Monday, April 7, 2008

Why the NHS is failing Wait Times

You’d think that when writing a blog on health care wait times, the interest would come from the countries where wait times are the worst and the population the greatest. In my own mind, I assumed that countries with socialized medicine, and long waits, would top the list of interest (especially the UK) followed far behind by the United States. After all, the US is the home of free market medicine, greater supply than demand and a hospital on every corner; right? So why is my list of readers exactly the opposite? Why don’t the clinicians of the National Health Service (NHS) in the UK seem to either care or be engaged in the issue?

The greatest interest and passion about low ER, surgical and health care wait times is undoubtedly coming from the United States. They care about the technology, the business of health care (practice management), and the impact on patients. At first I thought that it was because so much of the US is on a fee-for-service model and they benefit financially from it. But that is too superficial an explanation. Because, the bulk of health care workers are not compensated on a fee-for-service model (such as the nurses). And if my blog stats are to be believed, they are just as, if not more passionate, than those that stand to benefit from lowering wait times. Nor do I think it's a matter of a fee-for-service system creating greater accountability to the patient. Because, in all of our systems, there is a deeper moral accountability to someone who is suffering. On deeper reflection I think there is much more to it and something that both Health Canada and the NHS should learn from.

The first major meeting I attended about hospital costs was between an outside financial consultant and our surgical service (incidentally the consultant had closed our program when I was a resident and she was a VP of an inner-city hospital). She was amazed that we had little or no “cost awareness”.

She started in on the group of surgeons, “don’t you want to know how much you’re supplies cost?”
We all sat their like scolded school children (or pissed off teenagers – the debates’ still open), until one of the senior orthopods piped up, “No”
“Why not?”
“Because it doesn’t matter.”
“How could it not matter! If you know how much supplies cost and you choose a less expensive option you save the hospital money and it costs you nothing.”
“Because”, he responded, “I’ve been doing this for 25 years and I’ve already been through cost awareness programs. I’ve saved the hospital thousands and you still take my programs’ money away. On the other hand, a colleague costs the hospital tens-of-thousands, and you give him more”
“There’s no logic or control to how the money flows so why should I care? I’d rather just do my job”

That ended the conversation. Let me add, that this is one of the nicest most dedicated community surgeons I’ve had the pleasure of working with. And I’ve heard it from others as well,

“I just wish they’d make the government contact responsible for all the money without any levels of bureaucracy. At least that way, they’d feel some responsibility for what’s happening”. Or from a friend in the NHS when I asked him to pass the word of my blog around,

“Most of the control of patient flow is pretty much out of the hands of the clinicians over here. Not that I do much clinic work, but for the most part, the docs end up just being work horses. We show up to the out-pt [sic] department, get allotted a room for the session and plow through the stack of patients until they are all gone. We don't tend to have our own offices and staff when working in the NHS.”

And with those stories in mind, I think I know why clinicians in the US are so much more passionate about wait times; control. Because in the US, there are very few layers between the purse strings and the patients compared to countries with socialized medicine. The patients’ pay the hospital, and the hospital pays the employees. I am not making a plug for privatization. I believe that in a developed country you should have access to health care no matter your level of income. And, I will leave it to the economists, bureaucrats and politicians that study such things, to determine the most economical model.

But there is a fundamental difference between how clinicians view wait time problems in the US compared to other societies. I think it is a matter of their passion for efficiency. Since efficiency in health care is proportionate to life and death it doesn’t matter what role you play, you need to be passionate about it. But when you loose control it’s difficult to retain the passion. Without it, the managers are reduced to paper pushers and the clinicians to work horses. For there is no truer observation than that “when work, commitment, and pleasure all become one and you reach that deep well where passion lives, nothing is impossible”. So, when our countries reconnect the people that control the money with the patients that need the care, the impossible will happen.


Philip Boyle said...

I agree with central idea of what you're saying: "I believe that in a developed country you should have access to health care no matter your level of income."

The problem is how to achieve this. Just saying "And, I will leave it to the economists, bureaucrats and politicians that study such things, to determine the most economical model." doesn't move things forward. Do you have any ideas for a "blue sky" solution?

In Ireland we have a two-tier healthcare system. A free care for all system, and an opt-in private health insurance based system. The wait times for the free system are much longer than they are in the private system, so there are noises being made about creating a single system that is fairer for all, only no one can agree what this new system should be.

In the meantime they have taken to getting private companies to build public-private hospitals in partnership which will effectively continue the status quo.

The only way to acheive the fair free for all system here would be for the government to raise taxes, something they are very unwilling to do, because it would be an unpopular policy.

If they did provide a single tier healthcare system, and the wait times were longer than they currently are for the private system, there would be an outcry from the middle classes which would turn into a media frenzy, so you can see why they are shying away from changing anything.

Within Europe, things seem to be moving forward somewhat. Now, if your local healthcare system fails to treat you within a reasonable time, you are free to seek treatment in another EU country and have your local health system pay (up to a limit) for the treatment abroad.

This brings up the idea of health being a commodity though, and the question of which is better: An efficient effective privately run healthcare system, or a bureaucratic free state run system?

There is an inherent assumption in the question that a state run system can't be as efficient as a privately run system, which may not be true worldwide, but certainly is here in Ireland!

On a final note, I don't believe your implication that doctors in the UK and other countries are less passionate about their jobs. I think they just deal with a different set of problems and so have to prioritise different issues, but that's a whole other debate. :)

Ian Furst said...

Thanks for the comments Philip,

Although I didn't state it implicitly I am not saying that UK doctors are less passionate about their jobs. I am saying that they seem to have less passion about minimizing wait times. That is not to say that they do not have just a strong a desire to lower wait times, but it's harder to get emotional about it when you have no control. It's the difference between running to a patient who's heart has stopped in the hospital. When it's someone else's patient it is not hard to keep an emotional distance from the situation. If you have cared for the person for years it can be highly emotional.

A more direct analogy, is that I've spent hours and hours creating a block booking schedule. When an administrative staff fails to follow those rules, and it affects a patient, I am upset. If I had no control over the schedule I would not be (as is the case in our hospitals).

Finally regarding my comment about I'll leave it to ..... I do have ideas but I'm not so egotistical to think that mine are the correct ones. So that sentence was intended to say "I'm trying to improve clinic efficiency and that is a big enough task. As for policy level changes I'll let someone else study and change that). I've offered opinions (as in the post) such as improving efficiency, reconnecting the purse strings to the providers, etc... but there's only so much one person can blog about in a single post.