Decision making & problem solving - Essay Example

Decision Making and Problem Solving National Health Services The National Health Services, a publicly funded healthcare organization, was founded inUK near about fifty years ago. Their focus on modernization in the management has given new edge to the functioning of the NHS. It is significant that the NHS management has readily recognized the need for the charges, and timely implemented the plan. But the momentum for the charge has only started gaining pace. These changes are not necessarily the result of the internal market for health. They arise partly also from developments in the science of medicine itself. Four changes will have particular impact on the future organization of the NHS (Leathard, 1991, p.126). Problems faced by NHS The 'Problem' of Medical Practice Variations. Assuming that medical science remains in continual state of development and evolution, differences of opinions between doctors become inevitable. The law regarding medical negligence permits wide range of practice variations. The 'Problem' of Controlling Expenditure. Though the NHS does not have a profit motive, it is, of course, enormously concerned with control of expenditure. Surprisingly, however, it still lacks any real continuous evaluation of its performance against criteria. The 'Problem' of proper prescribing of drugs, choosing doctors and referrals Concerns about the irrational use of medicines has led the government to introduce scheme designed to put downward pressure on indiscriminate prescription. GP spending on pharmaceuticals is now subject to regulation by indicative amounts, or 'target budgets'. In the past, the stance of the British Medical Association has been that 'general practitioners should always acquiesce to any reasonable request by patient for second opinion' with the presumption that the choice of consultant was matter for the referring doctor to decide. What freedom do GPs retain in the choice of consultant These problems could be tackled using modern technology. The following benefits were expected to be gained by the use of modern technology: First, improvement in medical technology will help in reducing the number of days a patient has to occupy hospital bed. This will result in a corresponding increase in the number of out-patients. The concept of the 'general' hospital, with broad range of services designed to cater for the needs of a variety patients, will decline. Instead, there will be smaller number of specialist units which maximize the use made of expensive equipment (Astley & Van de, 1983, p.245-273). This will bring out movement from secondary to primary care and an increase in the power of GPs both in terms of the numbers of patients they treat and their influence over the distribution of health service resources. Their role as passive partners in the enterprise of health, removed from the reality of hard decisions about costs and benefits, will be change. Inevitably, they will become more involved in the debate about priorities in health care. Secondly, since the power to decide how resources should be spent gets decentralized, tension will arise between the duty of the Secretary of State to promote national strategies and objectives and the wishes of local doctors and health managers as to their own goals and aspirations. Thirdly, the use of market for health care will not discourage this trend. The use of the word 'market' is undoubtedly contentious and the exact future of the current system of funding, obviously, will be subject to the winds of political change. Equally, both main political parties would endorse the following two principles: (i) that effective care in the NHS is enhanced by the use of some measure of financial incentives for employees who achieve most, and (ii) that an entirely unregulated market for health care in the NHS would be largely ineffective and wasteful. Fourthly, the distinction between public and private care will become increasingly blurred. Private hospitals will be encouraged liberally and be able to sell their services to patients who are presently depending on NHS. Similarly, NHS hospitals may need to generate revenue by treating private, fee-paying patients. This will create the need for new lines of control and accountability, with respect both to purchasers of care and patients. In other areas in which public utilities have been bought by private enterprise, official watch-dogs have been created with the aim of ensuring that minimum standards are maintained in the public interest (Leathard, 1991, p.126). Solution and analysis The 'Problem' of Medical Practice Variations. As long as doctor adheres to certain practice which responsible body of doctors would endorse, he will be safeguarded against any of criticism of negligence even though large majority may still take different clinical view of the case. Often, this is perfectly proper. The medical evidence, on which decision must be based, may be Incomplete and inconsistent. In such case, matters of diagnosis, prognosis, or surgical management invariably involve the exercise of judgment. Doctors may have been taught differently, or from personal experience they may have learned that some things work better than the others. In this case, their own medical practice and judgement based on experience will tend to determine their particular expertise. Further, doctor who provides a particular treatment which proves unsuccessful may be less willing to resort to the same in future. This is an inevitable part of the evolution of medical science (Bacon & Eltis, 1976). Increasingly, health service managers have become critical of the professional latitude enjoyed by doctors, and they are less likely to accept without question the fact of medical practice variations (Leathard, 1991, p.126). Medicine is