Productivity in the NHS


Some doctors seem to be confused by productivity. It is the ratio of outputs to inputs. Output per hour is, more properly, a partial productivity measure. When I was a registrar in anaesthesia, I did more than 1000 anaesthetic procedures a year; nowadays a registrar is lucky to do 400. This means less output per doctor, but the cause is working fewer hours, so output per hour is similar. Twenty five years ago, my department did 21 000 anaesthetic procedures a year with six consultants, four registrars, and four senior house officers. Now, we do 25 000 with more than 30 consultants, eight registrars, and eight senior house officers; do the maths.

John Appleby, Chief Economist at the Kings Fund, rightly emphasises the productivity problem in the NHS—it is the crucial “missing piece” that few will talk about.1 Most self interest groups, such as political parties and trade unions (including the BMA and royal colleges), prefer to stress inputs, rather than outputs.

This navel gazing stops us learning from other systems, such as many European health systems (none of the top 10 European systems are tax-funded). When I worked in France, it was normal to work on Saturdays, cases at the end of lists were never cancelled through “running out of time,” and orthopaedic surgeons performed 500 primary joint replacements a year, compared with about 250 in the NHS.

The solution to the productivity problem includes the following: adoption of new technology, deregulation of restrictive practices, and changes to the way clinicians work. All these are frequently and effectively blocked by complacent and self- serving special interest groups.

1  Appleby J. UK NHS: Less money (but more bangs per buck)? BMJ2015;350:h1037. (10 March.)

‘A time to be born and a time to die’ (Ecclesiastes 3:2)

a time for...This may come as a shock to you, but you’re going to die!  From a human perspective, the ultimate outcome of life is death.  The rate of mortality is 100%, i.e. everyone born dies.

It may also come as a surprise, then, that the trendiest quality measures for hospitals relate to mortality:  the Hospital Standardised Mortality Ratio (HSMR) and the Summary Hospital Mortality Index (SHMI, or ‘shimmy’).  The theory goes that hospital quality and mortality rates are inversely related: the higher the quality, the lower the mortality rate.

To be clear, HSMR/SHMI relate to particular cohorts over particular time periods, and they provide a number, which shows whether there are more or fewer deaths than expected.  This, ‘expected’ bit is crucial; it relates to historic data and is the sum of the estimated risks of death.  A HSMR/SHMI of 100 is ‘average’, meaning that 50% of hospitals will have lower than ‘expected’ and 50% will have higher than ‘expected’.  Unfortunately, statistical niceties are lost on most of the public and journalists, so phrases like, ‘worse than it should be’, or ‘2,000 excess deaths’, are commonly heard.

There is huge debate and argument amongst the medical community about the validity and reliability of HSMR/SHMI, but the upshot is that they are here to stay and hospitals are judged on them.  Mortality ratios are to hospital bosses what the share price is to the CEO’s of listed companies; they live or die by them!

I have attached a couple of documents that explain the ratios.

Understanding HSMR


Caldicott 2


Dame Fiona Caldicott has just published her latest principles of good practice (attached) concerning the use of personal confidential data (PCD), whether paper or electronic.  These consist of the original 6 principles, plus an additional seventh: 

  1. Justify the purpose
  2. Don’t use PCD unless it is absolutely necessary
  3. Use the minimum necessary PCD
  4. Access to PCD should be on a strict need-to-know basis
  5. Everyone with access to PCD should be aware of their responsibilities
  6. Comply with the law
  7. The duty to share information can be as important as the duty to protect patient confidentiality (my emphasis)

 This new, final principle is highly significant as it is designed to encourage appropriate sharing of data, and to counteract the ‘overly cautious’ approach taken by some clinicians (Taylor, 2013). 

It’s worth pointing out also that there are 26 recommendations, including one that patients should have the fullest possible access to their electronic records and that an audit trail should be available.  This is relatively easy to do within a single system, such as Lorenzo, but may be more difficult to do when data is shared between systems.  The danger here is that this recommendation could have the perverse effect of restricting sharing of data if a comprehensive audit trail can’t be compiled. 

