Value of our health measured by every hour of hospital targets

Review of People Scrutiny Meeting June 6th

The main topic of this meeting was a general report from the Managing Director of Southend Hospital/Chief Operating Officer of the Mid and South Essex NHS Trust, reviewing the winter just gone, operational improvements and presenting targets for the future.

This was the first time I had seen him and whilst I believe he believes what he says and comes across committed to getting things right, my review of his review is quite possibly a little undeserved.

The pressure to run three hospitals must be immense and I would not envy his task.  Lives are at stake with every stroke of his pen and I believe entirely that he is doing everything he can to ensure Southend and the wider population are as safe as is financially viable.

However, I can only judge upon what I see and on this meeting and where there were gaps or unanswered questions, or realities that contradict theories, I could not help but to give them half a spotlight.  And this is indeed where I start.

Fantasy Numbers

The facts, figures and targets he ran through did not translate into people’s experiences of the hospital’s performance and it reminded me of management meetings I have sometimes had to endure.

In the interests of professional confidentially, I shall need a wide-ish berth as I very vaguely describe a set of people who would spend entire meetings commentating on their Microsoft Excel spreadsheet via a Microsoft PowerPoint masterclass detailing how the numbers were about to explode off the page.

We would be taken on a ‘if this happens’ journey full of perfectly logical justification for how success would happen for which would be forgotten by the next meeting in which the same fantasy approach would begin again.

They certainly worked hard at putting the presentations together.

You could imagine them pondering on which number to stick in there and looking at the result with more ponder, finally settling on something that was founded on nothing more than a ‘think and see’.  When it came to the presentation most people were under a spell/numb.  There would be far too many questions that would take far too long to ever get anywhere near understanding how these figures came to be, and in truth, the numbers were rarely met.  If they were, it wasn’t anything really to do with the strategic vision or tactical ingenuity of the decision-maker.  They just happened.  Moreover, the processes, procedures, organisational and personnel changes and targets bore no resemblance to the reality of the situation.

Without undermining the MD as it was his job to report on performance, when I was watching this meeting I felt a long, lost but familiar feeling.

The talk was of a good game.  The assurance with which the information was communicated was there.  There was an air of humble self-satisfaction of the difference that he made as he described the changes in January shifting beds from ward to ward, opening up spaces (17) that weren’t previously there, expanding nursing numbers, and improvements in ambulance handover times whereby there is now a 'race' for Southend to beat Chelmsford.  He could only work with what he was given and he seemed to have done well with the limited resources available.

Here come the targets

Setting targets is one of the easiest, but most useless managerial tasks I can think of.  I do them myself out of some kind of managerial auto-pilot.  But they rarely work out.  My favourite are the economists who think they can predict the behaviour of millions of people based on theories they read of in books.  Numbers are merely a photograph.  They do not begin to tell the story.

So when the MD announced the targets I felt eyes 'a' rolling.

He plans to expand capacity in A&E and reduce waiting times to meet the national standard of 76% (from 65%) of people waiting 4 hours.

Ambulance handover times are currently 28 minutes and he wants them to be 15 minutes. At 45 minutes there is even a ‘drop n go’ policy to make sure there is a space - somehow.

He announced ‘zero tolerance’ in the event of a 12-hour wait (for which there are around 6 or 7 per day currently).

According to his figures, 350 patients came into A&E, which on average, amounts to 100 ambulances a day in Southend. So, one of the key areas to work on was patients being discharged after they have been deemed ready to leave.  He said the winter just gone has seen improvements in ‘flow’ and they are looking at further discharge capabilities. This time he plumped for a number no more than 150 across the Trust.

And lastly, he is looking to open 60 extra beds over the coming winter across Basildon, Chelmsford and Southend.

On a side-note, he ‘suspected’ that the cost of consultants and cover nurses were costing more than the savings made by refusing to pay the 35% extra the Junior Doctors were asking for.

Commentary

For me, a target of 4 hours is still an admission of failure - not by the MD, but by the people in charge of the NHS.  What’s worse is that this is likely to be wildly off.  A Councillor spoke of an elderly lady who had to wait ten hours to be seen in A&E.

In terms of the ‘zero tolerance 12 hour’, it is stunning that a boardroom of people could possibly agree to such a disconcerting target. The idea that we might be reassured by this is laughably horrifying.  What exactly is the punishment for the doctors and nurses if this were to occur? Do we want any punishment for them?  What more could have been done that would be in their hands to have done so?  What is the punis Withhment for the MD himself if he doesn’t meet the target?

You can see how meaningless this is.

Onto discharge times. A story from another Councillor was that the discharge time for her father was at least two days longer than it needed to be and was ‘chaotic’.  His answer: ‘"with the systems we put in place that shouldn’t have occurred.’  Either he is on the ground-floor every day, but somehow misses these glaringly obvious operational snags or he is rarely there and relies on others telling him what’s going on. There is no win either way.

Opening up 60 beds across the three hospitals amounts to 20 beds for Southend.  I do not feel I need to make a long comment here and just settle with: this is nowhere near what is required.

Regarding his comments about Junior Doctor’s pay, this is far too emotive to ‘suspect’ to put out into the world.  Suspicion is not fact and it was not right that a person in his position should publicise anything that isn’t. In principle, we all know that our health is the most valuable commodity to each of us, therefore, the people that help keep us healthy should be paid the most in society.  In fact, negotiating in percentages is starting at a losing position. 35% (which is what they want) of £29K would take the salary to around £41K. Better to state that £50K is where they want to be.

Conclusion

And so this is a tale not of criticism, but realism.  The distance between Microsoft Excel and actuality.  Day-to-day. Personal experience.  It reminds me of the award for Southend Pier.  It’s good, but anyone who sees for themselves knows there’s nothing really down there.

Admittedly. I am being wholly ignorant because I have absolutely no idea how he carries out his job and the instruction he is following. Having said that,  I ‘suspect’ there is a huge chasm between the frustration and worry by what is experienced by Southend residents and the pride with which he presents his targets.

There is a wider conversation about capacity, demand, population growth, prevention, government investment, and the underlying real ambition of those that are in charge that is out of his hands.  But what his targets show are more examples of the ambition that is hiding in plain sight.  Every extra hour we wait is the measure of the urgency in which our health is valued by those in power.  In a way, we could be accused of being ungratefully fortunate when we complain if we have to wait 12 hours to be seen or 3 years for an operation, where, in the words of Alan B’stard MP, "in the good old days if you were poor, you got ill, and you died".

Things have improved enormously and beggars shouldn’t be choosers. And as the health beggars that we have become, we should not complain and thank those that have taken our taxes and chosen to spend it on other areas deemed more important, such as speedier internet connection, shopping centres and trying to turn car parks into cinemas.

On a brighter note, I would like to say what a brilliant Chair Tricia Cowdrey is!

To view the webcast: https://southend.public-i.tv/core/portal/webcast_interactive/776703

https://www.nhsemployers.org/system/files/2022-03/Pay%20and%20Conditions%20Circular%20%28MD%29%201-2022.pdf