widely held to be science, but many medical decisions do not rely on strong scientific foundations, simply because strong scientific foundation for such matters has yet to be explored. Hence, what often happens in the decision-making process is complicated interaction of scientific evidence, patient desire, doctor preferences and all sorts of exogenous influences, some of which may be quite irrelevant ("Institute of Health Service Management", 1990, p.45). Reappraising the Role of Managers. It is relevant here that there has also been an appraisal of the role of health service managers. Before 1980s their role was compared to that of 'diplomats'. Their function, in those days, tended to be passive: to reconcile conflicts between competing demands (from doctors, nurses, patients, and managers themselves) and 'to react to problems rather than to pursue objectives.' Managers were expected to exercise only limited control because many activities of the hospitals were determined centrally, or by senior clinicians acting in isolation. In addition, there was an absence of precise information. No specific records were maintained to keep track on how and where money was spent in the service. Thus the process of effecting change became very difficult. In place of the general manager was system of 'consensus management' of the NHS, in which the disparate elements of the NHS personnel--managers, doctors, nurses, midwives, health visitors etc.--were expected to produce generally held and acceptable local policies. During this time managers engaged in 'problem-solving, organization and maintenance and the facilitation of processes (Astley & Van de, 1983, p.245-273). The general managers, as their title suggested, managed everyone(Bennett, 1994, p.128). Whereas the old district administrators simply chaired the meetings of the management team, each general manager was real boss, in charge of the treasurers, the cleaners, the nurses, the doctors, and the entire personnel department. Here, then, was revolution. . . . In short, it was general managers, not the clinical trades, who were now to decide . . . The Griffiths Report had significant impact and is now reflected at every level of the NHS, both in structure and operation. Inevitably, the result of this change of emphasis in the health service is to shift organizational power from clinicians to managers. They set performance targets, and because the managers are responsible they will have to acquire greater authority over the entire hospital and its facilities. For the present, the corporate strategy established by the Secretary of State is relatively distant and limited, possibly with the intention of promoting local initiatives in the internal market for health (Blackler, 1993, p.863-884). Besides, effective management requires tolerably clear corporate objectives. Some have expressed wish to see restatement of the purpose of the National Health Service, clear expression of corporate purpose, greater clarity concerning the role of competition and the principles on which the internal market ought to be regulated, and clarification of the lines of accountability between purchasers and providers. There is no doubt that these are indeed necessary to ensure better transparency of operations. Without them, inconsistencies will develop between regions and the 'national' quality of the health service will become fragmented and undermined (Bennett, 1994, p.128). Doctors as Managers. The major part of NHS expenditure is incurred for acute hospitals, which consume around 40 per cent of total NHS spending. Obviously, doctors seem to owe direct responsibility in deciding where the money is spent. It, therefore, makes sense to involve doctors in the process by which spending priorities are decided (Astley & Van de, 1983, p.245-273). This in itself is radical development. Traditionally, managers and doctors have always been thought to possess entirely different and incompatible aims and aspirations (Coupland, Giles & Wiemann, 1991, p. 346). In management culture, individual interests get subordinated to whole or collective objectives. The role is an essentially collectivist one, emphasizing strategic planning, establishing the corporate mission and goals of the organization. . . . In contrast, medicine's values lay emphasis on the individual, the assumption being that the doctor will work on behalf of the best interests of the individual patient. Clinical Directorates. Following the recommendations of the Griffiths Report, hospitals have created units responsible for taking decisions about priorities and resources. Doctors, therefore, have been invited to suggest solutions to managerial problems, and are expected to account for their spending, to the hospital general manager. The model adopted for turning doctors into managers is that of the clinical directorate, in which doctors, as directors; assume responsibility for the performance of particular part of hospital's activity. Clinicians must participate effectively in the utilisation of resources and help to generate further resources for the hospital to care for patients. . . . The main tasks of clinical director include the definition of strategy for developing and improving services for patients, the setting of priorities for the budget and the provision of timely and accurate information about the performance of services. With responsibility for these tasks comes the accountability of the clinical director to the hospital. The 'Problem' of Controlling Expenditure Resource Management Initiative. significant component of clinical directorates is resource management initiative, which evaluates the success with which clinicians have carried out their responsibilities and measures the various elements of cost involved in medical decision making (Blackler, 1993, p.863-884). The