it would be nice if it did..)

Dr Grumble said...

I fear it didn't say anything like that, Julie. It would have been nice if it had.

Lest anybody thinks we are mad, the comment before Julies was in suspect Chinese and has now been deleted.

Anonymous said...

We can't seem to get through to "them" that they are trying to reach a very narrow band of people. Most of us professionals will carry on doing a good job. A few will carry on doing a bad job, regardless. There is a very narrow band of people who will do a better job because of the tick boxes. Why can't they put a little more resources into those people, get a lot harder on the dangerously useless, and switch the resources currently harassing the useful onto making them even more effective?

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