29th December 2023

The underlying forces

In the last few blogs, I have been writing about the proliferation of guidelines, targets, and regulatory work in the NHS. Hopefully I have managed to give you a sense of how much time and effort these pile on to everyday work. Time and effort which eats away at clinical time, erodes morale and drives down productivity.

None of this is unique to the NHS. It is not unique to healthcare, and it is certainly not unique to the UK. An ever-tightening regulatory framework is affecting almost everyone, worldwide. ‘Ratchet world’ as I call it.

However, I believe that healthcare, specifically the NHS, represents the highest regulatory pinnacle. The Mount Everest in the target and regulation world. This is because it is driven by three different, but interconnected forces:

• The risks attributed to medico-legal/patient harm.
• Complexity – and the desire to micromanage.
• The size of the organisation.

Medico-legal pressure to record absolutely … everything

In this blog I am only going to start looking at the first of these forces. Medico-legal/patient harm. Even here I can barely scratch the surface.

‘The provision for claims against the NHS increased from £85.2 billion ($108 Bn) to £128.6 billion ($163Bn) n March 2022.’ ¹

More and more people are suing the NHS for damages. More and more people are complaining about their treatment, whether or not they go on to sue.

Is care getting worse, or does this represent a rise in complaint culture? ‘No-win no-fee’ lawyers are certainly advertising harder than ever. And if you think your care went wrong, why not sue? There’s nothing to lose, and you could end up several thousand pounds richer. Maybe far more.

Whatever the underlying reasons, complaints clog up the machine, directly and indirectly. Even if they are not ‘successful’, they take up vast amounts of time to resolve. Not that long ago I received a nasty complaint about my poor care for a patient. I was on holiday at the time and could easily prove it.

I still had to spend many, many hours dealing with it. So did my manager, and the complaints team at the hospital. And the unit manager and …One phone call by the General Medical Council was all that was needed. ‘Yes, he was on holiday all week.’

Leaving that to one side. The issue I want to look at here is the downstream, or indirect impact, that the threat of litigation creates. The moment any complaint arrives, management circle the wagons, then pore through the patient’s notes to check that all guidelines and regulations were followed – to the letter.

Was the falls audit done? Were all the Water Lows done? Were all care indicators filled in. Below is an example of a ‘Water Low’ chart. It has to be completed within six hours of admission, repeated if there is any change in the clinical condition, and done at least weekly otherwise, in some cases up to three times a week. God help you if it is missing.

And, no, I don’t know why it is called Water Low. I think it should actually be Waterlow.

There can’t be any gaps in ‘excellent’ patient care. All cups of tea offered, and drunk, with the correct number of sugars stirred clockwise. Everything will be scrutinised. The mantra here, as always, is that: ‘if it isn’t written down, it wasn’t done.’

Recording everything, no matter how unimportant, is how lawyers believe a perfect world should be ordered. Their view is that you cannot possibly defend yourself by saying. ‘Of course I did that, it’s what all doctors do. What we are trained to do. Now, you need to prove I didn’t. I shouldn’t need to prove I’m innocent, you need to prove I’m guilty’… Jurisprudence page one, paragraph one. In England least. [Scots law is subtly different]

When I started out in GP-land, all consultations were written out by hand, and we had seven minutes per appointment. Which included the patient’s agonisingly slow walk along the corridor, trying three wrong doors along the way, taking a history, the examination, making a diagnosis, and writing notes. Then, finishing with a prescription. Along with any friendly chat.

If someone had a cough, and possible chest infection, the entire consultation could be written up as. LRTI. Rx Amoxicillin 500mg TDS. Review 1/52 if symptoms no better. MK. 12/6/1993

[Translation: Lower respiratory tract infection. I prescribed amoxicillin 500mg three times daily. I advised the patient to come back in a week if symptoms were no better. My initials and date at the end].

This would now be considered indefensible medical practice. Why did I fail to record the respiratory rate, the oxygen levels, the blood pressure, what did I hear in the chest? Were there signs of possible sepsis, and on and on and on.

You know, if there had been anything important to find, I would have written it down. And if I believed the patient was ‘proper’ ill, I would have sent them to hospital. Or asked them to come back in the next day to make sure they were not getting worse. But no, not now. All shall be written down.

Inexorably, we have ended up with endless drivel in the notes, from all and sundry. ‘I went into the room and introduced myself as George, a physiotherapist. I checked how the patient would like to be identified. They said their name was Mabel, but they like to be called Iris. They consented to my examination ….’ And on, and on. Names changed for patient confidentiality.

In my view anyone writing nonsense like this inpatient notes should be taken to one side and told, in no uncertain terms, to stop writing this bilge … right now, immediately, and never do it again.

It is a complete and utter waste of everyone’s time. It is not clinically relevant in any way. It also makes it almost impossible to find anything that might be important buried in there somewhere. Such as, what you thought was wrong with the patient, what you actually did, and what happens next, and anything you would like me to do  …George.

However, management absolutely love this exponential expansion in record keeping. Indeed, they want more, and more … and more. When a complaint comes in, they can point to this endless verbiage.

The chest was examined for fifteen minutes, all negative findings meticulously recorded. Nothing was actually found anywhere else, meticulously recorded. Although they complained of a headache, I spent ten minutes examining their abdomen, all recorded.

I do not want to know what is ‘not’ wrong with the patient. I want to know what is wrong with the patient. This nonsense comes to a head with NHS 111. This is the service that patients can call, outside of GP surgery opening times. If they are unwell, but do not need an ambulance.

NHS 111 staff record everything, every breath taken. They are especially keen on capturing information about what the patient does not have wrong with them. The patient had not suffered a head injury, the patient was not pregnant, and on, and on.