There are other concerns, too.  De-identified  or pseudonymised data that could possibly be reconstructed by linking data sets can only be accessed within ‘safe havens’, such as the Health and Social Care Information Centre (HSCIC).  This could limit the activities of ‘big data’ analysis.  Assumed patient consent is also outlawed. 


Taylor P, (2013). Caldicott 2 and patient data.  BMJ 2013;346:f2260

Kicking down the wall!

BerlinWallFreedomSome people are describing the new changes to the NHS as the biggest ever.  It depends on your perspective.  I can guarantee that from a patient’s (i.e. ‘user’) perspective, you won’t notice much if anything.  If you have a health problem, you’ll still probably contact your GP, have a frustrating conversation with the receptionist, who may eventually ‘allow’ you an audience with a GP.  S/he may or may not know much about your condition, and so, by lottery, you may get referred on.  In time, you may get seen by a doctor who knows what’s wrong with you, and hopefully they’ll prescribe the right treatment.  The whole process usually takes a long time, is unpredictable and liable to fail at many points.  ‘Gatekeepers’ hinder your progress at every turn.

The central, simplistic issue is how to join together the person with the problem and the person with the answer.  All the rest is intermediary.  It seems to me that IT systems are very good at ‘disintermediation’, i.e. routing the message to the right destination quickly, even if it is highly circuitous.

Wouldn’t it be good to easily get past the ‘gatekeeper’, and rapidly find the right answer?  Referrals could be ‘shaped’ upstream, that is, directed appropriately, and a few, suitable alternatives presented, which could then be accessed straightaway.  Isn’t it about time that the NHS broke down the dividing walls between health issues and solutions?

There are many instances in the past of where barriers have been constructed to ‘protect’ something we’re told is highly valuable.  In the end, they look like Berlin walls of oppression.  Eventually, they get kicked down!

A week in the life of CSC’s UK Medical Director…and a consultant anaesthetist

Monday: It’s 6:30 am as I get into my car to drive from Doncaster to Solihull where I have an excellent full English breakfast before meetings with my Clinical team and update calls all morning. A further afternoon of meetings is scheduled with the weekly NHS Executive Board and, later on, the Governance Board.

Tuesday: Today I’m attending a meeting at Westmorland General Hospital, a University of Morecambe Bay NHS Trust hospital. It’s approaching 5:00 pm as I pull into the car park at Kendal for a meeting about the clinicians’ perspective of Lorenzo. This amicable meeting, between like-minded doctors from University Hospitals of Morecambe Bay NHS Trust, NHS Connecting for Health and CSC, is essential to demonstrating to clients our commitment and understanding of working on the NHS frontline. It also provides me with intelligence to share with the CSC Executive Board, which may otherwise be extremely difficult to obtain. On the way out, it’s great to see CSC’s Healthcare Self-Service Kiosks in outpatients.

Wednesday: I’m working from home today. My day begins with an 8:30 am Executive Update call. Each executive shares their important and/or urgent business. This keeps us joined-up as a team and allows us to find areas for collaboration. Afterwards, much of my morning is spent researching topics and building networks for new business opportunities. ‘Bundling’ solutions together looks promising. A ‘bundle’ is a blend of several CSC products and services that, when combined, result in more customer value than when implemented individually. At 12:30 pm I catch the train to London to meet senior doctors at the Royal College of Physicians. I compose a new blog post for C3, en-route. Professional groups are crucial for shaping how IT use will develop in the NHS. The Royal College of Physicians and the Academy of the Medical Royal Colleges are leading organisations in this area. I’ll also attend the Council meeting of UKCHIP, a registration body for health informatics professionals.

