Archive for the ‘Health’ Category

Measuring for the right reasons.

March 18, 2013

In a recent article Simon Caulkin gives a vivid description of how it emerged at a recent event on ‘results-based management’ run by the consultancy Vanguard that “what to measure may be the single most important management decision a company makes.”

 For an indication of why, take the case of a typical local authority child protection department which operates to two standard measures. For children at serious risk, it must carry out a fast initital assessment of 80 per cent of cases within seven days. For a full core assessment, the standard is 35 days. The department meets both standards; under the widely-used ‘traffic-light’ signalling system (red-amber-green) it rates a green, so managers judge that no further action on their part is necessary. 

 Now look at the same department through a different measure: the end-to-end the time taken to do the assessment from first contact to completion. The picture that emerges is very different. The urgent assessment predictably takes up to 49 days, with an average of 18.5, while the 35-day assessment takes an average of 49 days, but can equally take up to 138. Worse, the clock for the core assessment doesn’t automatically start when the initial assessment finishes but only when it is formally opened. So the true end-to-end time for the 35-day assessment is anything up to 250 days. ‘Now tell me Baby P and Victoria Climbié were one-offs,’ says Vanguard consultant Andy Brogan, who gathered the data, grimly. ‘They weren’t – they were designed in.’

 When the underlying cause is looked for we find, Caulkin says, that “from assessing and protecting children, the imposition of the government-mandated measures ..has shifted the de facto purpose to meeting the standard within officially laid-down parameters”

Unlike standards, the end-to-end measure on the other hand throws light on how well the department is meeting its purpose. Learning takes place. The workplace conversation is no longer about how to meet the standard but what accounts for variation and how to how to save time in assessments to make children safer. Contradicting the traffic lights, action is urgently needed. As the process is repeated, improvement becomes continuous.

 The “why” we measure must, Caulkin insists, always precede the “what”,  and in the remainder of his article he states very plainly why this must be so.

Box-ticking, bean-counting, target-meeting in the NHSdoctors

March 4, 2013

Here, in a  comment is free  column for today’s edition of The Guardian north London GP and Urgent Care Centre doctor,  Dr Fred Kavalier , gives readers some insights into how the flawed management of which Simon Caulkin wrote on Friday is viewed by someone who has seen it close up.

In today’s box-ticking, bean-counting, target-meeting NHS, doctors and nurses are forced to concentrate on things that can be measured and quantified. In the process, we are forgetting many of the things that really matter – the things that are difficult to count and measure.

From 1 April, when all NHS services will be up for grabs by the private sector, it’s going to get much worse. For all its failings, some of which were highlighted by the recent Francis report into deaths at Mid Staffordshire hospital, the NHS has always had the care of patients as its core activity. GPs and hospitals were all singing from the same NHS hymnsheet.

In the new privatised NHS, many of the players will be singing from hymn sheets written in corporate boardrooms. Every single activity will need to be specified in a commercial contract. If some vital aspect of a service is left out it will not get done, or it will appear as an “extra” when the bill comes in…..

All of  which goes to show that the NHS has been in wrong hands for some considerable time now.

The Mid Staffs NHS scandal – the consequence flawed management system?

March 2, 2013

There was a terrific piece in last Friday’s edition of The Guardian by Simon Caulkin auggesting that ‘NHS management failures stem from the same flawed system that gave us Enron and Lehman Bros in the private sector’

The Mid Staffs NHS scandal will not go away. The collapse of the hospital trust into administration and the subsequent resignation of two board members. ensures that the wound will continue to bleed, ratcheting up the pressure on the embattled NHS chief executive Sir David Nicholson. Investigation of suspicious death rates at a number of other hospitals just increases the sense of foreboding.

One reason that scandals like these both run on and recur is that we persist in thinking of them as exceptional; one-offs caused by a few incompetents or rotten apples in an otherwise wholesome barrel. But they’re not. The terrible outcomes at Mid Staffs were the logical consequence of a disastrously flawed management system that systematically forces people to face in the wrong direction, counts the wrong things, and focuses management attention on the wrong part of the job…….

What’s flawed about the system is, according to Caulkin, performance management, which was originally presented as “an enlightened expression of shared interest’ has in reality “morphed into its dark opposite, synonymous “not with developmental HRM and agreed objectives but with a claustrophobically monitored experience of top-down target driven work”.

