{"id":2822,"date":"2013-02-23T13:28:31","date_gmt":"2013-02-23T13:28:31","guid":{"rendered":"http:\/\/www.saasoft.com\/blog\/?p=2822"},"modified":"2013-02-23T13:28:31","modified_gmt":"2013-02-23T13:28:31","slug":"creep-crack-crunch","status":"publish","type":"post","link":"https:\/\/hcse.blog\/?p=2822","title":{"rendered":"Creep-Crack-Crunch"},"content":{"rendered":"

The current crisis of confidence in the NHS has all the hallmarks of a classic system behaviour called creep-crack-crunch<\/strong>.<\/p>\n

The first obvious crunch may feel like a sudden shock but it is\u00a0usually\u00a0not\u00a0a complete surprise and it is\u00a0actually one of a series of\u00a0cracks\u00a0that\u00a0are leading up to a BIG CRUNCH. These cracks are\u00a0an early warning sign of pressure building up in parts of the system\u00a0and\u00a0causing localised\u00a0failures. These cracks\u00a0weaken the whole system. The underlying cause is called creep<\/strong>.<\/p>\n

\"SanFrancisco_PostEarthquake\"<\/a><\/p>\n

Earthquakes are a perfect example of this phenomemon. Geological time scales are measured in\u00a0thousands of years and we\u00a0now know that the surface of the earth is a dynamic structure with vast\u00a0contient-sized plates of solid rock floating on a liquid core of molten\u00a0magma. Over millions of years the continents have moved\u00a0huge distances and the world we see today on our satellite images is just a\u00a0single frame\u00a0in a multi-billion year geological\u00a0video.\u00a0 That is the geological creep<\/strong> bit. The cracks<\/strong> first appear at the edges of these tectonic plates where they\u00a0smash into each other, grind past each other\u00a0or are pulled apart from each other.\u00a0 The geological\u00a0hot-spots\u00a0are\u00a0marked out on our global map by\u00a0lofty mountain ranges,\u00a0fissured earthquake zones, and deep mid-ocean trenches.\u00a0And we know that when a geological\u00a0crunch<\/strong>\u00a0arrives it happens\u00a0in a blink of the geological eye.<\/p>\n

The\u00a0panorama above shows the devastation of San Francisco caused by the 1906 earthquake. San Francisco is built on the San Andreas Fault – the junction between the Pacific plate and the North American plate.\u00a0The dramatic volcanic eruption in Iceland in 2010 came and\u00a0went in a matter of weeks but the irreversible disruption it caused for global air traffic will be felt for years. The undersea earthquakes that caused the devastating tsunamis in 2006 and 2011 lasted only a few minutes; the deadly shock waves crossed an\u00a0ocean in a matter of hours; and when they arrived the silent killer\u00a0wiped out\u00a0whole shoreside communities in\u00a0seconds. Tens of thousands of lives were lost and the\u00a0social after-shocks\u00a0of that geological-crunch will be felt for decades.<\/p>\n

These are natural disasters. We have\u00a0little or no influence over them. Human-engineered disasters are a different matter –\u00a0and they are just as deadly.<\/p>\n

The NHS is an example. We are all painfully aware of the recent crisis of confidence\u00a0triggered by the Francis Report. Many could see the cracks appearing and tried to blow their warning whistles but with\u00a0little effect – they were silenced with legal gagging clauses and the opening cracks were papered over. It was only after the crunch that we finally acknowledged what we already knew and\u00a0we started to search for the creep.\u00a0Remorse and revenge does not bring back those who have been lost.\u00a0 We need to focus on the future and not just point at the past.<\/p>\n

\"UK_PopulationPyramid_2013\"<\/a>Socio-economic systems evolve at a pace that is measured in years. So when a social crunch happens it is necessary to look back several decades for the tell-tale symptoms of creep and the early signs of cracks appearing.<\/p>\n

Two\u00a0objective measures of a socio-economic system are population<\/strong> and expenditure<\/strong>.<\/p>\n

Population is people-in-progress; and national expenditure is the flow of the cash\u00a0required\u00a0to keep the people-in-progress\u00a0watered, fed, clothed, housed, healthy and occupied.<\/p>\n

The diagram above is called a population pyramid and it shows the distribution by gender and age of the UK population in 2013. The wobbles tell a story. It does rather look like the profile of a bushy-eyebrowed, big-nosed, pointy-chinned\u00a0old couple standing back-to-back and maybe there is a hidden message for us there?<\/p>\n