idea is to encourage hospital managers and clinicians to agree on objectives and priorities and to devolve responsibility for their accomplishment to tiers of authority further down the hierarchy ("Initial Project Plan", 1989, p. 98). No specific formula has been set down, any generally accepted means of measuring whether improvements in patient care have been achieved, and there are no objective standards by which goals can be put in order of priority. The idea behind the system is to improve patient care by giving doctors and nurses greater role in the management of resources and devolving responsibility for budgets to clinical teams within hospitals, enabling managers to negotiate workload agreements with these clinical teams, and improving information systems to provide staff with better data about their services (Clatworthy & Mellett, 1997, p.41-46). However: the costs of implementing resource management were underestimated and . . . the process of involving doctors is more complex and time consuming than had been assumed. Research also suggests that there are few tangible benefits yet to emerge in terms of better services for patients and improved value for money. . . . Even after five years of experimentation . . . no hospital is yet able to claim to have fully developed resource management process in place in which doctors and other staffs is involved in the way envisaged in the Griffiths Report (Clatworthy & Mellett, 1997, p.41-46 ). There is obvious merit in including doctors in the management of health care resources, but this involvement significantly affects the traditional concept of the doctor-patient relationship. Clinicians now have managerial obligations to hospital managers as well as to patients, so that the director's own clinical practices, and those of the colleagues for whom he is responsible, may be modified. Some will ask: how far can considerations of management interfere with relations between doctor and patient This is surely matter driven solely by clinical considerations which provide the basis of the relationship of trust between doctor and patient. Medical audit and clinical practice guidelines have provided means of encouraging doctors to re-appraise their own practices and priorities (Cyert& March, 1963, p.213). Medical Audit. 'Medical audit can be defined as the systematic, critical analysis of the quality of medical care, (Harrison, 1997, p. 27-31) including the procedures used for diagnosis and treatment, the use of resources, and the resulting outcome and quality of life for the patient.' The logic of medical audit is to encourage doctors to adopt critical and evaluative attitude to medical decision making. If, as some research suggests, patients are sometimes treated more from habit than positive choice about clinical benefit, then the process ought to enable the light of experience to shine on those practices which are ineffective or inappropriate compared to others. Audit is voluntary system of assessment which may be applied to the whole range of medical services, from the treatment offered to individuals to the large-scale assessment of medical technologies. For example, the extensive research conducted into treatment regimes has demonstrated the value of low doses of aspirin to those at risk of heart attack, that amniocentesis carries risk of miscarriage and may cause breathing difficulties, and that an extension of day-case services provides good quality services to patients and excellent value for money. In future, hospitals will increasingly be expected to show what proportion of patient's survived surgery so that comparisons between hospitals, and between surgeons, can be made. The principle of medical audit appears to be extremely valuable ("Institute of Health Service Management", 1990, p.45). Although the large-scale studies carry persuasive authority, the value of audit when applied to individual doctors is more difficult to assess (Harrison,1997,p. 27-31). Some regard the whole process with suspicion and consider it waste of time and effort. The extent to which doctors and other medical staff have become involved varies from place to place, as do the ways in which audit has been introduced. survey of audit procedures adopted in hospitals revealed that there is no consistency as to the composition of the audit team, except that consultants are generally included and patients are almost always excluded. Nor is there common practice concerning the medical evidence on which the audit is conducted. Case note review is the most common, mortality and morbidity review less so, and patient surveys are used only rarely (Harrison, 1997,p. 27-31). The 'Problem' of proper prescribing of drugs, choosing doctors and referrals Clinical Practice Guidelines. One of the effects of medical audit has been to reveal the extent of practice variations between doctors (Holliday, 1992, p.12). The habitual, rather than rational, way in which some operate, and the difficulty in justifying both the outcomes of their treatments and the differences in their costs, have significantly promoted the idea of clinical practice guidelines. They have concerned matters of clinical practice and hospital management, and have been formulated on the basis of both local experience and the recommendations of national professional bodies. As the experience of audit accumulates, their number is likely to increase ("Institute of Health Service Management", 1990, p.45). The development of guidelines is part of significant cultural shift, move away from unexamined reliance on professional judgment toward more structured support for, and accountability of, such judgment. The explosion of medical information and the increased complexity in today's health care system has made this support necessary. . . . Moreover, the need for standards in terms of administrative accountability to the payers--private insurers, corporations and government--has spurred the development of guidelines (Burch & Wood, 1983). Non-Clinical Regulation. The managerial techniques discussed above remain within the control of doctors themselves. By contrast, the following are imposed on doctors by managers ("Institute of Health Service Management", 1990, p.45). Choice of Medicine. The cost of medicines to the NHS increases relentlessly and there is concern that not all of it is justified. 