ROBOTIC SURGERY: THE FUTURE BECKONS...

ROBOTIC SURGERY: THE FUTURE BECKONS...

Guest Blog by

Dr. Soumyadeep Bhaumik MBBS 

GP, Independent Researcher and Medical Correspondent

 

In 1921 Czech playwright Kapel Clark introduced the concept of robots (and in the process coined the term robot too) in his science fiction epic Rossum’s Universal Robots. Domin, the lead character of the play describes the future of robots as, “all work will be done by living machines. Everybody will be free from worry and liberated from the degradation of labour. Everybody will live only to perfect himself.” Ever since then robots have captured the imagination as well as the reality of humans. Robots are used nowadays in specific, precise, speedier and often hazardous work in domains ranging from industries to research to warfare. The entry and progression of robots however has been comparatively slower in the field of medicine.¹

Robotic surgery is a new and emerging field that has taken the medical and particularly the surgical community by storm. Robotic surgery is a technique which in the simplest term can be described as a surgeon performing surgery using a computer that remotely controls very small instruments attached to a robot with multiple arms.

History of Surgical robots:

The background of development of robotic surgery is inherently intertwined with the development of minimally invasive surgery (MIS). MIS has various advantages like smaller incisions, lesser infection, shorter hospital stays, quicker discharge from hospital, decreased pain, better cosmesis, and better postoperative immune function^2-4  An inherent problem with current laparoscopic equipment is the loss of haptic feedback (force and tactile), natural hand-eye coordination and dexterity¹. Moreover laparoscopic instruments have restricted degrees of motion (usually 4) whereas the human wrist and hand have 7 degrees of motion. There is also a decreased sense of touch that makes tissue manipulation more heavily dependent on visualization (which is essentially two-dimensional). Finally, physiologic tremors in the surgeon are readily transmitted through the length of rigid instruments. These limitations make more delicate dissections and anastomoses difficult ⁵. Most surgeons harped over these limitations and argued the supremacy of traditional surgeries but biomedical engineers collaborated with a handful of surgeons and developed the Puma-650 which was first used in precise neurosurgical biopsies² and then in Trans-urethral resection of prostate (TURP)⁶. Robotic surgery gained rapid strides with the development of the PROBOT, ROBODOC, NeuroMate, PAKY-RCM, AcuBot and AESOP ^1,7.The da Vinci Surgical System ultimately made the robotic surgical system popular globally. More than 1752 da Vinci systems are already installed in across 44 countries of the world.⁷

Pros and cons:

Robotic surgery promises to overcome the traditional obstacles of surgery¹. They have better geometric accuracy, remain stable and do not get tired, can scale motion and offer more degrees of freedom than the human hand. They are precise and can access spaces or areas which a human hand cannot--thus making micro-anastomoses possible. Unlike humans, robots are not susceptible to radiation/infection or fatigue. Robots eliminate the fulcrum effect and also physiological tremors of the surgeon. Having fewer surgeons in the operating room and allowing doctors the ability to operate on a patient long-distance (tele-surgery) would also lower the cost of healthcare in the long term.⁷ More over because the surgical cuts are essentially smaller it provides all benefits of MIS, albeit in a greater dimension.

The prime disadvantage as of now with robotic surgery is not technology (which is bound to improve further in the future) but the costs involved. Robotic systems cost a whooping US $ 1 million to procure and recurring costs of $100,000/year. Such huge sums mean a lot if viewed in the light of public health measures in resource-poor developing and underdeveloped nations. Other concerns that have been raised are the requirement of extra staff to operate, steep learning curve and it’s yet to be proven cost-benefit ratio. A major cause of concern is the fact that robots do lack the capacity to earn the trust implicitly assumed in a surgeon-patient relationship⁸.What would be the psychological state of the patient peri/post operatively when he knows that his body parts is being handled by a machine made of ‘tins and oils’ ? What if the robot malfunctions? What if it is fed with the data for a wrong patient or for that matter even a wrong surgery? Who will be to blame in case something goes wrong?

What the future holds?