Thursday: Today I swap my business suit for theatre greens. I leave the house at 7:00 am and drive to the hospital ‘Park and Ride’ facility at Doncaster Racecourse, but choose to walk the mile and a half to Doncaster Royal Infirmary. My day at the hospital starts with seeing my patients on the wards prior to surgery. By 8:30 am I’m in theatre. Today’s theatre list includes some minor orthopaedic surgery, and four big cases: hip replacements on two elderly gentlemen, a baby with a congenital dislocation of the hip and a teenager for a repair of the cruciate knee ligaments – there’s different anaesthetic risks with each. I also provide other colleagues with advice on difficult cases. At 5:30 pm I check each patient again in recovery, sort out their post-op pain relief, intravenous fluids, etc, and then walk back to my car. I use this time for reflection and to check CSC emails on my BlackBerry®.

Friday: Today I’m at Doncaster Royal Infirmary Women’s Hospital where I assist with two caesarean sections under combined spinal/epidural anaesthesia. Mum is awake for skin-to-skin contact with her baby. Newborns still amaze me! At 11:30 am we fit in two urgent cases; a miscarriage and an ectopic pregnancy. The labour ward is busy, but it’s very satisfying to provide pain relief to women at the end of their tethers. Early afternoon I do some online continuing professional development questionnaires between cases until 4:00 pm when a 36-week pregnant patient arrives with severe pre-eclampsia. She’s on the verge of fitting so we rapidly administer intravenous magnesium and perform an emergency caesarean under general anaesthesia. This is high-risk so we monitor her carefully in the high-dependency unit. A midwife bleeps me to say the locum doctor won’t arrive for a couple of hours, and could I do an epidural in room four, please? “Oh, by the way, she weighs 140 kg and says she’s got ‘scoline apnoea’. Is that important?” [yes, very!]

Intersection of health, finance and telecoms

Africa suffers more than 24% of the global burden of disease but has access to only 3% of health workers. With the fast growth in mobile penetration rates in Africa, NGOs, Donor Agencies, healthcare providers and governments are focussing on the evolving use of communication technologies within the healthcare community in Africa.

mHealth programmes are evolving to provide healthcare services to even the most remote communities throughout Africa. Mobile Health Africa will bring together key pioneers of the mHealth evolution in Africa, from donor agencies to NGOs and governments, and technology providers to MNOs, to establish how to evolve the mHealth industry from pilots to successful live deployments that deliver cost effective and measurable results.

In Africa, many people access financial services through mobile phones (without the need for a bank account). Some health services can be provided this way, too. Combine this with telecoms and you have the potential to provide mobile health solutions – mHealth.  Even the poorest people can access mobile phones, by ‘renting’ them from roadside vendors, to make a call for tiny fees.

It seems to me that CSC has expertise in all three areas. Is anyone aware of any activity looking at how we could provision solutions for mHealth in Africa? I have recently been invited to such a conference, with sponsors such as HP, IBM, Vodaphone and Deloitte. Payers are NGO’s, donor agencies and governments. This looks like a potential opportunity for CSC, and is especially appealing from a corporate/social responsibility perspective.

Patient-level costing

I was doing a theatre (operating room) list the other day, which I felt was under-utilised – two relatively minor operations. I thought, ‘we must be making a loss on this list’. I tried to find out what the revenue was for the list and what the costs were. It is theoretically possible to find out the tariff for each procedure, but surprising difficult to do. What was even more difficult were the costs. These are fixed ones, like overheads (and in the NHS, salaries), and variable ones depending on things like disposables used. What surprised me was, not so much that the information had to be tracked down manually and was probably inaccurate, but that there was little interest shown by any of the ‘managers’ (Theatre and Directorate-level) in helping me! I asked some IT colleagues at CSC if this was the sort of thing that CSC could help with, and they explained about Patient-Level and Information Costing Systems (PLICS). Unfortunately, we don’t have any development partners in the NHS to work with on this. Does anyone have any information relating to PLICS? Essentially, it means integrating financial, administrative and clinical systems and ‘overlaying’ a business intelligence layer.