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7 April 2003

How to win a million pounds

Theodore Dalrymple explains the tricks hospitals will use to meet a new government target for emerge

By Theodore Dalrymple

The penny has finally dropped in some quarters, after only four or five decades of experience, that unfilled beds in hospitals are not necessarily a sign of inefficiency, any more than the absence of empty beds in hospitals is a sign of efficiency.

If the number of beds in my hospital were reduced by half, as in the past it was cut by two-thirds, all the beds would still be occupied all the time: there would be no loss of efficiency according to the old-style criterion. It would merely take twice as long for a patient to be admitted to a bed, that’s all.

But things are changing. According to the wreckers who inhabit the Department of Health, and who obviously believe in the concept of permanent revolution, we should measure efficiency differently: not by bed occupancy, which is far too crude a measure, but by the time emergency cases take to find what I hesitate to call their final resting place.

That is why my hospital is being offered £1m in extra funding per year if it succeeds in finding a bed within four hours for at least 90 per cent of the emergency cases arriving at its doors.

Any public servant will be able at once to see at least two possible ways to claim the prize. The first is to redefine what constitutes an emergency. If you reduce the number of emergencies, then it should be easier to find them beds within the required time. No doubt ways can also be found to slow down the passage of time: for example, by excluding the period during which patients wait for X-rays or blood tests and so forth.

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No one should underestimate the creativity of the British bureaucrat when put to this kind of test.

The second of the two obvious possible ways to achieve the target is likely in practice to prove the more important, though it is not strictly in contradiction to the first: namely, to discharge patients after ever-briefer periods in hospital, or what the Americans pithily describe as “quicker but sicker”.

It is already the case that discharging patients before they have made a full recovery has certain statistical advantages to the hospital that follows this practice: when the patient returns with complications arising from his or her premature discharge, the hospital is able to claim that it has successfully treated not one, but two illnesses. It is all a little like the way votes were counted in Zambia in the days of President Kenneth Kaunda. But now the pressures on doctors to discharge patients too soon will increase yet further.

One might have supposed that the days of overfulfilment of the plan expired with the Soviet Union: but no, they survive in the National Health Service. Stakha-novite doctors who mercilessly discharge their patients before they are fully prepared for life in the outside world will become Heroes of NHS Labour and no doubt will receive medals, and perhaps even emoluments. Their pictures will be put on hospital noticeboards: this month’s Hero Discharger. Those who keep their patients too long, however, will be vilified, perhaps at hate sessions.

As it happens, I see both sides of the coin, as a doctor working in a hospital, and outside as a doctor referring patients to the hospital. I know the pressures to discharge patients as soon as possible, as well as the consequences to the patient when this is done.

Even without a monetary incentive, hospital doctors feel the need to get their patients out of hospital quickly, to prevent too large a number of patients building up in casualty, as they wait for admission.

The doctor has to weigh the comfort of one patient against the life of another: and comfort (or sometimes even safety) has to be disregarded. After all, doctors outside the hospital can pick up the pieces and readmission is always possible, provided death doesn’t supervene.

The managers will start snooping around the wards, demanding why this patient or that has not yet been discharged. Doctors will be judged by their performance: never mind the cure, measure the length of stay. This is already happening: managers in some hospitals are demanding that patients be moved from casualty in order that targets be met, irrespective of clinical needs and priorities. What counts is the figures: or rather, certain figures.

Management by targets, especially in a system without a genuine bottom line, is likely to result in dishonesty, statistical fraud and (where such fraud is impossible) outright cruelty and neglect.

By setting a goal to be reached at all costs, it prevents other goals, equally or more important, from being reached or even aimed at. Everyone will agree that it is desirable that patients should not wait inordinate lengths of time: but the reduction of waiting time is not the only goal of medical treatment.

The substitution of procedural outcomes for genuine medical ones is dangerous, but it is, increasingly, the story of our times. It represents an accretion of bureaucratic power, while at the same time permitting real problems to go unsolved. But then – unsolved problems need more bureaucrats to solve them.