The “eyebrow”\u00a0between ages\u00a067 and 62 is the increase in births that happened 62 to 67 years ago: betwee\u00a01946 and 1951. The post WWII baby boom.\u00a0\u00a0The “nose”\u00a0of 42-52 year olds\u00a0are the “children of the 60’s” which was a period of rapid economic growth and new optimism. The\u00a0“upper lip”\u00a0at 32-42 correlates with the 1970’s that was a period of stagnant growth, \u00a0high inflation, strikes, civil unrest and the dark threat of global thermonuclear war. This\u00a0“stagflation” is now believed to have been triggered by political meddling in the Middle-East that led to the 1974 OPEC oil crisis and culminated in the “winter of discontent” in 1979.\u00a0\u00a0The “chin” signals\u00a0there was another population expansion in the 1980s\u00a0when optimism returned (SALT-II was signed in 1979) and the economy was growing again. Then the “neck” contraction in the 1990’s after the 1987 Black Monday global stock market crash.\u00a0\u00a0Perhaps the new optimism\u00a0of the Third Millenium led to the “chest” expansion but the\u00a0financial crisis that followed the sub-prime bubble to burst in 2008 has yet to show its impact on the population chart. This static chart only tells part of the story – the animated chart<\/a> reveals a significant secondary expansion of the 20-30 year old age group over the last decade. This cannot have been caused by births and is\u00a0evidence of immigration of a large number of young couples – probably from the expanding Europe Union.<\/p>\n

If this “yo-yo”\u00a0population pattern is repeated then the current economic downturn will be followed by a contraction at the birth end of the spectrum and possibly also net emigration.\u00a0And that is a big worry because each population wave takes a\u00a0100 years\u00a0to propagate through the system. The most economically productive population –\u00a0the\u00a0\u00a020-60 year olds\u00a0 – are the ones who pay the care bills for the rest. So having a population curve with lots of wobbles in it causes long term socio-economic instability.<\/p>\n

Using this big-picture long-timescale perspective;\u00a0evidence of an NHS safety and quality crunch;<\/strong> silenced voices\u00a0of cracks<\/strong> being papered-over; let\u00a0us look for the historical evidence of the creep<\/strong>.<\/p>\n

Nowadays the data\u00a0we need is literally at our fingertips – and there is a vast ocean of it\u00a0to swim around\u00a0in – and to drown in if we are not careful.\u00a0 The Office of National Statistics (ONS) is a rich mine of UK socioeconomic data – it is the source of the histogram above.\u00a0 The trick is to find the nuggets of\u00a0knowledge in the haystack of facts and\u00a0then to convert the tables of numbers into something that is a bit more digestible and meaningful. This is what Russ Ackoff descibes as the difference between Data\u00a0and Information. The data-to-information conversion needs context<\/em>.<\/p>\n

Rule #1: Data without context is meaningless – and is at best worthless and at worse is dangerous.<\/em><\/p>\n

\"boxes_connected_PA_150_wht_2762\"<\/a>With respect to the NHS there\u00a0is a Minotaur’s Labyrinth of data warehouses\u00a0– it is fragmented but it is out there – in cyberspace. The Department of Health publishes some on public sites but it is a bit thin on context so it can be\u00a0difficult to extract the meaning.<\/p>\n

Relying on our memories to provide the necessary context is fraught with problems. Memories are\u00a0subject to\u00a0a whole range of distortions, deletions, denials\u00a0and delusions.\u00a0 The NHS has been in existence\u00a0since 1948 and there are not many people who can personally remember the whole story with objective clarity.\u00a0\u00a0Fortunately cyberspace again provides some of what we need and with a few minutes of surfing we can discover something like a website that chronicles the history of the NHS in decades from\u00a0its creation in 1948 – http:\/\/www.nhshistory.net\/<\/a>\u00a0– created and maintained by one person and\u00a0a goldmine of valuable context. The decade that is of particular interest is\u00a01998-2007 –\u00a0Chapter 6<\/a><\/p>\n

With\u00a0just some data\u00a0and some context it is\u00a0possible to pull together the outline\u00a0of\u00a0the bigger\u00a0picture of the decade that\u00a0led up to the Mid Staffordshire healthcare quality crunch.<\/p>\n

We will look at this as a NHS system evolving over time within its broader UK context. Here is the\u00a0time-series chart of the population of England – the source of the demand on the NHS.<\/p>\n

\"Population_of_England_1984-2010\"<\/a>This shows a significant and steady increase in population – 12% overall between 1984 an 2012.<\/p>\n

This\u00a0aggregate hides a 9% increase in the under 65\u00a0population and 29%\u00a0growth in the over 65 age group.<\/p>\n

