- Email: [email protected]
2. AS A HOSPITAL ADMINISTRATOR SEES IT
1248 "
Perhaps he has been invited to share in planning a longcharity " days when administrative costs had to be seen be low ? Perhaps one of the most important things the awaited outpatient department. Instead of reading up what Health Service requires is a greater expenditure on top they do at the Mayo Clinic, he needs to describe how his colleagues want to work, so that the architect, briefed properly for management ". may clothe new ideas in new bricks. Savings will be made Where can we go for help ? The organisation of post- once, if the clinic-schedule does not produce high peaks in demand: graduate courses is obviously desirable and the success of at E10 a square foot it is worth ensuring that the new departour first course (which we organised jointly with the ment is no bigger than it need be. Board of Management Studies, Glasgow University) has Perhaps our doctor has escaped, or evaded, the grind of indicated the need for others. The Ministry of Health, committee work. All the more need to think hard about the through its Statistics and Research Division, the Home way in which he, personally, is using precious hospital resources. and Health Department in Scotland, through its Research When did he last see the statistics of his ward ? When was he and Intelligence Unit and the Hospital Centre, in London last given statistics worth looking at.? Has the nurse-staffing to the patient-load ? Does his ward cost more to and Edinburgh, would be prepared to offer information been related run than the identical ward next door’? Do his patients stay in and practical advice. hospital longer than strictly necessary, and does it take too long
to
"
a bed after discharge ? Do outpatients, or their records, both, get lost in the labyrinth ? Are some of the many followup points of the ward round getting missed ? Do key laboratory
to
refill
or
2. AS A HOSPITAL ADMINISTRATOR SEES IT
JAMES
ELLIOTT
F.H.A. GROUP SECRETARY, EAST BIRMINGHAM HOSPITAL MANAGEMENT COMMITTEE
THE hospital doctor is so used to giving help to others that he often fails to notice that the hospital itself needs help: not medical, but organisational. Speculation on N.H.S. finance tends to centre on the politics of obtaining more money, rather than on how we can best use what we already receive. Administrators use this money to provide hospital resources: doctors use these resources. To improve the use of resources, most doctors need administrative help. If patient-demand rises by 5%, and revenue rises by only 2%, what can be done to bridge the gap ? We can neither hold the rise in demand at 2%, nor increase the income of the N.H.S. by 5%. So we must either descend to apathy, rise to fury, or learn to manage. Only the electorate can decide how to pay for the scientific advance of medicine, the cost of which is increasing almost exponentially; but if we can get the most out of the resources already at our disposal, we shall achieve more than we are doing today, and we shall be able to identify much more accurately how much more money we truly need, and why. I will leave to others the question of community priorities, and the politics of getting more money into the N.H.S., and will concentrate here on some of the ways in which we can use better the not inconsiderable sum of E836 million which the taxpayers already pay over to the hospitals each year. DECISION TAKING
Any hospital committee, trying to finance new developments, has to make choices. Suppose there be a declining but convenient clinic at an outlying small hospital: nurses, clerks, and cleaners cost E5000 a year. If the clinic closes, E5000 each year might be used instead either to staff an emergency cardiac unit, to extend home dialysis, to strengthen the intensive-care unit, or to buy E5000 worth of research equipment. To help make the right choice, a committee doctor needs to write a kind of medicosocial equation. Will he know how ? What objective evaluation is made of the likely return, in terms of meeting human need, of money invested in, say, an
outpatient department extension, or a new X-ray room, or a new anaesthetic room, or the re-equipment of the cardiac resuscitation unit, when only one of them is financially possible ? Does our committee doctor nod his head sagely and indicate a pragmatic choice, does he stay silent, or does he attempt to assess the long-term effects of each one of these choices ? Can he carry out this assessment in any but subjective terms ?
reports get tidily filed away before the consultant has them ?
