17 08 2009

Few people can have missed the American Republicans’ disastrous approach to the healthcare discussion straying beyond normal political posturing into farce, exaggeration, lies and the plain ridiculous when it comes to using the NHS as an example of how bad healthcare can be. One of the expressions of annoyance at this criticism of the NHS has been a spontaneous twitter campaign #welovethenhs, even supported by the Prime Minister himself.

But I believe there is something we can learn from American healthcare.  Am I aligning myself with Conservative “maverick” Daniel Hannan? Not in the slightest. My point is to echo a line from a paper by Reinertsen (2007) at The Institute for Healhcare Improvement. They have tried to address some of the difficulties in engaging clinicians in a quality agenda and ways to improve it. I have to confess to having a physical reaction on reading this paper, which for me and management science must count as a first:

 “Administrators need to stop regarding clinicians as customers and start treating them as partners in the delivery of healthcare.”

There is a lot clinicians have to learn about management and the whole topic of engagement I suspect will never be fully analysed. I accept there are dramatic differences in funding and organisation (sic) of American healthcare but this I believe is something they have correct.  I believe it sums up a fundamental difference that both offers solution and defines some of the difficulties. Clinicans are not overspending budgets, failing to make cutbacks, having shortfalls in clinic returns rates. Clinicians are dealing with patients. With the patient at the centre of this debate and the ONLY reason for the service being there each side may stop regarding the other with suspicion and regard each other as partners in the delivery of healthcare.

The reasons why we are currently at this juncture may contribute to our learning and progress from here. That I suspect will be my thesis.

Reinertsen, J., Gosfield, A., Rupp, W., & Whittington, J. (2007) Engaging physicians in a shared quality agenda. Institute for Healthcare Improvement, Cambridge, MA.




8 responses

17 08 2009
anne marie cunningham

Life in hospitals really must be very, very different to life as a GP. Do you really think that hospital administration regards you as a customer? Surely, the customer analogy in the US is based on a completely different way of organising healthcare.
Why is it such a challenge to engage hospital physicians in a quality agenda? Are they slow to implement best practice?
Can you give a concrete example of what we should learn from US healthcare?

17 08 2009


always good to have you comment.

Yes, we are seen as consumers, the source of cost and punitive charges and those who spend the budget.

The IHI paper makes very interesting reading; you should download a copy, it explains better than I will.

A topic I will be looking into is this being forced into behaviour, even if that behaviour is something you would do naturally, by someone who does so for ends not the same as yours. Quality agendas are (sadly) often NOT about improving care but about reducing cost of say- re-attendance, complications etc. These are factors that are difficult to plan for and insurance agencies don’t like them, so don’t pay for them, thus they “cost” the healthcare provider. They are NOT about best practice primarily and this duplicity (in the true sense of the word) is what upsets clinicians.

The US healthcare setup is VERY different to the UK. Its driving aim is about making money thru’ serving the population’s desire for healthcare. Accepting that fact is central to understanding of how health is then practiced. That does not, in itself, make healthcare evil, merely differently purposed, differently directed and differently influenced. Making clinicians partners in that delivery (whatever the underlying goals) can only be seen as a positive thing.

A concrete example of what we should learn from US healthcare? Data collection. Because data = money, data collection is CENTRAL to the system, hugely well developed and funded and therefore accurate. information can then be accessed by whoever needs it to find our prescribing rates, complications, time of anaesthesia, whatever you want. and it is robust. unlike our frankly pathetic attempts.

18 08 2009

I agree with the IT point. Quite frankly how can we ensure that we optimise both cost and quality without accurate data. Moreover how will we ever improve commissioning if we can’t calculate the unit cost. IT is one of the key problems within the NHS and a stumbling block to innovation and improvement. You can’t fix something if you can’t diagnose it!

As an aside, I’d refute that the NHS management see clinicians as customers/clients. Essentially both managers and clinicians view Healthcare through different lenses and it is that which separates the groups. As a manager I am aware that the clinical groups are those which I need to keep happy; a group which will not only see things differently, but have different tools to carry things out. However, considering that all are aiming for the same end point (or should be), why do we have to have this disparity and cynicism? We are different. Accept it! Move on! Leverage the various view points and tools and seek to achieve the shared objective instead.

18 08 2009

Thank you for you comments KD.

