Improving productivity

As demands on health care increase and patient expectations rise, and as competition for resource intensifies, delivering health care productively has never been more important. However, faced with an individual patient, the financial consequence of our decisions is not usually uppermost in our minds. The reality is that an average clinical team is responsible for spending millions of pounds each year with, in most cases, little financial accountability and, worse still, very little incentive to be more productive. It is no wonder that most health services are regarded to be unproductive compared with the commercial sector. The good news is that even in a tight fiscal environment, small improvements in productivity have the potential to improve quality and/or release resource for service developments. Understanding productivity is the first step to being more productive. Productivity is often confused with efficiency. Efficiency is a key component of productivity but productivity is a much broader concept. At its simplest, productivity is about the relationship between input and output. The problem in health care is that neither the input, nor the output, is easy to describe, let alone measure. Providing health care is not the same as making cars. For example, the cost of a doctor or nurse’s time can be measured but it is more difficult to quantitate the cost of their training or the future costs of their pensions—real costs to the system. On the output side, the net gain of an intervention (eg, consultation, investigation and treatment) is the sum of good and harm. However, it is often more complicated than that because the good might happen a long way in the future (such as with screening for cancer or treatment of hepatitis C). Harm is usually more immediate. To achieve a benefit in the future, the health care system is effectively borrowing money and thus the real cost of that benefit (the so-called discounted cost) is greater than if the same benefit was accrued immediately. Health outcomes are difficult to measure. For example, we might recognise a ‘good’ death from an undignified one, but even if we could measure what good is in this instance, we would struggle to put a value on it. To complicate things further, the benefits of an intervention may impact on other services or individuals within the system: early endoscopy will reduce length of stay; optimal management of IBD will reduce costs of surgery; effective communication with referrers enables them to be more efficient. Finally, the impact of what we do affects the lives of our patients and their ability to work productively, or care for their family or support their friends. Measuring this impact is fraught with difficulties. Thus when thinking about how to be more productive it is necessary to have a system-wide view and be aware of both positive and negative unintended consequences. In a constrained financial climate, our managerial colleagues will want us to focus on efficiency—and quite rightly so. However, while we have a responsibility to work as efficiently as possible, there is a wider agenda. Health care professionals are best placed to appreciate the wider view and explain this to those who may not see it this way. Our collective goal should be to use the resource available in the most effective way. In recognition of the importance of improving productivity, Frontline Gastroenterology welcomes papers that address the challenge of productivity. It is recognised that evidence of improved productivity is tough to generate and difficult to evaluate. We need examples to demonstrate what is possible. In time, it will become clearer what our readers find most useful and that knowledge will inform future submissions and evaluations.