No 17. - What is a root-cause of the problems with the NHS in 2021? A Black Swan?
TLDR
More money for the NHS is not always the answer.
I’d like to persuade you that the system could be improved with a couple of changes in regulation and rule changes. A great thing about the regulatory problems is that they are testable and solvable quickly and without any more money!
If you are sceptical then please read on.
This morning I was listening to a Freakanomics podcast with Marcus Du Sautoy discussing his latest book “Thinking Better” and it got me thinking about how to think about root-cause problems in healthcare.
The papers and Twitter are full of “news” that the NHS is under pressure and is allegedly performing the worst it ever has in its history. People are discussing the ambulance queues, ED waiting times, months long waiting lists for operations, investigations and outpatient clinics and of course, that GPs are taking more calls than ever before but you still can’t get an appointment.
Many people have noticed these problems and have tried to come up with individual solutions to each of these system problems.
However, few people talk about what could be the root cause of all of these problems? These problems are really symptoms of the systemic problems rather than the underlying problem.
The Usual Culprits
So, if you read Twitter or articles on the BBC or the Guarding then you will see the following suggestions as the root-cause of the NHS’ problems:
1 A Tory Government
2 Silly government interventions
3 A government trying to privatise the NHS
4 A government not spending enough money on the NHS
5 An unhealthy population getting older and not looking after themselves and putting more pressure on the NHS
6 Unhelpful staff leaving the NHS for better pay elsewhere
7 COVID
Now, I can’t prove that none of these are the root-cause but I have a slightly different suggestion that is rarely talked about:
I believe one of the major root-cause problems with the health service and society in general is that there is too much government regulation and NGO regulation that is often poorly thought through. Regulation can have side effects too.
Now, before you shout at me in the comments section or switch off and give up reading, lend me a few minutes of your time to try and persuade you why some of the regulation might be a problem.
The usual mantra goes something like this:
Something bad happens = people in positions of power decide that “something must be done” = they implement new regulations = the new regulations will force people to perform better = so patient safety will be improved and less money will be lost due to law suits and inefficiency etc
So, the usual hypothesis is = more regulation makes patients safer and the system better.
The Black Swan
As Nassim Nicholas Taleb is famous for pointing out, if you have evidence that supports your hypothesis that is good but not conclusive, whereas, if you have just one example of your hypothesis being wrong then you know that you have to re-think your hypothesis. He called this the black swan effect because people used to believe that “all swans were white” until they got to Australia and saw black swans for the first time.
So, if we can find a few examples of where regulation has in fact made patient safety worse or the system worse, then you need to re-assess the above hypothesis and think again.
Examples of poor regulation that may cause problems:
Who decides how many parking spaces a hospital should have
Who has to do mandatory training
Who looks after ambulance patients
Who can take bloods and cannulate patients
Who can dispense medication
Who can request scans
Who can enter a training programme
Who can work at certain hospitals or GP practices
Now, I realise that is quite a broad list and it may not be clear why they are all relevant to “too much regulation” but let me explain. And please remember, even if you are only convinced by just one of these examples, then you have found a Black Swan and need to think about how to reduce some of the regulation in our system.
1 - Hospital parking is a massive issue for staff and patients. It causes anxiety, stress, being late, having to get to work an hour early just to find a space. So why is this an issue?
Normally, because hospitals don’t have enough parking. And why is that?
Because when a hospital is built the planners have to ask the council for permission to have car parking and councils have been under pressure to reduce the number of car parking spaces to increase the pressure on people to use alternative transport to personal vehicles.
However, due to shift times and distances travelled often makes public transport impractical for hospital staff and patients. So, the regulation on hospital parking should be relaxed to allow a lot more people to drive to and park at the hospital. This would reduce staff stress and patient worries and it would reduce the commute time for many staff members not sitting in a parking queue and ensure more staff start work on time and probably improve their QOL at work and improve retention. With 1 small change, more parking!
2 - Mandatory Training
There is just too much of it. It needs to be cut down to the absolute bare essentials. Someone is in charge of this. Almost no one does this properly or finds it useful and if you rotate between different trusts you often end up completing the same thing over and over again. This wastes staff time and increases stress and annoyance which could drive healthcare professionals away from the NHS.
3 - Ambulance patients and delays
Ambulance delays are in the news at the moment and there are always pictures of ambulances waiting outside ED. This is a huge waste of resources. If ED’s had a few more trained staff to keep an eye on patients brought in by Ambulance then it would free up the ambulances to leave and go back on duty. Surely, this is not beyond the wit of man? It’s a bizarre regulation that keeps ambulances and crews sitting in ED rather then being back on the road. It isn’t rocket science. This would almost instantly improve ambulance response times and reduce burnout of the crews.
