Professor Tracey McDonald AM PhD FACN, National Lead Clinician: Ageing, 2014
In economic terms, ‘efficiency’ means getting the most benefit for the least investment, without transgressing health care regulatory requirements or killing anyone. Cycles of efficiency dogma come and go in the health care system, and each time something is lost. ‘Efficiency’ diminishes us in various ways.
I am not convinced that the people driving the current ‘efficiency wagon’ realise that being efficient must incorporate being effective to achieve the service goals defined for the health care system and the people using it. While non-financial measures enable us to claim that our health care system is ‘world class’ or ‘excellent’, rarely, if ever, do we hear public announcements that our health services are financially frugal and or that no laws have been broken.
Health care managers and clinicians have different roles
In complex systems such as health care, competing priorities and vested personal and professional interests continually struggle for control of scarce resources. At the heart of this contest is the natural tension that exists between clinicians, and managers or administrators who both pursue laudable goals.
Role of clinicians
Clinicians are appointed because of their depth of accumulated knowledge and skills in a particular health discipline. They apply these skills in a clinical setting to generate health benefits for their patient, client or customer. The most crucial interpersonal skill for clinicians is communication in close circumstances to build a therapeutic relationship with patients and a collegial relationship with colleagues. Clinicians’ activities are geared to particular tasks that will help patients regain or maintain health and functional capacity.
Role of health care managers
Health care managers are appointed to ensure the organisation survives and prospers. Their administration is hierarchical, as is their required leadership style, and they work to design and refine the processes of systems that deliver utilitarian or collective welfare.
Managers rarely focus on a single person, unless that person is seen as having a problem to be solved or as representing a problematic group. Managers need interpersonal skills to direct and control a group of people through a range of mechanisms that will generate a pre-set result. There is a natural tension between the goals of managers focused on the good functioning of the organisation, and clinicians who are focused on individual patients in their care and who try to advocate for them within the organisations that may or may not be sufficiently resourced to support the clinician’s efforts to treat patients successfully.
Wending their way through all of this is the diverse and extensive array of people who come to all types of health services in search of care, treatment, support and sometimes protection.
Managerialism distorts clinical priorities
For the past decade, the importance of ‘managerialism’ has trickled down to become an increasing part of clinician responsibility.
In many clinical areas now, clinicians are expected to be local administrators and must meet productivity criteria set by line managers with an eye to profit or surplus (so that the managers can meet their own performance indicators). Mostly these administrative tasks (referred to by clinicians as ‘administrivia’ involve endless checklists and routine throughput reporting.
The danger of clinical priorities being distorted by such tasks to such an extent that managers have been known to set key performance indicators for clinicians working in their unit, that include looking for and reducing ‘unnecessary’ admissions of older adults. The obvious problem with that is, clinicians who fail to reduce access to health services by older adults who distort the unit’s performance statistics by not healing as well or as quickly as younger people, are seen as undermining the efficiency rating of the service.
Efficiency jargon is also applied to clinical pathways, with administrators/managers deciding how much time each step along the pathway to recovery should take, and how much clinician time is required to achieve this efficiency gain.
Clinicians working in these environments can be pressured into pushing patients through the system as quickly as possible, despite:
The danger in rapidly processing people through health services is that core elements of clinical interventions can be compromised on the bonfire of organisational efficiency.
Of course, if five clinicians can achieve these efficiencies then four should be even more efficient. Expectations of ‘continuous improvement’ could indicate that three could be the ultimate goal – provided the clinicians don’t collapse or run away!
Shifting the health care risks
Management efficiency measures can create constraints on time, personnel, equipment and space, and leave insufficient time to:
This means that risks are being shifted onto patients and families who continue to believe the rhetoric about Australia’s health care system being world’s best. Because they must, people trust their clinicians who tell them that it’s OK to go home even though they don’t feel well enough. Usually, it all works out and disasters don’t happen - often.
But is it really efficient for health services to sacrifice clinical standards for economic efficiency?
Is it efficient to expect patients and the community to compensate for the health system when things do not go as hoped?
There seems to be little research interest in calculating the personal and economic burden of misdiagnosed and undiagnosed health problems as a result of under staffed and poorly resourced clinicians caused by efficiency constraints.
Of course, it is possible that I have completely missed the point. If the word ‘efficiency’ has become a code word for ‘risk shifting’, then the phenomenon of creeping administrivia in the clinical space makes marvellous sense.