Their reports now run to nineteen pages, with a great deal of information about what the patient did not have. Sitting on the receiving end, I do not even bother to read them. Because it is almost impossible to find out why the patient called in the first place.

It will be in there somewhere. But it should be page one, line one. ‘The patient called the service because they had a bad headache.’ This may be buried on page five. After two pages recording when the patient called, who took the call, when it ended, what phone numbers were used. What service the patient was referred to, by whom, when. Sigh. Followed by another two pages of conditions that the patient does not have. The patient was NOT hit by an asteroid.

When the patient arrives in my room, having been directed to see a doctor by NHS111, I just ask. ‘What seems to be the problem today?’ They always look aghast. ‘But I have already told NHS 111 all this.’ Yes, but there is not the time in the day for me to read such endless, pointless, garbage… I think this, but do not say it. I just smile in a kind and reassuring way. Whilst snapping a pencil in two under the desk.

The function of medical records is not for them to be written in such a way that they can be used to defend against litigation. It is to pass clinically important information between medical professionals, to enable them to do their job better. Therefore, it must be brief – and to the point.

Try saying that to a manager in the NHS. It is a concept so alien to them, that they almost certainly cannot understand what you just said. Blink! Hard disk reset.

I was recently told that I should write something in the patient notes, every day. Such as what? ‘Clinically, the patient is exactly the same today as they were yesterday. So I didn’t examine them, or prescribe anything.’’ What of patients attending hospital out-patients for a review when I go to see them? ‘The patient was not in the unit today, so I do not know if they are clinically unchanged since yesterday.’

Is that the type of thing you’re looking for?

Yes, was the answer.

Can we row this back?

Perhaps we could start with Winston Churchill who, as always, puts it best.

Churchill knew, as we all know, that pages of meaningless guff serve only to block effective communication. For example, the notes that arrive with patients from the local hospital are, still, written out by hand. It is literally impossible to gain any useful information.

If I do manage to raise the enthusiasm to read them, I find that I often have no idea why the patient was admitted, what happened to them, or why. But, by crikey, you need to go the gym regularly to lift them.

Brevity is what we need. But endless recording, of everything, is what we get. Along with a massive increase in the ‘everything else’ that simply must be done. It is a great burden to carry. It gets heavier every day.  It is driven by a number of forces, but the strongest driver is litigation, and the threat of future litigation.

My estimate, plucked from thin air, is that ninety per cent of what is written down is never read by anyone, ever again … ever. The only time anyone shows any interest is if there is a complaint. Then, the interest becomes obsessive, and the management demand that ‘everything’ must be recorded grows.

My other estimate is that medical staff now spend far more time writing, than doing. ‘Doing’ meaning clinical work. Looking after patients – perish the very thought. I have idly tried to work out how much time the physios in our unit spend writing vs. doing. I think it is currently around 80:20.

And what do patients and relatives complain about most? It is almost always that no-one had any time to look after them or pay attention to their needs. I have yet to hear of anyone complaining that medical staff did not spend enough time writing in their notes.

My prediction would be that, if we spent more time doing, and less time writing, there would be far fewer complaints. Because more care could be provided, the patients and relatives would be happier, and so would the staff. Improving morale, and thus patient interaction.

However, this will not happen until we decide to turn the burden of proof round though one hundred and eighty degrees. As I may have mentioned a few times, the current mantra is that ‘if it is not written down, it was not done.’

My counter-mantra would be. ‘We are highly trained professionals, you (Mr Lawyer) need to prove that we did not do our job, properly.’

This does not mean that you can get away without recording anything at all. Clinical notes are still needed. But they need to be clinical notes that are of use to fellow clinicians, not lawyers.

NHS 111 reports should be a few lines max. ‘Mr X has had a cough for three weeks. He reports that is bringing up green sputum, he recorded his temperature at 38.5⁰C. Chest feels tight. No other relevant symptoms. Past medical history of asthma and COPD. Has not yet seen a GP.’’ The end. I need no more than this.

Imagine such a thing. A note that Winston Churchill might have approved of:

 ‘The discipline of setting out the real points concisely will prove an aid to clearer thinking.’ 1: https://resolution.nhs.uk/2022/07/20/nhs-resolution-continues-to-drive-down-litigation-annual-report-and-accounts-published-for-2021-22/#:~:text=The%20amount%20spent%20on%20claims,billion%20to%20%C2%A3128.6%20billion.

8th December 2023

Nothing can simply be ‘good enough’. Before beginning this blog, I thought I would introduce you to the first two laws of regulation ‘regulation-omics’:

I know that many of the things that are obliterating productivity in the NHS are happening in all health care services, everywhere. A couple of blogs back I mentioned a US study which looked at all the guidelines primary care practitioners (PCPs) are now required to follow. If they were to do all the work required, it would take them twenty-seven hours a day.

So, clearly, they don’t.

Which raises a few interesting questions that I shall just let hang there at present. For example, what are these PCPs doing? Making stuff up? Hoping no-one notices? As for those creating these endless guidelines. Does it bother them that the vast majority are being quietly ignored?

Or do they simply announce. ‘Hear ye, hear ye, hear ye. The mighty guidelines hast been written; our work is done. Now, make it so.’ Snapping of fingers, courtiers shuffle off, heads bowed, hidden and exasperated eyebrows raised.

Very recently a conference for GPs in England debated a motion. One that was easily passed. It was reported in Pulse magazine – a weekly magazine for GPs – as: ‘NICE ‘out of touch with reality of General Practice, say GP leaders.’ The motion was:

‘That conference applauds the aspiration for clinical excellence across the NHS but believes:

(i) that NICE guidance is often out of touch with the reality of working in general practice

(ii) in the current climate practitioners should be judged against ‘good enough’ rather than unrealistic ‘gold standards’

(iii) that the GMC and NHS Performance teams should not be judging practitioner performance against NICE guidelines

(iv) that GPC England should lobby for professional and clinical standards to be aligned to current workforce and workload capacity.’ ¹

As Voltaire once said. ‘The excellent is the enemy of the good.’