seen
To use resources well we must manage the hospital and not let it manage us. This requires a clear understanding of what the hospital’s overall objectives are, and what has to be done to reach those objectives. The doctor prepared to be interested in the attempt to define these objectives can influence greatly the direction his hospital will take in the next ten years. A simple book by Andrew Forrest1 which can be read twice in half an hour explains management by objectives, which, used for some time in the business world, is beginning to appear in a few hospitals. It is sure to spread with the growing realisation that unless we manage objectively, our hospitals will never be able to concentrate resources where they matter most. In all these fields, help, in the form of new knowledge, new skill, and new thought is needed. There is so much in which the doctor, if properly equipped and helped, should be participating or leading. How can a hospital doctor get this help ? HARD FACTS
Firstly, he needs help to understand how his hospital at uses its resources. A great deal of statistical information is already available, often hidden like a mineral lode in the depths of the administrator’s filing cabinet. In the critical review of his work, the doctor would be greatly helped by Hospital Activity Analysis, particularly when computer based, which can offer, for each consultant, if required, diagnostic indices, length of stay by diagnosis, waiting-list analysis, lists of operations and a daily analysis of the use and abuse of hospital beds. He might also try asking for routine Ministry returns which cover patient and staff statistics, though not very deeply; form AGD303, which shows, each month, how the revenue money is being spent; the treasurer’s annual financial statements; the books of national costing comparisons issued yearly by the Ministry; a list of the prices of commonly used drugs and medical equipment; the Prescribers Yournal; the British National Formulary; the annual reports of the chief medical officer of the Ministry of Health and of the local medical officer of health; the Ministry’s Hospital Abstracts of world health literature. He could also, on inquiry, find out the nature of the local management system, how the committee works, how and why it allots its money, and
present
so on.
These apparently unlikely sources can produce the most lively information about hospital activity; it is worth remembering what Chadwick, Simon, and Florence Nightingale achieved by blue-books and white-papers. Nothing moves an administrator so much as the doctor who has read his papers and mastered his facts. 1.
Forrest, A. The Managers Guide Society. London, 1966.
to
Setting Targets: the Industrial
1249
techniques of operational research, and may be moving towards integrated management information, the consistent and continuous integration of statistics about patients, staff and resources, and money. There is no point in finding out weaknesses, and producing remedies, unless the men and women of the hospital team themselves recognise failure and desire improvement. Revans2 has shown how beneficial it is for hospital leaders and staff to recognise the individual needs and dignity of their colleagues, and the contribution those colleagues are able to make, if only they are encouraged to
participate.
What then is it reasonable to expect a busy clinician to do? Surely he can find out how his hospital committee works, where the money comes from, and how it is at present used. From statistics already to hand he can judge 2.
being properly used. He of the range of management skills which the administrator can either offer or lay his hands on. He can be alive to the possibilities of the more farreaching disciplines of whose existence the good administrator is beginning to become aware. And he can help to create a climate in which improvement is possible. Can the administrator deliver the goods ? Not if he still runs the service on 1937 lines, custodially and carefully, concentrating busily on means rather than ends. But a growing number of enthusiastic administrators are trying to understand the nature of hospital organisation, and how to better it. Until now, if we have thought about hospital organisation at all, it has been in terms of anatomy rather than physiology or psychology. It comes to this: the administrator can help to locate faults in the hospital, and to produce remedies, but these can only be of use if the doctor brings his medical knowledge and scientific curiosity into the enterprise. Hospitals need to use resources better, and since doctors decide the use of a great deal of resources, they need help in the task. Most of the important hospital decisions are medical decisions, but to meet the challenge of an N.H.S. which tries to give an open-ended service on a relatively fixed income, doctors need help from the general management team, from other professions within the hospital, from specialists in management techniques, from the experience of universities and business schools, and from the findings of researchers. It is crucial to the N.H.S. for doctors to use this diversity of help today. whether
HOW TO IMPROVE
Whilst study of this kind will show where improvement is needed, the hospital needs to decide how to improve. This is a more difficult task, often requiring more skill in management techniques than a doctor can be expected to possess. The good hospital administrator is a generalist who knows something about the possibilities and sources of these techniques; he will know how to get organisation and methods help from his Regional Board; he ought himself to possess some of the personnel skills, and be able to obtain more specialised backing in these from his Board. The Board itself may have access to the more complex
Revans, R. W. Research into Hospital Management and Organisation. Milbank meml Fund q. Bull. 1966, 44, no. 3 part II.
