BMJ  2006;333:358 (12 August), doi:10.1136/bmj.333.7563.358

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More and better management is the key to fixing the NHS

Recently Paul Miller, chairman of the BMA's consultants' committee, accused my profession of being a "large part" of the NHS's problems (www.timesonline.co.uk/article/0,,8122-2215070.html). His comments typify the arguments of those against reforming the NHS. To these people all problems—deficits, long waiting lists, infection control problems—result from lack of resources, bureaucracy, government interference in clinical judgment, and the "greedy" private sector. Things would be much better if we didn't waste money on big IT systems, independent treatment centres, management consultants, and private finance initiatives and instead spent it on "frontline" staff. This sums up the attitude of the leadership of the medical profession to NHS reform, but the underlying assumption is that the only thing that matters is how many doctors and nurses we have.

This assumption is demonstrably untrue and pernicious—distracting the NHS from seeking easily achievable improvements that derive from better organisation (which might—horror of horrors—require more spending on managers or computers). Changing how a hospital is organised can improve the quality, quantity, and speed of patients' care more than the most extravagant spending on doctors and nurses does. Evidence for the benefits of better organisation can be seen in two areas in particular: emergency departments and bed management.

Over the last few years waiting times in English emergency departments have improved dramatically. At the same time many departments have recruited extra doctors and nurses. But—and this comes from the Healthcare Commission (Acute Hospital Portfolio Review: Accident and Emergency, August 2005), not some "dodgy" consulting firm—there is no relation at all between staffing levels and performance. Nor does any relation exist between changes in staffing and performance. None of the intuitively "obvious" factors that might be thought to influence performance seem to matter much.

This finding that staffing levels matter so little is so surprising it should at the very least have caused the antireform brigade to pause in their tabloid rhetoric. But it didn't, probably because they are too blinkered to see that the way a department is organised has more influence on its performance than even major changes in staffing. In other words, management matters. And just increasing resources is a poor way to fix performance problems.

Even major investments in staff or equipment won't fix badly organised departments; well organised departments often don't need the investment. Departments don't spontaneously become well organised—not least because few doctors or nurses have the management expertise to know how to organise processes well (which is why the suggestion to run the already undermanaged NHS with even fewer managers is ludicrous).

Are hospitals doing enough to solve their bed problems through better organisation? Credit: PETER MARLOW/MAGNUM PHOTOS

 

Just increasing resources is a poor way to fix performance problems

Antireformers point out that the number of beds is falling and use is going up. They say low bed availability causes major delays and infections are harder to deal with if turnover is high. Thus we need more beds—oh, and more frontline staff too. What they never say is that hospitals could solve their bed problems quickly and cheaply by organising beds better. Few hospitals have moved more than a fraction of the way to doing this—or rather, some hospitals have done well but few others have copied their good practice.

Many hospitals admit their elective patients in the mornings but don't discharge any patients until the afternoon. This means the hospital needs one set of beds for the day's worth of elective arrivals and another set for the patients being discharged. It also means hospitals are most short of beds when they are most needed for emergency arrivals (peaking in the morning). The simple practice of discharging as early as possible and admitting as late as possible could free perhaps 10% of beds for the time of day when they are most needed. Only minor changes in working practices would be needed. Even bigger benefits could be gained if hospitals kept accurate records of which beds patients were occupying and when they were due to be discharged (hospitals typically operate like a hotel where the only way to find a free room is to knock on every door).

There are other ways to improve bed management (see www.dh.gov.uk/assetRoot/04/08/36/70/04083670.pdf). The Audit Commission found that many hospitals discharge few patients at the weekends, so patients admitted on certain days spend a day longer in a bed than they should (Bed Management: Review of National Findings, 2003). Simple changes in working practices could lead to major improvements in bed availability.

What these changes in practice involve is a focus on management; this perhaps explains why so few hospitals have applied them. It seems that even when benefits are obvious and easy to explain, antipathy to management prevents wider implementation of such change. The efforts of the antireformers (now including the BMA's leaders) to oppose reform and denigrate anything that smacks of management have distracted hospitals from implementing simple ways to solve some of their most critical problems. In the old NHS poorly organised units never had to do better, as the worse their performance was the more likely they were to get extra resources to "solve" their problems. Indeed the rhetoric of antireformers is still based on the assumption that more stuff (doctors, equipment, beds) will solve any problem.

Perhaps one of the roots of the BMA's antipathy is its naive assumption that productivity is all about making its members work harder. But managers are not slave drivers. A well organised hospital is a better place to work than a badly organised one with twice the number of staff. Investing more in better organisation, good managers, and appropriate IT may be a far more effective way to improve the working lives of doctors and nurses than recruiting more doctors and nurses.

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management consultant, PA Consulting, London stephen.black{at}paconsulting.com

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