Good enough is no longer… good enough. In the NHS it is now demanded of everyone that all workers should constantly strive for excellence. Woe betide anyone who dares let their standards fall below perfect excellent-ness.

This is where all those one hundred and twenty-six organizations [one hundred and twenty-five, plus NICE] who are involved in regulating the NHS – cause so much pain. Whatever they look at, it requires constant improvement. You must now do this better, and this, and this, and most certainly this. No bed sore shall ever be missed. No patient shall ever fall over. Falls audits shall be completed relentlessly.

All patients shall be asked each and every hour if their every need is being met. At all times all staff shall be attentive, and smiling and helpful and, and, and….and? All guidelines will be met, at all times. All sinews shalt be strained in a constant drive for improvement. To quote Joseph Stalin at the First Conference of Stakhanovites in 1935:

‘These are new people, people of a special type … the Stakhanov movement is a movement of working men and women which sets itself the aim of surpassing the present technical standards, surpassing the existing designed capacities, surpassing the existing production plans and estimates. Surpassing them – because these standards have already become antiquated for our day, for our new people.’

There is nothing wrong in asking people to provide a good, and safe, standard of care. But there comes a breaking point in striving for ‘the excellent’. A point that has long since disappeared in the rear-view mirror.

I have not analysed the time it would take GPs in the UK to meet NICE guidelines, but I strongly suspect it would be far more than twenty-seven hours a day. Here, for example, plucked at random, is a reference to the latest NICE guidelines on the management of hypertension (high blood pressure) in adults. This, the short version document, runs to fifty-two pages.²

Have I read the entire document. No. Has anyone. Possibly. But this, the primary guideline on hypertension for adults, is but one of many. There are associated guidelines on hypertension in pregnancy. In addition, there are links to formal risk assessment in cardiovascular disease. With bonus hyperlinks to NICE’s guidelines on hypertension in chronic kidney disease and type I diabetes and type II diabetes and on and on.

In short, this fifty-two-page document is but the tip of a massive iceberg when it comes to high blood pressure, monitoring, measuring, and treating. Which, in turn, is one very small part of the totality of medical practice. No-one can read all this stuff. No-one can keep up. You sure as hell can’t remember it all. It is, truly, impossible.

So, what do GPs actually do when presented with such demands? Well, at present, many of them are considering RLE. Retire, leave, emigrate. “RLE” is now popular trope in GP discussion fora. This is because the sheer stress and overall unpleasantness of the job has become overwhelming.

There was a time when being a GP was an enjoyable job. No more. Those days are gone my friend. Twenty years ago, a partnership in General Practice attracted hundreds of applications. Today, many adverts result in no applications at all.

If you set people an endless barrage of targets and guidelines that can never be reached, it drains people of any, and all, enthusiasm. Every day at work becomes a day of failure. Rolling that great rock up a slope, only to see it roll straight back down again.

Yet, those who drive this catastrophic system just can’t stop themselves from cascading more and more guidelines, and targets, upon a workforce that long since gave up trying to meet them all.

Not only does this crush morale; it also obliterates productivity. So very many pointless tasks. So much time doing work that has only the most tenuous link to patient care, and benefit. I have focussed on GPs in this blog, but everything I have written is much the same, everywhere. Primary care, secondary care.

I think nurses have it worse than doctors. Indeed, from chatting to them, I know they do. Whilst doctors have still managed to cling onto some small scraps of clinical freedom. By which I mean the ability to manage and treat the patient in the way they think best. Nurses have no such freedoms. Their guidelines, and targets, are cast from hard, unbending iron. You do it, or else. And do not dare deviate.

Why can’t these organisations just, stop? Even better go into reverse. Can they not even attempt to define what is ‘good enough.’ No, we the mighty, have told you what constitutes perfect care for raised blood pressure. So, this is what you must do. Even if it takes about ten hours per patient, per year – for one condition.

How long does a GP get with each patient? On average, ten minutes, six times a year. That is, to deal with everything.

There are a number of interconnected reasons why regulations and targets and guidelines cannot, currently, be reversed, and I intend to look at a couple of the most important in the next blog.

1:https://www.pulsetoday.co.uk/news/workload/nice-out-of-touch-with-reality-of-general-practice-say-gp-leaders/

2: https://www.nice.org.uk/guidance/ng136/resources/hypertension-in-adults-diagnosis-and-management-pdf-66141722710213

27th November 2023

Relentlessly falling productivity (Part a).

Regulatory constraints.

I was in the midst of writing another blog on what is wrong with the NHS, happily highlighting a few of the many pointless tasks that get in the way of clinical work. But my attention kept being drawn to the more general issue of the widespread fall in productivity.

Here, from the report: ‘Is there really an NHS productivity crisis?’

It is certainly true that measuring productivity in the health service is wrought with difficulty. But in our view, the available evidence strongly points to the NHS – or, at the very least, NHS hospitals – having an ongoing productivity problem. ¹

Productivity is by far the biggest problem the NHS faces. The one ring that binds them all. And it must be dealt with. If productivity continues to fall, the NHS will steadily become less and less efficient. Until … until what?

In truth, I am not entirely sure. Nor I suppose is anyone else. The NHS cannot just go bust like a commercial business. Mainly because it has a hundred and fifty billion pounds pumped into it every year (~$200Bn). Which means it is doomed to stumble on for years. Kept upright by massive infusions of money? Until …

One trend already picking up pace is that and more people are paying for private medical care. Either directly, or through health insurance. At some point in the future, we will end up with a fully established two-tier system. The rich getting good medical care, the poor … not so much.

