Examination of Witnesses (Questions 360-379)
PROFESSOR DAME
CAROL BLACK,
MR GEORGE
BLAIR AND
DR KAREN
BLOOR
8 JUNE 2006
Q360 Dr Naysmith: Following up on
this Hospital Episode Statistics, no matter how crude it is if
you use it to measure consultant activity you find huge variations
between the amount of "work" that is reported by using
that statistic between different consultants. Why does that happen?
If it is as crude as that and not of any use, then we should not
use. It must be telling us something.
Dr Bloor: Yes, it does, but it
is a very partial picture. At the moment the distributions that
we have produced have been on in-patient episodes not including
out-patients and not including any real measures of quality or
outcome. That is where we really need to focus our efforts in
developing better patient outcome measures. There is huge variation.
Some of that can be explained, some of that can explained by differences
in patients and case mix. Severity of patients differs and I do
not think that is always adequately adjusted for. The only adjustment
we could make was by HRG and tariffs which is an imperfect adjustment
for case mix. There are differences in the consultants, their
age, their gender, their contracts, their other interests, their
other responsibilities, they might be medical directors, they
might be clinical leads, they might be teachers and trainers,
they might be researchers. There are differences at consultant
levels and there are differences between Trusts, and perhaps the
access to operating theatres might create differences in productivity.
Q361 Dr Naysmith: Do you think it
is misleading?
Dr Bloor: No, it is a basis for
discussion.
Q362 Dr Naysmith: Between whom?
Dr Bloor: I would not use it as
a performance measure, but I would use it if I was a medical director
of a Trust. I would use it to have a conversation with my consultants
around job planning and appraisal. If there are bottlenecks that
are being created that limit consultant productivity in some area,
then that would be discussed and hopefully resolved. I would use
it if I was involved in job plans and appraisals in that way.
I might even use it in clinical excellence awards.
Q363 Dr Naysmith: You could use it
to measure and theoretically increase productivity as a partial
measure?
Dr Bloor: You could use it as
a basis for discussion. I do not think it is an overall measure
of performance. It is a very partial picture but it does give
some transparency.
Q364 Dr Naysmith: How do the discussions
you are talking about begin? "Dr So-and-so, it looks as if
you are not doing as many episodes of activity as someone further
along. Can you explain to me why?"
Dr Bloor: Yes. There may well
be good reasons why Dr So-and-so is not doing as many episodes
and it might be that he is a clinical lead or medical director
or something like that.
Q365 Dr Naysmith: Presumably the
management would know that?
Dr Bloor: Yes. If, for example,
you have a group of ophthalmologists and they are all doing a
relatively similar amount of episodes per year. If you are then
faced with a national distribution that puts all of those in the
lower quartile and says that in other hospitals other consultants
are doing twice as many episodes per year, that is a reasonable
question for a manager or a medical director to ask what is creating
these episodes.
Q366 Dr Naysmith: It is probably
useful for that purpose as well, comparing between Trusts.
Dr Bloor: Yes.
Professor Dame Carol Black: To
add to that and give you a very practical example, if in a Trust
where you have surgeons who do transplant surgery or highly complicated
surgery where there may be quite a lot of complications post-surgery,
the people who look after those complications, because they are
usually metabolic, will be the physicians. You might in a hospital
like that find, although it is never recorded, your physicians
spend all day keeping "Mr Smith" alive and well post-surgery
from medical complications but that is never recorded anywhere.
That doctor has actually spent that day interacting with and on
behalf of their surgical colleagues. You have to know what is
the hospital case mix. What is it doing? What might its doctors
be asked to do that is not recorded through the data that we do
collect? It is about using this data intelligently.
Q367 Dr Naysmith: Is that why the
impression has got around in some quarters that the medical profession
is resisting this kind of productivity measure?
Professor Dame Carol Black: The
medical profession does not resist data collected appropriately,
in which let us hope they have had some say in what is being collected,
if it is related to outcome. Doctors are quite hungry for that
sort of data and they certainly are prepared to look at that.
They have been quite resistant in some cases to look at HES data,
but it depends how you are going to use this HES data. You have
to use it intelligently and appropriately and know what its limitations
are.
Q368 Dr Naysmith: Is there any indication
that this resistance is likely to increase? Is the situation getting
better, in other words?
Professor Dame Carol Black: I
think if we improved our quality of data, it would certainly get
better. What frustrates a lot of doctors at the moment is this
hoped-for improvement in IT. We would like to get there and we
would like to be able to have this data as that would make a difference
to what we could look at and what we could do.