Round the World
can
Canada The anti-brain-drain* publicity was well done. The advertisements appeared in the right journals, Scientific American, Lancet out of Boston, some others likely to be read by immi-
Money wasn’t spared, lay-out and wording were admirable; it was nice to think the old men in the Old Country knew their way around here and could afford to do the job grants.
properly. *
A letter
on
the team’s visit
to
the United States appears
on
p. 1252.
resources are use
Distant fields look green; after many years what we had do was done and it was time to think of a move. The British way of life still had something to be said for it. Striding Edge ought to be possible, even if Crib Goch and Twll Ddu proved too much for us. It was said there was a dinghy fleet on Ullswater. Pubs in various counties could stand revisiting and there were rivers unfished, Wye, Kennet, Eden, Windrush. Things were on the move in England: motorways, mores, Jodrell Bank, the new architecture, and a new look apparently in the Health Service. Even new hospitals. It might be very interesting to bring the lessons of a decade in the aggressive North American society back to U.K. and the N.H.S. It could be fun. And there were still old friends and old relations whose nearer company it would be nice to have. We sent in our name. Acknowledgement came from the Embassy in Washington, no less, suggesting an interview. Later came a venue and a date, this time from the Elephant and Castle, where the no. 10 bus used to go. The appointed day found us at Expo, fabulous, psychedelic-Canada at her astonished best. A friend phoned us long distance. When were the interviews. He could find out nothing at the hotel where they were to be held. We arranged to meet him there and caught our homeward-bound plane. First snows sprinkled the Kawarthas and the lakes were fringed with ice. We got the car from the parking tower and drove downtown to the aging, rather passe hotel. No, there was no message for us at the information desk; they knew nothing about any doctors’ interviews. A brief search discovered our friend (there was a message at the desk), a lost-looking middle-aged female with an English accent, whom we took in tow, and a small easel with " British Medical Interviews Room 123 " in small white plastic letters. We reported ourselves there. The interviewers were charming. They were interested in what we had been doing. Yes, there were vacancies in the hospitals, or perhaps a job at the Ministry ? The Health Service must move forwards and our experience would be most valuable. Funds were available, but of course within limits. Our present project here would hardly be practicable, except in a very major centre. We touched gently on remuneration. We come to
Australia This year drought stalks the pastures and wheatfields of Victoria, as last year it threatened the viability of New South Wales. So far the annual rainfall is the lowest of the 117 years in which records have been kept. For those who live in Europe, where wide swings in climate are inconceivable as a source of national disaster, it is hard to imagine an advanced nation fearful of one or two seasons of low rainfall. But this country is still so marginally established around the moist rim of a vast central desert that it can be brought to its knees by shortage of water. In Melbourne our lawns are dead or dying, and the surrounding countryside is sizzling and brown with up to a hundred bush fires at any one time throughout the State. You cannot wash the car with a hose or spray the flowerbeds. The medical fallout is so far indirect, although, mindful of last year’s experience of bushfires in Hobart’s suburbs, disaster plans include the possibility of dealing with large numbers of burnt patients in circumstances other than nuclear war. Indirectly, the effects are more obvious: no foetal-calf-serum for tissue-culture work (the calves and mothers have been moved inter-State), bills not being paid so readily in country districts, a general lowering of morale as the country fears a downturn. For those engaged in university and hospital planning the most dangerous result could be a slowing down of development, for disaster is a convenient excuse to conserve money and delay projects in health and education.
