Sitting on Our Hands?
Roger Kerr yesterday reiterated his disappointment in the dismissive reception given to his report on hospital productivity. I have blogged about Cunliffe being entitled to some doubts about the report, because medical productivity is complex and often not fully related to the outcome measured. For example, a laparoscopic appendicectomy (removing the appendix via a keyhole) requires more expensive equipment, more skill and more theatre time than an standard appendicectomy (with a long cut in the abdomen). The outcome (a well patient) is the same, but the cosmetic result and speed of recovery of the laparoscopic patient is far superior.
Now that I have had a chance to read the actual report (PDF here), I have found this interesting statement:
“Overall productivity of personnel in public hospitals decreased 8 percent over the five years between 2000/1 and 2005/6. This compares with a productivity decrease of approximately 15 percent for medical personnel and 11 percent for nursing personnel. (Productivity figures for all personnel are somewhat distorted by the contracting out of certain services like cleaning, maintenance and information technology.)”
To translate the reportese: There were more actual doctors and nurses producing less work.
Now Cunliffe thinks that doctors and nurses should be insulted by this report, but I am merely curious. I see absolutely no evidence of doctors and nurses sitting around on their hands. So where has this extra work gone? As Kerr says:
“The findings of the latest study are of no small moment. Just keeping hospital productivity at its previous level would have allowed District Health Boards to carry out work equivalent to an extra 30,000 hip replacements. Alternatively, they could have cared for as many additional patients as the Waitemata DHB cared for in 2005-06.”
Kerr suggests the current favorite of National – extra administrators – as at least one factor. I am certain he is partially correct. What I do see is a lot of nurses spending a disproportionate of their time doing paperwork. Much of that is defensive. A nurse’s word is no longer good enough to defend herself against a complaint, now everything must be documented. But the flow-down effect of paperwork from just one administrator can tie up dozens of nurses for hours.
Doctors, however, deal with substantially less paperwork than nurses (unless they are GPs – the poor things). I suspect the real reason for loss of doctor productivity is that doctors were dangerously productive ten years ago. Junior doctors have gradually managed to negotiate themselves much saner rosters and the decrease in actual hours worked has lead to an inevitable decrease in productivity.
This is precisely why productivity as a lone measure for hospital performance is dubious. This report does not capture the better working conditions of doctors and the fact that junior doctors (the ones most likely to make mistakes) are not continually and dangerously exhausted. This is not to say that productivity cannot be improved or should not be looked at at all (Cunliffe’s position), but that it should be but one of the measures we use for assessing medical performance and by no means the most important.
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Nov 12 08 5:31 pm
Although I agree with most of what you have written, there are some points that I think you have completely misread.
A lot of the missed opportunities for increased productivity are because of poor planning by the MOH
- poor work force planning leading to shortages of vital components in the production line such as ICU nurses to attend to patients after cardiac surgery
- poor infrastructure planning such as insufficient number of operating rooms to handle the demand for surgery
- poor demograhic analysis for proper planning for budgeting the health dollar to where it is needed.
The work hours of the ‘junior’ doctors has not really done much for decreased productivity – this has just resulted in senior doctors doing the work (and less research, teaching, etc) and has created another time-bomb, that of an insufficient number of adequately experienced, dedicated, hard working doctors to run specialised medicine in the future. We had young healthy junior Dr’s unable to work long hours – now we have older, more feeble senior Dr’s doing the long hours instead! This is madness.
The pay issues with junior doctors is such that they are not committed to the hard work of getting to the top, but instead are seeking out the easier, more social hours of locum work and overseas appointments.
GP’s are not the only ones doing paperwork. Have you ever thought about how many check lists, forms to be completed in duplicate, extra reams of ‘data’ to be collected, WHO protocols to be followed, etc, that can be created by an army of bureaucrats in a hospital? That’s before the ‘Ministry’ requests.
Nov 12 08 8:15 pm
I agree that it terms of surgical output, MOH miscalculation has lead to a shortage in theatres and staff – the same thing has been targeted in National’s health policy. Ironically, much of this miscalculation was driven by Cunliffe’s much-vaunted hospital rebuilding policies, which built the new hospitals too small in order to “save costs”.
The issue of Junior doctor’s hours has a much bigger impact on productivity than you think. There is a real drive in medicine to move away from the old “on call” system and its long hours to shift-work for everyone, including specialists. This will inevitably lower productivity when measured against absolute doctor numbers. The junior doctors are well on the way to structured shift-work only, with a maximum of 16 hours for any one shift.
Nov 13 08 1:30 pm
The issue of Junior doctor’s hours has a much bigger impact on productivity than you think
With the RMO strike, the efficiency of the hospital increased enourmously. The SMO’s were able to make decisions far quicker, with fewer investigations and there was a resulting quicker management of patients, either to get their surgery, be admitted or discharged. I’m not running the RMO’s down, but this was a fact purely because of the greater experience of their seniors. The SMO’s are working far longer and many more hours than before – and more often even more than their RMO’s.