Outside the marginals

a commentary on the politics that followed the UK 2010 & 2015 elections

Subversion and Unintended Consequences

Whenever a government (or business) announces a new “performance measure” to gain headlines, sorry to solve a problem, we should be sceptical.

A moment’s thought will probably reveal how we can subvert the measure – to make the measure “right” without actually getting the performance “right”. Such subversion will inevitably bring about unintended consequences which could be exceedingly adverse. That is not to say that subversion (at least as a thought experiment) is not worth-while.

It should be applied to the (UK) Health Select Committee’s call for the publication of staffing levels on each ward in England’s hospitals.

Hospitals in England should publicly display the number of nurses they have on duty on each ward – and whether that figure is high enough, MPs say.
The call by the Health Select Committee comes amid concern about staff levels.
Earlier this year, the Safe Staffing Alliance said wards were regularly breaching the one-to-eight nurse-to-patient ratios that it recommends.
BBC News Website 18 September 2013 Be open over nurse numbers, hospitals urged by MPs

The “one-to-eight nurse-to-patient ratio” is a blunt instrument and to set the expectation that there should say be a webpage or notice board by the entrance to every hospital displaying the actual ratio for every ward is foolish. It encourages a view that “one-to-nine” is means bad care and “one-to-six” is wasteful. The call to publish “whether that figure is high enough” attempts to avoid this problem but such a tick-box is subjective and will not be noticed by many of the public (or journalists).

To keep the “numbers right”, hospital managers will be tempted to subvert the measure by swapping staff between wards. This will be for political not clinical reasons.

One of the reasons for separate wards is that different patients have different needs. Pre-op and post operative patients have different needs. The elderly often have higher personal care needs. Children probably benefit for nurses with specific attitudes. Oncology and dialysis patients (to take just two examples) probably require specialist nurses. “One-to-eight” is a blunt instrument and the unintended consequence of the application of that ratio to all wards is that you will have inappropriate staff levels in many wards and often an inappropriate staffing mix.

If the hospital is a “general hospital” you may be able to apply a “between seven-to-one and nine-to-one” ratio to the whole hospital. It would be a more sensible measure that would avoid some of the unintended consequences detailed above.  But wait!

We can subvert even a “whole hospital” measure by being creative with how and what you measure. The managers who hold a nursing qualification can be counted into the measure and care assistants may be included by fudging the definition of “nurse-to-patient” – possibly with justification. You may even be able to fudge the definition of patient – I am sure that an under-pressure hospital administration will be able to find a way to so! Do you include all nurses “on the books” (even those on meal-breaks, or even off-shift or off-sick) and what in the age of agency nurses is “on the books”?

The conclusion to be drawn is to distrust any politician-promoted headline-grabbing performance measure – particularly if you can quickly dream up a way to subvert it. Subversive thinking can be good!

(Apologies to anyone attracted to this article purely by the tag “subversive”)

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