hospital
encourage the
Perhaps he has been invited to share in planning a longcharity " days when administrative costs had to be seen be low ? Perhaps one of the most important things the awaited outpatient department. Instead of reading up what Health Service requires is a greater expenditure on top they do at the Mayo Clinic, he needs to describe how his colleagues want to work, so that the architect, briefed properly for management ". may clothe new ideas in new bricks. Savings will be made Where can we go for help ? The organisation of post- once, if the clinic-schedule does not produce high peaks in demand: graduate courses is obviously desirable and the success of at E10 a square foot it is worth ensuring that the new departour first course (which we organised jointly with the ment is no bigger than it need be. Board of Management Studies, Glasgow University) has Perhaps our doctor has escaped, or evaded, the grind of indicated the need for others. The Ministry of Health, committee work. All the more need to think hard about the through its Statistics and Research Division, the Home way in which he, personally, is using precious hospital resources. and Health Department in Scotland, through its Research When did he last see the statistics of his ward ? When was he and Intelligence Unit and the Hospital Centre, in London last given statistics worth looking at.? Has the nurse-staffing to the patient-load ? Does his ward cost more to and Edinburgh, would be prepared to offer information been related run than the identical ward next door’? Do his patients stay in and practical advice. hospital longer than strictly necessary, and does it take too long
to
"
a bed after discharge ? Do outpatients, or their records, both, get lost in the labyrinth ? Are some of the many followup points of the ward round getting missed ? Do key laboratory
to
refill
or
2. AS A HOSPITAL ADMINISTRATOR SEES IT
JAMES
ELLIOTT
F.H.A. GROUP SECRETARY, EAST BIRMINGHAM HOSPITAL MANAGEMENT COMMITTEE
THE hospital doctor is so used to giving help to others that he often fails to notice that the hospital itself needs help: not medical, but organisational. Speculation on N.H.S. finance tends to centre on the politics of obtaining more money, rather than on how we can best use what we already receive. Administrators use this money to provide hospital resources: doctors use these resources. To improve the use of resources, most doctors need administrative help. If patient-demand rises by 5%, and revenue rises by only 2%, what can be done to bridge the gap ? We can neither hold the rise in demand at 2%, nor increase the income of the N.H.S. by 5%. So we must either descend to apathy, rise to fury, or learn to manage. Only the electorate can decide how to pay for the scientific advance of medicine, the cost of which is increasing almost exponentially; but if we can get the most out of the resources already at our disposal, we shall achieve more than we are doing today, and we shall be able to identify much more accurately how much more money we truly need, and why. I will leave to others the question of community priorities, and the politics of getting more money into the N.H.S., and will concentrate here on some of the ways in which we can use better the not inconsiderable sum of E836 million which the taxpayers already pay over to the hospitals each year. DECISION TAKING
Any hospital committee, trying to finance new developments, has to make choices. Suppose there be a declining but convenient clinic at an outlying small hospital: nurses, clerks, and cleaners cost E5000 a year. If the clinic closes, E5000 each year might be used instead either to staff an emergency cardiac unit, to extend home dialysis, to strengthen the intensive-care unit, or to buy E5000 worth of research equipment. To help make the right choice, a committee doctor needs to write a kind of medicosocial equation. Will he know how ? What objective evaluation is made of the likely return, in terms of meeting human need, of money invested in, say, an
outpatient department extension, or a new X-ray room, or a new anaesthetic room, or the re-equipment of the cardiac resuscitation unit, when only one of them is financially possible ? Does our committee doctor nod his head sagely and indicate a pragmatic choice, does he stay silent, or does he attempt to assess the long-term effects of each one of these choices ? Can he carry out this assessment in any but subjective terms ?
reports get tidily filed away before the consultant has them ?
