Wednesday, 27 June 2012

A Long Smooth Handover

The Cheltenham Ladies College had Mrs Vicky Tuck as the Principal for 15 years. Mrs Tuck left her post on Saturday 9 July 2011. Her successor is Miss Eve Jardine-Young.

That in itself is just a routine thing - one principal replacing another.

But hear....

Miss Eve Jardine-Young was appointed as Principal (in waiting) about 8 months before the actual transition date to enable a very thorough, detailed, induction and hand over (including equal or higher role in strategy formation, new appointments, etc) .

No surprise the school is able to state confidently that they are they are ready to face the future, financially secure and have excellent leadership. All of which is of course true.

CLC, they are just a school, though with a reasonable claim to being the best girls boarding school in the world, we in healthcare are in the business of saving lives. Any lessons for us in the NHS?

At the managerial level
An 8 month hand over/induction process! With about £23 million income which is really small compared to an average NHS trust, for a school to do this is truly remarkable. It reflects a culture of cooperation and shared values that enables organisations to gain from the past and progress to a new future at the same time. I have heard no hospital do this. Well, I am sure that there must be organisations in healthcare that do have overlap between outgoing and in-coming heads at the level of CEOs or senior medics but I suspect long smooth hand-overs are not the norm. We live in a world where one senior person clears their office to be occupied by another one; this gets reflected as an abrupt change which percolates down the organisation, that cannot be good.

I learn that when the health service have tried such an overlap there has been either acrimony or the new appointment muscling into everything too early. It reflects the very autonomous individualistic approach we bring to healthcare delivery. We may not have yet found an ideal balance between continuity and change; I would argue to some extent that continuity is a pre-requisite for successful change. I would like to see senior appointment overlaps in healthcare of at least 6 months with some crucial questions in mind that if you are not able to agree with your predecessor how are you going to find agreement with his/her organisation and on the other side if you cannot work with your successor is your organisation ever going to find success? Clinical medicine changes slowly for good reasons, why should managers change abruptly especially in non-crisis situations? We know for instance that there is a long transition periods for Royal College presidents which is a form of induction, we should be doing it in the NHS and other health service organisations.

At the clinical level
We need to begin by taking very seriously the induction of staff, especially clinical staff into hospitals. Perhaps we can learn from the army about immersive simulation techniques for induction of junior doctors; surely it will be a shade more interesting than the sleepy afternoons with a series of mandatory lectures. Hand overs by junior doctors to other junior doctors at the end of their duty periods is another crucial area which could be made into more than a session where the sceptical in-comer curses everyone for the volume of jobs left over and the out-goer who is desperate to leave the place. In truly sharp acute situations the handover can still be good, perhaps we can learn a fast yet perfect synchrony like that of F1 pit crews; you could enquire what Ferrari did at Great Ormond Street. 

Induction and hand overs need not be a tick box. It could be lovely long and smooth like a warm summer's afternoon. There are specific methods to achieve this, the question that remains is if we have the will do it.

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PS: I am an in a situation of self-validation, bias towards CLC but the topic seems to make sense despite that.

Saturday, 9 June 2012

High Mortality Hospitals Cannot Afford To Pay

In a previous post I showed that most high mortality trusts did not pay bank holiday extra rates/wages to staff for the Queen’s diamond jubilee bank holiday, while most low mortality trusts paid higher wages. 
A friend of mine who is an academic wrote back to me and said he could not resist doing a chi square on the numbers and found the p=0.01. I am no don to argue or explain stats but irrespective of statistical significance it is important to probe if there might be a deeper meaning or relevance. 
It is important to understand why the high mortality trusts did not pay higher holiday rates. Are they ‘mean spirited’ as the Unite Union portrayed them?

In my mind the underlying reasons are very simple and here it is:

And a high HSMR is broadly speaking poor quality care.

Financial reasons?

It might be something as simple as they had no money left to pay. Now that would be a perfectly reasonable assumption to make. Trusts get paid for activity, things like hernia repairs, aneurysm repairs, cardiac stenting, the kinds of things that you do to make patients get better. As far as I know the NHS tariff system through which the trusts get paid does not include things like deaths or complications. 

But in-hospital deaths are very costly; in-hospital complications are very costly. There is no mechanism for payment for that. So a hospital/trust which has high deaths and complications will obviously not have money to do anything else.

Well, it therefore might turn out that their inability to pay higher wages had no a financial reason at all; it may well be a by product of poor quality. High cost, deficits, losses are all a function of poor quality. 
If you pushed them they will come out with something like ‘in this financial climate we would like to channel all our sparse finances directly into patient care’ and you know what, they sure do; their patient care must cost excessive amounts of money due to higher rates of standardised mortality and higher complications.

Cultural reasons?

Perhaps they were unwilling to pay higher rates; management might not have felt the need to 'reward' staff who are unable to produce high quality measured in terms of mortality. Another reason might have been that the money might be better spent in a high mortality hospital in trying to reduce the mortality rather than paying more to staff when the law does not demand that you do so. These are a part of the mental make up and cultural reasons of management. They are right, well, partly right. It is also just possible that well rewarded staff might be motivated to engage in improvement. Works both ways but always difficult to decide which one is right for the given circumstances.

