427 MAKING DO
SiR,—Ihope that your series will not lead to yet another spate of naive organisation and methods studies. I did not understand Mr Wickings’ article (Jan. 29, p. 239). He appears to be doing what the Chancellor did last year and calling an absence of expansion a saving. Will the new ward clerk’s post have to be paid for by savings next year? Or will the post, now that it is established, be paid for out of revenue? Dr Davies (Jan. 29, p. 241) advocates changes in organisation which will certainly work if the departments are adequately staffed, but they will mean an enormous increase in costs. A single unit in outpatients appears to cost between L30 and 50 per hour. Investigations transferred from inpatient to outpatient do not cost any less. A ward which is adequately staffed to care for 10 seriously ill patients is not staffed for 20. Removing the "light" patients from a ward increases the work. Everyone has found during the various alarms and excursions of the past few years that, when admissions are restricted to urgent cases only, the work of the ward increases. There is not the slightest evidence that any considerable change from inpatient to outpatient investigation and treatment can happen without extra staff and equipment. A shortening of the time scale during which a patient is in hospital care means accurate and humane administration, and a general rise in the seniority of the hospital staff involved. American experience is irrelevant because the N.H.S. is, or can be, held responsible for the care of the patient from the moment he gets sick to the time he is returned to complete health. There has been frenetic political pressure during the past 15 years to find cheaper methods of health-care delivery. One fashion has succeeded another while the cost of the N.H.S. has gone soaring upwards. The general trend has been to employ more and more expert people with proportionately less and less equipment to use. Mrs Castle’s document subtitled "People before Buildings" describes the activities of a peasant country. Therapeutic medicine is technology, and there are no soft options or short cuts in technology. A given amount of technology costs a given amount of wealth, and the only way to save money on diagnosis and treatment is to stop doing it. Central to the problem of all the nationalised service industries is the fact that they are labour-intensive organisations with huge fixed costs and tiny variable costs. Economies in all these services in the past few years have been directed to chipping away at the variable costs while the fixed costs have usually gone on increasing. The N.H.S. is particularly unfortunate in that its accounting system separates capital from revenue, and this has allowed all sorts of peripheral activities to multiply, based on arguments that money is being saved. We have no idea how much laundry or centralised sterile supply or the ambulance service really cost. The only way to save money in a labourintensive organisation is to reduce staff, reduce wages, or increase work. With all the power of the State behind it, because of its primitive accounting system the N.H.S. has forfeited all its advantage in the markets which it uses. It has indeed, at almost every point, taken the opposite decision from the successful commercial enterprise. The hospital is the largest buyer of food, furniture, laundry, and transport in most districts. Instead of using its economic power to buy the best most cheaply we have set up parallel organisations. If an outside supplier produces a poor service he can be changed, but if we complain about our own services all that happens is extensive explanations of the difficulties in running it. It is completely demoralising that after 15 years or more of politicians and Civil Servants going on and on about management, the N.H.S. accounting system is completely useless for this purpose. In the first place, the gross figure given as the cost of the N.H.S. is the amount of money spent by the N.H.S. and not on it. The figures produced by other countries in the West are the total cost of delivery which includes all the service charges on the money provided for the services. But the worst stupidity in the accounts is that equipment is not amortised. Put simply this means that if you buy a motorcar now you have to replace it
in X number of years, the number of years being pretty well fixed. Every piece of equipment commits you to maintenance and replacement, and unless these figures are projected forward into the accounts of succeeding years there really is no idea of how much anything costs or is going to cost. On behalf of the nation one could reasonably demand a charge for interest since the State is so heavily in debt, and also for alternative investment because this is being shouted about so much-but I suppose this is a counsel of perfection. Mr Wickings’ little group is a microcosm of the N.H.S. Money has been transferred from patient care, which are the variable costs, into capital or staff, which are the fixed costs. Unless they establish the extra expenditure next year they will have less money to spend on their patients. Admittedly the bathroom is a much more sensible idea than the secretary, but nevertheless the principle is the same. It is a form of the "do you realise he saved his salary in his first year at work?" type of catch-what about years 2, 3, 4 and subsequent years? Fiddling and fussing about with minor items of medical expenditure keeps the grass-roots busy, but it contributes absolutely nothing at all to the control and effective use of N.H.S. money. Without a real accounting system strict control is not possible. Bexhill Hospital, Bexhill-on-Sea TN40 2DZ
P. F. PLUMLEY
SIR,-Mr Wickings seems to be gently knocking the medical profession. The great problem with arguments such as his is that they are based exclusively on economics. There seems to be no room or weighting for the values concerned with psychological, philosophical, or sociological needs of man. The Westminster Hospital project was certainly interesting but, if the assumptions and defects of the research model used were made explicit and allowances made for the influences of self-fulfilling prophecy and the Hawthrone effect the most important variable may have been that the clinically accountable teams (c.A.T.) were free to spend their savings as they wished "to fund expenditures they valued more highly" (a very doubtful criterion). Who would not do the same for a carrot? It seems to me that it would be more useful if well-meaning writers would stop making such esoteric-sounding noises and admit that the basic problem in the reorganised N.H.S. is that it was created without appropriate management systems, of which regular and efficient financial information is an essential part.