In spite of the fact that robotic surgery is fast spreading globally it is important to note that it is still in its infancy. The future of robotic surgery will take this current platform forward by improving haptic (touch) feedback, vision beyond the magnified eye, robot accessibility with a reduction of entry ports and miniaturizing the slave robot.⁷ In the near future robotic systems are expected to integrate various other technologies and modalities that are currently being used in the operating room. Efforts are already on to relay touch sensations from the robots to the surgeon and develop better suture less anastomoses⁷. Diagnostic modalities like USG, CT scan and MRI will soon be merged with robotic surgical equipments and guide the surgeon in better dissection and pathology identification. Nano-robots too are being developed across the world. Surgical training is also expected to radically change with robotic systems being used to rehearse procedures before doctors actually operate on a patient. Eventually tele-robotics will develop thereby enabling super-speciality surgeons to operate at inaccessible rural location without them being physically present in the operation theatre.

Evaluation of its safety, efficacy and long term effects vide randomised controlled trials is the need of the hour. Efforts to bring down costs should be specifically attempted. Unlike in industries or warfare clinical judgement is way too complex process which takes into account various factors beyond the operation table. The patient's socio-economic background, physico-intellectual status, his aspirations from life, emotional state, and cultural factors are issues which are taken onto account by the surgeon. Owing to the very nascent stage in which artificial Intelligence is currently the view that the automation age in robotic surgery has arrived and " it’s only a matter of time when it will run our lives for us” ⁸ is but a vision of the very distant future.

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Soumyadeep Bhaumik is a blogger and his blog Caffeinated Works & Random Musings is one of the largest healthcare blogs in India

You can get in touch with him via

in.linkedin.com/in/soumyadeepbhaumik
www.soumyadeepb.wordpress.com
https://twitter.com/DrSoumyadeepB

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References:

1. Lanfranco AR, Castellanos AE,Desai JP,Meyers WC.Robotic surgery: a current perspective. Ann Surg 2004;239:14-21
2. Kim VB, Chapman WH, Albrecht RJ, et al. Early experience with telemanipulative robot-assisted laparoscopic cholecystectomy using DaVinci. Surg Laparosc Endosc Percutan Tech 2002;12:34–40.
3. Fuchs KH. Minimally invasive surgery. Endoscopy 2002;34:154–159.
4. Allendorf JD, Bessler M, Whelan RL, Trokel M, Laird DA, Terry MB et al. Postoperative immune function varies inversely with the degree of surgical trauma in a murine model.. Surg Endosc 1997;11:427–430
5. Prasad SM, Ducko CT, Stephenson ER, Chambers CE, Damiano RJ Jr. Prospective clinical trial of robotically assisted endoscopic coronary grafting with 1 year follow-up.Ann Surg. 2001;233:725–732.
6. Davies B. A review of robotics in surgery. Proc Inst Mech Eng.2000;214:129–140.
7. Wedmid A,Llukani E, Lee DI. Future perspectives in robotic surgery. Brit J Urol Int ;108:1028-1036( Avalilable online http://onlinelibrary.wiley.com/doi/10.1111/j.1464-410X.2011.10458.x/pdf)
8. Nath NC.Robotics –the future of surgery. J Ind Med Assoc 2011;109:12-13

Don Berwick Report

Don Berwick NHS patient safety report - will it work?

It will. Though there is a blind spot to watch out. 

A blog from a particular perspective

Don Berwick report 'A promise to learn, a commitment to act, improving the safety of patients in England' has been published (https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/226703/Berwick_Report.pdf). There is all round praise which is well deserved. The entire report is full of gems of wisdom. As a practising clinicians who also values work life balance, I have still managed to fast read the report, I will read it again in detail. As a student of improvement science I am sure I will learn a lot from the report. I am a fan of Don Berwick, I have heard him speak a number of times and every time I am not only moved but I always come away with great learning. It was one of the cherished moments in my professional life when I shook his hand at the Forum in London in April 2013 and he walked with me to personally introduced me to Sir Brian Jarman.

Don's report is pretty comprehensive as expected, I hope the report will be effective.