seen
To use resources well we must manage the hospital and not let it manage us. This requires a clear understanding of what the hospital’s overall objectives are, and what has to be done to reach those objectives. The doctor prepared to be interested in the attempt to define these objectives can influence greatly the direction his hospital will take in the next ten years. A simple book by Andrew Forrest1 which can be read twice in half an hour explains management by objectives, which, used for some time in the business world, is beginning to appear in a few hospitals. It is sure to spread with the growing realisation that unless we manage objectively, our hospitals will never be able to concentrate resources where they matter most. In all these fields, help, in the form of new knowledge, new skill, and new thought is needed. There is so much in which the doctor, if properly equipped and helped, should be participating or leading. How can a hospital doctor get this help ? HARD FACTS
Firstly, he needs help to understand how his hospital at uses its resources. A great deal of statistical information is already available, often hidden like a mineral lode in the depths of the administrator’s filing cabinet. In the critical review of his work, the doctor would be greatly helped by Hospital Activity Analysis, particularly when computer based, which can offer, for each consultant, if required, diagnostic indices, length of stay by diagnosis, waiting-list analysis, lists of operations and a daily analysis of the use and abuse of hospital beds. He might also try asking for routine Ministry returns which cover patient and staff statistics, though not very deeply; form AGD303, which shows, each month, how the revenue money is being spent; the treasurer’s annual financial statements; the books of national costing comparisons issued yearly by the Ministry; a list of the prices of commonly used drugs and medical equipment; the Prescribers Yournal; the British National Formulary; the annual reports of the chief medical officer of the Ministry of Health and of the local medical officer of health; the Ministry’s Hospital Abstracts of world health literature. He could also, on inquiry, find out the nature of the local management system, how the committee works, how and why it allots its money, and
present
so on.
These apparently unlikely sources can produce the most lively information about hospital activity; it is worth remembering what Chadwick, Simon, and Florence Nightingale achieved by blue-books and white-papers. Nothing moves an administrator so much as the doctor who has read his papers and mastered his facts. 1.
Forrest, A. The Managers Guide Society. London, 1966.
to
Setting Targets: the Industrial
1249
techniques of operational research, and may be moving towards integrated management information, the consistent and continuous integration of statistics about patients, staff and resources, and money. There is no point in finding out weaknesses, and producing remedies, unless the men and women of the hospital team themselves recognise failure and desire improvement. Revans2 has shown how beneficial it is for hospital leaders and staff to recognise the individual needs and dignity of their colleagues, and the contribution those colleagues are able to make, if only they are encouraged to
participate.
What then is it reasonable to expect a busy clinician to do? Surely he can find out how his hospital committee works, where the money comes from, and how it is at present used. From statistics already to hand he can judge 2.
being properly used. He of the range of management skills which the administrator can either offer or lay his hands on. He can be alive to the possibilities of the more farreaching disciplines of whose existence the good administrator is beginning to become aware. And he can help to create a climate in which improvement is possible. Can the administrator deliver the goods ? Not if he still runs the service on 1937 lines, custodially and carefully, concentrating busily on means rather than ends. But a growing number of enthusiastic administrators are trying to understand the nature of hospital organisation, and how to better it. Until now, if we have thought about hospital organisation at all, it has been in terms of anatomy rather than physiology or psychology. It comes to this: the administrator can help to locate faults in the hospital, and to produce remedies, but these can only be of use if the doctor brings his medical knowledge and scientific curiosity into the enterprise. Hospitals need to use resources better, and since doctors decide the use of a great deal of resources, they need help in the task. Most of the important hospital decisions are medical decisions, but to meet the challenge of an N.H.S. which tries to give an open-ended service on a relatively fixed income, doctors need help from the general management team, from other professions within the hospital, from specialists in management techniques, from the experience of universities and business schools, and from the findings of researchers. It is crucial to the N.H.S. for doctors to use this diversity of help today. whether
HOW TO IMPROVE
Whilst study of this kind will show where improvement is needed, the hospital needs to decide how to improve. This is a more difficult task, often requiring more skill in management techniques than a doctor can be expected to possess. The good hospital administrator is a generalist who knows something about the possibilities and sources of these techniques; he will know how to get organisation and methods help from his Regional Board; he ought himself to possess some of the personnel skills, and be able to obtain more specialised backing in these from his Board. The Board itself may have access to the more complex
Revans, R. W. Research into Hospital Management and Organisation. Milbank meml Fund q. Bull. 1966, 44, no. 3 part II.
