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THE STORY SO FAR . . . . . . . . .
This series has created a virtual accident and emergency (A&E) department to highlight management issues. This “paper edition” is only a summary of the information available and a wealth of background information exists in emjonline.
The “Feedback” section allows reflection on previous problems and the “in tray” section provides a summary of the new papers and problems that have arrived.
The “task” section outlines the management tasks that you are being asked to consider. If you respond to these tasks by submitting your view to the EMJ, then one hour of external CME may be claimed and this is registered with the Faculty of A&E Medicine. Many readers have replied, some replies have been posted on the web site and in the near future we hope to include feedback from Australia. This will explore how the different health care, legal, and political systems affect the management of an emergency medicine department.
The “time out” sections explore some of the theory that lies behind management.
Good management practice dictates that we should actively seek the views of our customers, in this case that is you the readers. We welcome any feedback on the series and suggestions of major topics to be covered, especially if you are willing to be an author.
The runaway SHO has caused you a number of sleepless nights but was there anything you could have done differently? The case is now with the General Medical Council and out of your hands. Confidentiality was broken on the grounds of patient safety and the health of the SHO. Part of being an effective manager is realising what is your responsibility and what is not. This is no longer your problem and it is time to move on and deal with the active problems of the department.
The offer to sponsor the departmental advice cards has been turned down. The amount of income that this would have generated compared with the perceived hassle involved was considered insufficient. When the letter was brought up at a departmental meeting, there were a number of uneasy voices that were concerned that the sponsorship might be perceived as a direct recommendation of this chemist. Would there be a danger of losing some moral independence or even face pressure about prescribing patterns?
A similar line was to be taken on the school visits as neither Mr London nor Dr York felt they had “spare time” to carry out such public relations. However, Rebecca Devon heard about the letter and has asked if she could try and arrange visits with the school. The consultants have accepted this but they have asked for the visits to occur later in the year, as it will hopefully be quieter then. Remember, even if you are not interested in a project there may be someone else who is interested and to whom you can delegate. When delegating a task to a junior, you still remain responsible and must remain aware of progress and any potential problems that may arise. The degree of freedom given to the junior will depend on their level of training, experience, and your assessment on their management capability. Outline the issues Miss Devon should discuss with her consultants. The school outing to the department may be good public relations but runs the risk of having children in a functioning emergency department.
The personal injury report is on the internet. You may wish to review this and debate the opinion (see “in tray” tasks).
TIME OUT—SPECIALIST SUBJECTS
Finanace—where does the money come from
Maintaining financial balance is one of the key objectives of any organisation and perhaps should be for individuals. A&E is almost exclusively a publicly funded activity in the UK, therefore the financing is fairly straightforward (although always insufficient). This section will look at financial management at the A&E directorate level. How is the service funded? What is the difference between capital and revenue? What is a budget? How do you control a budget? For those interested in the finance of whole organisations such as Trusts, an introduction to the basics of reporting accounts for a large business is included in the internet section. (see St Jude's PLC).
Up until 1990 finance in the NHS was relatively straightforward. Money was allocated to district health authorities who in turn financed individual hospitals. This system had the value of simplicity but gave very little ability to control expenditure and to ensure value for money. It also bred inequalities in the system in that large expensive institutions were given more money and smaller DGH units might receive proportionately less. The NHS reforms of the 1990s tried to apply normal market ideas to health care. Health authorities became the “purchasers” of health care and acute Trusts the “providers”. Contracts were set so that a certain number of operations/admissions/outpatient attendances were supplied to agreed standards by acute hospitals. Capital was no longer “free” but had to generate a “6% return” as Public Dividend Capital Dividend.
The effect was to put the NHS onto a psuedo-business footing. This made sound business and political sense and achieved greater equity in the distribution of resources and greater control. However, the cost was a step change in the numbers of staff required for contracting/accounting/monitoring and the new emphasis on costs might be a factor in staff demotivation. The trend towards the NHS being run as a business is likely to increase with more and more “Private Finance Initiatives” (PFI). One of a manager's major responsibilities is to remain within budget and financial discipline will be an increasing burden on all clinical managers.
Capital and revenue
Capital expenditure is usually characterised by “one off” purchases. Technically it is money that is spent on items that are going to benefit the business for more than one year. In practice in the NHS the lower limit for capital expenditure is usually regarded as £5000. Such money is usually needed to provide buildings and equipment. Up until recently this money all came from the government. Most capital in the NHS is meant to generate a “6% return” on the “investment”. Trusts receive an annual “block allocation” for small capital items. Major capital projects are subject to a detailed business planning process and increasingly the private sector is involved through the PFI.
