14 February 2010

What do our managers read?

As far as Grumble knows the only journal our managers read is the Health Services Journal. Dr Grumble cannot read this rag. It is not something he subscribes to. But the little snippets he reads from their blog make it seem like the Daily Mail. It seems to be one of those 'journals' that reinforces the mistaken models of the world that some people stubbornly carry in their heads. It might even be responsible for creating these falsehoods.

There are general themes which run through the HSJ output. Doctors are bad is one. GPs are idle money-grubbers is another. And the canard that markets are always good persists despite all the recent overwhelming evidence to the contrary. Doctors are just out for themselves and not interested in the welfare of their patients is another brutal allegation that really hurts. Dr Grumble has decided that he can no longer stand by and ignore the garbage that forms the output from the HSJ. Managers and doctors need to work together. Managers need to support doctors. How can we expect this when the HSJ publishes such falsehoods about us?

Doctors more than management want good care for patients. It's our raison d'etre. It's the overarching focus of our daily work. We, unlike managers, see the consequences of poor care. We more than managers have to communicate the consequences of poor care to our patients or their relatives. How can these people have the effrontery to educate us that patient care is paramount and accuse us of just being out for ourselves? They are the ones who sometimes fail to grasp the primacy of patient care. Not doctors. Unbeknown to our managers concern about patient care is a cardinal reason for the divide between us. We want to provide good care regardless of the cost. Managers always want to keep the lid on spending. That is a constant cause of friction. Doctors are bound to lobby for their patients to see that they get what they need. We are always battling for our patients. But we do live in the real world. We do see that costs must be contained. But what chance is there of our working together when we are constantly being undermined by HSJ blather?

It's a strange irony that it is managers who seem intent on trying to turn us from public servants with a genuine interest in patient care into the money grubbing people the HSJ likes to portray us as. Managers were the ones who essentially forced new contracts onto consultants resulting in our being paid for the very first time (on paper anyway) for all the work that we do. Doctors who were reluctant to move from a professional and vocational contract are now being paid more. Did our masters expect us to be paid less? Perhaps they really did. Perhaps managers just cannot grasp that doctors do whatever is necessary to meet the vital needs of our patients whether we are paid or not. And the same people made similar mistakes with GPs. For it was managers who forced GPs to jump through ever more hoops to be paid - which they promptly did. The BMA dutifully told the government that it would result in their being paid more. But the BMA was not believed. Yet the HSJ continues to distrust them.

The problem is that the HSJ has repeatedly fed a very wrong model of the world into our masters' minds. It has come from a number of inaccurate sources. Sometimes these have been blatant perversions of the truth. Below is just one small example of how the HSJ twists the truth. It is a quote from the editor's blog from a post entitled Public services failing to satisfy customers:

Figures from the UK Customer Satisfaction Index revealed that national public services, including the NHS, achieved the second lowest score among the 13 sectors measured.

The picture was repeated for local public services such as GP surgeries, which were also in the bottom half of the customer satisfaction service league table.

Now from that you would get the impression that GPs are a pretty bad lot, wouldn't you? Like the Daily Mail HSJ reader you might think that something must be done. But if you take the trouble to look at the facts, you would be surprised to learn that GPs were in the top ten of local services just behind the ambulance service:

  1. Your local Ambulance Service — 81.6
  2. GP surgery / health centre — 77.5

They were not only in the top ten. They were second! And, if you want to compare them with other categories, they scored more than Starbucks, VW and Virgin Media. But the HSJ won't tell you that. Now why do you think that could be?

The Jobbing Doctor describes another unwarranted attack on doctors in the HSJ. And like a sheep a manager weighs in and puts his misguided boot in only to have to back down when the redoubtable Clive Peedell puts him right. Read JD's post and put your blood pressure up.


A. Medstudent said...

Thanks Dr Grumble for this link to the brilliant and eloquent Dr. Peedell's comments. I find it very encouraging that somebody of his integrity and intellectual stature is prepared to speak out in this way.

Dr Grumble said...

It's not often you see somebody recognise in response to a few comments that their model of the world is wrong. I take my hat off to the manager for seeing the truth and honesty in Clive Peedell's powerful comments - despite having his mind polluted by the HSJ and, doubtless, many other bad influences.

Our problem is that we are so convinced of our good intent that we see no need to explain it. That has been our biggest mistake because there are evil people out there whose only interest is making money. These people spend lots of money influencing politicians and managers with the intent of sewing the seeds of discontent with the present system. This includes raising suspicions about doctors and portraying public provision as inefficient. I suspect with regard to inefficiency they may now be right because the market systems they have insisted on waste a very great deal of money.

Don't ever think these things happen by accident. They happen by design wrought by a small number of powerful wealthy evil people. It is the strong influence of these people which has meant that all the major parties have the same policies on the NHS. We and the public need to resist these malign forces. But, in reality, we are probably too late.