Whilst people going private will relieve some pressure on the NHS, it won’t impact on the fundamental issue. Which is that the UK taxpayer is throwing ever more money at the NHS, whilst getting less and less in return.

Why is it happening? Are staff working less hard?

‘Fewer patients being treated per staff member should not be interpreted as NHS staff working less hard. Staff are not the only input into the system. The point is that if there are more staff, or staff are working more hours, but the system is providing less care, then something appears to be going wrong.’

There is no evidence here for the staff slacking. So, what is this something of which they speak.

To see if anyone else had any brilliant insights, I read a few different reports. Here is one from the Institute for Government (whatever this institute is, exactly). It was entitled: ‘The NHS productivity puzzle. Why has hospital activity not increased in line with funding and staffing?’

It droned on for sixty-two pages, before limping to three main conclusions. First, that we don’t have enough beds, so hospitals are running above capacity, which make them more inefficient. True.

Quite how much more inefficient was not entirely clear. But we certainly could do without running hospitals full to bursting point. Just to give one example of why this damages productivity. If a hospital is completely full, then planned operations will have to be postponed, even cancelled. Because there are no beds available for recovery. Fewer operations = decreased productivity.

Second conclusion. The NHS is losing too many experienced staff who can’t stand working in the NHS any longer (my words). Due to ‘staff burnout, low morale and pay concerns’ (their words). Experienced staff tend to get things done faster, and better. When you lose them, things slow down, get done worse, and cost more.

This is also true. So, you would think staff retention should be a ruthless focus – but it is not. Not even remotely. ‘You want to leave… well then leave. There’s the door. Bye! … and good bloody riddance.’ This, by the way, is the current NHS staff retention strategy.

Finally, the report concluded that the NHS is badly undermanaged … cough, splutter, strangled gasp of disbelief. Although the authors also discovered the following…

‘We found that hospitals that had more managers or spent more on management were not rated as having higher quality management in the staff survey, nor did they have better performance. The implication being the overall hospital performance is dictated by clinical actions and behaviour, while hospital management is focused on administrative tasks ensuring regulatory constraints are met. The number of managers in each hospital was largely determined by the administrative tasks that needed to be fulfilled, with the scope of management circumscribed to these well-defined tasks.’ ²

As with many such reports, it managed to contradict itself from one sentence to the next. In one section it claims that the NHS is undermanaged, but when the authors looked at hospitals that spend more on management, there was no difference in performance.

Anyway, apart from a couple of relatively minor issues, there was nothing much in either report here, or indeed anywhere else, to explain the widening productivity gap. Which is a common finding of such high-level reviews. Report writers very rarely bother to visit hospitals and speak to the staff, who might be able to enlighten them.

So, I thought I would have a go. I began by going back to basics, starting with two key facts.

Fact number one. There are far more clinical staff working in the NHS:

‘Hospitals had 15.8% more consultants, 24.6% more junior doctors, 19.5% more nurses and health visitors, and 18.5% more clinical support staff in January to July 2023 than in January to July 2019….’

Overall, around twenty per cent more clinical staff:

‘But in the first nine months of 2023, they had 4.3% fewer emergency admissions and 1.3% fewer non-emergency admissions than over the same period in 2019. They carried out 1.8% more outpatient appointments and 0.8% more treatments from the waiting list than in 2019. This means that the number of patients treated per staff member – one crude measure of productivity – has fallen substantially.’¹

Fact number two. There has been no increase in clinical output.

Which means that in the last four to five years, productivity has fallen by around twenty per cent. If it keeps going down at this rate, in twenty years’ time, the NHS will be doing nothing at all.

By the way, clinical output means activities such as, seeing a patient in accident and emergency, or in the outpatient department. Or carrying out an operation, or doing a scan, and so on and so forth. Otherwise known as clinical activity. Consulting, scanning, diagnosing, treating, operating. Which is what hospitals, and GPs of course, are there to do.

Was there any evidence to be found in this second report that the staff were working twenty per cent less hard? Nope. My own observation is that clinical staff are working harder than ever. Work, work, busy, busy, chop, chop, bang, bang.

A view reinforced by the fact that healthcare workers are suffering a crisis of ‘burnout and low morale’ … and also taking far more sick leave. In addition, they are quitting, in droves. These are hardly strong indicators that the workers are all lounging about in cushy jobs.

Bringing these facts together, what we have is twenty per cent more staff, working just as hard, probably harder. Yet, they are creating no additional clinical outcomes. Where does this leave us?

There is only one possible conclusion. Which is the following. At least twenty per-cent of the work that clinical staff are doing is non-productive.

I suppose this is another statement of the bleeding obvious. But at least it does get us looking in the right direction, towards non-productive work. At which point the next obvious question arises. What is all this additional, non-productive work?

One clue is to be found in the report I quoted earlier, and two key statements that it contains.

Statement one: ‘hospital performance is dictated by clinical actions and behaviour.’

Statement two: ‘hospital management is focused on ‘administrative tasks’ ensuring regulatory constraints are met.

Here, I believe, we find ourselves looking directly into the heart of the problem. The underlying disease. The dichotomy, the split. The war within healthcare. Whatever you want to call it.

Which is that clinical staff do clinical work, and produce clinical outcomes, and therefore drive productivity. On the other hand, the primary role of management is to do something else. Namely, fulfil administrative tasks.

‘The number of managers in each hospital was largely determined by the administrative tasks that needed to be fulfilled, with the scope of management circumscribed to these well-defined tasks.’

As a manager might say, but never would. ‘You do clinical stuff; we will do management.’ And never the twain shall meet.

One of the first things people say to me, whenever a discussion turns to the NHS, is that there are far too many managers. ‘They don’t do anything. We should sack them all.’ Well … it certainly sounds tempting. The truth is that I have no idea if we have too many managers, or not enough managers, or just the right number.