Applied to individuals such tactics lead directly to Mid Staffs, a system which reshaped people into target-chasers who couldn’t afford to care. At the level of the supply chain the same kind of fierce control gives us a different form of butchery. Scaling up the performance-management tyranny, the big supermarket chains treat meat suppliers as adversaries, writing short-term term contracts, playing one off against the other and driving prices way below the point where something had to give. The immediate result was horseburgers. But behind the scenes is a much bigger, very British tragedy: a meat industry that is in long-term crisis and decline, wholly unable to defend itself against less cannibalistic European counterparts.

Anybody who has read Caulkin over the last 20 odd years, as I have, would expect him to end on an upbeat note. Much of what he has been saying in that time has gone wholly unheeded. Why should things be different now?

Few these days would want to be treated with the mixture of superstition, ideological prejudice and pseudo-science that constituted medical knowledge in the Middle Ages. But that’s hardly an exaggeration of the state of management today. It is management not medicine that has put our institutions in intensive care, and until we decide to do it better unfortunately that’s where they will remain.

Atos & NHS in partnership?

February 18, 2013

It is reported in today’s Guardian the NHS trusts  are being handed back some of the work that the Department of Work and Pensions must have originally thought theyit was not capable of doing in the first place.

Atos, the company contracted by the Department for Work and Pensions to carry out medical assessments of people claiming benefits, has subcontracted elements of the work back to a number of NHS trusts in England.

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A number of NHS trusts south of the border are now reported to have been contracted by the company to help carry out assessments for a new disability benefit, the personal independence payment (Pip), which is due to replace the disability living allowance from 2013. The government aims to cut spending on the benefit by 20% over the next three years.

University College London, King’s and York will deploy thousands of health professionals to carry out the assessments, according to the Financial Times.

It emerged last October that Atos Healthcare had appointed the Scottish healthcare provider NHS Lanarkshire’s occupational health arm, Salus, to help carry out assessments for Pip.

Lanarkshire NHS will receive £22m from Atos to carry out the work until July 2017. Atos won contracts worth more than £400m in August to test whether disabled claimants were eligible for the new benefit.

Atos is receiving £238m for work in Scotland, north-east and north-west England, according to the Department for Work and Pensions.

At the time, the company described its subcontracting of work to NHS Lanarkshire as a “partnership”, adding: “It means that consultations will take place where people feel most comfortable – in the heart of their local community – and they will be conducted by health practitioners that have first-class expertise in dealing with the needs of disabled people.”

Atos said the supply chain model in Scotland was likely to be similar to those soon to be announced in England.

A DWP spokesperson said: “We are taking a new approach working with regional providers for a service which best meets local needs. It was open to NHS organisations to bid for a place on the health and disability assessment framework but none did so.

“We believe that it is right for Atos to partner with the NHS to offer Pip claimants familiar surroundings and experienced health professionals. The partnership proposed here demonstrated best value for money for the department and its claimants.

I wonder how this so-called “partnership” work when the a person deemed to be worthy of a benefit by the NHS is returned for re-evaluation Atos. Does the the NHS partner stick with the original evaluation, or does Atos have the right insist that the patient be reevaluated?  Ane where is the patient in all of this?

The NHS- a lesson learned.

February 11, 2013

On the 22nd of March 2009, not long before he was unceremoniously dumped by The Observer, a paper for which he wrote a compelling management column for some 16 years, Simon Caulkin, with a considerable prescience wrote the following:

MRSA, Baby P, now Stafford  hospital. The Health Commission’s finding last week that pursuing targets to the detriment of patient care may have caused the deaths of 400 people at Stafford between 2005 and 2008 simply confirms what we already know. Put abstractly, targets distort judgment, disenfranchise professionals and wreck morale. Put concretely, in services where lives are at stake – as in the NHS or child protection – targets kill.

There is no need for an inquiry into the conduct of managers of Mid Staffordshire NHS Foundation Trust, as promised by Alan Johnson, the health secretary, because contrary to official pronouncements, it is exceptional only in the degree and gravity of its consequences. How much more evidence do we need?

>>>>> 

Target-driven organisations are institutionally witless because they face the wrong way: towards ministers and target-setters, not customers or citizens. Accusing them of neglecting customers to focus on targets… is like berating cats for eating small birds. ……………

And why, in Calukin’s opinion, was this all wrong?

