How TRIZ can help Junior Doctors

Posted on May 25, 2016
Archive : May 2016
Category : Triz Blog

In England at the moment there is a debate raging over junior doctors’ contracts – and by extension the future of the NHS.

How can TRIZ help us understand what is happening, why – and help junior doctors decide what’s best to do next?

Background

The term “Junior doctors” covers every working doctor except consultants and GPs – 55,000 doctors in England, representing a third of the medical workforce. It includes both doctors who have just left medical school, right up to doctors with 10 years or more experience who are about to qualify as consultants.

Their working contract has been under negotiation for a number of years but talks have broken down to the extent that there has been industrial action – a number of strikes have taken place over the last few months. At the moment doctors receive a salary for regular work, and doctors who regularly work unsociable hours (nights and weekends) receive additional pay for doing so.

The New Contract – What’s Good & Bad

The government is pushing for a new way of calculating doctors pay, increasing the hours that are considered normal working hours from 7am-7pm Monday to Friday to 7am-10pm Monday to Friday and Saturday 7am-5pm, and reducing the level of additional payment doctors receive for working unsociable hours. The government claims doctors won’t be any worse off as they will receive a 13.5% basic pay increase, and online calculators were released allowing doctors to calculate that salary they receive would remain in most instances roughly the same 

This seems to be a solution in search of a problem – the the government claimed that this is needed in order to create a “7 day NHS” and studies were cited saying that patients were more likely to die when admitted to hospital at the weekend [ref www.bmj.com]. This has since been demonstrated to be untrue. [ref hsr.sagepub.com]

Also doctors work as part of a team and other supporting services were not going to be increased – such as nursing staff, physiotherapy, imaging and laboratory services – and other methods for helping reach a diagnosis, determine and then deliver the best course of treatment, so it was uncertain how having only more doctors would even help. If increased services are needed for safe patient care, surely all of them should be increased.

Doctors have resisted this change to their contract as they claim that this will likely increase the number of unsociable hours they work – as the overall pay won’t change, but more doctors are working at the weekend, logic dictates that they must be working more hours for the same money.  This increase in hours will lead to a reduction in patient safety with tired doctors potentially making mistakes, and a worse work-life balance. Junior doctors do most of the unsociable hours medical work, with consultants generally on call at home rather than working in the hospital. There are worries that the real reason this is happening is that it’s a precursor to the privatisation of the NHS, by making weekend working cheaper to run and therefore easier to sell.

I should confess I have a horse in this race – my partner is a junior doctor training in intensive care – one of several  specialities which delivers 24/7 care to patients, so he works a lot of nights and weekends. He couldn’t take part in the first strikes as they reduced staffing down to the same level as Christmas Day – in intensive care this is the same as every other day. Patients are sick and are cared for, all day and all night, seven days a week.

There are other troubling aspects to this new contract – not only with doctors in the future likely earning less money, but worse, how junior doctors achieve seniority through their career will change.

At the moment you earn more with each year you work: what this means in practice is that doctors can gain additional, tangential experience to their core speciality with fellowships in other areas, or by completing masters or PhDs in their chosen speciality, without losing out in their career progression, both in terms of salary and perceived seniority. This results in doctors with a broader range of experience and knowledge when they become consultants; given that a large part of their job as a consultant is to make difficult, often life-or-death decisions, it is not seen as necessarily desirable to qualify as a consultant quickly, and this additional, wider experience is not only encouraged but valued. People can also work part-time (for example if they have young children or are carers for others) but still progress at the equivalent rate.

In the future this will change so as doctors will only achieve more seniority and increased salary as they progress through each level of training (there are 5 – nominally over 5 years). This will not only discourage doctors gaining more broad experience but more troublingly, will disadvantage working parents (usually mothers) who are working part-time. This new contract has actually been shown to be unfair to women [ref www.bma.org.uk] and the government has described this discriminatory and potentially illegal change as “proportionate means to achieve a legitimate aim” [ref www.huffingtonpost.co.uk]

How can TRIZ help?

After 10 days of talks, an agreement has been reached between the BMA (the British Medical Association – the doctors’ union) and the government and just been announced. It can be hard to compare very different options – especially when emotions are running high – and TRIZ can help by providing an objective method for doing so. While the full details have yet to be released, some broad comparisons can be made by comparing their Ideality – and junior doctors can use this thinking to both understand and communicate the differences between the two contracts. 

