Friday, 14 November 2014

Averages don't tell the whole story

There is an obvious danger that anyone objecting to Cameron’s insistence on continuing intervention in discussion on the Welsh NHS is seen as being a supporter of a service which is failing.  And indeed, some of the responses coming from the Welsh Government do make it appear that they are more concerned with the politics of the matter than with addressing the very real problems that the NHS faces.  The fact that Cameron’s intervention has more to do with politics than with health is no excuse for responding in the same vein.
Part of the problem is that there’s a great deal of heat, but not a lot of light.  Last week, Cameron again drew attention to the difference in waiting times for diagnostic tests, where 30% of people in Wales wait for more than 6 weeks, compared to only 1.5% in England.  In purely numerical terms, that’s a shocking gap between two neighbouring countries, but there’s much more to this than averages can reveal.
From the perspective of each and every individual patient, whether they’re part of the 30% in Wales or the 1.5% in England is irrelevant; the figure for them as individuals is 100%.  And given the small size of Wales compared to England, even on those figures there are almost as many individuals waiting longer than 6 weeks in England as there are in Wales.  If it were really the best interests of patients driving Cameron’s concern, he could halve the total number of people waiting more than 6 weeks in EnglandandWales by eliminating the 1.5% in England, where he does actually have direct responsibility.
There’s another thing about averages as well; whilst they tell the headline story, they hide the detail.  These are averages for all specialities across all locations; there will be a lot of variation in there.  Are there no specialities in particular locations in England where the lists are longer than for the same speciality in some locations in Wales?  I don’t know; but I do know that overall averages will never tell us that.
And how about urgency?  A 6 week target for all tests of all types is nice and easy to shout about, but as a patient, there are some tests that I would want to have immediately, and others that I wouldn’t mind waiting a while for if priority was being given to those in greatest need.  Again, an overall average will never tell us anything about that; yet from a patient perspective, it’s outcomes which matter more than anything.  If Wales could achieve a much lower average (and thus undermine Cameron’s argument) by concentrating on doing the least urgent cases first (if, for instance, they were easier to do), would anyone really think that was the right thing to do?  Fixing the numbers isn't the same as fixing the problems.
Let me stress this: I don’t know the answer to the questions I raise above about the detail underlying the averages.  But I doubt that Cameron does either.  Worse, I’m not sure that he really cares; he’s only after making a political point which has more to do with winning English constituencies in the upcoming election than it does with care for the wellbeing of Welsh patients.
But the underlying problem here isn’t the politics of health, nor the way that politicians use statistics (although it would help if some of them were a little more numerate).  It is that, in Wales as in England, there is a target-meeting approach to managing the health care system, and as long as that continues, the Welsh Government is inviting this sort of criticism. 
Whilst we’d all like to be able to have whatever tests we need ‘on demand’, what really matters to patients is whether we get the tests (and treatment) we need at a time which makes a difference to the outcome for us.  In some cases, that may well be very much less than 6 weeks; in other cases, it could be longer.  Do we want our doctors to be deciding what to do on the basis of meeting a simplistic target to keep the politicians happy, or on the basis of meeting the clinical needs of patients?


Anonymous said...

The consequences of devolution are now sharply being brought into focus. Consequences that, for some, are not particularly welcome especially in the areas of healthcare and education.

But it matters not how much the NHS crumbles in Wales or, for that matter, England. There will always be ways and means of securing appropriate and timely treatment. It's up to individuals to take responsibility for themselves. Margaret Thatcher taught us this long ago.

Should it be like this? Well yes, because we voted for devolution. Will it improve. No, I very much doubt it, it's going to get worse.

The secret to a good life in 'devolved' Great Britain is to own or rent a property in at least two or more of the devolved regions. And if not a property then try having children living in one of the devolved regions and you living in another. And if not children then good friends who you can go and stay with for extended periods of time. Perhaps a caravan in the garden or some such. By so doing you can take advantage of whatever is best in each region, be it healthcare or education, pick and mix, choose as you see fit.

Yes, I know, it's bad for the poor. But jolly good for the wealthy. Those wealthy that never voted for devolution in the first place.

Perhaps the poor and poorly educated should take time to reflect.

G Horton-Jones said...


You are totally correct
I have some experience with the Ambulance service in Wales -- specifically Swansea though I now live in Pembrokeshire

It is impossible to meet incident attendance times in the targets given. Time in emergencies are not the sole criteria. Patients were and are road transported at 20 mph under escort That said

Ambulances inc fast response vehicles these days are very well equippped and it is this fact alone that means a person can be stabilised in an ambulance and be looked after on a one to one basis until acceptance into A and E.
In many ways the Ambulance staff are the first stage and in many cases the most critical stage of the A and E process

Anonymous said...

'Do we want our doctors to be deciding what to do on the basis of meeting a simplistic target ........ or on the basis of meeting the clinical needs of patients?

In think most would be happy with either.

At the moment appointments are determined by the administrative clerical staff responsible for sending out letters confirming appointments. And it is the management of these staff that determine who gets what appointment when.

Doctors don't get a look in!

Anonymous said...

I've always thought the existence of 'targets' to be an indication of bloated middle management in a dysfunctional organisation. Even more so where the product or service is bespoke, as inevitably healthcare must be. It's just a mechanism for middle management to shuffle blame around. When you go into a food establishment and they have a 'tick sheet target' finned to the toilet door saying when it was last cleaned it just indicates that management have a dirty toilet problem and don't trust the front line staff to take on cleaning duties in a professional manner. As far as 'waiting list targets' in the NHS is concerned, as no patient is the same as another, there must be some clerk pigeon-holing ailments into categories to be stop-watched. Patients inevitably have complications and issues, and are often 'parked' under clinical supervision to decide what form of, and how treatment can be progressed. It's nonsense for example, to say patients get a scan quicker in England if they're getting an on-the-spot ultrasound scan which only gives a preface to a condition when, for example an expensive full MRI scan would actually speed if the full term treatment of the patient as more information can be obtained. Also, it would be clinically appropriate in some cases to park treatment of patients for one condition in order to treat a more serious condition. In the recent England v Wales spat in the media, some examples were exposed where actually the clinician deliberately delayed treatment because the patient first had to loose wait or time was needed to ensure existing medication was effective or tests to be done where alternatives might be harmful. The devil is in the detail, and who decides when the 'clock starts' on a waiting time target?

G Horton-Jones said...

Medical Targets are all related to payment/financial systems hence if you want to make say 75k per year you have to do y number of consultations x number of hysterectomies and so on
The clinical needs of patients are in theory open ended financially.
General practitioners are what it says on the tin ie generalists so they are essentially number crunching consultations across the population spectrum

G Horton-Jones said...

Toilet cleaning tick boxes are there to perform a number of functions one of which is to record that staff have cleaned and reequipped the toilet at intervals after public use or should I have said abuse

I rather admire the way the French after WW1 gave war widows the opportunity to man toilets across France in order to supplement their income or lack thereof but that is an aside.

Here in Wales however we could offer manning toilets within the unemployment benefits/ criminal rehabilitation or to pensioners as a tax free supplement

As with all my comments If you would like to take up an opportunity as described above I will make the necessary arrangements for a loo for you near you