The Blind Spot

My problem with the report is not the content, my problem is with the membership of the advisory group. It is elementary in leadership that while what is said does matter, how it is said and who said it really matters more. Why do you think football celebrities endorse non-sports products?

The committee was happy that they were independent.

The advisory group was made up of 17 persons whose expertise is unquestionable. 4 of them were Americans from the Boston-Harvard area; with 3 of the 4 Americans from the same organisation. 12 out of 17 were non-NHS, the 13th was NHS Scotland. No Europeans. No one else from the US aside or instead of this close knit group.

9 of the 17 were women - finally it looks like we are recognising that the half the real world is indeed made up of a gender who are not male, well done. 

17 out of 17 seem to be white. 

Don Berwick is no stranger to England, he is no stranger to inclusive leadership. Don was obviously so dedicated to answering the questions put to him that his human limitations prevented him from recognising that in London when he walks the streets 50% are foreigners, 40% are Black and Minority Ethnic. If Don entered any hospital he may have noticed that about 40% of doctors are from BME origins and in London nearly 40% of healthcare staff are of BME origin and about 10% of this country are from BME backgrounds. Don's report speaks about adequate staffing. Where do you think that comes from? We are hearing reports of urgent recruitment of rota fodder to deal with the A&E staffing crises from countries like India, Don and his committee would recognise Indians are part of the BME group.

The Quality Chasm and Leadership Deficit

Who speaks to whom matters. Constituencies matter. Don is now a politician, he will do well to remember that his country's president won his office on the black vote (though certainly not exclusively on the black vote). If Don looked and did not find an person who has some expertise in quality and safety who also happened to be non-white he should have mentioned that a part of the system failure that he talks about.

The report talks about culture and fear. Amongst the most afraid in day to day clinical practice are BME doctors who face a higher rate of referral to their regulator; they are also thought to have higher rate and higher intensity of sanctions by their regulator. BME doctors also face extraordinarily adverse pass rate in their specialist examinations, unlike in Don's country.

It is not as though the committee did not have a BME connection. It did have a most profound and tragic BME connection. Lisa Richard Everton, a patients' representative on the committee lost her husband Paul Everton due to a lethal overdose at Heartlands. Paul Everton was black. Don would know that in our much revered NHS BME's get poorer health outcomes.

I was actually hoping to have interactions, debates or arguments on the technical aspects of improvement and patient safety issues with Don; I am sure I will in the near future. Instead I am talking about leadership, culture, inclusivity and race. On my initial reading, the report excels and succeeds at the theoretical and technical aspects where the content experts lead by example. The report fails in its operational aspects especially in the context of what the manpower constituency might recognise, mirror and reflect, the report and its committee fails by example

The inability to include or cope with a real mix of normal people is the biggest wall that prevents our already good NHS from achieving even higher standards. A different committee with some persons who have BME style thinking (as opposed to just simply being from a BME origin) in it would not have made any difference in the content of the report, I suspect it might have made a difference in the sincerity and speed of adoption. I am not a race warrior, this blog is not about race, regular readers of this blog would already know that. This blog is about contextual leadership which in essential for success in healthcare.

I remain a fan of Don Berwick, I do not write this in protest or complaint. I write this due to a genuine concern that Don, a person whom I admire and his recommendations should not fail. I write out of a genuine desire that the NHS should cross the quality chasm by overcoming the massive leadership deficit that it faces.

© HEMADRI

Follow me on twitter @HemadriTweets

PS: I recommend the report. It is up to us, normal NHS staff to make sure that we take this report to the front line and deliver it there to benefit our patients.

Skin in the Game

DO DOCTORS AND NHS MANAGERS HAVE ENOUGH SKIN IN THE GAME?