Complex new management patterns such as C.A.T.S may sound exciting (though many still need to be convinced of this) but many doctors and nurses would, I suspect, settle for regular financial information that they could rely on. Given the right kind of management information even the present organisation could work provided always that patients/ clients/people are recognised to be social beings and not just economic units. I am reminded of J. Sackur’s healthy cynicism (Management To-day, May, 1974): "More and more insistently, managers are being asked what they are doing about ’organisation development’. More often than not the answer comes in prepackaged form ... It is scientism which turns useful and interesting speculation into full-blown theories, and leads to a whole industry of packaged solutions and techniques of management ... Change is no more and no less than a learning "
process. Brent Health District, Central Middlesex Hospital, London NW10 7NS
JAMES
P. SMITH
ADMISSIONS BY THE BOOK
SIR,-Icongratulate Mr Cox on his excellent article (Feb. 5, p. 301). My surgical unit is run on almost identical lines, except that we did not have the advantage of starting from scratch as at Northwick Park, but had the added difficulty of
428 district general book" has been which is carried at all times
grafting the system on to an existing unit in hospital. Our other difference is that "the
a
scaled down to an ordinary diary, in the consultant’s pocket. The system works well on the whole. The patients like it because they are given their admission date as soon as the decision is made to operate, and not placed on a long impersonal waiting-list. Telephone numbers of those willing to come at very short notice are invaluable in filling sudden list vacancies. The team work-load can be planned well ahead. And most of all, as Mr Cox points out, the system is doctor controlled-in fact consultant controlled. I agree with Mr Cox that loss of the book could be disastrous. The "team" has been seen wandering the hospital corridors, not knowing where they should be next! But happily it is a well-known book, and is usually returned to the consultant’s pocket within minutes of being mislaid. However, we have the added safeguard that all the operating-list information is entered on the hospital computer and the consultant receives an updated print-out twice a week. But this system has one disadvantage which is especially evident in the district general hospital. The demand for outpatient referrals from G.p.s far outstrips the operating capacity of the hospital. Therefore to make this system work, without an appreciable inpatient waiting-list, the load is transferred to the outpatient appointment waiting-list, which may reach many weeks. Thus an added responsibility is placed on the general practitioner to indicate clearly to the consultant the degree of urgency of the patient upon referral-which is perhaps not a bad thing because normally the general practitioner in his health centre should be the "sorting station", not the consultant in his hospital clinics. This system of running a surgical unit is not new. Mr Cox is the first surgeon I know to have written about it, but I first learnt it from Mr Andrew Desmond at St. James Hospital, Balham in 1959. Southend
Hospital,
Westcliff-on-Sea,
BRIAN STERRY ASHBY
Essex SS0 0RY
SIR,-I found Mr Cox’s article
most interesting. In a unique he has resorted to a simple method of admission control. I wonder if, when he plans the list, he has found out if nurses are likely to be available to care for the patients. His excellent plans could be further frustrated and the patient inconvenienced if nurses are not there.