This is hard evidence of demographic creep<\/strong> – a ticking health and social care time bomb. And the curve is getting steeper. The pressure is building.<\/p>\n

The next\u00a0bit of the\u00a0map we need\u00a0is a measure of the flow through hospitals – the activity – and this data is available as the annual\u00a0HES (Hospital Episodes Statistics) reports.\u00a0 The full\u00a0reports are\u00a0hundreds of pages of fine detail but the\u00a0headline summaries contain\u00a0enough for our present purpose.<\/p>\n

\"NHS_HES_Admissions_1997-2011\"<\/a><\/p>\n

The time- series chart shows a steady increase in hospital admissions. Drilling into the summaries revealed that just over a third are emergency admissions and the rest are planned or maternity.<\/p>\n

In the decade from 1998 to 2008 there was a 25% increase in hospital activity. This means\u00a0more work for someone – but how much more and who for?<\/p>\n

But does it imply more NHS beds?<\/p>\n

Beds\u00a0require wards, buildings and infrastructure – but it is the staff that\u00a0deliver the health care. The bed is just a\u00a0means of storage.\u00a0 One measure\u00a0of capacity and cost is the number of staffed beds available to be filled.\u00a0 But this\u00a0like measuring the number of spaces in a car park – it does not say much about flow – it is a just measure of maximum possible work in progress – the\u00a0available space to hold the queue of patients who are somewhere between admission and discharge.<\/p>\n

Here is the time series chart of\u00a0the number of NHS beds from 1984 to 2006. The was a big fall in the number of beds in the decade after 1984 [Why was that?]<\/p>\n

\"NHS_Beds_1984-2006\"<\/a><\/p>\n

Between\u00a01997 and 2007 there was about a 10% fall in the number of beds. The NHS patient warehouse was getting smaller.<\/strong><\/p>\n

But the activity – the flow – grew by\u00a025% over the same time period: so the Laws Of Physics say\u00a0that the flow must have been faster.<\/p>\n

The average length of stay\u00a0must have been falling.<\/p>\n

This\u00a0insight has another implication – fewer beds must mean smaller hospitals and lower costs – yes?\u00a0 After all everyone\u00a0seems to equate beds-to-cost; more-beds-cost-more less-beds-cost-less. It sounds reasonable. But higher flow means more demand and more workload so that would require more staff – and that means higher costs. So which is it? Less, the same or more cost?<\/p>\n

\"NHS_Employees_1996_2007\"The published data says that\u00a0staff headcount \u00a0went up by 25%\u00a0– which correlates with the increase in activity. That makes sense.<\/p>\n

And it looks like it “jumped” up in 2003 so something must have triggered that. More cash pumped into the system perhaps? Was that the effect of the Wanless Report?<\/p>\n

But what\u00a0type of staff? Doctors? Nurses? Admin and Clerical? Managers?\u00a0 The European Working Time Directive (EWTD) forced\u00a0junior doctors hours down and prompted an expansion of\u00a0consultants to take on the displaced service work.\u00a0There was also a\u00a0gradual move towards specialisation and multi-disciplinary teams.\u00a0What impact would that have on cost? Higher most likely. The system is getting more complex.<\/p>\n

Of course not all costs have the same impact on the system. About 4% of staff are classified as “management”\u00a0and it is this group that are responsible for strategic and tactical planning.\u00a0Managers plan the work –\u00a0workers work the plan.\u00a0 The cost and efficiency of the management\u00a0component of the system is not as useful a metric as the effectiveness<\/strong> of its collective decision making. Unfortuately there does not appear to be any published data on\u00a0management decision making qualty and effectiveness. So we cannot\u00a0estimate cost-effectiveness.\u00a0Perhaps that is because it\u00a0is not as easy to measure effectiveness as it is to count admissions, discharges, head counts, costs and deaths. Some things that count cannot easily be counted. The 4% number\u00a0is also meaningless. The human head\u00a0represents about 4% of the bodyweight of an adult person – and we all know that it is not the size of our heads that is important it is the effectiveness of the decisions that it\u00a0makes\u00a0which really counts!\u00a0 Effectiveness,\u00a0efficiency and costs are not the same thing.<\/p>\n

Back to the story. The number of beds went down by 10% and number of staff went up by 25% which means that the staff-per-bed ratio went up by nearly 40%.\u00a0 Does this mean that each bed has become 25% more productive or 40% more productive or less productive? [What exactly do we mean by “productivity”?]<\/p>\n

To answer that we need to know what the beds produced – the discharges from hospital and not just the total number, we need the “last discharges” that signal the end of an episode of hospital care.<\/p>\n

