Sunday, 7 June 2015

"More resources to the front line": great slogan but bad for the NHS

In the often heated debate about the future of the NHS there is one surprising thing politicians seem to agree on: most are happy to use the slogan "more resources to the front line". But the slogan is not just naive, it actively damages the service.

The slogan effectively captures the public mood. When a UKIP politician claimed that the NHS has more managers than nurses on BBCQT he was not immediately disbarred from further comment despite having not just exaggerated but grotesquely overestimated the manager count by a factor larger than 20. If statisticians had the power of football referees this would merit not just a red card but a ten match ban. (see the useful analysis of the real numbers here and here).

And this is the first reason the slogan is so dangerous: it reinforces beliefs about the NHS that are simplistic, naive and provably incorrect by anyone with the wit to look. But the slogan is so attractive almost nobody does look beyond it.

This probably wouldn't be a problem if the people running the system didn't also share the belief. But Andrew Lansley wrote the slogan right into the health bill. Despite the whole thrust of the bill being to free up local NHS organisations from central control to give them freedom to decide how to run the system, he built in a centrally imposed target on how much could be spent on management. This target was derived directly from the idea that we should put more resources to the front line and didn't appear to involve any further thinking (the best evidence available at the time suggested that the system was undermanaged before the changes see the Kings Fund analysis). Does anyone at all think that Whitehall politicians or bureaucrats with hardly an hour of operational experience among them are well placed to judge how many operational managers the NHS needs locally?

The second effect of the slogan impacts how well the services run, damaging their quality and productivity. The slogan encourages us not to think how a hospital works as a system. Instead people casually accept that all that matters is how many doctors or nurses there are. Every proposal to spend money somewhere else is rejected by reflex without ever being subject to any actual thought.

It never seems to occur to people that a hospital is a complicated system of interacting people and components that requires a lot of coordination to function at all. There is no point having a doctor in the operating theatre if the anaesthetist hasn't turned up, the theatre hasn't been cleaned, the hospital has run out of AB -ve blood and there is no bed available to receive the patient when the operation is over. But the slogan just diverts thought from those complexities never letting us ask just how many supporting people we need to enable the surgeon to do his work well.

And we apply the same lack of thinking to infrastructure. We'd rather spend money on nurses than computers. The consequence is that if Tesco were a hospital your checkout girl would manually write down the name of each product in your basket, manually look up the price and, when she had emptied your trolley, manually add the numbers without any aid from a calculator to give you your handwritten bill. Which would be wrong more often than right. And the supermarket would frequently run out of the things you wanted due to the lack of automated reordering or stock control. And everything would be both really slow and really expensive.

A recent estimate from one doctor suggested that perhaps 3 hours a day were consumed in paperwork. We might have more staff on the front line, but we are not spending it in front of patients: we are wasting medical time doing badly designed administrative tasks that should mostly have been automated and computerised. More resources to the front line is leading to less front line time with patients.

In a world where our attention was not distracted by a beguiling political slogan, we might ask more intelligent questions about how the NHS works. A hospital is a complex machine where all the parts must work in harmony. It needs a lot of cogs other than doctors and nurses to function and sometimes the reasons it doesn't work well are because there isn't enough support of the front line. Sometimes investing in better systems and investing in more support staff (and managers) is the way to improve the effectiveness of doctors and nurses. Maybe, for example, better organised A&Es are more pleasant places to work and therefore find it easier to recruit the doctors they need to function well (but his might mean they need to invest in managers or systems first). This isn’t just speculation, we have strong evidence that good management dramatically improves the quality and cost effectiveness of what doctors and nurses do (see the papers and documents here).

A more nuanced view of how the NHS actually works might give managers a better sense of their role. They should be making sure the systems and processes make it as easy as possible for the front line staff to do their work. They should be supporting the front line. We might even choose to invest in more managers or more computers or more support staff because that was the best way to make the whole system work better. But we won’t, because we are all befuddled by the damn slogan: more resources to the front line.

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