Q369 Chairman: I have a question
for Mr Blair. In your submission, you commented on the "complete
lack of clarity regarding who is responsible for trying to improve
productivity", and you recommend that the NHS trusts should
have a dedicated lead for productivity. How would you see this
role working and is not productivity, if not a matter for all
the workforce in any institution, certainly a matter for the managers
of the workforce?
Mr Blair: Certainly it is a matter
for managers, but I think it has not had an adequate focus and
I think many of your questions really point to that, that some
organisations were historically well resourced, others were poorly
resourced and resource in the past was purely incremental, so
there were no rewards for improving productivity historically.
I think there needs to be more focus on it. I think it is for
all organisations to try and answer that question and come up
with their own solution. You are quite right that it would vary
locally, but my sense is that productivity does not just include
financial measures, "How are we doing financially?",
but there is a whole wider range of issues and going on to things
like hearts and minds, that brings in working practices, it brings
in human resources. I think it goes back to what we were hearing
earlier about silo mentality and I think there needs to be a productivity
group. I think that would be a better way to develop that idea
which somebody convenes and is responsible for with all the various
inputs. I do not see examples of that, although admittedly some
trusts perform very well. When I circulated my paper, one wrote
back to me saying, "Oh, we've done this, George", so
I do not want to imply that there are not examples of very good
practice, but I think a lot more could be done to pull together
a whole range of people to look at this in a more consistent way
across an organisation.
Q370 Chairman: Perhaps I could ask
the other two witnesses, do you think we should have dedicated
people in NHS organisations looking at productivity or should
it be managers having time to do this, as it were?
Professor Dame Carol Black: My
personal view is that you have got the people there who should
be deeply involved with this. You have got clinical directors,
you have got clinical leads, you will have senior nurses and you
will have managers, and really if you put another person in there,
you take the responsibility away, I think, from the people who
should be deeply concerned about productivity, so I would like
it to be the people who are delivering the care. Of course that
does require time and that might be a factor, but again if we
had better data, if Connecting for Health was working well, then
that would again help.
Dr Bloor: I am inclined to agree
with Dame Carol on this. I think if you have a person who is director
of productivity or whatever, it might feel like it is their job
to deal with productivity and not everybody else's. I would be
inclined to give it to the medical director.
Q371 Chairman: We have been taking
evidence sort of in this area and a number of written submissions
we have had to the inquiry commented on the lack of integration
between financial activity and workforce planning in the NHS.
Indeed in one of the earlier sessions we had about this was this
issue about what has effectively been the over-recruitment certainly
beyond targets that were set and now there are the problems that
we have in some areas of NHS organisations with over-expending,
as it were. Whether these are related or not, we will be looking
into at a later stage. Do you think that improving productivity
really should be a way of helping to integrate this sort of planning
process of workforce planning and the economic activity in institutions
as well?
Dr Bloor: Yes, I think it should
actually. I think it should certainly be integrated into the workforce
planning, that productivity should be an integral part of workforce
planning. I guess it is particularly obvious now that workforce
planning and forecasting and financial planning and forecasting
have not necessarily been done together when we have got a finance
squeeze and also people coming out of medical school and business
school and those expansions in the workforce have been substantial,
so it has perhaps focused the mind on that mismatch, but yes,
I think more attention to productivity, more integration of productivity
into workforce planning should help to address that.
Professor Dame Carol Black: I
think had we taken it from the point of view of a pathway of care
for a patient and said, "If you have a certain condition,
what sort of health intervention do you need? What kind of workforce
do you need to create? Do you need a nurse, a physiotherapist,
a doctor? What do you need", we might then have been able
to start to think together about the shape of the workforce. Rather,
we have increased nurses, physiotherapists and doctors, but we
never said, "What do you require along a pathway of care?"
and I think that would have been a much better way to have approached
it. Then we could have employed the workforce that, as far as
we can see, and it is always difficult to see what you are going
to need 10 years down the road, but we could have surely made
it more appropriate to what the pathway indicated. I think we
did not do any of that thinking in any of that planning.