\"NHS_LastDischarges_1998-2011\"<\/a>The time-series chart of last-discharges shows the same pattern as the admissions: as we\u00a0would expect.<\/p>\n

This output\u00a0has two components – patients who leave alive and those who do not.<\/p>\n

So what happened to the number of deaths per\u00a0year over this period of time?<\/p>\n

That data is also published annually in the Hospital Episode Statistics (HES) summaries.<\/p>\n

This is what\u00a0it shows ….<\/p>\n

\"NHS_Absolute_Deaths_1998-2011\"<\/a>The absolute hospital mortality is\u00a0reducing<\/strong> over time – but not steadily. It went up and down between 2000 and 2005\u00a0– and has continued on a downward trend since then.<\/p>\n

And to put this into context – the UK annual mortality is about 600,000 per year. That means that only about 40% of deaths happen in hospitals. UK annual mortality is falling and births are rising so the population is growing bigger and older.\u00a0 [My head is\u00a0now starting to ache trying to juggle all these numbers and pictures in it].<\/p>\n

This is not the whole story though – if the absolute hospital activity is going up and the absolute hospital mortality is going down then this raw mortality number\u00a0may not be telling the whole picture. To correct for those effects we need the ratio – the Hospital Mortality Ratio\u00a0(HMR).<\/p>\n

\"NHS_HospitalMortalityRatio_1998-2011\"<\/a>This is the\u00a0result of combining these two metrics – a 40% reduction in the hospital mortality ratio.<\/p>\n

Does this mean that NHS hospitals are getting safer over time?<\/p>\n

This observed behaviour can be caused by hospitals getting safer – it can also be\u00a0caused by\u00a0hospitals doing more low-risk work that creates a dilution effect. We would need to dig deeper to find out which. But that\u00a0will distract us from telling the story.<\/p>\n

Back to productivity.<\/p>\n

The other\u00a0part\u00a0of the productivity equation is cost<\/strong>.<\/p>\n

So what about NHS costs?\u00a0 A bigger, older population, more activity, more staff, and better outcomes\u00a0will all cost more taxpayer cash, surely! But how\u00a0much more?\u00a0 The activity and head count has gone up by 25%\u00a0so has cost gone up by the same amount?<\/p>\n

\"NHS_Annual_Spend\"<\/a>This is the time-series chart of the cost per year of the NHS and\u00a0because buying power changes over time it has been adjusted using the Consumer Price Index using 2009 as the reference year\u00a0– so the historical cost is roughly comparable with\u00a0current prices.<\/p>\n

The cost has\u00a0gone up by 100% in one decade!\u00a0 That is a lot<\/strong> more than 25%.<\/p>\n

The published financial data for 2006-2010 shows that the proportion of NHS\u00a0spending that goes to hospitals is about 50%\u00a0and this has been relatively stable over that period – so\u00a0it is reasonable to say that the increase\u00a0in cash flowing to hospitals has been about 100% too.<\/p>\n

So if the cost of hospitals is going up faster than the output then productivity is falling –<\/em> and in this case it works\u00a0out as a 37% drop in\u00a0productivity (25% increase in activity for 100% increase in cost = 37% fall<\/strong> in productivity).<\/p>\n

So the available data which anyone with a computer, an internet connection, and some curiosity can get; and\u00a0with bit of spreadsheet\u00a0noggin\u00a0can turn into pictures shows that over the decade of growth that led up to the the\u00a0Mid Staffs\u00a0crunch we had:<\/p>\n

1.\u00a0A\u00a0slightly bigger population; and a
\n2. significantly older population; and a
\n3. 25% increase in NHS hospital activity; and a
\n4. 10% fall\u00a0in NHS beds; and a
\n5. 25% increase in\u00a0NHS staff; which gives a
\n6. 40% increase in staff-per-bed ratio; an an
\n7. 8% reduction in absolute hospital mortality; which gives a
\n8. 40% reduction in relative hospital mortality; and a
\n9. 100% increase in NHS\u00a0 hospital cost; which gives a
\n10.\u00a037%\u00a0fall drop in “hospital productivity”.<\/p>\n

An experienced Improvement Scientist knows that\u00a0a system that has been left to evolve by creep-crack-and-crunch<\/em> can be re-designed to deliver higher quality and higher flow at lower total cost.<\/p>\n

The safety creep at Mid-Staffs is now there for all to see.\u00a0A crack has appeared in our confidence in the NHS – and raises a couple of\u00a0crunch<\/strong> questions:<\/p>\n

