It was Louis XVI’s finance minister who came up with the ultimate management slogan: “If a thing is possible, consider it done. The impossible? That [too] shall be done.”
Louis, of course, ended up on the guillotine. But that hasn’t stopped various gung-ho organizations from making the idea their own.
In Britain, there are signs that a similar mindset has taken over that country’s hospital system. Health planners have been trying to grind out savings that some caregivers thought were impossible.
The results, and the controversy they’ve caused, are worth study, because some of the same ideas are being tried here in B.C.
The problem, as always in health care, is money. Attempts to cut spending have consumed two decades and more. Most of the easy-to-find economies have long since been made. The next steps are more difficult and more dangerous.
The answer in Britain was to offer hospitals money for meeting government targets. These included moving patients through the system more quickly, cutting the cost of surgical procedures and reducing wait times in emergency wards.
The plan worked — initially. There were improvements in these areas.
But they came at a cost. Examples started to surface of substandard care, and some of them were truly shocking.
In one instance, a young patient at St. George’s Hospital in London was so desperate for water, he called the police for help. In the most notorious case, patients at Stafford Hospital were left starved and thirsty in soiled bed linen. Several died of what could only be called neglect.
An inquiry at Stafford later heard that managers were so intent on meeting government targets, they established a “culture of fear.” Nurses were told to falsify waiting times, and medical staff were threatened with dismissal if they failed to follow orders.
Those are extreme cases. Many hospitals managed improvements without undermining care.
Yet essentially the same policy is now being field-tested by the B.C. Health Ministry. Hospitals around the province are being offered $100 for every low-risk patient they move through the emergency ward in less than two hours. They also get $100 for every high-risk patient discharged within four hours.
And bonus money is paid for increasing throughput in operating theatres and diagnostic imaging facilities. For a medium-sized agency like the Vancouver Island Health Authority, incentives might reach $10 million per year.
Two important reassurances must be given here. The Health Ministry has made clear to hospitals that appropriate standards of treatment are to be maintained when pursuing economies. A review process is in place to make sure this happens.
And there are indeed opportunities for improved efficiency that do not threaten quality of care. Nanaimo Regional General Hospital reduced emergency wait times 20 to 40 per cent by identifying patients with more acute problems and treating them in a separate area with less congestion.
Yet this is dangerous ground. It’s one thing to offer rewards for improvements in care, such as reduced wound-infection rates or fewer patients injured in falls.
However, throughput incentives, like those in Britain and now here in B.C., are a different matter. Their immediate focus is not quality of care, but speed of care.
Of course speed is important, sometimes vitally so, but not as an end in itself.
The risk is that managers who can’t find valid ways to meet their quota will resort to other means. Money speaks, after all.
This is an experiment that needs hawk-like attention. There will be important successes, and we will all benefit from those.
But somewhere along the way, a struggling management team or a harried nursing staff might try the impossible. It will be our head on the guillotine.