Mr Blair: I would like to come
in about the planning process, my experience of previous local
delivery planning processes. We get central guidance from the
Department, there is a finance bit, an activity bit and a workforce
bit and there is this sense that they are experts providing for
their needs. Then it comes at strategic health authority level
and they think, "How can we pull this together? How can we
make this meaningful and easier for our trusts to contribute to?"
and then each of them will try to come up with some sort of approach
and some produce quite good spreadsheets and then they cascade
that down. Then you get somebody in finance usually, somebody
looking on the service side and somebody in the workforce all
with their own spreadsheets, all trying to communicate. I have
had quite a lot of experience of budgets now being cut for whatever
reason, so finance reduce their figures, but the message has not
gone through to HR because it is done in such a fragmented way
that that particular trust passes on to the strategic health authority
and the Department the demand for staff that even then it cannot
afford, so that whole planning process lacks integration all the
way through. I know that there have been attempts to change it,
but I think we need a lot smarter thinking. It is very easy to
write software nowadays where you can feed information in, and
I think what is necessary is for them to be planning software
where, if you have got this money, you reduce the budget and,
therefore, you have got to reduce the staff accordingly and you
cannot just send effectively three different submissions stapled
together.
Q372 Chairman: We had one submission
to this inquiry which said that the alignment between workforce
and financial planning was "woeful". I assume from what
you have said, Mr Blair, that you would agree with that?
Mr Blair: Yes.
Q373 Chairman: Not in all cases obviously.
Mr Blair: That is right, but there
are too many cases of that, yes.
Q374 Dr Taylor: Going back to improving
productivity, Carol, you said that the people on the ground who
do this are the clinical directors and the clinical leads. How
well do you think they are prepared for this job?
Professor Dame Carol Black: I
would have hoped that somebody who takes on the role now of the
clinical director, a medical director or a clinical lead would
certainly have got some of the necessary training to be able to
think and do this. I think it is about sitting down together.
I do not think there is magic in this. If you think of productivity
as quality as well as just efficiency, then I think you will engage
doctors, so I think it is about getting people to work together.
Q375 Dr Taylor: One thing, I think,
some of us were quite impressed with in California where we have
been is that they pick out what they call `emerging medical leaders'
early on and actually train them. Are we actually doing any formal
training in medical management because, I quite agree with you,
in my day you picked it up as you were going along, but I am not
sure that is the best way to do it?
Professor Dame Carol Black: That
is an exceedingly good question and it is something that we have
all been very aware has been missing in the training of the average
doctor. I think, for example, BAMM has done a very good job of
training at the level of people who are committed—
Q376 Dr Taylor: The British Association
of—
Professor Dame Carol Black: Yes,
the British Association of Medical Managers, when people have
committed to becoming a medical director or a clinical director
and they are already down that road, but what we have not been
good at, and it is now changing, is how you get into both undergraduate
and postgraduate education the skills that will allow you to be
a clinical leader and to have medical management skills so that
this is spread much more across, I would not say all consultants,
but that you are getting this ability into the consultant body.
There is the emerging leaders network which has just been set
up in the Department of Health which is now seeking to identify
such people and we have all been asked to offer names, so there
is a young emerging leaders network, there is work from the NHS
Institute for Improvement and Innovation with the Academy of Royal
Colleges to really now start getting programmes out there. It
is perhaps a bit late in the day and we should have done it earlier,
but it is—
Q377 Dr Taylor: But it is coming.
Professor Dame Carol Black: We
have had a very good programme with middle managers and young
consultants going for the last year in which they have done problem-solving
together. They have come from the same trust, the clinician has
identified the manager and together they have had to bring a problem
that needed a solution, so they had to do some systems reform.
It has been actually riveting in showing how people can work together
and they have increased productivity in each of those projects.
There was, almost without exception, increased productivity if
you put quality into that, so I think a lot is happening now.
Q378 Dr Taylor: Will this help to
cut down the barriers between the silos because this is one of
the awful things, that there are so many barriers?
Professor Dame Carol Black: Yes.
Q379 Dr Taylor: Obviously clinical
directors and doctors in management have got to work very closely
with managers. Do you think central targets have driven a split
between managers and doctors where they contrast? I think it was
Dr Fielden who said that doctors and managers would work well
together as long as the aims were the same. Have government targets
tended to drive these apart?
Professor Dame Carol Black: Well,
quite a few of those targets would be things that a lot of doctors
would think were not unreasonable. We might not have designed
them in quite the same way and we might have wished to modify
them, but I think managers and doctors do have the same aims which
are to improve the care for the patients in their institutions.
I think managers are under quite different constraints from the
centre and I think it adds tension, but one would hope it might
enable doctors and managers to understand each other better and
perhaps to be able to work together more effectively.
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