Organisational Dementia

I have been in in my current job for over seven years. In that time, at my PCT I have seen the comings and goings of four chief executives, four directors of finance, seven directors/managers of primary care, two directors of commissioning, three finance managers, three directors of clinical governance and three directors of human resources. Not one of the heads of the major departments was in post more than three years ago.

This need not be a bad thing. indeed, for these individuals, it's usually a very good thing. New appointments usually mean promotion, more cash and new interests. For those of us left behind, it is often a source of irritation and frustration.

Why is it frustrating? Well, because quite often we find that the useful suggestions (and accepted as such by the management), we made about improving services fall by the wayside. The replacement arrives at the next meeting with a clean sheet, fresh start, and other manifestations of the lack of an effective handover. The good idea has to emerge all over again and the clock is reset. As far as the new incumbent is concerned, there is no delay because the count has just started.

Then there's the irritation. We negotiate an agreement with a director and do whatever the agreement requires of us. A couple of directors later, the new leaner, meaner, "we must reduce costs" senior gunslinger calls us in and says we're not doing it properly. Our response that "we are doing what was agreed" is brushed aside. "I wasn't here then" which is intended to mean: "that agreement doesn't count and we can and will ignore it".

Efficient organisations learn from their successes and their mistakes. The NHS doesn't seem to learn. I cannot see any evidence of any determination for our PCT to retain a clear view of who did what, when, and the outcomes. The process of finding a replacements for a departing senior executive usually starts after his or her departure. Frequent reorganisations mean the shifting of some duties from one person to another and departments are broken up and re-established with the energy of a Scottish country dance. In amongst all this organisational musical chairs, knowledge and experience evaporates.

Never mind, a new director will soon be here, brimming with "fresh" ideas.

Tidy processes but untidy outcomes

General Practice is managed by its local Primary Care Trust. Our PCT has a population of 330,000 patients and spends hundreds of millions of pounds of your money and mine. They are responsible not just for ensuring we are performing our duties properly, but also for introducing new services and the procedures to support them. They also commission new buildings; they modify and adapt the complex arrangements that are involved as a patient moves through the system from GP to hospital or to a specialist clinic, and then back again. From a general practice perspective, virtually everybody with who we come into contact is a "manager".

It may come as a surprise to you that so many of them have no specific previous relevant experience that they can apply to the tasks for which they have been recruited. The important essential criterion seems to be the ability to produce impressive word-processed reports with lots of tables accompanied by a multi-page spreadsheet with lots of colours. Too often, it is the triumph of style over substance.

Don't believe me? Then consider the following:

Yesterday I attended a meeting of a group meant to be steering an important screening service for people suffering from complaint found frequently in our population. There were seven of us managers and we all like to think we have the best interests of patients at the heart of everything we do. We were discussing the local hosptials failure to achieve a fourteen-day target for seeing urgent referrals.

Nice manager from the hospital: "We have a high rate (40%) of non-attendance in clinics."
Nice assistant director of PCT: "What are you doing about it?"
Nice manager from the hospital: "We're recruting a locum consultant to work thought the backlog".
Nice PCT service manager: "That's good to know. How long will it take?"
Nice man from hospital: "We are recruiting now and we believe it will soon make a signficant improvement".
Nice assistant director: "That's good to know."
Me: "Hang on a minute. If two in every five people aren't turning up for their appointment, why get more capacity when the capacity you've got sits unemployed for 40% of their clinic time?"
Nice man from hospital: "The consultants won't let us double book clinics".

Apart from the inherent nonsense of the consultants' stance, nobody else seemed the least bothered. They had dealt with the problem i.e. they had pushed and prodded it a bit (but not too hard) and had a response to write in the minutes.

Meanwhile, patients are still not getting urgent appointments within two weeks, and there is no date given at which it is forecast that this entirely avoidable situation will improve.

Their process is nice and neat but the outcomes which were poor are no better.

The Lowest Common Denominator - again!

There are good doctors and there are some that are not so good. A few are dreadful. Such things are inevitable when there are so many of them and none of them every get younger. GPs are not except from this. In fact, given that most of them run their own businesses (i.e. their practice) the opportunity for variation is all the bigger.

Enter the "primary care trust". The job of a PCT is to be the part of the NHS with responsibility for signing contracts with these GP practices to deliver the services that the NHS wants delivered. Our contract is three inches (7½ cms) thick.

If you suffer from insomnia, you might leaf through the odd tonne of gumph spouted by the NHS about " ... devolving power to ensure local services reflect local needs, blah, blah, blah ..." It seems such lofty aims stop at the PCT. They simply cannot cope with lots of practices each doing things in their own way, especially when some of them don't do it properly or well enough.
Their response to such variations?? Simple!

Make everyone do it the same way, irrespective of whether or not that is better or worse than what was going on before in the non-problem practices. In other words, find the lowest acceptable performance level that everybody can meet and then make all do it, irrespective of how well they were doing it already.