Revenue expenditure is the money used to pay for items used within one year. This includes staff pay, drugs, costs of tests, consumable items.
Revenue income is generated by operating the business, in the A&E department this is mainly the income from treating patients. At present this money comes from district health authorities. It is not yet clear how A&E services will be delivered when commissioning is devolved to Primary Care Trusts (PCTs). Each locality might have a different system but PCTs are going to be much more influential in budget stetting in the future. There will be some allocation for providing teaching and research through the Service Increment for Teaching and Research (SIFTR), perhaps some grant research income. There are small amounts from other sources such as recharges to insurance companies for the care of road traffic accident victims or for the provision of copies of notes to solicitors.
If we were starting St Jude's as a business we would need buildings, equipment, supplies, services, and people. All of these elements require money. We would have to estimate how many staff we need, costs of that staff, and the costs of supplies and services. All of these costs have to be paid on a continuing basis and thus would be recurring costs. Some equipment purchases might be recurrent, but buildings and larger items of equipment would normally be regarded as capital costs. Adding up all our recurring costs along with the “mortgage payments” and devaluation cost on capital would allow us to develop an estimate of the amount of money we would need annually to provide our service. This type of “bottom up costing” is the logical way to start a budget setting process. However A&E budgets are almost never derived in this way. The commonest model is that of “top down” budget setting. That is the previous year's budget is used as a baseline with additions for inflation, cost pressures and service improvements minus “cost efficiency savings”.
Box 1 Common additions/subtractions used in yearly budget setting
Inflation—each year costs of employing people and buying goods increases and NHS budgets are adjusted by a set amount to allow for pay and non-pay inflation.
Cost pressures—increases in budgets may be given to allow for increases in expenditure over which the manager has no control, for example increased costs due to a national agreement on rates of pay for out of hours work by junior doctors.
Service improvement—increases in budgets may be given to allow an increase in the level of service, for example the appointment of a new consultant.
Cost efficiency savings—all NHS trusts are expected to reduce budgets each year by a set percentage, typically 1% or 2% per year. This is a common business practice and is designed to ensure that any unnecessary expenditure is removed from budgets. However, in service with chronic under resourcing problems this logical device can mean cuts in the level of service provided.
Box 2 Summary of information on the internet
St Jude's diary
Note of conversation with Sister Oak
Letter from paediatrician
Clinical problem—a patient has arrived unconscious with an advanced directive!
Paper on financial reporting
There may be increases for cost pressures but these are often subject to negotiation. Each trust has to add up all the cost pressures from different directorates and then go to purchasers of services to try and obtain further funding. This is not an easy process and the amounts obtained seldom cover the increased costs. Service improvements usually have to be fought for over a prolonged period, unless there is a legal need (for example Health and Safety) or a major political need (for example, cutting waiting lists). Cost efficiency savings are extremely difficult to find in A&E budgets. Fortunately these are subject to negotiations within Trusts and some A&E clinical directors spend a lot of time arguing about this part of the budget. It is critical that departmental managers become heavily involved in the yearly budget setting process, currently known as “Service and Financial Framework”.
Having derived the budget the next step is to manage the budget. There is some possibility of being proactive and using the budget in slightly different ways but most Trust's Standing Financial Instructions leave little room for manoeuvre. Most of the management of the budget is really just monitoring the expenditure against the budget and looking for variance. Table 1 shows a typical budget statement showing the expected expenditure, the actual expenditure and the variances. The reasons for variance must be explained. St Jude's seems to be overspending. What are the reasons for the overspend? How are you going to explain these to the chief executive? Can any action be taken to correct the overspend? These are some in tray tasks for this month.
The control of finance is a key part of the A&E manager's role. We have introduced some very basic ideas in budget setting and control. Fortunately the financial management of a UK A&E department is relatively simple compared with that of similar departments in the USA. However, we have only scratched the surface. Other financial issues will surface form time to time and you may wish to tell us if you want any other boring areas covered in the series!
Review your department's own budget
Review your Trust's annual accounts, is there a balance sheet, income and expenditure statement, and a cash flow statement?
Review the personal injury report. Examine the evidence base for period of disability after a simple neck sprain after a road traffic accident
What action do you take when an SHO goes off sick? How do you fill the rota? How do you document it?
How do you handle delegation of a task?