What I can tell you is that, instead of having a tight focus on helping clinical staff do more productive work …

‘…hospital management is focused on administrative tasks ensuring regulatory constraints are met.’

And what is a regulatory constraint when it’s at home? Don’t you just hate language that means almost nothing, to almost everyone. A regulatory constraint is something that regulators insist has to be done before you can get round to all that pointless clinical stuff, like seeing a patient. Regulatory constraints, in turn, are met by the many and varied administrative tasks.

Where to start in attempting to explain how administrative tasks play out in the day-to-day life of any healthcare worker? On the basis that I know what I do best, I lay before you a few minor examples from my own work. I do realise each of them may seem trivial. With every additional task only adding a few minutes to each working day.

However … (exclamation mark) please bear in mind that I am only talking about one tiny area of medical practice, in one very small part of the NHS. Multiply this a thousand times, at least.

To begin.

In the GP Out of Hours department we used to have a locked drug box on the wall of a small side-room. It held a limited number of commonly prescribed medications. Having this stock meant that when the pharmacies were shut overnight, we could open the box, and hand out drugs directly to the patients. This saved them waiting till eight or nine the next morning to start treatment.

It used to be a pretty simple job. We wrote out a prescription, got the key to the box, opened it up, then handed the drugs to the patient. We left the prescription in the box to allow the used-up medications to be replaced.

There is now a behemoth of a multiple drawer thing in the department, that must have cost thousands. It looks a bit like those lockers where people can pick up on-line orders for Amazon. Somewhat smaller, yet vastly more complicated.

This locker has a touch-screen interface. It requires a smart card, two sets of key-codes – which keep changing, and no-one can remember what they are. A nurse must also accompany you, to ensure that … what? We don’t nick the drugs, I suppose. Locum doctors have no access to this locker and have to get another doctor to open it up.

This new, and vastly more complex system, adds about three to five minutes to the job in hand. Which, when you have fifteen minutes to see each patient, represents a very significant increase in time spent per patient. Up to thirty-three per cent.

Okay, yes, I can almost hear you thinking … trivial. Suck it up. Work a bit faster.

Here is another small thing from out of hours. In days gone by, when we went out on home visits, we plucked a handwritten prescription pad out of a drawer, then brought it back when we returned to base. Minus the scripts we had written.

Now, we can only take six scripts out with us, maximum. Not an entire pad – perish the thought. Once you have seen six patients you have to return to base to pick up more. And if you make a couple of mistakes, in writing out a couple of scripts, you can only see four patients before being dragged back to base. Which may be a half hour drive away, or more.

There is also an additional sign-out procedure for the prescriptions. On a good day this adds an extra couple of minutes. On a bad day, which is most days, we have to stand around and wait for the nurse to finish a phone consultation before they can countersign the book. Then the script prescriptions must be painstakingly counted out, with all serial numbers double checked. These must be matched up with the case numbers of the patients seen.

Sticking only to drug prescribing here. We have printers in each room for the electronic prescriptions we use at the base. At one time, if the paper for these electronic prescriptions ran out, we would pick a few new ones from boxes lying about the nurses’ room and load them back in the tray.

Now, the printable prescriptions are locked away, and the printer trays are also locked shut. Today, if you run out of paper for the printed prescriptions, which happens frequently, the task of re-filling the tray can take about ten minutes. Assuming the keys can be readily located.

Yes, yes, small additional tasks. Suck them up, see the patients faster. Make room in your day, lazy scum. But these few tasks add about half an hour to each working day, yes, I added them up. Thirty minutes out of each eight hours. You do the math(s).

In Japan they have a word for incremental improvements in the way work is done to improve quality and productivity. It is called Kaizen. Improvement in a gradual and methodical process. In the NHS we have anti-Kaizan. Anti-Kaizan means a reduction in productivity as a gradual and methodical process. Grinding, relentless.

My own term for this is ratchet world. It seems that almost every day, some new additional new regulatory constraint has been met .‘Click’, new task, goes the ratchet. The ratchet clicks ever tighter, the workload increases. Tomorrow ‘click.’ The next day. ’Click.’ Eventually all these clicks can no longer be sucked up. Inexorably they cut into real work.

In parallel with this, there is no longer any free time, for anyone. No moment for a chat and a cup of coffee. No time for bonding and creating a team. No fun, no joy left in work. Everyone is just head down, working harder and harder. In some A&E departments, doctors are being followed around by clipboard wielding managers, ensuring that they don’t dare to stop working. No cup of tea for you, scum.

Can I, as a doctor, announce. ‘I am not doing any of this crap, it is a waste of bloody time, and it is stopping me from seeing patients.’ No, I cannot. Because regulatory constraints take precedence over everything else. Absolute priority number one.

If you fail to meet a few regulatory constraints then, when the Care Quality Commission comes to visit – knives sharpened – you will FAIL your inspection. You will be MARKED DOWN. Your hospital trust will be deemed INADEQUATE!

There will be shame and public humiliation. The chief executive will have his head placed on a spike outside the hospital … maybe not quite. But failed inspections in other areas, such as schools, have recently led to suicides.

Unsurprisingly therefore, regulatory constraints are what managers relentlessly focus on. It is also what they demand that clinical staff focus on. So, I, like everyone else, sigh gently and get on with it. Do these endless additional administrative tasks make me happy in my work? Have a wild guess on that one.

Of course, it is not the managers who do the vast bulk of actual additional work. This is almost entirely done by clinical staff. It is the clinical staff filling in forms, and completing audits, and ticking drug boxes, and checking every patient for bed sores – no matter what age. Which means that ‘Administrative tasks’ are what clinical staff spend much of their time doing. The job of managers is to ensure that all regulatory constraints are met. Or else.

