Sunday, 19 October 2008

NHS Computing and the 12 rules of NHS management a case study

If you read the above and have an IQ greater than the Party then you will see a pattern here with health policies. Let us use Choose and Book (C&B) as an example.

Rule 1) If there is no problem make one

There has never problem with GPs referring to anywhere until Comrades Gordon and Tony (G&T) decided that there was a problem = no choice. Anyone who has worked in the NHS for all the years that comrades Blair and Brown have done would know that there has always been a choice but G&T based on their vast experience of healthcare decided they had to introduce choice to replace that which was there in the first place.

The only restrictor of choice was, and still is, NHS management and government not NHS doctors. So Choose and Book was a solution to a problem that was never ever there for either patients or doctors. It therefore fulfils the first rule par excellence.

Rule 2) If it is simple make it complicated

In the before G&T “Choice” days GPs used to send letters to their consultant colleagues with what was wrong with their patients and which consultant they as GPs felt their patients should see. The consultants read the letter decided if the referral was appropriate and then arranged for a letter to be sent out to the patient with an appointment or sent the letter to the correct consultant.

Now this simple process has been made complicated. Instead of a secretary typing a letter putting in an envelope and sending to a consultant for their consideration the following extra “enhanced service” has been produced.

Letter goes to a “referral management centre” RMC where, instead of referring up to a more specialized and qualified individual (a consultant), it is passed to a clerk or alternative therapist. The patient, instead of receiving a letter with an appointment, now gets a letter with an appointment to ring a call centre to be told what “choice” they have. This “choice” is determined by the local Politburo who use RMCs to restrict choice. Instead of one letter it is now one letter, a phone call and maybe many, many more of both (this is an abridged a summary of 3 pages of A4 as to what can happen for a simple Choose and Book referral).

For the elderly this is extremely confusing. C&B is now a choke for if there are no appointments on the C&B system (because of the 18 week rule) then patients are told to ring again to a call centre (several times) before being told to ask for another referral from their GP. If you don’t get an appointment you don’t appear on a waiting list and so the 18 week rule is achieved using Choose and Book.

Rule 3) If you can’t find a solution have another meeting

Choose and Book = meetings meetings meetings meetings meetings and over time the Gods of C&B cease to talk to those that identify the many problems. This leads to more meetings to find out why no one talks to those having meetings from which they are excluded.

And so the cycle repeats and achieves nothing but more meetings.

Rule 4) If other meetings don’t work employ more managers

More managers have to be employed to sort this simple problem out. Rule 4 is simple it is the way of the health service and a growth industry with zero return.

Rule 5) Do not involve anyone with ability as they might come up with the solution and put you out of a job

Drs used to get asked for their opinions but do not now go to meetings unless they are brain dead or like to avoid patients. Even the people who the C&B system was designed for Drs, the secretaries in surgeries and clerks in out patients, have not been invited to meetings for months as they dared to criticise and interrupt the local C&B commissars pre written answers to their questions which they were not allowed to ask.

So the managers who never use C&B for they never see patients drive C&B forward. Ever onward and downward.

Rule 6) If you fail you will be promoted. If you are not, set up a consultancy (see 7)

Many idiots who have failed to deliver even basic working IT systems at a local level have been promoted due to their failures. Bit like a pilot who crashes their paper dart being allowed to fly the space shuttle. NHS IT is full of failed rocket scientists who the private sector would not touch with a barge pole. Makes sense and explains a lot does it not?

Rule 7) If 1-6 do not work employ management consultants (not consultants see rule 5).

Due to the fact that NHS managers are thick this has to happen. Who do they employ who knows anything about the NHS problem they have created? They employ their thick friends indirectly. The thick failures set up as management consultants and tout their “alleged” experience in the NHS to the private sector who use them to milk the political gravy train. Commercial and successful companies pull out. We get the dross.

Rule 8) All new policies must generate extra work for all involved to achieve the same goal or ideally less.

Anybody using Choose and Book seen their workload reduced? Just ask how many doctors use it because it saves them so much time? Ask their secretaries which was easiest to use the old paper based system or the new system?

Ask hospital consultants how it has doubled their workload in some departments because the wrong patients turn up at the wrong clinic and how much extra paper work has been generated at the hospital end for clerks?

If you can’t refer to a particular department you now send a letter (even ‘though all referrals must go electronically) with a covering letter saying why you are sending a letter because the electronic system did not work. If you don’t send the second letter the referral will bounce because it has not been sent electronically.