Skin in the game is a term mainly used in the financial world where it is thought that those persons who are playing the game (e.g. fund managers) should have their own money and reputation involved so that they are as rewarded or as damaged as the people on whose behalf they play the game (i.e. their customers, investors). Philosopher and author Taleb has ignited a debate on the importance of this, he points to a Hammurabic code where if a house were to collapse and kill the owner of the house then the builder will be given the death penalty - now that is some real skin. This blog has already written on how Warren Buffet would not take a fee unless he crossed a certain level of achievement for his investors (http://successinhealthcare.blogspot.co.uk/2012/01/getting-paid-for-performance-buffet.html); apparently Buffet also has his own money invested along with his investors - he has enough skin in the game.

This got me thinking on what kind of 'skin in the game' we have in the NHS. Of course that is a large one to put out in a short blog. Lets try a limited short version.

In the past when doctors were employed as consultants in the NHS there was a requirement to live within a defined distance of their hospital so that they can respond to urgent and emergency calls when they are on duty and also help their colleagues when necessary even if they were not on duty. In the past consultants had an obligation to let the hospital know if they will be out of the area (even if they were not on call or on annual leave). Doctors were paid some money as relocation expenses to facilitate the same.

This obviously meant that the doctors working in a hospital lived within the catchment area of the hospital. In the event of an urgent need for healthcare for the doctor or for their families, they are highly likely to attend the hospital where they work. The success and failure of the hospital had the potential to directly affect them. In the last decade or so, the obligation to live within the local area seems to have disappeared due to a combination of societal changes of both spouses working and the officialdom seeming to demand that the doctor be available only when rostered to do so. However a large number of permanent senior doctors still live in the catchment area of their local hospitals. By definition there is skin in the game - if your hospital mortality or morbidity or general services were bad you and your family were likely to be affected by it.

The other aspect for consultants in the NHS is many consultants expected to work for many decades in one hospital, they do not expect to move. This has seen a slight change recently but it is substantially true that you would generally not find NHS substantive consultant post holders move very often. They develop, grow skin into the game. There is of course the issue of excess skin in the game where people with too much stake take too much risk, perhaps in the case of NHS consultants it may be a case where due to their superior knowledge of local and national situation they learn to avoid personal risk while all the risks remain for their patients. The doctors have a reputation risk - this is really serious - so serious that a doctor can be struck of for damaging the risk of their profession; at a personal level the reputation is equally serious;  due to peer pressure and long service reputational damage can be devastating.

I am unable to find a historic or current requirement that states that executive directors of NHS hospitals were/are obliged to live in the catchment area of their hospitals. I know of many hospital directors who do not live in the geography covered by their local hospital. This means in reality they have not much skin the game. In contrast to NHS consultants, board directors stay in post only for a fraction of the time that a consultant stays in post - compared to consultant appointments, executive director appointments are practically musical chairs or passing the parcel. Again there is not much skin the game. Of course there is a reputational issue but with performance measurement in the NHS for managers not being so accurate as say for a financial fund manager a large gooey fudge substitutes for reputation.

I don't know how practically applicable the above thoughts are. I have already written about the fact that NHS board director contracts have no reward or punishment for anything other than financial performance (Whose job is it to reduce mortality? http://successinhealthcare.blogspot.co.uk/2013/06/whose-job-is-it-in-nhs-to-reduce-deaths.html) Modern life and employment conditions may mean that we may not be able to demand that people live where they work. However we do need to find a way to ensure the skin in the game for NHS managers and directors; increase skin in the game for doctors.

Perhaps a starting point might be to publicly declare if they live within the area of the hospital where they work and how long have they lived within the area (not asking for private addresses, just for HR to declare if they live within the area). Perhaps remuneration and penalties should be linked to quality of performance (when we get around to understanding how we can measure quality meaningfully). We must think of other ways that suit the modern world to increase skin in the game. Healthcare is person to person business, very important for healthcare professionals to remember - no skin means poor game.

©M HEMADRI 

Follow me on twitter @HemadriTweets

Improving the morale of NHS Staff

Improving the morale of NHS Staff

The vital role of improving the frequency of positive emotions and using positive feedback as a source for improvement. Time for the public/patients to be a part of the action.