Although I do remember listening to the chief executive of a hospital trust on the radio saying that she employed eight people just to put together all the reports and audits that were demanded of her by the organisations above. This managerial workforce, alone, was costing her hospital trust two million pounds a year. Two million pounds worth of pure unadulterated productivity … not.

Winding back the ratchet I could write a hundred pages, a thousand pages, on all the additional paperwork, the additional forms, the clicks on the ratchet that have been introduced over the last few years. Instead, I give you a picture of Dr Gordon Caldwell, who is an A&E consultant. In this picture he is demonstrating the paperwork that has to be filled in when a patient arrives at the department. He is using his body as an indicator of scale. He is not dead.

These are the forms that now have to be completed to admit one patient in Accident and Emergency. He wrote an article about it all entitled ‘The NHS is drowning in paperwork.’ ³

Once again, I hasten to add that this is not the fault of hospital managers. They are simply following the orders handed down to them by others. And who, exactly, are these others?

They are the regulatory bodies that sit above the hospitals, controlling their every action. And there are a hell of a lot of them, churning out regulatory constraint after regulatory constraint. How many? Here from a report in the British Medical Journal:

‘We found that in total, more than 126 organisations are engaged in safety related regulatory activities in the NHS.’ ⁴

Here are the names of but a few. The Care Quality Commission (CQC), and NHSE (NHS England) and the Integrated Care Boards (ICBs) and NICE (The National Institute for Health and Care Excellence). The four horsemen of the apocalypse, as I like to think of them.

These bodies carry greater power and influence than most others. But each and every one of those one hundred and twenty-six is eternally busy, thinking up new regulatory constraints. New targets to be met, regulations that MUST be fulfilled. Administrative task after administrative task, my precious.

All of these tasks have one thing in common, and only one thing.

The all take time away from clinical work. They all reduce productivity. Every single one of them. These are the ‘anti-Kaizan’ jobs. Ratchet click after ratchet click.

Are they all necessary?

Would the NHS fall over sideways if we just stopped doing some of them, or all of them? Next time I will look at the rationale for the introduction of these million new anti-Kaizan jobs that are dragging the NHS – and social care – to their knees.

1: https://ifs.org.uk/articles/there-really-nhs-productivity-crisis

2: https://www.instituteforgovernment.org.uk/sites/default/files/2023-06/nhs-productivity-puzzle_0.pdf

3: https://www.spectator.co.uk/article/the-nhs-is-drowning-in-paperwork/

4: https://bmjopen.bmj.com/content/9/7/e028663

20th October 2023

(With lessons from, and for, all other health services around the world)

The Quality and Outcomes Framework

The Quality and Outcomes Framework (QOF) was to be the glittering triumph of Evidence Based Medicine. Many of the commonest and most deadly diseases afflicting humanity would be picked up early, then treated. Almost entirely by using medications which had proven benefits.

People at risk of cardiovascular disease would have their cholesterol levels checked. Then, if high, put on statins. They would have their blood pressure measured and put on antihypertensives. Other drugs to be added as required.

Anyone with diabetes would be prescribed blood sugar lowering medications. The entire list of QOF indicators is long, the funding large. The workload vast. General Practitioners gain QOF points for achieving certain targets, or ‘thresholds. For example, the percentage of their patients with high blood pressure where it is successfully lowered to achieve the required level e.g., < 140/90mmHg – or less¹.

In my view this is not medicine, it is accounting. It is also stultifyingly boring. Yet, at the same time, stressful, as you desperately attempt to record ever possible point, during a consultation. And patients wonder why their GP never looks up from the computer screen. They are probably playing QOF bingo.

Each point is worth a couple of hundred pounds, and several hundred points are on offer. The average UK practice, which has just over nine thousand patients, can earn around £135K (~$200K). Money which goes directly to the GP partners. It makes up a significant portion of their income.

The aim of all this? The aim is to reduce death and damage from nasty things such as heart attacks and strokes. With diabetes, the aim is also to reduce heart attacks and strokes… additionally kidney failure, and amputations, and blindness. All exceedingly worthwhile. There are many other QOF areas.

You could argue that GPs should have been bloody doing this anyway. It’s their job, after all?

Well. Possibly. Pushing that issue to one side (Conflict of Interest statement, I am a GP) I am more interested as to whether it has worked… whether it could ever have worked. Or why it is yet another reason why the NHS is falling over sideways, burdened with an ever-increasing workload, which is of almost no use whatsoever.

The supporters of QOF, and there are many, would argue that all this activity must do good. We have all the evidence we need from rigorously controlled clinical trials, no less. We know that lowering blood pressure is highly beneficial, as is lowering cholesterol and blood sugar levels. We simply know these things.

We do, we do, we do we do.

Or maybe – we don’t.

QOF was introduced in 2004. In 2017, a study in the BMJ reported the following:

‘England’s incentives that pay GPs for performance have not delivered better care for people with long term conditions, a systematic review of evidence has found.

The study said that there was “no convincing evidence” that the Quality and Outcomes Framework (QOF) influenced integration or coordination of care, self care or patients’ experiences, or improved any other outcomes for these patients. Rather, QOF may have “negative effects,” the reviewers said, and abolishing it may allow practices “to prioritise other activities which could lead to better care.” ²

A system that has added up to payments to GPs, since its introduction, of something in the region of £20Bn ($25Bn). The end result? It may have had ‘negative effects’. Which is a polite way of saying … not only does it do no good, but it is more likely to be causing harm.

In truth, it has cost a great deal more than £20Bn. One thing the NHS never, ever, considers is the time and money it takes to do such additional work? It is something economists call opportunity cost. What else could you be doing, if you were not doing this (useless) thing?