'Although much of the variation between prescribes can be explained by factors such as age, there remain wide unexplained differences.' In its report on Repeat Prescribing by General Practitioners in England the National Audit Office estimated that, of total of 2.6 billion paid by the Department of Health for prescriptions, perhaps two-thirds were prescribed on repeat basis. No doubt, as the report acknowledges, there are many advantages for both doctor and patient in avoiding the need for frequent consultations during long-term therapy. Equally there are disadvantages, both clinical and financial, if the patient's compliance with the therapy, or benefit (or harm) from it, are not regularly monitored. Without more research, there is no more than suspicion that unregulated repeat prescribing ought to be discouraged, and that closer supervision over the practice could achieve savings. On the other hand, medicines are often extremely cost-effective. They may obviate the need for admission to hospital or surgery. Indicative Prescribing Amounts. Concern about the irrational use of medicines has led the Government to introduce scheme designed to put downward pressure on prescribing. GP spending on pharmaceuticals is now subject to regulation by indicative amounts, or 'target budgets'. The scheme, which does not apply to GP fund-holders, requires Fuses to impose notional amount on GP drug spending. The corresponding duty of GPs is contained in section 18 of the 1990 Act: 'The members of practice shall seek to secure that, except with the consent of the relevant Family Health Services. Authority or for good cause, the orders for drugs, medicines and listed appliances given by them . . . in any financial year [do] not exceed the indicative amount notified for the practice.' The stated object of the scheme is not to inhibit clinical discretion. Indeed, it is incapable of doing so because GPs have an existing obligation to Fuses under their Terms of Service to 'order any medicines or appliances which are needed' by their patients. In proper circumstances GPs will be entitled, indeed expected, to exceed the amount prescribed by the FHSA. One of the salient principles underlying the scheme is of the 'patient's entitlement to receive all the medicines they [sic] require'(Holliday, 1992, p.12). An influx of new patients to the list, or unexpectedly expensive requirements from particular patients, would justify exceeding the recommended amount. However, the ultimate sanction against overspending is for deduction to be made from GP's remuneration when: 'the cost of any drug or appliance ordered by doctor on prescription form in relation to any patient is, by reason of the character of the drug or appliance in question or the quantity in which it was so ordered, in excess of that which was reasonably necessary for the proper treatment of that patient.' One would expect discussions between GPs and Fuses to avoid the need for invoking this procedure, so that it will be used very rarely. Clearly, drug costs present challenge to the NHS which has not been properly addressed. If restrictions are to be imposed on GPs, the matter cannot be made the responsibility of FHSAs. Their duty is to ensure that GPs adhere to the Terms of Service by prescribing the medicines which patients need. Any other duty designed to curb responsible clinical freedom exposes them to an unacceptable conflict of interest. If particular treatments are to be restricted, the matter ought to be considered at national level under the supervision of the Secretary of State. Such discussion will have far-reaching implications for the doctor-patient relationship, as well as for the basic obligation of the Secretary of State to provide 'comprehensive health service' under the National Health Service Act 1977. For the present, limited attempt to consider the problem has been made in relation to the use of local formularies and selected lists of medicines(Bacon & Eltis, 1976). Local Formularies and Selected Lists. One method of containing costs is to limit the variety of drugs which doctors may prescribe to patients. Such restriction already operates in the form of 'black-list' of drugs for which GPs may not issue an NHS prescription. The list was introduced in 1986 and was intended to save money by discouraging use of 'drugs which were considered to be unsafe, obsolete, or of marginal therapeutic value.' There are new proposals to extend the blacklist to cover drugs which have greater therapeutic value, including contraceptives and drugs acting on the skin; this raises further important issues about clinical freedom (Black & Champion, 1976, p. 234). more positive approach has been suggested: that we should be more specific about preferred medicines by introducing 'whitelist' of medicines, or Selected List, which covers the cross-section of patients' needs and from which doctors should always prescribe. The House of Commons Health Committee has recommended logical extension of this argument: that there should be National Prescribing List for the entire service. The Committee suggests that all new drugs should be granted product license in the normal way, but that the medicine should be evaluated over five-year period during which time its therapeutic value would be assessed by clinical trials. Those