Bad news all around

Poor care, cover ups, whistle blowers, gagging orders, complaints, et al; we very often hear about all of them these days through profoundly sad media reports, social media (twitter, facebook, blogs) and reports of various organizations. If you are following the news recently its bad news everywhere with Mid Staffs, Francis, Tameside, Morecambe Bay, Keogh 14 at the extreme end and A&E crisis, GP OOH crisis, rationing of services etc at the moderate end. (It is a worrying state of affairs, isn't it when the GP and A&E crises are called moderate?)

Dealing with what is wrong

When things go wrong there are a number of mechanisms present to address them – the immediate boss, PALS, complaints, medical director, nursing director, chief executive and other directors. There is the healthcare ombudsman if your local systems cannot sort it out. There are national bosses, DoH, NHS employers, NHS confederations and others who are very willing to intervene when things go wrong. Medico legal specialist lawyers who are very willing to take up and chase anything from the trivia to the grievous. There are regulators CQC, GMC (for doctors), NMC (for nurses), Monitor (for foundation trusts, more recently for all trusts). There are plenty of important bodies all willing to tell us how to practice clinical care; the Royal Colleges, NICE, various specialty organizations and others. All of these people and organisations issue the euphemistic 'guidelines' which are basically rules/regulations which if not followed clinical staff will be in trouble.

The NHS tracks its complaints and publishes it – quite rightly so. NHS bad news is reported big time when there is a serious complication or death or when there is a serious let down of an individual’s expectations – quite rightly so. Openness when things do not go right is very comforting for the affected patient and families; it also helps organisations learn and improve.

The Impact of Constant Bad News

'Bad news' i.e. news about poor performance, negligence, criminality, never events, serious untoward events, harm, complications and bad behaviour of healthcare staff even after accepting that it is grossly under reported forms a small part of the overall picture of healthcare and NHS. Vitally important part, but small part.

Majority of healthcare staff are well performing, well behaved, caring and produce good clinical and social results for their patients. An overwhelming majority of patients get good results. This is of course no excuse or balance and cannot be used to justify avoidable problems or even to defend the impact of unavoidable problems.

Having set that out very clearly, let us look at the impact of negative feedback, negative experiences or negative behaviour that healthcare staff get constantly from their newspapers, from their managers and from their patients. 

Studies by psychologists have shown that the effect (value or impact) of negative emotion we feel is twice (2.25 times) as stronger than the effect of a positive emotion. Here we explore how this plays a part in the morale of NHS staff. Let us say the impact of praise (and we feel a positive emotion due to that) is +1 and the impact of non-constructive criticism (we feel negative emotion due to this) is -2. So if we praised a person once and criticised them once, the net effect on an employee's emotion is not 0 or neutral, the employee ends up with a mental state or mood or feeling of negative emotion which in our scale will be rated at -1. Let us assume we praise an employee four times in a day and have a go at them four times in a day the net impact is likely to feel negative emotion rated (+4 -8 =) -4 and if we repeated this for a whole week the employee will have a mental state which on this scale will be valued at -20 or full of negative emotions.

It is indeed no wonder that NHS staff suffer from a low morale. There is plenty of negative news in every media, constant pressure from government and managers. The complaints from patients have reached record levels. It is indeed a surprise that NHS employees have any morale at all.

What can patients (service users) do to improve morale?

We now know that poor morale and unhappy staff results in poor healthcare delivery. As patients we would want to prevent that. We know that majority of the times, majority of the patients get very good results. We know that negative emotion has double the impact on the mind than positive feedback. So as patients I think we want to be congratulating, thanking, praising NHS staff every time we get a good service and/or a good result so that positive emotion can flourish. We should try to do that at a ratio of positive to negative feedback of at least 3:1 (you see a positive:negative feedback ratio of 1:1 leads to low morale staff and 2:1 will lead to neutral morale staff). We know positive and happy staff often translates into good results for patients.

As a patient it is in our specific and direct self interest to increase positive emotion in healthcare staff when things are going right for us as it does most of the time for most of us.

As a manager that is what you want to be doing to your staff, being aware of the impact of positive and negative emotions and using the ratio to boost morale.