Rule 9) If a change is unpopular tell them you are re-applying for your job or change your job title and tell them it’s someone else’s department.

Can anyone complain about Choose and Book? If you do who do you complain to? No one answers or gets back to you or it is someone elses’ department and you never hear from them. You have to sort it out yourself or use something that works called paper.

Rule 10) If you cock up have a listening exercise. Hear and change nothing.

Choose and Book managers no longer talk to the users’ of Choose and Book as all they get is abuse it is so bad. If you do not talk to the end user there can never be a problem and you can report this back to Party Central and get a promotion (see rule 6).

Lots of listening but nothing has changed. It has just got worse and worse and worse. A previous simple and flexible system made worse on a political whim and flight of fancy.

Rule 11) You have power and are unaccountable.

Many Politburos’ Chief Commissars have imposed unilateral “every one must use Choose and Book” policies in order to be awarded their Order of Postman Pat 1st class unless of course it is one of the 575 exclusions where C&B does not work and you MUST use paper. Managers have imposed a failed system and by using rule 10 they are completely unaccountable. The Party and C&B move on like a glacier with all using it waiting and praying for global warming in order to stop its progress.

Rule 12) Reinventing the wheel is called innovation just make sure that the new wheel is a square one.

A system that worked has been replaced by a very expensive failure. Just ask a politician how many countries have bought Choose and Book? Compare that with other IT systems like Windows.

People pay to use commercial software e.g. Windows because it is useful. Choose and Book has to bribe people to use it because it is crap.

Rule 13) Managers can’t be expected to count.

The Bottom Line guys. What was meant to cost £ 6 billion is now forecast to cost up to £ 50 billion with the clock ticking constantly. Peanuts considering all the banking bale outs but remember the US moon race is reckoned to have cost $ 100 billion to put a man on the moon in a decade. You do the maths.

If any journos want a story on sleaze ask yourselves how many politicians from our last Prime Minister’s administration were/are directors or advisers to companies supplying the NHS IT disaster? This is one waiting to be reported.

Possibly the biggest IT white elephant of all time? Probably. A large bean counter by any other name certainly something of no use to any one involved in health care . . .

Other than Managers and the Party.

Praise be to them both.

1 comment:

Deb Acle said...

Superlative summation there ND.

Ever noticed how people at the coal face (i.e. clinical staff and patients) agree on so much...?

I believe we could also invoke the Deb Acle Cant Rule of Pollex here: Charters and constitutions and mission statements and vision documents excresce from any given system in inverse proportion to the availability of the rights they appear to bestow and the putative belief in the values they cantingly espouse.


That bit of shamless self-publicity aside, only this morning I was thinking of writing a blog post about the apparently vexed issue of consultants.

Having hung around policy-makers and strategists for long enough, I concur with your estimation about NHS (or any public service) managers. Quite simply, the majority are not too bright. They are employed because they have just enough savvy to have a go at implementing yet another twerpish political kwikfix. Often they're lovely people in themselves, but not all that sharp.

When the big bananas want some real thinking and real solutions they go outside to consultants. Let's stop for a moment here and consider that many earn a great deal of money from a wide range of clients, public and private.

So, the consultants come in. They look at the environment, do all the research, write the reports, do as well as they can to follow the bananas' briefs (a mindboggling picture arises unbidden there so let's quickly move on...)

Then the big bananas pick and choose from amongst the ideas the consultants have come up with. They rarely take on board and implement the whole package. They take the easy bits, like the overarching mission statement or painting the clinic's old loos or upgrading the office's PCs to Vista. These are cheap, simple, appear to have the ring of action about them.

Everyone gets excited. Hey! This is going to be real change. Imagine the disappointment when staff wake up to the reality....cosmetic changes and no fundamental difference because the bottom line is that the big bananas need to adhere to political imperatives.

Staff cannot cast aspersions and criticisms very easily at their bosses and paymasters. It's far simpler to dross them *%&& consultants who make a &%(* £mint and then p*ss off.

I've met and worked with many consultants. Many are far more professional and far smarter than their clients. And far more innovative. Certainly a few are jerks and parasites who should be given the elbow. But they are more often smarter jerks and parasites than most of their public service clientele, amongst which sector the jerk-parasite predominates.

As I said, excellent post.