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 Where are we heading in “Modern” Health Services?

Although I am aware that there are significant differences between health services in different countries -and in fact within the same country-; as health worker, we all share an underlying commonality to a certain degree. I am writing this article under the assumption that, in this current era of “globalisation” and “standardisation”, there is a universal demand for the “modernisation” of health services. The health system has been forced to incorporate, within its constitution, terms such as health delivery management, strategic planning, strategic improvement, governance and quality, amongst many other fashionable words brandished around these days (the likes of which, yours truly finds confusing sometimes). However, we must accept that all of the above are part of the continuous evolution of the health service.

Before I proceed further, I would like to clarify to the readers the use of the word “modernising” in the context of this article. Here, I am referring to the involvement of numerous and diverse areas of expertise (e.g. business, aviation) within the field of health. This new approach has placed additional expectations on the clinicians, requiring them to possess reasonable knowledge in various fields. These skills include management, budgeting, cost, strategic development and other tasks which were previously left to the administration ‘to deal with’, whereas we clinicians were expected to focus on improving our clinical skills and, even more importantly, satisfying /managing our patients. I imagine that many of you will agree with me that this is a very nostalgic view, which is rarely found in this modern day and age.

I am not going to bore you with details about the health service where I work, as I do not believe it to be of significant importance; it would in fact defeat the purpose of provoking a debate relating to the key question of this article (i.e. the title). It would suffice to say that there is a pressure, as a health provider, to embrace a great deal of management, business and budgeting concepts. I am like most clinicians; work in a rapidly “modernising” health system.  Hopefully, once the reader continues scanning through the article, they will understand why I elected to use this generalization.

My guess is when we look at “modernizing” health services in different countries there appear to be a significant difference between them at first glance but once we “dig deep” and examine in depth the fundamental structure of most of the health services (wither it is private, governmental, insured, free or hybrid) I assume that the reader will find common points, at least partially.

 I, as a health provider find myself in a strange position of being instructed to be knowledgeable about “quality ” , “management”, “strategic planning” ,”updating my evidence based knowledge” , “understanding the fundamentals of accounting and budgeting”  amongst many other words, which my memory could barely remember ,let alone grasp.

The main problem is all of the above are dictated to me by different parties whose priorities (rightly or wrongly) lie within their own “primary target”.  

One could argue that all of the above could be part of one thing and by doing one; this will lead to the achievement of the others (i.e. domino effect). This is a point which I hope my article would encourage debating.

From my humble point of view, I still cannot cope with all “the priorities” I am bombarded with and I do find contradiction in many of them; especially when it comes to (if we break it down in to a simple, old fashioned targets) patients’ care versus cost which- rightly or wrongly- in my opinion, what the main issue boils up to (this is again a controversial statement and subjected to debate).

I am here not to find a solution or to offer an “ideal” way to balance a juggling act, as I am still picking up the pieces and trying again and again to be able to pull up the act efficiently in front of many anticipating audiences, each looking at me from a different angle with different expectation.

I wish that I could say that I managed but the reality is that I could not. My department and my hospital could not and more importantly my health service leaders cannot which is the most worrying concern because it is these “experts” who are suppose to guide us,  yet sometimes you feel that the blind leading the blind.

So what happened in a decade or so to lead us; and I apologies for the generalization; to be entangled in this “modernizing” health service?

I myself are nostalgic for the day when we say patient comes first and we DO mean patient comes first. Yet, I find myself focusing less on patients and looking more at statistics, strategies, missions, visions, audits, surveys etc and although (please do not get me wrong) I am all for the above, but it is becoming harder and harder to balance my already flawed juggling act.

Allow me to give an example to demonstrate what I mean. As a consultant psychiatrist, I obviously posses skills that my colleagues may lack or are not be “privileged/ technically speaking” to carry. An example for a surgeon is a type of surgical procedure, for a radiologist a special radiological technique. In my case a therapy for certain disorders that required years of supervision and learning. Again, one may argue that I should take responsibility and that this is my own fault as I should transferred my knowledge to my colleges, but here where the dilemma lie, as time, ethics are against me. Clinically I am expected to priorities my time but this raises another dilemma as my time is not entirely in my hand and the vicious cycle goes on.   

Let me give a real life example which I hope will demonstrate the above argument. When I joined my current department I started (naively) to accept undertaking therapy for patients with personality disorder (i.e. a condition which requires specific skills learned through years of supervision and practice) as the waiting list was long, and I was the only person with the expertise to manage this population. I went to my secretary and with an authoritative instruction, told her to arrange booking one hour a day every Tuesday at 11am for at least 20 weeks minimum, with the possibility of increasing the number of session. The poor secretary looked at me and did the necessary.  After two sessions of relatively positive rapport building with my client, the time for the third session approached.  As the time for the session came my secretary called and informed me that there is a “mandatory” emergency meeting for all heads of department with the human resources to discuss an extremely important issue. Dilemma again, what should I do?  I thought that our motto of “do no harm” and ethically as my patient has a real risk of feeling abandoned (which could have a catastrophic effect on therapy) and more important could lead to risk of serious self harm, I made the decision not to attend the meeting and see the patient instead.

Next day, a warning letter was delivered to me through my work email and due to my absence (even though I have sent the reason, and asked one of my colleges to attend the meeting) our department has lost in term of some administrative decision making.

That was my baptism of fire and my welcome to the modern health care. As a head of department I find myself more and more involved in writing the ideal setting to serve our clients but the time consumed in this preventing me from doing exactly what I am writing!.

I wish that the issue is related to me only, but even down the “chain of command” each member of my staff is finding it more and more difficult to focus on patient, and more of their work involving replaying to emails, cutting cost, achieving targets, filling endless forms, auditing, teaching, gathering educational hours, coming with initiatives, fulfilling their objectives in the appraisal and much much more.

I hope that my experience and my words echoes with similar experiences with the readers and as I have mentioned in the beginning, I am not looking for solution but I am hoping to provoke a serious debate about where are we heading in this era of so called “modernisation” and is the involvement of many parties and philosophies in the process beneficial to the end result (patients)?.

I am looking forward for a thought provoking debate and would be grateful for any of the readers from different evolving health services to share their thoughts and opinions.