4 Who cannulate patients?
Almost all hospital inpatients and ED patients need a cannula at some point in their admission and bloods taken on a regular basis. Different hospitals have different policies but many of these are done by junior doctors because either there are no phlebotomists or trained nurses or physicians associates or EHTs. Completing these jobs takes doctors away from seeing other patients or gaining educational opportunities in clinic or theatre. A common frustration is AHP’s who say “I haven’t been trained to do that” or worse is “I haven’t been signed off to do that in this trust”.
Training someone to take blood or cannulate is not theoretically difficult but they are skills that require practice. Non-doctor healthcare professionals are often not trained to take bloods from difficult patients and are allowed to give up and pass it back to the doctors if they struggle, if we improved their training then this would massively reduce the workload of junior doctors.
However, we could also expect all nurses, EHTs, PAs and phlebotomists to be “signed off” as competent to take bloods and cannulate. This would massively improve the pool of people available to do this. As being “signed off” as competent should be something done on day 1 of some one starting their job. If they have been observed completing the skill successfully then they shouldn’t need any more training or signing off.
This also links with the point about mandatory training - why are hospitals expecting staff to complete theoretical mandatory learning sessions on blood taking when they may have been doing it for years! It’s just a waste of time.
5 - Who can dispense medications?
In hospitals it is almost always nurses and student nurses who dispense medication. Unless you are in ED where there are not enough nurses and doctors often help out but then need to ask a nurse to open the drug cupboard.
Whereas, in the community pharmacy technicians often dispense the meds from the pharmacy. It would be quite simple to hire and train pharmacy technicians to dispense medications on drug rounds in hospitals. Specialising this job would free up nurses to do other jobs and potentially could improve workforce pressures and save some money because pharmacy technicians are paid less than nurses. This would be a simple regulation/rule change that could free up staff.
6 - Who can request scans?
Requesting scans is currently a doctor or Nurse Practioner or Physio Consultant’s job, however, senior nurses often have the experience to do this and Physicians Associates (PAs) should be able to do this as well. The flow in ED could be improved if triage nurses were trained and allowed to request basic radiographs (XRs) and if PAs could request scans without a doctor countersigning it. Surely, just develop a simple short course in basic radiograph indications and let them do it. Again, a simple change in regulation.
Likewise, much of a junior doctors role on the ward could be done by PAs or nurses with a bit of training and a few rule changes. This could save a fortune for the NHS, improve staff numbers and allow doctors to gain more educational experience.
7 - Who can enter speciality training programmes?
The UK training of doctors is incredibly regulated. The national training programmes involve lots of hoops to jump through and often push people to work in parts of the country that they don’t want to move it.
This system should be changed so that individuals have more choice over where they work and what jobs they take. The regulation of the number of trainees should also be relaxed so that more people can become qualified. Essentially, I believe the entire post-grad training system in the UK needs reform to be more like the Australian system.
My ideal system would be that post-grad doctors sign up for training with a short online form to the specific Royal College. The RC sends them a curriculum and list of things they need to tick off and a list of exams to pass. Then the individual applies for a job at a hospital. They then tick off the curriculum and apply for the exams and organise their own rotations. If people would like a more streamlined pathway then the RCs could establish some preset rotations that were optional for people to apply for. Also there would be no limitation on the number of years involved or the number of trainees in each RC programme. This system would get rid of most of HEE, most of the deaneries and most of the HR administration around speciality trainees.
Set people a standard, set out a pathway and then just let people get on with it. Training doesn’t need any more regulation than this. It would massively save stress, money and burnout.
8 - Who can work where?
Again, the national training programmes determine where trainees are employed, which takes a lot of admin and hoop jumping. If you free this up and let people train where they want to, this would be better for everyone involved.
More money for the NHS
My last comment is about “there is not enough money spent on the NHS”.
How does funding work in the NHS?
People and companies pay their taxes. This money goes to HMRC and then to the Treasury. The Treasury then passes some of this money to the Department of Health and borrows some more money and sends this to the DoH.
The DoH passes money down its many, many levels and then passes money to about 500 different NHS organisations, trusts and CCGs.
Within these organisations, the CEO and Treasurer then pass money down to the middle managers, who then pass the money down to the departmental managers, who then tell the frontline staff how much money they have to spend… sort of.
Obviously, this is over simplified but I hope this has highlighted why its not as simple as “more money for the NHS = more money for frontline patient care”. There are many, many ways how this money can be siphoned off for other pet projects before it gets anywhere near frontline patient care.
Summary
I hope this short list of examples of where regulation could be change has been persuasive. This is by no means a comprehensive list of issues or a list of solutions and I am sure there are many more. If you have any then please do let me know in the comments.
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