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Counting on the NHS

December 3, 2014

By Basket Press

 We all know how to count, don’t we? But there’s counting – and then there’s NHS counting. It’s been in the news quite a bit recently (here and here for example) so let’s have a closer look.

First, we must acknowledge something exists to be counted (who knew you need high level understanding of phenomenology and epistemology to be a nurse?). How can you count something if you don’t acknowledge it’s there to be counted? Allied to this is an arcane argument about how what might be there to be counted is defined. Does it exist as an object to be counted or not? And if it meets the necessary criteria for counting, could it sometimes fail to meet them? Or (in as much as permanence can be said to exist) is that definition permanent?

Then there is the “when” of counting. At what time does a thing exist or not exist for counting purposes? This can lead to a huge detour into the nature of time itself, which is sometimes necessary for absolute clarity about “when”. Because clarity is paramount, isn’t it?

Where does something have to be to be counted? How do we define its position in space and the boundaries of the area containing it? Topology now! This is why nursing needs to be an all-graduate job! Has counting occurred if a certain group of people have not seen the numbers? Does its existence depend on who sees the figures? Must we consider the effects an observer may have on the counting? So, quantum phenomena may be involved also.

Then what happens after something is counted? Is the counting a discrete event? Does something else follow? Is this also counted? And if not does that exist? Or does the thing cease to exist after official counting?

Broaching moral and ethical philosophy, there are related questions about who can count, and what happens if the wrong person counts? And who might be a wrong person? And what is the nature of their wrongness?

Or if someone repeats a figure several times does that mean it exists several times? This is most usually applicable to money and is often described as The Blair Gambit or more recently The Clegg Manoeuvre or The Lamb Effect.

It’s tricky stuff: it’s no wonder politicians can never agree on figures relating to anything to do with the NHS; the poor dears must be tied up in philosophical, conceptual and mathematical knots just trying to understand the essential nature and meaning of what they are dealing with. Mediaeval theologists and their angels on pin heads? Lightweights compared to those who have to do battle with NHS counting!

That’s the theory, now the practicalities. A favourite NHS thing to count is waiting time, which, surely, is straightforward? No. In no particular order, let’s break this one down…

Who is to be counted? GP makes referral, referred person is counted as waiting. No. Some specialist services, like many Child and Adolescent Mental Health Service (CAMHS) teams I worked in, will look at a referral and decide if it fits the criteria for acceptance (which GPs have). Many – often up to 50% – do not and can be dealt with elsewhere. In other cases, there is so little information that acceptance is impossible. So counting may start only once a referral is accepted.

At times only certain patients exist for waiting time counting purposes. In the days of GP Practice-Based Commissioning (PBC), it was only those whose GPs opted into PBC who did. This led to huge numbers not officially existing, and to clinical distortions, as we were instructed by management to see PBC GPs’ patients before others within whatever arbitrary time limit we had, regardless of clinical need. So low-clinical-priority Johnny, from a PBC GP, might be seen before higher-clinical-priority Joanne, from a non-PBC GP – because Johnny officially existed and Joanne didn’t. Cue disputes between clinicians and management.

That stopped. But we soon had a new game called “When is waiting not waiting”. To play successfully one needs an elastic interpretation of professional ethics, as one is deliberately setting out to mislead patients. In essence all those referred are seen within the arbitrary time limit for a one-off appointment, so they come off the official waiting list and managers and politicians are happy because the figures are good. What happens to the patients after that? They sit on something that doesn’t exist (except for when it does): an internal waiting list.

This has been endemic for years. Managers like it; most clinicians don’t. Unwilling or unable to stand up to managers, many colleagues go along with it, and it gradually becomes the way things work. (I note that the first team leader I knew who actively endorsed this approach gained rapid promotion to senior management, while the other team leaders in the same service opposed the practice and were ostracised). It’s sometimes described as “screening” or “triage”, which is fine if decent records are kept of those “screened” and the suggested outcome. But when this doesn’t happen, patients disappear. It’s a harder trick to pull off with electronic record systems, but you still needs to know that there is something to look for before you can begin to get to grips with “where”.

Misuse of the Choice And Partnership Approach (CAPA) MODEL in CAMHS has made this sort of not-an-internal-waiting-list more common, as CAPA is often not implemented properly, but is used as a screening or triage tool to disguise waiting times. As I said, a deliberate attempt to mislead. This distortion of CAPA is completely against what its developers say should happen (I’ve met them, spoken to them, and read their literature).

Has counting happened if the “right” people don’t see the figures? Back before electronic record systems, my service submitted monthly clinical activity figures to senior management, who passed them to the commissioners. Or did they? I know our figures were collated and submitted to the right person at the right time, as I was one of those responsible. But for two years the numbers went no further, i.e. the commissioners never received any clinical activity figures for the service. They concluded we did nothing, leading to mythology about us being the most expensive service in the country.

The question remains: can we believe anything politicians or managers tell us about what is happening in the NHS? I doubt it: I didn’t really know and I was in the thick of it, trying to make sense of what happened around me, trying to square that with what I was told was happening, trying to remember which counting tool was being used that week and what set of definitions were in use.

Suffice it to say, you cannot believe waiting time figures as presented by politicians or management, as they will have been manipulated some way, somehow, to show what whoever is presenting them wants. Truth is that no-one really knows what is happening in terms of patients waiting for treatment, because no one is looking for an accurate, objective, repeatable measure from which meaningful, consistent conclusions may be drawn. They’re looking for people to do as they are told.

A lot of information does exist, but I am not convinced it is always the right information nor that it is used in any meaningful manner.

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