How much time has it swallowed up? I have no idea. I have not seen anyone attempt to quantify this. Or, if they have, I have failed to find it.

From my own experience I would estimate that, at a bare minimum, QOF takes up an hour each day. An hour of GP time is worth approximately £100. This figure is not GP pay. Despite what you read; we do not get paid that much. It includes building costs, other staff costs e.g., receptionists, heating, lighting  – and all the other stuff you need to run a small business.

Now for a quick, back of a fag packet calculation. There are around thirty thousand GPs. Which means that, over and above the money directly paid out for meeting QOF ‘thresholds’, there are an additional three million pounds that need to be covered each and every day to do QOF work. Which is close to a billion a year. Another twenty billion or so, since introduction in 2004.

For which princely sum the NHS has gained, absolutely nothing at all. Apart from burnt out GPs, enormous waiting lists to see GPs. Annoyed and upset patients who end up going straight to overflowing A&E departments because they can’t be bothered to wait and see their own GP.

Here, right here, we see another reason why the NHS is going so badly wrong. And the underlying problem that drove the thinking behind QOF is mirrored in other health services around the world.

Other countries may not have the formalised system of QOF, but they too have guideline after guideline for managing long-term diseases. And meeting guidelines takes up vast amounts of time and effort. As mentioned in the previous article, it has been calculated that if Primary Care Physicians (GPs) in the US, were to follow all the treatments guidelines, it would take twenty-seven hours a day, all day, every day.

A stitch in time

QOF, and all other guidelines are based on the same principle which I shall call ‘the stitch in time strategy.’ Pick up diseases early, treat them early, and this will prevent downstream illnesses and death. Huzzah. This idea seems to mesmerise both doctors and politicians.

In truth, if you choose not to think about it too carefully it does sound good…must work surely. And, if it did, I would call it… a good thing. Bring it on. But no-one made any effort to find out if QOF was going to work, before rolling it out nationwide. There was no pilot study. There was no study of any sort. It was simply assumed that we had all the facts we needed We had all the evidence required. Such hubris.

There were those, and I was one of them, who were concerned that we were about to embark on the most gigantic healthcare experiment ever. One that could, potentially, do far more harm than good. I had many concerns, but I will just stick to one here.

Whilst we had evidence (from drug company sponsored clinical trials) demonstrating that certain actions e.g., taking an ACE-inhibitor after a heart attack, reduced the risk of future heart attacks. We did not know whether or not giving four different drugs – together – would result in greater benefit. Or, if the interactions between all four drugs might cancel out any benefit. Indeed, possibly cause harm.

Currently, after any heart attack, standard therapy includes four different medications. Often five, and if you have a raised blood sugar level, which many people are found to have, you get a couple of additional of drugs to lower blood sugar at the same time.

Has there been any trial looking at the cumulative benefit, or harm, of taking so many different drugs together? Compared to taking only one, or none? Nope. Never. The term for giving a large number of drugs simultaneously is polypharmacy.

Here is a recent study published in Nature:

‘Polypharmacy, hospitalization, and mortality risk: a nationwide cohort study’

‘Polypharmacy is a growing and major public health issue, particularly in the geriatric population. This study aimed to examine the association between polypharmacy and the risk of hospitalization and mortality,,,

Polypharmacy was associated with greater risk of hospitalization and death… Hence, polypharmacy was associated with a higher risk of hospitalization and all-cause death among elderly individuals.^{’ 3}

My main current job involves working in a unit looking after elderly people who, for one reason or another have ended up in hospital. Usually as a result of a fall, and a resulting injury of some sort. Our job is to fix them up and get them back home again.

In this unit we use drug charts called a wardex. These have sixteen spaces available for regular medications. Last time I looked, fifty per cent of patients needed two drug charts, because they were taking more than sixteen different medications. Ergo  there was no room for them all on a single wardex This explosion in the number of medications prescribed is mainly a result of GPs trying to meet QOF thresholds.

It is now widely accepted, by anyone who has looked at this issue, that polypharmacy increases mortality. However, if I dare to take patient off a single drug then, when that patient goes home, there are often howls of protest. I have had several letters of complaint.

It seems that we are stuck with a system that costs billions, takes up a huge amount of GP time, and effort, and has achieved nothing other than ‘negative effects.’ It has also created mass polypharmacy which I know (from a great deal of other research) does harm.

1: https://www.england.nhs.uk/wp-content/uploads/2023/03/PRN00289-quality-and-outcomes-framework-guidance-for-2023-24.pdf

2: https://www.bmj.com/content/358/bmj.j4493.full 3: https://www.nature.com/articles/s41598-020-75888-8#:~:text=Hence%2C%20polypharmacy%20was%20associated%20with,cause%20death%20among%20elderly%20individuals.

9th October 2023

(With lessons from, and for, all other health services around the world)

Whilst awaiting the Judgement on my libel trial – three months from the hearing and counting – I decided to write about things other than statins and cholesterol. Lest I damage our case in some unforeseeable way. I do this humbly, as a public service. To keep people informed, and perhaps amused. Today, I shall touch upon the issue of:

Spending vast amounts of time on things that are almost completely useless.

Guidelines. Guidelines, guidelines, and more guidelines – and other mandatory stuff. These cascade down upon all health services from on high. As a starting point, and mainly because it is the most recent thing to hit my desk, we can cast our eye over gambling.

It’s true that many people’s lives are destroyed by gambling. But is it an illness, or a  disease? NHS mental health director Claire Murdoch certainly thinks so. In the most recent missive from National Institute for Health and Care Excellence (NICE) Dr Murdoch not only describes gambling a disease, but a ‘cruel’ disease. Unlike all those cute and cuddly diseases we deal with on a daily basis. As she states:

‘Gambling addiction is a cruel disease that destroys people’s lives. We will work with NICE on this consultation process.’ ¹  

Here from the draft guidelines:

‘Health professionals should ask people about gambling if they attend a health check or GP appointment with a mental health problem, in a similar way to how people are asked about their smoking and alcohol consumption, according to new draft guidance from NICE.’

