Want to know about crisis management? Just ask any chief executive who works in the NHS.
A big-city hospital like Aintree Hospitals NHS Trust at Fazakerley, on the edge of Liverpool, is a £100 million-a-year, high-profile just-in-time manufacturing plant with an infinitely variable product line and an output of life and death for its customers. It is, in short, the ultimate stake-holder concern. Two-thirds of its workload, sometimes more, arrives in ambulances or off the street for treatment carried out to order, at any time of day or night. All hospitals operate on the edge: at the borderline where planning, improvisation and political pressures meet in a framework of financial and physical constraints. Ultimately dependent on trust and the combination of many different high-level skills under pressure, such institutions can't be managed like hierarchical companies. Nor would the fiercely independent loyalties of the medical professions allow it. Hospital management requires leadership, listening and value-setting skills of the highest order. In February Management Today followed Aintree's chief executive, David Wood, through a typical day in the life of an NHS hospital.
David Wood, a quiet spoken, direct Midlander, trots into his office in the Victorian core of Fazakerley Hospital. Regular first appointment of the day: a 10-minute meeting with operations and nursing quality directors to review the previous day and what's in store for today. No major headaches, but the hospital is bulging: just 11 empty beds out of 1,255 are empty, which leaves a perilously small safety margin for emergencies.
Letters, diary, messages. Wood signs replies to all complaints - 389 last year for 382,387 'episodes of patient care', or around one in 1,000. More messages than usual: Wood was in London yesterday delivering a joint conference paper on the 'electronic patient record', a computerised information system that could revolutionise patient management and treatment. Computerisation has a chequered record in the NHS: Aintree has gone out on a limb by installing a radically new UK-designed information system, primarily as a clinical aid but also to handle patient admissions and management information. The conference went well, and the train journey was an opportunity for Wood to catch up with reading. Top of the list is the new Green Paper Our Healthier Nation. 'These things are released to the press before they get to us,' says Wood, 'so there's no way we can comment properly' - although this should change when everything goes electronic on NHSnet, the service's intranet. He scans the medical press, particularly for anything on the Year 2000 problem - an urgent issue for all NHS trusts, since problems with electrical equipment, such as lifts, air-conditioning and heating, can easily become life-endangering in a hospital setting.
This is almost the last moment Wood will have on his own in his office.
He checks the local paper, the Crosby Herald, for which Fazakerley is a fertile source of stories. This is a fact of life. He needs to meet the editor soon. There's a piece of consultancy work to authorise on organisation development to ensure the top two tiers of hospital management - managers and clinicians - work together rather than in isolation. There are also the minutes to review of a zonal meeting of chief executives of all Merseyside and Cheshire NHS Trusts, of which Wood is convenor - important, since the meeting was with the regional director of the NHS Executive, 'who has secretary of state clout'.
Report from John Wood, corporate development director, on a vital meeting with Aintree's paymasters, the three local health authorities of Liverpool, Sefton and St Helens. This is a crucial week leading up to the financial settlement for the year. Like all NHS trusts, Aintree must not only balance its budget but achieve a 6% operating return on its assets (which it always has done). At issue now is part of the £6 million a year savings in running costs that Aintree is making by consolidating two sites into one. This huge project has been carried out without missing a beat, says Wood proudly, at a cost of £25 million compared with £200 million for the new Charing Cross Hospital in London - 'and we do more work than they do'. Most of Aintree's saving has been reinvested in better patient facilities. Now the HAs want to claw back half of the final £1.2 million tranche for themselves. Not acceptable. Negotiating (and lobbying) will continue. John Wood thinks a compromise, maybe two-thirds/one-third, may be possible at the next meeting.
Brisk walk to the new accident and emergency (AE) department. Fazakerley is huge, at 120 acres one of the biggest hospitals in the country. Even though yesterday's emergency intake was low (50 compared with the normal 60 or 70), pressure on beds is intense. No one slept on a trolley, but there were seven overnighters waiting for discharge or a bed, and all the treatment rooms were used. It's not just a problem of space, says AE clinical director Alan Armstrong. The department is two or three consultants short, which slows up the discharge process. And Aintree is also affected by what happens in Liverpool as a whole - for instance, when the Royal Liverpool Hospital's AE department is at full stretch ambulances may be diverted without warning to Fazakerley. Wood and Armstrong discuss co-ordination between the three hospitals most affected. Other subjects of discussion, around three or four telephone interruptions for Wood, are AE staffing and ward secu-rity, a growing problem.
Fourth meeting of the day, sixth cup of coffee, with Doreen Roberts, general manager of radiology and clinical laboratories. At the top level, the trust is managed by a board and five executive directors (Wood, finance director Ann Marr, operational services director Colin Smith, nursing and quality director Chris Pearce and medical director Peter Bousfield), overseeing 21 clinical directorates. These are ranged in six main service groups, each with a general manager responsible for service delivery and allocation and control of resources. The general managers are powerful figures in their own right, managing sizeable budgets - Roberts' is £8 million - and responsible for key targets which resonate far outside Fazakerley and even Liverpool: quality of service and waiting lists, for example.