Let us take a hypothetical example of a treatment which has a 90% success rate and a 10% failure/complication rate (this will generally be high rate of complications); let us assume that all patients provided feedback with 90% thanking and praising the staff for the successful treatment we have had and 10% of patients complaining about their result. We may have staff in great mood feeling very positive about themselves and are likely to deal with complications/problems in a confident positive manner.

Positive feedback as a source of improvement

The NHS has no system of capturing congratulations and kudos. Complaints are logged, measured and acted upon. Congratulations are not formally logged, hence not measured and almost never acted upon. If a patient writes in with a complaint hospital looks not only for resolution but also to try and prevent it from happening again. If a patient writes in with a compliment it will be a very rare place to study it immediately learn the lesson and roll it out. We learn if at all, on how to avoid bad things, we do not seem to learn on how to improve on good things. My premise is learning to avoid problems puts healthcare providers in a neutral position; learning to improve on what is already working well puts healthcare staff in a strong position. Here is why we need to do it, if you slip from a neutral position you go into a negative situation; if you slip from a strong position you either become less strong or even (though there is a small chance of getting into neutral).

Well we know that it is not exactly very British to be loud, vocal and break into a song and dance to praise when things go right but if we knew what is good for us that is what we would do. It is very wrong not to complain when things have gone wrong, it is very wrong not to whistle blow, it is very wrong not put in extreme effort into getting care right and not remedying problems effectively when they occur. It seems to me now that it is also very wrong not to praise NHS staff when things go right. The silence of the majority could be a major reason for the low morale. It is time patients and managers made the effort to improve the morale of NHS staff, it seems a route to good care.

©M HEMADRI 

Follow me on twitter @HemadriTweets

Notes: The strength of positive and negative emotions we feel and its impact is well described in N Taleb's Fooled by Randomness.

Keogh Review

KEOGH REVIEW OR KEYHOLE REVIEW? TIME WILL TELL

The Keogh review team visited my work place. I volunteered to meet them. Twice. Once as a part of a group discussion. Again on what was supposed to be a one-to-one drop in session.

The group session was very interesting - individuals and as a group there was a delicate balance on many fronts. The one I found really intriguing was the pride we felt about our work place when faced with these external bodies which had to be balanced with the view that if we were really worthy of the pride we felt those external bodies would not be in our hospitals in the first place. Difficult emotions to cope with.

The group session was supposed to be for people who had signed-in before but eventually allowed people who had not registered. The advantage of a free discussion was probably cancelled out by poor management of 'air time'. There were some highly placed persons whose attendance might have dampened the sessions but I cannot be sure about that. The one-to-one drop in session turned out not to be one-to-one at all, I was invited in to sit as a previous person was talking to the Keogh people and a person who followed me was invited in to join as I was speaking. Of course we were asked if that was okay with us, what is the point of asking if it fundamentally changes the nature of the session. In my case the person before me and after me have a history of thinking on similar lines so I did not feel constrained and the person who followed me mentioned no feeling of constraint (in a private conversation later)

The Keogh people have promised that this will be a very open and transparent enquiry. So I am not going to put out what I said or did not say, as obviously without the bigger picture context in place I cannot make sense. In any case, if the promised transparency turns out to be true everything that we said (though anonymised, I think) would be available to everyone when the review is published.

I took the opportunity to ask them some questions. I wanted to know who exactly will write the report for my trust and whether that person or persons were actually present in the premises as a part of the visit. They were not sure about that.

I asked how the success of the Keogh review will be measured. They were unsure about that as well. 

There was an assurance that there will be all the support needed for the 14 trusts to deal with their problems. I am particularly keen that Keogh review should only be called a success if the 14 trusts under review were no longer outliers two years from now and remained so for a further four or five years. Having commissioned a review on high mortality, in my mind the obvious end point will be the reduction of mortality for which Keogh and DoH should take joint responsibility from now. To publish a report, however well informed it is, to provide support however intensive it is, will be meaningless unless our mortality gets low and remains low. Having lent his name, Sir Bruce should have no choice but to link his success to ours.