As you may have gathered from this, asking people about their gambling hasn’t happened yet, but it will. Once NICE has reached the dread stage of a consultation process, it is basically a done deal. ‘We shall consult with all relevant ‘stakeholders*’, then do exactly what we have already decided to do’. Yes, I do love a consultation. ‘We consulted, but we heard only what we wanted to hear, and ignored everything else.’

*stakeholder is a word that, in my humble opinion, should be removed from the Oxford English Dictionary. It increases my BP to dangerous levels.

As for asking about gambling, and all the additional work that will inevitably be associated with this. Forms to be filled, appointments to be made, audits to be done. But if it helps people with gambling then this is all fine, wonderful, super great?

Or maybe not. As I say to nurses, when some new ‘thing’ – which absolutely must be done – thuds onto their desk. Ask them (whoever them may be) what you can now stop doing. If we assume that nurses are busy, and they sure are, you can’t simply squeeze extra stuff into their working day. Something has to give.

But in the health service nothing ever gives. Everything is additional work. Everything is an add-on to a service that is, currently, on its knees. Does anyone ever think. Hold on. It would be nice to do this, if there was any time left in the day. But right now, there isn’t.

Last week I spent two hours of my life, that I shall never get back, doing the Oliver McGowan Mandatory Training course on learning disability and autism. This was recently introduced by another body, the Care Quality Commission (CQC) – don’t ask. The CQC employs dementors, who descend upon their victims and suck out their very soul. ‘And why have you not met the falls audit target of 99%.’ Evil cackle.

As for the Oliver McGowan training itself:

‘The requirement states that CQC regulated service providers must ensure their staff receive training on learning disability and autism which is appropriate to the person’s role. Employers can refer to The Oliver McGowan Mandatory Training.’

Again, fine, wonderful, super great? We should all know how to work with these people better. In truth I found it repetitive, dull and patronising. And I learned nothing that I did not already know. In my opinion it could be summed up in nine words ‘Be nice to those with learning disability, and autism.’ Or else?

However, it is mandatory. Which means I had no say in the matter. Nor do the other 1.27 million people who work in the NHS. The on-line system also detects if you have wandered off for a chat and a coffee, then takes you right back to the beginning. Bastards.

I feel that you can look at this a couple of ways.

One: It is just two hours of around two thousand or so that make up your working year. One thousandth of your working life. So, suck it up and stop complaining. Get with the programme.

Two: 1.27 million people spending two hours on a mandatory training course represents 2.54 million hours. This is one thousand three hundred years of NHS staff time. Gone, never to return. At a cost of many, many, many, millions. Millions that could have been spend on something else. Such as patient care?

Earlier this year I was interested to discover the following fact. If every doctor in the US were to follow all the guidelines for disease management that are issued by various medical groups, it would require them to work twenty-seven hours a day.

‘Primary care providers (PCPs) were estimated to require 26.7 h/day, comprising of 14.1 h/day for preventive care, 7.2 h/day for chronic disease care, 2.2 h/day for acute care, and 3.2 h/day for documentation and inbox management. With team-based care, PCPs were estimated to require 9.3 h per day (2.0 h/day for preventive care and 3.6 h/day for chronic disease care, 1.1 h/day for acute care, and 2.6 h/day for documentation and inbox management).’ ²

I am just guessing here. But I don’t believe that primary care providers in the US are actually working twenty-six point seven hours a day. Ergo, these lazy swines are not following all the guidelines. So, which ones are they not doing? And does it matter? Has anyone noticed?

In the UK NICE guidelines cascade upon doctors in the UK like confetti… silage, the plague (insert metaphor of choice here). Some of the individual guidelines are more than six hundred pages long. I read one once, from start to finish once. By the time I finished it, I had forgotten why I bothered in the first place. It took well over a week.  I ended up none the wiser.

But it does not stop with NICE and the CQC. A couple of years back, there was a study in the British Medical Journal entitled: ‘Patient safety regulation in the NHS: mapping the regulatory landscape of healthcare.’

Their main finding:

‘We found that in total, more than 126 organisations are engaged in safety related regulatory activities in the NHS.’ ³

All of them, I presume, have but one aim. To introduce new stuff that simply must be done, by order of the management. Ideally by making it mandatory. Each activity, I suppose, has some evidence to back it up. Evidence that is, if you care to look, often very weak. It sometimes just seems to be someone’s hobby-horse, picked up by a politician who wants to bask the glow of introducing some ‘wonderful’ new life saving thing.

Weak or not, on it goes. And on and on….Gradually the proportion of time left to look after patients shrinks ever further. After all, it is the only part of the working day left from which you can steal time. All else is filled with audits, and measurements, and various complex scoring charts, and meeting targets and writing and writing, and writing and writing. And writing and writing.

In this short blog, I have but scratched the surface of the endless additional work that is required in NHS, and all other health services around the world. It leads to, what I call ratchet world. Each day brings an extra piece of work ‘click’. This ratchet never loosens, it only ever tightens. The pressure and stress increases with each malignant click. More and more work, less and less useful activity can be done.

Next time I will introduce you to QOF. Perhaps the greatest waste of time and resources in the history of medicine.

You may also enjoy my metaphor of the Terrible Trivium. Stolen shamefacedly from the book ‘The Phantom Tollbooth.’

1: https://www.nice.org.uk/news/article/nice-recommends-healthcare-professionals-ask-people-about-gambling-in-new-draft-guidance-out-for-consultation-today

2: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9848034/ 3: https://bmjopen.bmj.com/content/9/7/e028663