Andy Cowper said...

You'll be liking this piece from The Grauniad website, then ...

Michael said...

Hearing of administrators having the arrogance to think they are more concerned with patients they see only as account entries than are the doctors who actually see the people themselves makes me wonder if the folk at the HSJ have ever met someone who isn't a fellow health administrator.

Really stunning cluelessness from the HSJ. And that's giving them the benefit of the doubt.

Mike from Ottawa

Dr Grumble said...

Thanks, Andy. I have some sympathy with him on this perhaps because he seems to be attacking managers as well as clinicians.

For this sort of thing the responsibility for implementation lies principally with managers. Perhaps it proves the Grumble point that managers aren't really interested in patient safety. If it was money that would be another thing. Though, of course, neglecting safety is the most costly mistake of all.

Andy Cowper said...

I think the way to really address patient safety has to be a two-pronged attack.

The first bit is one for the medical professions themselves. It is very difficult, as it involves a massive cultural shift towards a self-policing, self-improving, learning from incidents, peer-reviewing your colleagues' clinical practice and getting them - or probably more effective still (because less polite), colleagues from other organisations - to review yours. Not very comfortable at all (I mean, why is it that most clinical director vacancies are lucky to get one application?). But essential. The WHO checklist for safer surgery, which Atul Gawande was involved in, is a useful starter for ten, but this is a massive task.

The second bit is for commissioners. It involves ensuring that they don't pay for sub-standard care, and they never pay for 'never events' like wrong-site surgery, avoidable VTE or HCAI (currently becoming policy, rather belatedly). This is also very difficult, because it involves following up treatment outcomes, and the IT is not in place to do this easily.

But nothing would concentrate the mind like not getting paid - or in extreme cases, losing percentages (or indeed all) of the contract.

Both are essential. Both are massive challenges to the NHS systems and culture. Neither is easy.

Cockroach Catcher said...

Too good a post not to quote! Thanks.

Dr Grumble said...

Andy, commenting on blogs must be a busman's holiday for you! (Dr Grumble just does it for fun.)

I have to admit to being puzzled by some of these things. Taking out the wrong eye or sawing off the wrong leg or removing the wrong kidney are such costly mistakes that not paying for the operation to motivate the managers has always seem to me to be a most extraordinary concept. As for the doctors I would think that most surgeons live in terror of muddling their patients or doing the wrong operation (certainly my father did and he died in the seventies long before managers bothered themselves with this sort of thing). The best way of helping these people is with check lists and time out to think. When lists are behind it is rushing things that leads to errors (not that I am ever in an operating theatre these days but I remember how it was).

Not paying for avoidable VTE I also have a problem with. The vast majority of patients in hospital are at risk but there are all sorts of grades of protection and all sorts of risks associated with the protection. In some groups of patients the evidence base for prophylactic treatment is very weak or non-existent. And it is dangerous to extrapolate from the results of trials to the real populations. You could penalise hospitals for not ticking a box for considering the issue of prophylaxis but ticking boxes is no substitute for an intelligent mind making good decisions.

I well remember the last patient of mine who died of a pulmonary embolism developed while in my ward. She was elderly and had a haemarthrosis. On that basis I decided not to given her prophylactic heparin. But she was a very high risk patient - age, trauma (and to the leg) and immobile. As things turned out I made the wrong decision but it seemed reasonable at the time.

I also remember a patient about whom I had a solicitor's letter. The allegation was that I had caused pressure sores on her heels as a result of using stockings to prevent VTE. Doubtless if I hadn't used the stockings and she had developed a DVT I would also have had a letter.

What I am saying is that you cannot reduce these things to box ticking. You need an experienced mind to make decisions taking the whole clinical picture into account.

I think it is even more difficult than you think and you only address the things that there has been publicity about. There many other issues. Take, for example, our poor treatment of heart failure. There is evidence that we have improved a lot but there is also evidence that we are still rather poor in getting everybody on the right treatment. But (and it is probably a poor defence) only 13% of our patients would have been elligible for the trials upon which our treatment is based. None of this is at all easy.

Anonymous said...

Some of us think that avoidable VTE has been grossly exaggerated. There is a great deal of doubt as to where the figure of 25000 deaths comes from and in any case not all these would be avoidable as is sometimes claimed. The true figure may be below 3000 deaths. Various people have an interest in trying to make out the problem is bigger than it really is.

Dr Grumble said...

You are probably right anonymous. The true figure is 2684 deaths per year.


And in the sort of patient Dr Grumble sees there is not much evidence that the usual prophylaxis has much effect on deaths.


If there is no evidence we can prevent the deaths how can it be that they want to penalise us for them?

It is the old story. Everybody wants it to be Christmas. We have a problem so there must be a solution. If there isn't, blame the hospital anyway.