Finally, here is some speculation
But, why did some high mortality hospitals pay staff bank holiday wages? Surely the above arguments apply to them as well. Why did some low mortality hospitals not pay higher bank holiday wages? 
Now I am moving into speculation something which I try not to do too often. My gut feeling is that the high mortality hospitals who paid a higher wage are probably going to find reduced mortality soon or at the best they may continue to stay where they without slipping and getting any worse and the low mortality hospitals who did not pay may find their mortality going up or at the best they may stay where they are without getting any better
My speculation is an extension of my theory about money in hospitals, the trusts who are doing clinically well might have the spare cash to spend it on staff. If that was indeed the case, the staff deserve it.

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Sunday, 3 June 2012

Any links between bank holiday pay and mortality?

The Queen's diamond jubilee celebrations are going on right now. The government declared a 'bank holiday' on Tuesday 5 June 2012 ( Some of us will still be working over the celebration period to keep essential and emergency services going. This includes NHS staff. Individual NHS organisations can decide on whether they will treat this extra holiday as 'bank holiday' or 'public holiday'; they do not have to follow the government declaration of a 'bank holiday'. 'Bank holiday' attracts a higher rate of pay for those who work on that day along with some other terms advantageous to the employees. 'Public holiday' does not attract a higher rate of pay.

Unite Union surveyed their members and found that 113 NHS organisations were treating this as a 'public holiday' and hence no extra pay for staff. ( They have called this 'mean-spirited' and called their publication 'named and shamed'.

My interest includes hospital mortality and I wanted to find out what the high mortality hospitals and low mortality hospitals did in terms of the bank/public holiday pay arrangements. I took the list of 21 low mortality hospitals and 19 high mortality hospital from drFoster's hospital guide and then cross checked with Unite's named and shamed list. The findings are interesting to put it mildly.

My findings are:

7 OUT OF 21 LOW MORTALITY HOSPITALS ARE IN UNITE'S LIST (suggesting that they are not pay bank holiday rates)

14 OUT OF 21 LOW MORTALITY HOSPITALS ARE NOT IN UNITE'S LIST (suggesting that they are paying bank holiday rates)

14 OUT OF 19 HIGH MORTALITY HOSPITALS ARE IN UNITE'S LIST (suggesting that they are not paying bank holiday rates)

5 OUT OF 19 HIGH MORTALITY HOSPITALS NOT IN UNITE'S LIST (suggesting that they are paying bank holiday rates)

Low Mortality Hospitals (as per dr Foster)

Unite's named-and-shamed list

Barnet and Chase Farm Hospitals NHS Trust In Unites' list
Barts and the London NHS Trust In Unites' list
Cambridge University Hospitals NHS In Unites' list
Chelsea and Westminster Hospital NHS Not in Unite list
Epsom and St Helier University Hospitals Not in Unite list
Frimley Park Hospital NHS Foundation Trust Not in Unite list
Guy’s and St Thomas’ NHS Foundation Trust Not in Unite list
Imperial College Healthcare NHS Trust† Not in Unite list
King’s College Hospital NHS In Unites' list
Kingston Hospital NHS Trust† Not in Unite list
Newham University Hospital NHS Trust† Not in Unite list
North West London Hospitals NHS Trust Not in Unite list
Royal Devon and Exeter Not in Unite list
Royal Free Hampstead NHS Trust Not in Unite list
Sheffield Teaching Hospitals NHS In Unites' list
South London Healthcare NHS Trust† Not in Unite list
St George’s Healthcare NHS Trust Not in Unite list
The Whittington Hospital NHS Trust† In Unites' list
University College London Hospitals Not in Unite list
University Hospitals Bristol In Unites' list
West Suffolk Hospitals NHS Trust Not in Unite list

High mortality hospitals (as per dr Foster)

Unite's named-and-shamed list

Blackpool Teaching Hospitals NHS Not in Unite list
Buckinghamshire Healthcare NHS Trust Not in Unite list
Burton Hospitals NHS Foundation Trust Not in Unite list
Dartford and Gravesham NHS Trust In Unites' list
George Eliot Hospital NHS Trust Not in Unite list
Hull and East Yorkshire Hospitals NHS Trust In Unites' list
Isle of Wight NHS Primary Care Trust Not in Unite list
Medway NHS Foundation Trust In Unites' list
Mid Cheshire Hospitals In Unites' list
North Cumbria University Hospitals In Unites' list
Northampton General Hospital NHS Trust In Unites' list
Northern Lincolnshire and Goole Hospitals In Unites' list
Shrewsbury and Telford Hospital In Unites' list
The Dudley Group of Hospitals In Unites' list
The Royal Wolverhampton In Unites' list
United Lincolnshire Hospitals In Unites' list
University Hospitals of Morecambe Bay In Unites' list
Worcestershire Acute Hospitals In Unites' list
York Teaching Hospital In Unites' list

Caution: This is a write up based on information that is publicly available so far. This analysis may not be accurate. We can find out the correct situation only when either NHS employers or individual trusts tell us whether they have paid extra treating it as a bank holiday or not paid extra treating it as a public holiday. So further enquiry and analysis would be needed to validate this. What is presented here is a mere observation and does not suggest cause and effect.

On the basis of current information (this may change when we have accurate information) it seems like there may be attitudes and cultures of organisations, management and staff, playing a bigger part in mortality and morbidity than we previously have assumed.

Please let me know if there are any factual errors in the above and I am only too willing to correct them.

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