Where Has All The Extra Money Gone?<\/strong><\/p>\n

\u00a0How Will We Avoid The BIG CRUNCH?<\/strong><\/p>\n

The\u00a0huge increase in NHS funding\u00a0over the last decade was the recommendation of the Wanless Report\u00a0<\/em>but the\u00a0impact of implementing the recommendations has never been fully explored. Healthcare is a service system that is designed to deliver two intangible products – health and care. So the major cost is staff-time – particularly the\u00a0clinical staff.\u00a0\u00a0A 25% increase in head count and a 100% increase in cost implies that\u00a0the heads are getting more expensive.\u00a0 Either a higher proportion of more expensive clinically trained and registered staff, or more pay for\u00a0the existing\u00a0staff or both.\u00a0\u00a0The evidence\u00a0shows that about 50% of NHS Staff are doctors\u00a0and nurses and over the last decade there\u00a0has been a bigger increase in the number of doctors than\u00a0nurses. Added to that the Agenda for Change<\/em>\u00a0programme effectively increased the total wage bill and the new contracts for GPs and Consultants added more upward\u00a0wage pressure.\u00a0 This is cost creep<\/strong>\u00a0and it adds up over time. The Kings Fund<\/a> looked at the impact in 2006 and suggested that, in that year alone,\u00a072% of the additional money was sucked up by\u00a0bigger wage bills and other cost-pressures! The previous year they estimated 87% of the “new money” had disappeared hte same way.\u00a0The\u00a0extra cash is\u00a0gushing though the\u00a0cracks<\/strong> in the bottom of the fiscal bucket that had been clumsily papered-over.\u00a0And these are recurring revenue costs so they add up over time into a future financial crunch<\/strong>.\u00a0 The biggest one may be yet to come – the generous final-salary pensions that public-sector employees enjoy!<\/p>\n

So it is even more important that the increasingly expensive clinical staff are not\u00a0being forced to\u00a0spend\u00a0their time doing\u00a0work that has no direct or indirect benefit to patients<\/em>.<\/p>\n

Trying to do a good job in a poorly designed system is both frustrating and demotivating – and the outcome\u00a0can be a cynical attitude of\u00a0“I only work here to pay the bills<\/em>“. But as public sector wages go up and private sector pensions evaporate the\u00a0cynics are stuck in a miserable job that they cannot afford to give up. And their negative behaviour poisons the whole pool. That is the long term\u00a0cumulative cultural and financial cost of poor NHS process design. That is the outcome of not investing earlier in developing\u00a0an Improvement Science\u00a0capability.<\/p>\n

The good news<\/strong> is that\u00a0the time-series charts illustrate that the NHS is behaving like any other complex, adaptive, human-engineered value system. This means that the\u00a0theory, techniques and tools of Improvement Science and value system design can be applied to answer these questions. It means that the root causes of the\u00a0excessive costs can be\u00a0diagnosed and selectively\u00a0removed without compromising safety and quality. It means that the savings can be wisely re-invested\u00a0to improve the\u00a0resilience of some parts and to provide capacity in other parts to absorb the expected increases in demand that are coming down the population pipe.<\/p>\n

This is Improvement Science. It is a learnable skill.<\/p>\n

18\/03\/2013: Update<\/strong><\/p>\n

<\/strong>The question “Where Has The Money Gone?” has now been asked at the Public Accounts Committee<\/a><\/p>\n

 <\/p>\n","protected":false},"excerpt":{"rendered":"

The current crisis of confidence in the NHS has all the hallmarks of a classic system behaviour called creep-crack-crunch. The first obvious crunch may feel like a sudden shock but it is\u00a0usually\u00a0not\u00a0a complete surprise and it is\u00a0actually one of a series of\u00a0cracks\u00a0that\u00a0are leading up to a BIG CRUNCH. These cracks are\u00a0an early warning sign of … <\/p>\n

Continue reading “Creep-Crack-Crunch”<\/span><\/a><\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[18,20,22,23,32,33,34,35,38],"tags":[],"class_list":["post-2822","post","type-post","status-publish","format-standard","hentry","category-finance","category-flow","category-healthcare","category-history","category-productivity","category-quality","category-questions","category-reflections","category-safety"],"_links":{"self":[{"href":"https:\/\/hcse.blog\/index.php?rest_route=\/wp\/v2\/posts\/2822","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/hcse.blog\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/hcse.blog\/index.php?rest_route=\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/hcse.blog\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/hcse.blog\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=2822"}],"version-history":[{"count":0,"href":"https:\/\/hcse.blog\/index.php?rest_route=\/wp\/v2\/posts\/2822\/revisions"}],"wp:attachment":[{"href":"https:\/\/hcse.blog\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=2822"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/hcse.blog\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=2822"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/hcse.blog\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=2822"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}