Roberts' clinical support services are a gateway to treatment and thus key to the efficient running of the hospital as a whole. No treatment can take place without lab tests and x-rays. 'Nothing is more frustrating than not being able to treat a patient for a week while results come back from the labs or x-ray,' notes Roberts. Radiology has recently installed a new MRI (magnetic-resonance imaging) scanner and nuclear medicine suite (cost of the two with building works: £1.5 million - but 'an American hospital this size would have three or four scanners,' says Wood ruefully). An important step will be digitising the results so that they go directly into the information system. When clinical test results are available electronically all over the hospital, there will be huge qualitative and speed gains over traditional transmission means of phone (with possibility of error) or paper (with possibility of loss or delay). Roberts can't wait. AE is already electronically linked to the labs, she notes, and (young) doctors in other departments have taken to running down to pick the results off the screen there rather than wait around for paper. Not all Roberts' concerns are hi-tech, however. She tells Wood about a new shift system she has devised. 'It will transform laboratory services - it's a major piece of work,' he says.
Preliminary sounding-out interview with a possible candidate for one of the clinical directorships at the hospital - a major and sensitive appointment.
Another brisk walk, this time to the Portakabins grandly entitled the post-graduate education centre. Aintree is a teaching hospital, and every week puts on a 'Grand Round' - an open seminar on a clinical or other topic. For Wood, it's an opportunity to grab a bite to eat while making himself accessible to a broad cross-section of the hospital's 3,100 staff. This week's speaker is Rob Wall, chief executive of Sefton Health Authority (where Wood previously worked), one of Aintree's key customers, who is giving a reaction to the new health Green Paper, a key framework for both trusts as 'providers' and authorities as 'purchasers' of local health care. Not surprisingly, there is a good sprinkling of senior managers present.
Wall's presentation makes it abundantly clear that there will be little additional cash for Aintree in the next year: the authority as a whole has just £2.5 million extra to distribute, while Fazakerley alone has identified at least £6 million of pressures and priorities to accommodate. Since the Green Paper rules out higher taxes, charges or reducing the scope of the NHS, Aintree, like other trusts, will have to do more with less by making better use of existing resources, tapping into new developments in management and technology, and aligning financial and clinical decisions (translation: making hard choices about medical priorities). In return, Wall holds out the prospect of more input for trusts in shaping local health improvement programmes, and greater clinical involvement in setting service standards.
Vigorous subsequent discussion is punctuated every other minute by bleepers summoning junior doctors who rush off to more pressing tasks. Is breast-screening worth while? What support will there be for clinical audit?
Wall notes that there is a pressing need to improve the service across the divisions between primary (GP), hospital and community care to prevent the most vulnerable falling into the gaps - while the best of the NHS is sensitive and caring, the worst can be cruel and damaging. Everyone agrees that relations between purchasers and providers need to become less confrontational but Wood worries that if demand continues to evolve at the present speed, no one will have the time to work out how to deal with, say, a particular condition across the boundaries of care. He hopes that clinically-led area health improvement plans will help to put things together. 'Otherwise there will still be a war of attrition with the health authorities that want to pull out resources for promotion rather than acute care.' Wood later discovers that Wall barely gets to the end of the meeting before collapsing with flu, which provokes one or two obvious jokes. But the seminar is judged a success. Wood and Wall know each other well. Relations are robust - 'we have pretty tough arguments' but there's give and take on both sides - not always the case with some HAs.
On the way out, Wood is buttonholed by the general manager for medicine, Mary Massey. It's the bed problem again. Sixteen patients are due in tomorrow - all elderly and liable to be in for a long stay. Should some of the operations be postponed to leave a safety valve for emergencies?
The trouble is that in orthopaedics, particularly, the hospital is on a knife-edge. Aintree's small orthopaedics team is twice as productive as another local one double the size, but it is short of staff and is being swamped with referrals. They decide to gamble on the mild weather and the generally low levels of emergencies since Christmas by leaving things as they are.
Back to the office for a regular weekly meeting with trust chairman Brian Cooper. Some of the exchange is routine, but over the last few weeks Cooper, by temperament a hands-on manager from a drugs industry background, has been heavily involved in negotiations with the health authorities to secure a contract 'that will satisfy the clinicians, just'. While the finance director does the direct bargaining, Cooper spends hours on the phone cajoling and lobbying behind the scenes. 'We're competing with other organisations out there. It's a tough old world.' Reflecting on his own background, Cooper notes that hospitals, where the most important resource is the individual skills of the nurses and doctors, can't be run like a private-sector company.
Nonetheless, he says, things are beginning to change as structures are gradually altered to allow government policies to be put into practice - for example, 'evidence-based practice', where proven intervention procedures will gradually take the place of the present wide variations from hospital to hospital. In another kind of framework, Wood is proud of Aintree's accreditation as an Investor in People, a mark of sustained good people management. In general, Cooper observes, Aintree has been managed 'very frugally, at the same time markedly improving both facilities and services - although there's still a way to go.' At least, he says with a sigh, the Green Paper promises that efficient outfits will keep the savings that they make. The chairman and chief executive finish by discussing plans for a new ward to be built in space saved from other hospital functions.