hospital
Manor
House,
Headington,
Oxford OX3 9DZ
J. FLINDALL
And so what? Is it beyond the wit of man to devise a system that is comparatively cheap? I ask, accepting the implied contention that the first requirement of a Health Service is that it should be cheap, albeit nasty. And what alternative do you offer? The mixture as before, make do and mend, make do and mend, until the whole structure sinks into oblivion, for all you care, as long as the precious free-at-the-time principle is not abandoned. And you ask this of doctors, while strengthening the impression given by previous Lancet editorials that you think they are nothing but money-grubbing parasites. No wonder morale is low. Whether they are so or not, they are the only doctors we have. So you are abusing resources too. One would wish you would contribute positively to discussion of the problems, if indeed you accept that there are any, instead of hastily concurring with the Minister in prejudging the issues being considered by the Royal Commission. Can you not discuss the possibilities inherent in the B.M.A.’s (and others’) suggestion, accepting the possibility that they are presented in good faith, and encourage a friendly and rational discussion of the issues? It may indeed emerge that the suggestion will not work, in which case we could all accept that. 22
Lugano Road, Bramhall, Stockport, Cheshire SK7 3HX
J. R. SAMPSON
SIR,-Some of the recommendations of the B.M.A. Council in its draft evidence to the Royal Commission on the N.H.S. would appear to ignore the needs of those with chronic conditions and, indeed, to increase the burdens which these patients may have to bear in the future. Many of these patients, such as those with severe psoriasis, are not exempted from the existing although there is a strong case for this, and yet they require daily treatment, frequent prescriptions, and in some cases hospital admission for periods of three weeks or more at least once a year. Implementation of the B.M.A.’s suggestions would mean that these people would be required to pay a substantial contribution to the hotel costs of hospital admission and possibly increased prescription charges, while some retired patients would additionally lose their present exemptions from payment. These recommendations are retrogressive, and it is therefore to be hoped that, in the forthcoming debate, greater sympathy and understanding will be shown for the needs and interests of the chronically sick.
charges,
-
Psoriasis Association, 7 Milton Street, Northampton NN2 7JG
R. G.
JOBLING,
National Chairman
PLASMA EXCHANGE IN MYASTHENIA GRAVIS TEN MINUTES FOR EVERYONE
SiR,—Your comments on my paper on work-load in general practice (Feb. 12, p. 344) are generous but not quite accurate. I did not conclude that demand could not be reduced, but that reduction (or, more important, a shift in content) must depend
relatively slow process of mutual re-education of patients and doctors rather than on primitive measures such as consultation charges. A shift to fewer but less superficial consultations is both possible and necessary.
on a
Glyncorring Health Centre, near
Port
Talbot,
Glamorgan
SA13 3BL
JULIAN TUDOR HART
B.M.A. EVIDENCE TO THE ROYAL COMMISSION
SIR,-You emphatically dismiss the British Medical Association’s proposals about financing the N.H.S. (Feb. 5, p. 293) on the feeble ground that these will lead to item-of-service payment which has proved expensive in some countries. Will they?
SiR,—Dr Finn and Dr Coates (Jan. 22. p., 190) ask whether the response we observed’ following plasma exchange in acquired myasthenia gravis might be attributed to a placebo effect, which they apparently concluded was responsible for their own patient’s improvement. Were this to have been the case in our patients, improvement should have begun at the onset of treatment and have declined thereafter. In the event, there was a latent period of several days before signs of decreased fatiguability and increased strength were evident, and improvement continued for some days after the last exchange. We have now treated four further patients with plasma exchange, all of whom have shown clear signs of improvement, and the latent period in one of them was ten days. The complete absence of response in the only patient with congenital myasthenia gravis, who knew of the beneficial results in the first two cases, further argues against the suggestion that theirs was a placebo response. 1.
Pinching, A. J., Peters, D. K., Davis, J.