How are you going to handle the paediatric management problem?
How are going to handle the unconscious overdose patient with a living will?
We would like to thank Mr P Driscoll and Mr C Perez Avila for their helpful comments.
Disclaimer Most of the characters and situations in this series are entirely fictional and any resemblance to any person of institution is coincidental. A few situations are based on real life but all the names have been changed.
- SIMS ARTICLE 7: INTERNET PAGES
The Internet pages are divided into "feedback" and "in tray". Feedback gives some of the actions taken over the previous management problems.
Article 6 - IN TRAY
Note of conversation with Sister Oak
Sister Oak very concerned about the handling of a paediatric resuscitation case by Dr. Ireland. Child had meningococcal rash and early signs of shock. Sister Oak wanted to call paediatric team and anaesthetics but Dr. Ireland said he would make the decisions. Had trouble in getting venous access and tried an intra osseous route. This failed. Sister Oak then called for paediatrics and anaesthetics. Child stabilised and transferred to regional Paediatric Intensive Care Unit.
Letter copied to Dr York
Dear Mr. London,
I hope you are well. It was good to see you on the APLS course and I hope we can call on your services as an Instructor once you get through your instructors course. Your skill and experience shone through on the course and you impressed all the faculty.
However I feel I should share some concerns about a recent case transferred to this unit. I was involved in retrieving the child from your resuscitation room. I had a discussion with the paediatric SpR who said that he felt that he had been called very late to help in the resuscitation and felt that your SpR had acted quite inappropriately when he arrived saying that he had not asked for him to come. I was told that the child was ill, had no venous access and had not been given antibiotics although he had been in the department for almost an hour.
I am glad to say that the child is now doing well but only after a very stormy time on PICU. The child�s parents said that they felt the A&E doctor was rude, shouted at them and seemed not to be in control. They are just so thankful that their child has recovered that they do not wish to complain.
In the past I have been impressed by the standard of care shown to sick children in your unit, especially when you have been around. I am sure that this is just a "one off" problem but I felt that you might like to have a "reflective teaching experience" (yuk) with your SpR.
A patient is admitted to your unit. She is 84 years old and is unconscious. She has taken an overdose of antidepressants. Her husband accompanies her and gives you a bundle of papers. These include a typewritten living will of the type issued by a society that advocates euthanasia. The will is signed, dated and witnessed by two people. The husband confirms that he is aware of the situation. There is also a suicide note that confirms the patient's wish to die and explains the situation to the police and coroner.
The patient has a Glasgow Coma Scale of 6, blood pressure of 70/50 mm Hg a respiratory rate of 14 and oxygen saturation of 85% on 10 litres of oxygen per minute by face mask. What do you do?
Name Mrs. Susan Smith
Address. 16, Plane View, Jamestown
Occupation. Shop Assistant. Right handed
Married. Two children
Date of incident. 2.2.01
Report prepared on behalf of the Court by Dr. E.S. York, MRCP,FFAEM, Consultant in Accident and Emergency Medicine.
Purpose of Report- To consider the causation, condition and prognosis of injuries sustained in an incident on 2.2.01.
Date of report 1.12.01
I have been asked by ......................................... to examine Mrs. Smith and her medical records and give an opinion regarding the causation or injuries sustained during an incident on 2nd of February 2001, to report on the present condition of those injuries, to give a prognosis for future recovery noting any effects that the injury might have on every day activities, employment or sport and leisure activity.
I confirm that I have examined the general practitioner records from 1965 to present.
In preparing this report I confirm that I understand my duty is to the court, I have complied with that duty and this report is addressed to the court. I full understanding of my duties as an expert witness are given in Appendix 1.
An abbreviated curriculum vitae is given in appendix 2.
Report from GP records.
Concerning injury 2/2/01
3/2/01 seen following an RTA. Rear end shunt. Neck Pain. Limited range of movement. Treatment, Physiotherapy. (sickness certificate for two weeks).
17/2/01 Still neck pain not seen physio,(two weeks sickness certificate)
3/3/01 Improving Return to work 10/3/01.
There appear to be no other mentions of this injury.
Review of previous notes
5/9/00 3 weeks history of neck pain. Stiff in mornings. No trauma. Range of movement good but with limitation of rotation and extension. Probable spondylosis. Analgesia. Advice on mobilisation.
5/10/00 Neck much better. Full range of movements.1994 Back pain. Physio. Three weeks off work.
Examination if Mrs. Smith. St. Theresa Hospital. on 1.11.01.
