NHS Consultants are an easy target when it comes to looking for an excuse to blame the woes of the NHS on. The following piece in this week’s BMJ suggest we are getting less productive. Yes, we are, but No we are not. Over the last 10 years we have been asked to take-on an increasing number of roles and jobs that were never on our clipboard and distract us from front-line care. I have never had more of a weekly backlog in NHS administration than I do now. The amount of background paperwork in the NHS has snowballed. For example, clinical and educational supervision, audits, mandatory training, multi-disciplinary treatment meetings, appraisal and revalidation, CME, CME diaries, online dictation, online checking of letters, electronic patient records, electronic ordering of tests, online checking of results, electronic communication, databasing, hands-on supervision, etc. At the same time NHS administration support has plummeted. Secretarial and nursing support is less than half of what it was 20 years ago. We work in a healthcare ecosystem that is complex and require different levels of skills; by making more of the routine administration the responsibility of the MSologist and less the responsibility of the support staff means I am busier, but far less productive, in terms of face-to-face clinical activity than I was 10 years ago. Good or bad? I am not sure, but job satisfaction is nowhere near as good as it was 20 years ago. I get the feeling I am spending increasing amounts of time interacting with my computer than seeing and talking to patients.
The commentary below suggests the picture is more complex than meets the eye. It seems as if productivity losses need to be balanced by quality gains. In the modern era about 25% of consults are taken up with discussions about information. Gone are the days of the ignorant compliant patient. Instead we have very well-informed expert patients who want to know details and specifics. Some patients now know more than their neurologists about their disease. This is all part of the democratisation of knowledge. These new roles take time and I would be hopeful that the quality of care we now provide and clinical outcomes have improved. The problem in the MS space is that we don’t have reliable well documented quality standards. This is why we are in the process of trying to define a set of standards as part of our #BrainHealth campaign. If you don’t measure it you can’t change it.
John Appleby. How productive are NHS consultants? BMJ 2017;356:j1520
….. Over the past seven years, the good news is that as consultant numbers have increased, so too has their elective activity (fig 1). The English NHS increased its elective activity output by around 19% from September 2009 to September 2016. But the bad news is that at the same time, the consultant workforce grew by around 22%. This means that the average productivity per consultant has fallen by 3% since 2009 (fig 2)….
….. But here’s the first problem with this calculation: consultants’ output is not just measured in elective activity but includes outpatient attendances and emergency work. Although consultants will also spend their time in meetings, management, and other administrative duties, these are assumed to be intermediate activities that contribute to their final output. But what about teaching and research? What to include in the overall output measure is not always clear. And though there are ways to aggregate the apples and pears of different types of activity into one overall measure of output (weighting them by the proportion of their total spend for example), this presumes their importance or value is related to their cost….
….. The problem is how to ensure outputs are comparable over time. For producers of mobile phones we can count the number of phones produced every year and call that their output. But it’s clear that, although still a phone, Apple’s 2016 iPhone 7 is somewhat different to Nokia’s 1997 6110 mobile (though both cost around the same). Over two decades the power and capabilities of mobile phones have increased hugely. The 2016 mobile phone product is not the same as its 1997 counterpart…..
… Adjusting the output of consultants to reflect changes in the quality of the “product” is not easy, but without it productivity can be seriously underestimated over time. For the NHS as a whole, Office for National Statistics adjustments for quality (improved waiting times, reductions in mortality, etc) have accounted for around 40% of the increase in the productivity of the NHS since 2000 and about 17% between 2009 and 2014 (fig 3). If such an addition, assuming the quality increase in 2015 was the same as in 2014, was applied to the elective outputs of consultants, it would have been enough to have just about compensated for the 3% fall in unadjusted productivity between 2009 and 2015 (fig 2)…..