N. Lancet, 1976, ii, 1373.
SiR,—Ihope that your series will not lead to yet another spate of naive organisation and methods studies. I did not understand Mr Wickings’ article (Jan. 29, p. 239). He appears to be doing what the Chancellor did last year and calling an absence of expansion a saving. Will the new ward clerk’s post have to be paid for by savings next year? Or will the post, now that it is established, be paid for out of revenue? Dr Davies (Jan. 29, p. 241) advocates changes in organisation which will certainly work if the departments are adequately staffed, but they will mean an enormous increase in costs. A single unit in outpatients appears to cost between L30 and 50 per hour. Investigations transferred from inpatient to outpatient do not cost any less. A ward which is adequately staffed to care for 10 seriously ill patients is not staffed for 20. Removing the "light" patients from a ward increases the work. Everyone has found during the various alarms and excursions of the past few years that, when admissions are restricted to urgent cases only, the work of the ward increases. There is not the slightest evidence that any considerable change from inpatient to outpatient investigation and treatment can happen without extra staff and equipment. A shortening of the time scale during which a patient is in hospital care means accurate and humane administration, and a general rise in the seniority of the hospital staff involved. American experience is irrelevant because the N.H.S. is, or can be, held responsible for the care of the patient from the moment he gets sick to the time he is returned to complete health. There has been frenetic political pressure during the past 15 years to find cheaper methods of health-care delivery. One fashion has succeeded another while the cost of the N.H.S. has gone soaring upwards. The general trend has been to employ more and more expert people with proportionately less and less equipment to use. Mrs Castle’s document subtitled "People before Buildings" describes the activities of a peasant country. Therapeutic medicine is technology, and there are no soft options or short cuts in technology. A given amount of technology costs a given amount of wealth, and the only way to save money on diagnosis and treatment is to stop doing it. Central to the problem of all the nationalised service industries is the fact that they are labour-intensive organisations with huge fixed costs and tiny variable costs. Economies in all these services in the past few years have been directed to chipping away at the variable costs while the fixed costs have usually gone on increasing. The N.H.S. is particularly unfortunate in that its accounting system separates capital from revenue, and this has allowed all sorts of peripheral activities to multiply, based on arguments that money is being saved. We have no idea how much laundry or centralised sterile supply or the ambulance service really cost. The only way to save money in a labourintensive organisation is to reduce staff, reduce wages, or increase work. With all the power of the State behind it, because of its primitive accounting system the N.H.S. has forfeited all its advantage in the markets which it uses. It has indeed, at almost every point, taken the opposite decision from the successful commercial enterprise. The hospital is the largest buyer of food, furniture, laundry, and transport in most districts. Instead of using its economic power to buy the best most cheaply we have set up parallel organisations. If an outside supplier produces a poor service he can be changed, but if we complain about our own services all that happens is extensive explanations of the difficulties in running it. It is completely demoralising that after 15 years or more of politicians and Civil Servants going on and on about management, the N.H.S. accounting system is completely useless for this purpose. In the first place, the gross figure given as the cost of the N.H.S. is the amount of money spent by the N.H.S. and not on it. The figures produced by other countries in the West are the total cost of delivery which includes all the service charges on the money provided for the services. But the worst stupidity in the accounts is that equipment is not amortised. Put simply this means that if you buy a motorcar now you have to replace it
in X number of years, the number of years being pretty well fixed. Every piece of equipment commits you to maintenance and replacement, and unless these figures are projected forward into the accounts of succeeding years there really is no idea of how much anything costs or is going to cost. On behalf of the nation one could reasonably demand a charge for interest since the State is so heavily in debt, and also for alternative investment because this is being shouted about so much-but I suppose this is a counsel of perfection. Mr Wickings’ little group is a microcosm of the N.H.S. Money has been transferred from patient care, which are the variable costs, into capital or staff, which are the fixed costs. Unless they establish the extra expenditure next year they will have less money to spend on their patients. Admittedly the bathroom is a much more sensible idea than the secretary, but nevertheless the principle is the same. It is a form of the "do you realise he saved his salary in his first year at work?" type of catch-what about years 2, 3, 4 and subsequent years? Fiddling and fussing about with minor items of medical expenditure keeps the grass-roots busy, but it contributes absolutely nothing at all to the control and effective use of N.H.S. money. Without a real accounting system strict control is not possible. Bexhill Hospital, Bexhill-on-Sea TN40 2DZ
P. F. PLUMLEY
SIR,-Mr Wickings seems to be gently knocking the medical profession. The great problem with arguments such as his is that they are based exclusively on economics. There seems to be no room or weighting for the values concerned with psychological, philosophical, or sociological needs of man. The Westminster Hospital project was certainly interesting but, if the assumptions and defects of the research model used were made explicit and allowances made for the influences of self-fulfilling prophecy and the Hawthrone effect the most important variable may have been that the clinically accountable teams (c.A.T.) were free to spend their savings as they wished "to fund expenditures they valued more highly" (a very doubtful criterion). Who would not do the same for a carrot? It seems to me that it would be more useful if well-meaning writers would stop making such esoteric-sounding noises and admit that the basic problem in the reorganised N.H.S. is that it was created without appropriate management systems, of which regular and efficient financial information is an essential part.