We discussed my motivation for meeting them. It was very simple - I live and work in the area, if I had a problem by default I will end up in my hospital's bed. If my hospital's mortality statistics are bad, it will be foolish of me to think I might escape from its clutches. So I want to see it get better.

We will have to wait and see if at the end of it all Keogh review will give us the keys we need to get out of this hole or will simply become a keyhole review. My healthcare, my life, my family's healthcare and my family's livers, my neighbours' healthcare and lives, my friends' healthcare and lives are at stake - so there is no other option than to get this right.

©M HEMADRI 

Follow me on twitter @HemadriTweets

Whose job is it in the NHS to reduce deaths and complications?

Recently there is an increasing concern about mortality and morbidity in the NHS. Let us for simplicity say that people are asking whether the death rates and complication rates can be reduced. People are asking if there are any avoidable components in relation to deaths and complications and whether those avoidable problems can be eliminated or at least reduced to minimum. People are also want to know who is responsible or accountable for ensuring lower death and complication rates.

NHS Directors

NHS trusts are in the business of delivering healthcare to their populations – that is the essential purpose of their existence. So it may be reasonable to assume that the directors, who are the top bosses of these trusts  and their bosses (SHA equivalent, NHS England directors) will be assessed and rewarded against clinical quality parameters of which deaths and complications are core.

Apparently not. The contract for the managers especially when it comes to pay uplifts and bonuses are very specific. I quote:

''It is an essential criterion of the performance bonus scheme that the organisation achieves its financial control target as agreed with its grand parent organisation (see paragraphs 64 and 65 below).

Where an organisation fails to do this, all its very senior managers will be treated as Category D performers and so no awards (either annual uplift or performance bonus payment) will be paid to them

The annual uplift will be applied to the basic pay being paid to the post holder (which would include any long-term RRP payment), provided that:

the organisation achieves its financial control target; and

the individual concerned is judged as performing at Category A, B or C.

Those in Categories A, B and C will receive this annual uplift to their basic pay, which will be pensionable

Those in Categories A and B will receive, in addition to the annual uplift, a non-consolidated bonus payment, provided the essential criterion is met –

i.e. that the organisation achieves its financial control target. Bonus payments will be non-pensionable, non-consolidated one-off payments

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/126865/pay-framework-vsm-strategic-and-special-has-pcts-amb-trusts-updated-july-2012.pdf.pdf ''

So it is seems the only officially contracted criteria to be eligible for a pay uplift and bonus is meeting the financial target (and something woolly about being classed as A, B or C. In any case if you don't meet the financial target it is an automatic D which means no pay uplift or bonus irrespective of how much quality is improved and mortality/morbidity is low

What do you think might be happening in a manager's mind when priority setting? Which director will be prepared to have a very low mortality and morbidity and yet be classed as a failure and given a D. If ever a CEO was prepared to do that what do you think that their directors's mind would think given the fact that various director's pay are set as a percentage of their CEO's pay. What does it tell Jo public when the Finance Director's pay is linked to and set at 75% of the CEO pay and all other directors get a lesser percentage? One lovely chain where there is clear financial incentive to reach financial targets and ensure the CEO gets a higher pay. I am sure my understanding is not perfect but it looks like a conflict of interest built into a contract - you could not make it up if you were writing fiction. Where do you think the emphasis will lie? No guess work – it is explicit – financial control target it is and nothing else.

Now do I think for a minute that any CEO or director gets to work and says 'kill patients but save money', heck no. But we have all heard about subliminals, motivation, contractual obligations playing a part in how we perform. It does not sound sweet.

REGULATORS

We then have regulators to oversee that trust bosses who are contractually only obliged to serve the financial agenda are still meeting some sort of standards that matter to a publicly funded healthcare system – i.e. clinical quality with death and complications at its core.

Lets look at some of the regulators purposes:

Monitor: Our main duty is to protect and promote the interests of patients. We do this by promoting the provision of health care services which is effective, efficient and economic, and maintains or improves the quality of services.

CQC: We make sure hospitals, care homes, dental and GP surgeries, and all other care services in England provide people with safe, effective, compassionate and high-quality care, and we encourage them to make improvements.