The cost is high - at least £650,000 - and no conclusion is reached.
Executive directors' meeting. Full board meetings - the five executive directors plus another five independents - are held in public, except for personnel and sensitive commercial items. This, on the other hand, is the hospital's monthly top-management get together to consider a variety of strategic and running issues. Wood, who listens as much as he talks, is clearly primus inter pares. Top of the agenda today is the 'team-on-team review', a process designed to encourage the clinical directorates to develop meaningful objectives and performance measures. The whole of the health service's underlying management agenda is here: how to bridge the culture gap between medics and managers, how to enlist the clinical staff of doctors and nurses in corporate issues, and conversely how to develop management processes which support rather than work against the point of the exercise: better, more effective patient care. There is a SWOT (strengths, weaknesses, opportunities and threats) analysis of the process - the main complaint being the time spent on what clinicians regard as bureaucracy rather than curing patients - and a lengthy discussion.
Conclusion: despite complaints and variable results, 'team-on-team' is too valuable to be abandoned, but it needs refining to link planning, performance and management development more closely. 'The only way of taking it further is to give the individual directorates more influence over the process: after all, the whole point was to involve them,' says one director.
After that, the meeting visibly relaxes. The year's insurance bill is an uncontroversial item except for professional liability coverage, where the present insurer wants to double the premium. So are local plans for the NHS's 50th anniversary celebrations. There is an issue about the final closure date of the second Aintree site - the finance director crisply reminds colleagues that every week it remains open accounts for another £50,000 in costs. The final item is R&D, where it looks as if Aintree is about to lose £50,000. Wood says he'll bring it up at the next zonal chief executives' meeting.
Back to base for a final check on the bed situation and a look at the diary for tomorrow. Wood has to leave earlier than usual for an evening meeting. At least the bed position is no worse than at lunchtime. Looming, however, is the transfer of the last wards from Aintree's second site, at which point Fazakerley will have to shut down the 'winter pressures' ward to make room. It will be touch and go. The transfer has been 'hard slog', notes Wood with feeling, for which Aintree hasn't had all the credit it deserves. As he tidies his desk, he reflects that by the end of the day, Fazakerley doctors and nurses will have delivered 10 babies and certified six deaths, seen 250 people in accident and emergency, carried out 100 operations and 50 day-case procedures, and treated more than 1,000 people in outpatient clinics, without major incident or crisis - a pretty good record. For most of the patients it will have been a day of exceptional stress and tension. For Aintree it is one day among 365, and tomorrow will be just like it.
BEDS AND WAITING LISTS - The problems and (possible) solutions
'It's madness to run a hospital at more than 85% of capacity: to be able to operate flexibly and efficiently, we should have 150 beds free at any one time,' says David Wood. Hospital bed management is the point at which all the pressures - medical, financial, capacity, information - intersect in a daily crisis.
Hospitals are paid by their health authorities to carry out a certain number of operations every year. The snag is that they can never accurately tell how much of their capacity to set aside for emergencies, particularly in winter with its constant threat of epidemics and cold snaps. Cross-infections can shut down whole wards.
So far this winter has been relatively mild. But it's not over yet, and the hospital is at full stretch. Last year was much worse, with many planned operations cancelled for lack of beds. This causes not only financial problems for hospitals, which don't get paid for operations they haven't done, it also upsets patients and lengthens waiting lists.
The problem has been getting worse. Since 1990 emergency medical admissions in the UK have increased by one-third, largely (it is thought) because GPs are using casualty to get ill but sub-emergency patients into hospital beds. The situation for hospitals is aggravated by pressures on the rest of the system: the difficulty of discharging 'bed-blocking' frail, elderly patients who can't be found a bed in community care, for example. As a result, although hospitals like Aintree are increasing productivity by 5% a year (one-third over the last six years), they are running twice as fast to stand still.
Some problems will be alleviated by Aintree's new information system.
At the moment, as in most hospitals, the only way senior managers can find out how many beds are empty is to send someone to count them. Better information will not only give much more accurate knowledge of the bed-state, it will also aid bed management by cutting the time that patients spend waiting for lab results or notes. (Aintree has no less than 700,000 sets of patient notes, sometimes composed of several thick files, stored in five locations.
For the NHS as a whole, 20% of files at any one time are in transit, missing or otherwise unavailable for use.) In addition, statistics available at the touch of a key will enable hospital managers to tell for sure where the growing AE demand is coming from and allow better management of waiting lists.
Hospitals are by far the NHS's most expensive component. It makes sense to ease the pressure on them by shifting the emphasis to primary care and health promotion rather than trying to increase capacity to meet demand that is in any case infinite. But in a civilised country, emergencies must be treated. Without adequate flexibility, as Wood notes, it is the hospital, and particularly AE departments, which take the strain for the entire system.