Complex new management patterns such as C.A.T.S may sound exciting (though many still need to be convinced of this) but many doctors and nurses would, I suspect, settle for regular financial information that they could rely on. Given the right kind of management information even the present organisation could work provided always that patients/ clients/people are recognised to be social beings and not just economic units. I am reminded of J. Sackur’s healthy cynicism (Management To-day, May, 1974): "More and more insistently, managers are being asked what they are doing about ’organisation development’. More often than not the answer comes in prepackaged form ... It is scientism which turns useful and interesting speculation into full-blown theories, and leads to a whole industry of packaged solutions and techniques of management ... Change is no more and no less than a learning "
process. Brent Health District, Central Middlesex Hospital, London NW10 7NS
JAMES
P. SMITH
ADMISSIONS BY THE BOOK
SIR,-Icongratulate Mr Cox on his excellent article (Feb. 5, p. 301). My surgical unit is run on almost identical lines, except that we did not have the advantage of starting from scratch as at Northwick Park, but had the added difficulty of
428 district general book" has been which is carried at all times
grafting the system on to an existing unit in hospital. Our other difference is that "the
a
scaled down to an ordinary diary, in the consultant’s pocket. The system works well on the whole. The patients like it because they are given their admission date as soon as the decision is made to operate, and not placed on a long impersonal waiting-list. Telephone numbers of those willing to come at very short notice are invaluable in filling sudden list vacancies. The team work-load can be planned well ahead. And most of all, as Mr Cox points out, the system is doctor controlled-in fact consultant controlled. I agree with Mr Cox that loss of the book could be disastrous. The "team" has been seen wandering the hospital corridors, not knowing where they should be next! But happily it is a well-known book, and is usually returned to the consultant’s pocket within minutes of being mislaid. However, we have the added safeguard that all the operating-list information is entered on the hospital computer and the consultant receives an updated print-out twice a week. But this system has one disadvantage which is especially evident in the district general hospital. The demand for outpatient referrals from G.p.s far outstrips the operating capacity of the hospital. Therefore to make this system work, without an appreciable inpatient waiting-list, the load is transferred to the outpatient appointment waiting-list, which may reach many weeks. Thus an added responsibility is placed on the general practitioner to indicate clearly to the consultant the degree of urgency of the patient upon referral-which is perhaps not a bad thing because normally the general practitioner in his health centre should be the "sorting station", not the consultant in his hospital clinics. This system of running a surgical unit is not new. Mr Cox is the first surgeon I know to have written about it, but I first learnt it from Mr Andrew Desmond at St. James Hospital, Balham in 1959. Southend
Hospital,
Westcliff-on-Sea,
BRIAN STERRY ASHBY
Essex SS0 0RY
SIR,-I found Mr Cox’s article
most interesting. In a unique he has resorted to a simple method of admission control. I wonder if, when he plans the list, he has found out if nurses are likely to be available to care for the patients. His excellent plans could be further frustrated and the patient inconvenienced if nurses are not there.