GMC: Our purpose is to protect, promote and maintain the health and safety of the public by ensuring proper standards in the practice of medicine.

But let us look at how it actually works out

CQC

The CQC talks about safety and quality but when you look into what they actually say there is no specific mention that organisations will be assessed against their death and/or complication rates

http://www.cqc.org.uk/public/what-are-standards/national-standards

For God's sake how else do you assess care quality if you do not start with death and complications.

MONITOR

It is the government's aim to provide independence to NHS trusts by allowing them foundation trust status. Clinical quality especially reducing mortality and morbidity is not a criteria for affording independence (though there is assessment on whether the trust is governed properly)

http://www.monitor-nhsft.gov.uk/sites/default/files/publications/An%20introduction%20to%20Monitor%27s%20role%201%20April%202013_0.pdf

With 10 out the 14 trusts under Keogh review being Foundation trusts, it is reasonable to wonder what actually the question 'well governed' means for Monitor.

BOSS' BOSS – The Grandparent Organisation is DoH

It looks like the department of health may have the overall responsibility for mortality and morbidity reduction though those are not explicitly spelt out in their website

https://www.gov.uk/government/organisations/department-of-health/about

It has taken nearly a decade and half after HSMR was introduced that DoH is making some moves to look into this. Perhaps better late than never. But as the grandparent organisation DoH is responsible for setting the contractual framework like it is in the first place.

What about doctors and nurses?

Doctors 

Doctors bonuses in the form of CEAs are based on quality of service and hopefully given to excellence. There is no requirement to demonstrate reduction of mortality or morbidity but the hope is that those two essential measures of quality will be considered explicitly when these awards are made. That is sometimes the case, sometimes that is not the case. In theory it is possible for even the highest award holders to hold the awards without ever demonstrating a decrease in mortality or morbidity.

https://www.gov.uk/government/publications/clinical-excellence-awards-2012-application-forms-and-guidance

Then of course there is the GMC who will come down on doctors who are caught out mainly due to significant single incidents which are reported. More recently the GMC due to its revalidation format demands 'quality improvement' though does not explicitly demand reduction of deaths and complications. 

Nurses

Agenda for change does not speak explicitly about improving clinical quality or reducing mortality/morbidity.

http://www.nhsemployers.org/PayAndContracts/AgendaForChange/Pages/Afc-Homepage.aspx

So who is responsible for deaths and complications in the NHS?

It is everyone's job but no one is required to do it and nobody is responsible or accountable for it.

It does not say in anyone's job description or contractual terms that 'it is your contractual duty to seek and achieve a reduction in mortality and morbidity of your patients and when it is not achieved to provide a reasonable explanation of why they have not been achieved and what you will do to achieve them'. Nobody's pay scale is linked to a reduction of mortality and morbidity. Therefore no one is responsible or accountable for deaths and complications. People do it as an optional extra, as a gesture of goodwill, from the goodness of their hearts, as a side effect of their day jobs. There are so many organisations all claiming to be working for patients' protection, quality and so on but all they do is announce diktats on what others should do; they do not hold themselves accountable on behalf of or as representatives of their members by measured reductions in avoidable deaths or complications. It is always everybody's job, somebody else's job, each one of us wants to hold somebody else to account but never us.

That is why it is so very impossible to deal with and so very difficult to get meaningful sustainable improvements. The contractual requirements, recognition and reward structures are all wrong in the sense they are not geared to look for quality improvement. Looks like this is a case where the structure and process results in just the expected poor outcome.

There are solutions – it is to use healthcare management methods to manage healthcare and not to use as we do now - business, financial, manufacturing, service industry or other management methods for healthcare. Whether there is enough interest, knowledge or expertise to do so is highly questionable.

©M HEMADRI 

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Further Info: I am informed by an NHS FT Board Director that the NHS Board director's contract that is referred to in this blog does not apply to NHS FT Chief Exec or Board Directors.
It will be interesting to find out who it applies to.
Hemadri
15 August 2013