If people experience services run on these lines as fragmented, bureaucratic and impersonal, that’s not surprising, since that’s what they are set up to be. Paul Hodgkin, the Sheffield GP who created NHS feedback website Patient Opinion (www.patientopinion.org.uk) notes that the health service has been engineered to deliver abstract meta-goals such as four-hour waiting times in A&E and halving MRSA – which it does, sort of – but not individual care, which is what people actually experience. Consequently, even when targets are met, citizens detect no improvement. Hence the desperate and depressing ministerial calls for, in effect, new targets to make NHS staff show compassion and teachers teach interesting lessons.

The evidence that Caulkin thought we did not need came with the release of Robert Francis QC’s final report last week. It contained so much of what Caulkin had indicated it might that in today’s edition of  The Guardian we have Labour’s shadow health secretary, Andy Burnham more or less parroting what Caulkin was saying four years ago.

I draw three central lessons from Francis, starting with NHS culture. Over the past 20 years, there has been a drive to import a commercial mentality into the NHS, which has given rise to a new managerialism and a focus on finance and targets. This approach may be well suited to retail, but there are limits to how far it can be applied to healthcare. On the plus side, it has helped to reduce waiting times and make hospitals more efficient. But in places the response was a tendency to focus on numbers, not people.

Francis is right to say targets, properly constructed and implemented, have a place. But he is also right to warn of an over-reliance on targets. This is a lesson Labour is learning. If we don’t, the NHS won’t be able to rise to the complex challenge of caring for older people – the second lesson from Francis.

He is right to ask us to rethink from first principles the way older people are treated. Stories of older people lost in acute hospitals – disorientated and dehydrated – have become commonplace. I have thought carefully about why this is happening.

The World Health Organisation defines health as “a complete state of physical, mental and social wellbeing, not the absence of disease or infirmity”. But for 65 years England has tried to meet one person’s needs through three separate systems: physical, through the mainstream NHS; mental, through separate buildings on the fringes of the NHS; and social, through a council-run, means-tested system…..

 Burnham’s party may have been slow on the uptake, but it looks as it may have someone within its ranks someone who realises the full implications of what’s happening.

Donna Dickenson on personalised medicine

August 26, 2010

In a fascinating essay published by Project Syndicate , and reprinted by ShanghaiDaily.com and in German by Welt Online, the American-born philosopher Donna Dickenson considers some of the possibilities that medicine based on belief that each individual has special characteristics that can be used to keep him or her healthy open up, but fears that resources will invested in developing drugs and interventions for this new and potentially profitable market, and in more effective health interventions that will benefit the many.

Francis Collins, Director of the United States’ National Institutes of Health, guides us through the upheaval in his new book The Language of Life – DNA and the Revolution in Personalized Medicine. As he puts it, “We are on the leading edge of a true revolution in medicine, one that promises to transform the traditional ‘one size fits all’ approach into a much more powerful strategy that considers each individual as unique and as having special characteristics that should guide an approach to staying healthy. But you have to be ready to embrace this new world.”

This seismic shift toward genetic personalized medicine promises to give each of us insight into our deepest personal identity – our genetic selves – and let us sip the elixir of life in the form of individually tailored testing and drugs. But can we really believe these promises?

Genetic personalized medicine isn’t the only important new development. Commercial ventures like private blood banks play up the uniqueness of your baby’s umbilical-cord blood. Enhancement technologies like deep-brain stimulation – “Botox for the brain” – promote the idea that you have a duty to be the best “me” possible. In fact, modern biotechnology is increasingly about “me” medicine, the “brand” being individual patients’ supposed distinctiveness………..

Read the complete article here.

Illustration by Zhou Tao (ShanghaiDaily.com)

A free market? The NHS? Don’t believe it!!

August 13, 2006

It’s unbelievable but apparently true; it seems that the Ipswich Hospital, having cleared the backlog of patients awaiting non-emergency operations, are not to be paid by the North Suffolk Primary Care Trust, the purchaser of care for the area, if it deals with new patients almost immediately.

This is because the hospital, in doing so, is in breach of a trust rule which says that all non-emergency patients must waiting a minimum of 122 days before receiving any treatment. The rule, it seems, was introduced to help the trust “manage demand” and keep within budget. Recent breaches of this rule has left £2.5m shortfall in the Ipswich Hospital budget and has earned hospital a severe reprimand from Richmond House, the NHS (National Health Service) headquarters. Surely, some would say, a hospital that is proving so efficient that it can provide its services almost on demand, as Ipswich appears to be able to do, is a hospital that deserves praise and reward not censure and penalty. You would think so, says Simon Caulkin in today’s The Observer Business, but then you have to understand how ‘ hard it is for managers to manage Labour’s idiosyncratic pseudo-markets.’ In this case, what interferes with the “free market” mechanisms, is a set of

.. simplistic NHS accounting rules give PCTs no …similar incentive to treat patients quickly. They are like an insurance company boosting this year’s profits by postponing carrying out repairs on a legitimate claim until the following year.