hospital
Manor
House,
Headington,
Oxford OX3 9DZ
J. FLINDALL
And so what? Is it beyond the wit of man to devise a system that is comparatively cheap? I ask, accepting the implied contention that the first requirement of a Health Service is that it should be cheap, albeit nasty. And what alternative do you offer? The mixture as before, make do and mend, make do and mend, until the whole structure sinks into oblivion, for all you care, as long as the precious free-at-the-time principle is not abandoned. And you ask this of doctors, while strengthening the impression given by previous Lancet editorials that you think they are nothing but money-grubbing parasites. No wonder morale is low. Whether they are so or not, they are the only doctors we have. So you are abusing resources too. One would wish you would contribute positively to discussion of the problems, if indeed you accept that there are any, instead of hastily concurring with the Minister in prejudging the issues being considered by the Royal Commission. Can you not discuss the possibilities inherent in the B.M.A.’s (and others’) suggestion, accepting the possibility that they are presented in good faith, and encourage a friendly and rational discussion of the issues? It may indeed emerge that the suggestion will not work, in which case we could all accept that. 22
Lugano Road, Bramhall, Stockport, Cheshire SK7 3HX
J. R. SAMPSON
SIR,-Some of the recommendations of the B.M.A. Council in its draft evidence to the Royal Commission on the N.H.S. would appear to ignore the needs of those with chronic conditions and, indeed, to increase the burdens which these patients may have to bear in the future. Many of these patients, such as those with severe psoriasis, are not exempted from the existing although there is a strong case for this, and yet they require daily treatment, frequent prescriptions, and in some cases hospital admission for periods of three weeks or more at least once a year. Implementation of the B.M.A.’s suggestions would mean that these people would be required to pay a substantial contribution to the hotel costs of hospital admission and possibly increased prescription charges, while some retired patients would additionally lose their present exemptions from payment. These recommendations are retrogressive, and it is therefore to be hoped that, in the forthcoming debate, greater sympathy and understanding will be shown for the needs and interests of the chronically sick.
charges,
-
Psoriasis Association, 7 Milton Street, Northampton NN2 7JG
R. G.
JOBLING,
National Chairman
PLASMA EXCHANGE IN MYASTHENIA GRAVIS TEN MINUTES FOR EVERYONE
SiR,—Your comments on my paper on work-load in general practice (Feb. 12, p. 344) are generous but not quite accurate. I did not conclude that demand could not be reduced, but that reduction (or, more important, a shift in content) must depend
relatively slow process of mutual re-education of patients and doctors rather than on primitive measures such as consultation charges. A shift to fewer but less superficial consultations is both possible and necessary.
on a
Glyncorring Health Centre, near
Port
Talbot,
Glamorgan
SA13 3BL
JULIAN TUDOR HART
B.M.A. EVIDENCE TO THE ROYAL COMMISSION
SIR,-You emphatically dismiss the British Medical Association’s proposals about financing the N.H.S. (Feb. 5, p. 293) on the feeble ground that these will lead to item-of-service payment which has proved expensive in some countries. Will they?
SiR,—Dr Finn and Dr Coates (Jan. 22. p., 190) ask whether the response we observed’ following plasma exchange in acquired myasthenia gravis might be attributed to a placebo effect, which they apparently concluded was responsible for their own patient’s improvement. Were this to have been the case in our patients, improvement should have begun at the onset of treatment and have declined thereafter. In the event, there was a latent period of several days before signs of decreased fatiguability and increased strength were evident, and improvement continued for some days after the last exchange. We have now treated four further patients with plasma exchange, all of whom have shown clear signs of improvement, and the latent period in one of them was ten days. The complete absence of response in the only patient with congenital myasthenia gravis, who knew of the beneficial results in the first two cases, further argues against the suggestion that theirs was a placebo response. 1.
Pinching, A. J., Peters, D. K., Davis, J.
N. Lancet, 1976, ii, 1373.