Mechanism of injury. Mrs. Smith was the driver of a Fiesta car. She was wearing a seat belt and a head rest was present and correctly positioned. She was stationary at traffic lights when her car was struck in the rear by another car. Mrs. Smith was thrown forward by the impact, restrained by the seat belt and then recoiled back wards. She did not strike the steering wheel or any other part of the car. She was able to get out of the car and exchanged details. Her car was still driveable.
Injury. She did have some aching in her neck at the time of the accident but the following morning the pain was much worse.
Treatment. She attended her general practitioner who advised her to take painkillers . She was certified as unfit for work. She had continuing pain and saw her GP again and physiotherapy was organised.
Work. Prior to the accident Mrs. Smith was a full time shop assistant. She was off work for 4 weeks. When she returned to work she was unable to do any heavy lifting. It took about three months before she was able to do her job normally. She has had no further time off work.
Activities if daily living. The neck was very painful initially. Her sleep was disturbed for 4 weeks. She took regular painkillers for 4 weeks. She was able to dress/wash/eat and cook. She was unable to drive for a five week period and when she did return she was very anxious and would avoid driving if possible.
Household tasks/amenities She required help with heavier household tasks for a six week period. She still has some problems in doing her shopping.
Hobbies and Leisure Mrs. Smith went to the gym once a week and swimming once a week. She was unable to do these for 4 months. She has returned to the gym but is still not doing all her normal exercises.
Progress and present position.
The neck was very painful initially with pain across the base of the neck, shoulders and down the right arm. The neck was very stiff. The symptoms improved after physiotherapy and after about 6 weeks she was able to do most things apart form heavy lifting. It took about 3 months before she could lift/hoover/shop although these did cause an increase in aching in the neck.
At present the neck is much improved. She still has aching in the neck on most days and this is worse if she has been doing a lot of activity the day before. It is stiff in the mornings. The pain is at the base of the neck and between the shoulders. There is no longer any arm pain or parasthesia.
She is still anxious when driving but this is mostly at traffic lights. She is has no flashbacks/nightmares and she does not avoid driving.
Past Medical History. Mrs Smith has been fit and healthy in the past, no previous neck problems. No medication at present. No other bone/joint problems.
Mrs. Smith is 1.67 meters tall and weighs 74 Kg. She appears a pleasant and straightforward lady.
General. She can talk freely about the accident and the injury with no evident distress or anxiety. She walks normally, sits normally and moves normally.
Neck. There is no swelling or deformity. There is tenderness over C6/7 in the midline, the right paraspinal muscles. Flexion is full. Extension is full with pain at end point. Rotation to the right is reduced by 20 degrees and is painful. Rotation to the left is to 85 degrees. Lateral flexion to the left is painful and reduced by 10 degrees.
Neurological examination shows normal power/tone/reflexes and normal sensation. Balance and gait are normal.
Mrs. Smith sustained an injury to her neck during an incident on 2/2/01. She required treatment from her GP. She was off work for 5 weeks and had significant disabilities in everyday activities for six weeks. She was unable to go to the gym for 4 months. She has now made a reasonable functional recovery but still gets some symptoms on heavier activity.
Neck Neck sprains are common injuries following the type of incident described by Mrs. Smith. I think that this is the most likely cause in her case. I note in the GP records a diagnosis of cervical spondylosis in September 00. However this episode appears to have been short lived and resolved within one month.
Neck sprains are very common and often give the types of initial disability described by Mrs. Smith. The time absent from work and length of disability with housework are in keeping with this diagnosis. While some literature claims little or no disability to be the norm following such incidents (see refs), one of the largest studies of this problem showed an average period of certified sick leave of six weeks.
At the time I examined Mrs Smith 9 months had elapsed. She was making a good functional recovery but with some residual symptoms. It often takes such symptoms between 6 and 18 months to resolve. I would expect these residual symptoms to resolve over the next 6 to 9 months. While there may be some aching on prolonged or heavy activity I do not think there will be any diminution in Mrs Smith�s capacity for work or leisure activity as a result of the incident on 2/2/01.
Anxiety and emotional upset are common after such incidents. The period of disability is not uncommon after such incidents.
Mrs. Smith appears to be making a reasonable recovery but a formal report from a psychiatrist or psychologist is recommended if it is felt important to further explore this area.
Section 35 statement (What is this?)
Appendix 1 Declaration of agreement with duties of an expert witness (What are they?)
Appendix 2 Abbreviated CV
Appendix 3 References
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