In the final analysis, having examined the how the “pseudo-market” is flawed in this and other ways, Caulkin comes to the conclusion that:

Under many circumstances, choice and competitive markets are powerful mechanisms to drive innovation and reallocate resources from less productive to more productive producers. However, given the requirement for equity and the inflexibility of capacity – even with the touring specialist treatment units – there are strong grounds for thinking that healthcare is not one of them.

You are not alone in thinking that, Simon.

August 8, 2006

Recent research would seem to confirm that teenagers who listen to songs with sexually crude lyrics start having sex earlier than those who listen to other types of music.  These is one of the main findings of the Rand Corporation, which carried out a study by telephone interviewing 1,461 adolescents between the ages of 12 and 17, most of whom were virgins when the study began in 2001. The subjects were questioned about their sexual behaviour and the music they listened to in 2001 with follow-up interviews being were conducted in 2002 and 2005. The conclusion published in this month’s issue of Paediatrics (the official journal of the American Academy of Paediatrics), runs thus: 

Listening to music with degrading sexual lyrics is related to advances in a range of sexual activities among adolescents, whereas this does not seem to be true of other sexual lyrics. This result is consistent with sexual-script theory and

suggests that cultural messages about expected sexual behavior among males and females may underlie the effect. Reducing the amount of degrading sexual content in popular music or reducing young people’s exposure to music with this type of content could help delay the onset of sexual behavior.

I just wonder just how many people would find this at all surprising. What concerns most people, I should think, is just how they are to get teenagers listening to songs which are without, as the Rand report terms it, “this type of content” while still keeping them engaged and entertained.  

 

August 8, 2006

Recent research would seem to confirm that teenagers who listen to songs with sexually crude lyrics start having sex earlier than those who listen to other types of music.  These is one of the main findings of the Rand Corporation, which carried out a study by telephone interviewing 1,461 adolescents between the ages of 12 and 17, most of whom were virgins when the study began in 2001. The subjects were questioned about their sexual behaviour and the music they listened to in 2001 with follow-up interviews being were conducted in 2002 and 2005. The conclusion published in this month’s issue of Paediatrics (the official journal of the American Academy of Paediatrics), runs thus: 

Listening to music with degrading sexual lyrics is related to advances in a range of sexual activities among adolescents, whereas this does not seem to be true of other sexual lyrics. This result is consistent with sexual-script theory and

suggests that cultural messages about expected sexual behavior among males and females may underlie the effect. Reducing the amount of degrading sexual content in popular music or reducing young people’s exposure to music with this type of content could help delay the onset of sexual behavior.

I just wonder just how many people would find this at all surprising. What concerns most people, I should think, is just how they are to get teenagers listening to songs which are without, as the Rand report terms it, “this type of content” while still keeping them engaged and entertained.  

 

August 8, 2006

Recent research would seem to confirm that teenagers who listen to songs with sexually crude lyrics start having sex earlier than those who listen to other types of music.  These is one of the main findings of the Rand Corporation, which carried out a study by telephone interviewing 1,461 adolescents between the ages of 12 and 17, most of whom were virgins when the study began in 2001. The subjects were questioned about their sexual behaviour and the music they listened to in 2001 with follow-up interviews being were conducted in 2002 and 2005. The conclusion published in this month’s issue of Paediatrics (the official journal of the American Academy of Paediatrics), runs thus: 

Listening to music with degrading sexual lyrics is related to advances in a range of sexual activities among adolescents, whereas this does not seem to be true of other sexual lyrics. This result is consistent with sexual-script theory and

suggests that cultural messages about expected sexual behavior among males and females may underlie the effect. Reducing the amount of degrading sexual content in popular music or reducing young people’s exposure to music with this type of content could help delay the onset of sexual behavior.

I just wonder just how many people would find this at all surprising. What concerns most people, I should think, is just how they are to get teenagers listening to songs which are without, as the Rand report terms it, “this type of content” while still keeping them engaged and entertained.