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Some lessons from the past

I was looking through old notes from my Trinity MBA year, when I came across a pile of Harvard Business Review (HBR) magazines. They’re from a decade ago so I wondered if they were still relevant or not.

No and yes.

The big issues at the time were recession due to the collapse of the dotcom bubble, and the financial scandals that brought down companies such as Enron and its accountants, Arthur Andersen. But government regulation was making capitalism safe again.

If only they knew what was coming to the global economy a few short years later.

A decade ago, there was a recurring concern in the US about over-capacity across industry. We do not have that problem in Irish hospitals. It’s the opposite.

Some articles have not dated well.

Charles Handy is probably a little embarrassed at his praise of BP for promoting sustainable development. Not long after, there was the Deepwater oil disaster in the Gulf of Mexico. Then there’s the author who wrote about Greg Dyke as a model Director-General at the BBC. He was gone shortly after it was published.

There are no articles on health, even though an astonishing 16 per cent of GDP in America is spent on health. In passing, I wonder why on earth we look to American health systems for ideas, given that staggering cost.

Lots of articles are still of interest, for all sorts of reasons. There’s a thoughtful review of greed, and its acceptability, through different times and cultures. An account of tiny ancient Athens, defeating the might of the Persian Empire at Salamis, has insights for us today.

Job satisfaction requires a sense of achievement. I reckon it can’t happen, for doctors or nurses, while our hospitals stagnate with trolley wards

Frederick Herzberg’s amusing and classic article on motivation could be published now. He points out that the causes of job satisfaction and job dissatisfaction are not the same. I find it relevant to the NCHD exodus. Falling salaries and long hours will surely cause job dissatisfaction; changing them may not be enough to create job satisfaction.

After all, nurses are also fleeing the Irish system, even though they don’t work NCHD hours. And if shorter hours are the key, filling posts in EDs shouldn’t be such a problem. The shift systems keep the hours down.

No, job satisfaction requires a sense of achievement. I reckon it can’t happen, for doctors or nurses, while our hospitals stagnate with trolley wards. It’s so disrespectful to doctors and nurses, as well as to the patients.

There are many HBR articles about identifying which customers are costly or profitable. None of them suggest getting rid of the low-cost, easily-profitable customers. That’s what the health service does whenever it outsources waiting list patients to the private sector.

It would make more financial sense to keep the easy, profitable patients and contract out the confused and immobile patients, who have multiple, complex problems. Nurse staffing levels could be kept low but the wards would be safer than they are now. It might not be kind to patients but it would cut costs.

Big projects fail in business, apparently, just as they do in healthcare. Actually, they fail more than half the time. Daniel Kahneman, Nobel laureate and best-selling author, wrote that the problem is overly-optimistic forecasts which exaggerate the benefits.

I suppose PPARS would be in that category. But there may be others: what about re-configuration? I hope it doesn’t apply to the ‘Big New Idea’ — activity-based funding of health.

In one of my MBA projects, I tried to do activity-based costing at ward level for an accounting course. I wasn’t very successful. It’s so hard to cost such a complex system. Good luck to them!

Under the current HSE system, patients sent home from medical assessment units are counted together with inpatient discharges. I find it very odd, a form of cooking the books. After all, assessment units have turned out to be a ‘false god’. They provide a valuable service but — what a surprise — hospital admissions keep going up. According to some colleagues, referrals to OPD have gone down instead.

To measure output, activity-based funding is using HIPE data based on hospital discharge letters.

Yes, in future our hospitals will be funded based on the information in the (often wildly innacurate) discharge summaries. Most doctors laugh hysterically at the thought. But it’s already underway.

I wonder what changes in behaviour are expected from activity-based funding. There is no capacity in any part of the system so it’s hard to see what change in practice there can be.

A final word from Harvard Business Review: beware of GroupThink and don’t ignore the naysayers!

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