The discussion of “customer/client” viewpoint unfortunately i don’t think we can just “accept and move on” as it is intrinsic to the way that the NHS currently thinks and works. This has been the way since the Griffiths Report and subsequent changes that were imposed upon the system and in itself is probably the source of most of the lack of engagement between management and clinicians (accepting the fact that this is a two sided relationship). The issue of limited resource and market forces have been the driver to management direction but it is hoped that the Darzi review will change this with its focus on quality of care not targets.

Your personal view is to be lauded and supported along with many others who espouse and practice it. Unfortunately the real nature of clinical work is not bearing this out. This very week we have received an instruction to cut outpatient reviews because by our practice we are costing the Directorate too much money.

18 08 2009

Unfortunately my point of “accept and move on” should have been explained more comprehensively. My point is that yes, the clinician is the person over spending on the budgets. BUT, this is not a pejorativen attack. It is an acceptance that the clinician will always view provision of healthcare through the best interests of the patient. And rightly so!! Management know very little of medicine. However, the management should be there to provide an additional lens, which informs and makes the hard decisions ALONGSIDE the clinicians as to where and how the limited funds should be spent; providing strategic direction and solutions to these problems. Each group bring a different skill to the table. In this respect we should accept our differences, embrace them and leverage them to achieve a World Class Health Service.

I agree that Griffith’s report had a huge impact on the reform of NHS management. However, whilst he looked to disenfranchise the management structure to ensure greater governance and independence, one of his recommendations was to include the clinicians within the structure. Whilst this inclusiveness in management has gone round in circles since the start of time, we’re currently at a place in which Monitor is encouraging clinicial engagement in management decisions with Service line management for FTs. Pilots are showing good results. Behavioural change is the hardest, but bit by bit the NHS will get there.

As a side point, whilst I support Darzi and his review (I am biased- a colleague of mine helped Darzi write it), do you believe that it will lose its impact given his recent resignation? I’m somewhat split on the matter.

I empathise with you re: the cost cutting pressures. There are many management staff within the NHS that support the entire concept of “cost cutting” (unfortunately) irrelevant of the level of care provided. And in this economic environment, the pressure is becoming more evident. The hardest of all management objectives is to balance the pendulum of quality and cost. But as David Nicholson says- it means we’ll have to find innovative ways of improving the system. If those of us that believe the patient is paramount successfully use innovative new ways to improve the system, then the hard line lean methodologists will have to follow and hopefully become redundant.

18 08 2009

Thank you.

All of which I think brings us nicely to where I started- a “partnership” in the provision of healthcare accepting the different values each brings to the negotiating table.

My current philosophical difficulty, and one of the steps in my thesis arguments, is that whilst many are encouraging and see the value of engagement between management and clinicians simply having clinicians IN management is not the answer.

I think Lord Darzi’s decision highlights a personal difficulty I have; he is a surgeon, not a manager. I suspect however your allusion may also be true and sadly may add further weight to my point.

19 08 2009
Anne Marie Cunningham

Interesting discussion! As a primary care physician ( and one with a strong public health bent) I would imagine that the hospital/managers have to take a population approach to budgets. There is a limited amount of resource. There does have to be rationing. Individual doctors managing individual patients do not tend to be good at working within these constraints. So someone else does have to do this.

Surely there are some clinicians who can take this public health approach?

I’ve had a look through the paper now and I am still not convinced that the customer/consumer analogy holds much water. But if it helps you that is fair enough!

19 08 2009

Anne Marie, thanks once again for your comments. The analogy comes, not from me, but from the Institute of Healthcare Improvement and their, fairly thorough knowledge and investigation of their healthcare system. I do accept that this may be America but my point, which I hope hasn’t been lost in all of this, is that clinicians (however we currently see them) should be changed (from whatever we currently see them as) to a position where they are regarded as PARTNERS in the delivery of healthcare.

That is the purpose behind the picture too and perhaps that highlights how stilted that relationship might be?

I don’t believe that clinicans within a hospital should develop a public health approach as they do not have an understanding of this clearly specialist role and knowledge.

What I am proposing is that, within the area in which they do work and do have specialist knowledge, their opinions and thoughts should be part of the delivery of healthcare. This is not currently the case for many, many clinicians and this poor relationship (whether customer or otherwise) is the source of not only discontent but obviously a large reason why the NHS fails to deliver to its best performance.

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