News from Nowhere

Guardian journalist Polly Toynbee has a good grasp of NHS politics and little time for those trying to undermine the health service. News from Nowhere moles respect her, even if they do not always agree with her. They were puzzled, therefore, to find in an article that was broadly right about extra funding making the NHS work better (The Guardian, The health service is on the up without radical reform 19/5/04) that she was puzzled by falling surgical productivity. This concern with productivity is central to the argument for introducing commercial mechanisms in the NHS, to motivate organisations and individuals to work harder and do more. This is no time to be puzzled about it.

The consensus amongst News from Nowhere’s motley crew is that falling productivity is real, and is due to improved quality of care, damage inflicted on the surgical production process by previous efficiency savings and the operation of the hidden hand of the market. These causes work in different forms in different places, making no one hospital quite like another, much to the annoyance of the Department of Health.

Quality of care has improved because anaesthetists spend more time monitoring and supervising patients before and after operations, creating down time for surgeons, and lopping one case of the operating list. Multiplied by all the surgical teams in the UK, this is a lot of work deferred. Changes in junior doctor training have also had an impact on throughput of patients, because consultants can no longer run two theatres in parallel, supervising two juniors during operations. Surgical training has to be under closer supervision in these more enlightened times, very probably to the benefit of patients and professionals alike, but throughput falls.

Surgery is the original multidisciplinary process, with activity dependent on patients being brought to operating theatres, given anaesthetics, prepared for operations, treated, returned to recovery rooms and then to wards. Past efficiency savings (among other damaging policies) have thinned the portering and nursing workforce that could keep the patient flow going, so the production process (sorry, care pathway) slows down. Another operation gets knocked off the list in every hospital struggling with staffing.

There are financial incentives not to work too hard, but market forces are likely to operate covertly. Surgeons pressured to speed up may (unconsciously) slow down, few professionals are immune to gaming the system to get more money for less work (especially in the name of better quality education and better standards of care), and private practice thrives when waiting lists are long. In places where surgeons and anaesthetists work in unofficial cartels in both public and private sectors the scope for slowing the system down is great.

So is falling productivity a problem at all? The first set of causes is worth having, the second may weaken if staffing levels improve, and the third seem likely to persist if market solutions are deployed in further ‘radical reform’ of the NHS.