Round the World
can
Canada The anti-brain-drain* publicity was well done. The advertisements appeared in the right journals, Scientific American, Lancet out of Boston, some others likely to be read by immi-
Money wasn’t spared, lay-out and wording were admirable; it was nice to think the old men in the Old Country knew their way around here and could afford to do the job grants.
properly. *
A letter
on
the team’s visit
to
the United States appears
on
p. 1252.
resources are use
Distant fields look green; after many years what we had do was done and it was time to think of a move. The British way of life still had something to be said for it. Striding Edge ought to be possible, even if Crib Goch and Twll Ddu proved too much for us. It was said there was a dinghy fleet on Ullswater. Pubs in various counties could stand revisiting and there were rivers unfished, Wye, Kennet, Eden, Windrush. Things were on the move in England: motorways, mores, Jodrell Bank, the new architecture, and a new look apparently in the Health Service. Even new hospitals. It might be very interesting to bring the lessons of a decade in the aggressive North American society back to U.K. and the N.H.S. It could be fun. And there were still old friends and old relations whose nearer company it would be nice to have. We sent in our name. Acknowledgement came from the Embassy in Washington, no less, suggesting an interview. Later came a venue and a date, this time from the Elephant and Castle, where the no. 10 bus used to go. The appointed day found us at Expo, fabulous, psychedelic-Canada at her astonished best. A friend phoned us long distance. When were the interviews. He could find out nothing at the hotel where they were to be held. We arranged to meet him there and caught our homeward-bound plane. First snows sprinkled the Kawarthas and the lakes were fringed with ice. We got the car from the parking tower and drove downtown to the aging, rather passe hotel. No, there was no message for us at the information desk; they knew nothing about any doctors’ interviews. A brief search discovered our friend (there was a message at the desk), a lost-looking middle-aged female with an English accent, whom we took in tow, and a small easel with " British Medical Interviews Room 123 " in small white plastic letters. We reported ourselves there. The interviewers were charming. They were interested in what we had been doing. Yes, there were vacancies in the hospitals, or perhaps a job at the Ministry ? The Health Service must move forwards and our experience would be most valuable. Funds were available, but of course within limits. Our present project here would hardly be practicable, except in a very major centre. We touched gently on remuneration. We come to
Australia This year drought stalks the pastures and wheatfields of Victoria, as last year it threatened the viability of New South Wales. So far the annual rainfall is the lowest of the 117 years in which records have been kept. For those who live in Europe, where wide swings in climate are inconceivable as a source of national disaster, it is hard to imagine an advanced nation fearful of one or two seasons of low rainfall. But this country is still so marginally established around the moist rim of a vast central desert that it can be brought to its knees by shortage of water. In Melbourne our lawns are dead or dying, and the surrounding countryside is sizzling and brown with up to a hundred bush fires at any one time throughout the State. You cannot wash the car with a hose or spray the flowerbeds. The medical fallout is so far indirect, although, mindful of last year’s experience of bushfires in Hobart’s suburbs, disaster plans include the possibility of dealing with large numbers of burnt patients in circumstances other than nuclear war. Indirectly, the effects are more obvious: no foetal-calf-serum for tissue-culture work (the calves and mothers have been moved inter-State), bills not being paid so readily in country districts, a general lowering of morale as the country fears a downturn. For those engaged in university and hospital planning the most dangerous result could be a slowing down of development, for disaster is a convenient excuse to conserve money and delay projects in health and education.
hospital
encourage the