which were found to be ineffective, or more expensive without additional therapeutic value, could be excluded from the National List. In this way national formulary could be created. These proposals are currently under review by the Government. Choice of Consultant: Extra Contractual Referrals. In the past, the recommendation of the British Medical Association has been that 'general practitioners should always acquiesce in any reasonable request by patient for second opinion' with the presumption that the choice of consultant was matter for the referring doctor to decide (Holliday, 1992, p.12). NHS contracts under the National Health Service and Community Care Act 1990 require District Health Authorities to make agreements with hospitals with respect to the services required by its residents. In doing so, they will seek to make provision for those most often in need of care and the most common conditions of illness. Inevitably, however, cases will arise for which contracts have not been made, perhaps because the condition is too uncommon to justify the creation of an NHS contract. Patients in such cases are treated under an extra contractual referral (ECR), i.e. referral to hospital provider which has no contract with the patient's district of residence. ECRs may create problems for DHA purchasers. Often it will be difficult to predict how much money should be held in reserve. The problem also arises with respect to 'tertiary' ECRs, in which the patient is referred by the hospital in which he is being treated to another unit for specialist care. Such referrals may require more lengthy or complicated treatment than anticipated and, being 'one-off' in nature, are difficult to cost in advance. Often, the most attractive arrangements between district and hospital will be on the basis of large volume of work on regular basis. Assessment of aggregate costs of treatments is greatly assisted by volume. In this way, reasonably accurate assessments are not affected by exceptional cases. But when the number of patients concerned is small the risk of exceptional post-operative complications (e.g. requiring hospital bed for two weeks rather than the anticipated two days) makes forecasting unreliable. Since these extraordinary expenses are more difficult to accommodate when numbers are small, there is cost advantage in agreeing to block contracts on large scale. By contrast, by allowing for the risk of complications, 'one-off' referrals will tend to be more expensive (Child, 1984). This system will only work effectively if GPs are prepared to adhere to the arrangements made by the DHA, by referring their patients to hospitals with whom sizeable contractual arrangements have been established (Black & Champion, 1976, p. 234). Referrals should be made when clinically required. This will reassure those with uncommon conditions for which their DHA has not arranged block contract, and those whose conditions become so serious as to require specialist facilities as tertiary referrals. Arguably, the requirement of 'comprehensive' health service obliges the DHA to take reasonable steps to provide treatment for all its residents taking account of national resources. Of course, demand for particular treatment may be so low, or its cost so high, or its efficacy so unproved, that facilities are not available from any hospital. In this case the treatment will not be provided. But if it is available, it ought never to be denied simply on the ground that no contract has been arranged under which it may be treated. comprehensive National Health Service requires more than patchwork of uncoordinated local facilities (Holliday, 1992, p.12). The system of health service resources ought to be examined from national rather than local perspective, and reasonable reserves ought to be set aside to allow deserving cases to receive extra contractual treatment (Barrett & Fudge, 1981). Some money, therefore, must be allocated by DHAs to cover the costs of ECRs. Health authorities have records of previous referral patterns and are obliged to make reasonable provision based on their past experience. failure to cater for known demand, either by contractual or extra contractual means, would require explanation. Equally, one must concede that money has always been short in the NHS and that there is nothing new about waiting lists. For this reason, it would be difficult to criticize an authority which put sufficient funds aside to deal with emergency and urgent cases on an extra contractual basis, but which consigned to waiting list those patients whose conditions could reasonably be considered to be of secondary priority. These patients would wait funding from the following year's budget (Child, 1984). Conclusion The management structure was reorganized and new methods of communication have been put in place. All of the Trust board meetings are now open to members of staff and the general public to attend, newsletters are distributed on regular basis, and team briefing process has been introduced. There have also been other initiatives such as increased availability, top-level commitment to staff training, an introduction of scholarship schemes and renewed look at staff facilities. These have begun to address some of the concerns expressed in the questionnaires that formed part of the management consultant's review. The NHS has faced constant barrage of change over the last 20 years and this group of hospitals is far from being unique in the difficulties it faces. Many of these difficulties are recognized and work is now underway to rectify some of the problems identified. References Astley, W. G., & Van de . H. Ven (1983). "Central perspectives and debates in organization theory". Administrative Science Quarterly, 28, 245-273. Bacon & Eltis (1976). 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