Ideality

Ideality is the TRIZ approach to understanding how good something is: you consider the proportion of the benefits you get (all the things you want) compared to its costs (all its inputs) and harms (all the outputs you don’t want).  

Ideality outcome for the Junior doctors strike

A benefit is an outcome that you want: it is not how you get it.

A cost is any input required to deliver the benefits: this includes money but also time (for both development and delivery), effort, resources.

A harm is any downside – any output you don’t want. Harms include any aspects of a system you don’t require, anything negative impact of our system on the users or the environment and also any risk – things that might go wrong.

This is much more powerful than just considering “pros” and “cons” because you are taking into account the time, effort and other resources required to deliver different solutions, and harms encompasses otherwise relatively intangible things such as risk.

Ideality is brutal – nothing is neutral.

A benefit is only something that is needed – if it’s not needed, it’s a harm.

As a result you are forced to really consider things from specific perspectives – because a benefit to one person might be a harm to another.

For example, when I’m using software to produce a written document, I only require a handful of functions – however graphic designers producing professionally designed and set documents want a lot more.  [ref www.trizfordummies.co.uk]

Let’s consider the changing Ideality from the old to the new contracts – from the perspective of the doctors, the patients, and the Department of Health.

New Contract – Ideality Change

Benefits and Harms table for junior doctors strike

Disclaimer: this is a much simplified (almost certainly over-simplified) interpretation of a contract which has not yet been fully released. However this is intended to demonstrate the approach and I would urge anyone trying to keep their thinking clear when evaluating the new contract when they consider its Ideality in more detail.

One of the reasons this contract is being rejected is it is perceived as part of an ideological movement within the Conservative government to privatise the NHS (other public assets such as the Royal Mail have already been sold, and others such as the Land Registry and high value council houses are next).

Certainly reducing the NHS’ overheads makes it more attractive to companies wishing to purchase parts of the health cover currently provided by the government. Whatever the reason for the change it is pretty clear that the government has been so focused on the benefits at the organisational level that they have lost sight of not only the reasons why doctors might reject these changes (patient safety and unfairness being the most critical) but also the long-term impacts – not only to individual doctors but to the profession as a whole, the NHS and UK.

Mapping these impacts in time and scale might help clarify our thinking.  

Thinking in Time and Scale

Thinking in Time and Scale

What this shows is that there are really difficult problems the NHS faces in the future – but what is the right option moving forward?

The Future of the NHS – with TRIZ (?)

Fundamentally, the problem as I see it is (at least in part) that there might be conflicting views of the future of the NHS. If I were to run a TRIZ session on planning the future of the NHS, I would suggest the starting point would be to complete an Ideal Outcome to capture what everyone wants. TRIZ suggests that there can be no conflict in benefits if you capture them at the correct level.

Ideal Outcome

The Ideal Outcome is a TRIZ tool for defining requirements quickly and simply. You all the things you would get in a perfect world, freeing your thinking from any constraints of practicality. This is a very important exercise for thinking clearly: while you never expect to achieve all of those things, it sets the direction for your thinking, and encourages you to work towards the things you really, really want, rather that what you just think is possible.

You lift your head and see the big picture, rather than getting stuck in details of the way things are done now. Often things can be changed – dramatically if needs be – if you can only first imagine new ways of working.Too often when people are asked what they want, they offer you a solution – one way of getting what they want. The Ideal Outcome has no solutions – it’s a list of benefits. Benefits are the outcomes that you want, not how you get them; often disagreements in things like public policy come because people get stuck in solutions or ways of getting what they want. By the same token, sometimes the Ideal Outcome can help you work out where this is no resolution to be found, because you are working towards different Ideal Outcomes.

Ideal Outcome for the NHS

I cannot possibly capture all the things everyone wants for the NHS, but the current aims for the NHS are described on the NHS England website as “high quality care for all, now and for the future” [ref www.england.nhs.uk]

Benefits that flow from that are:

  • Safe for everyone (patients, healthcare workers, patients’ carers)
  • People live longer, higher quality lives
  • Care is compassionate, inclusive, and constantly improving
  • Individuals, communities and the population have greater control of their health and well-being
  • Care is sustainable economically

Please note none of the above involve any kind of solution for delivering these benefits.

I don’t know the right way forward – but I can tell you there is definitely more than one.

Like many other people I suspect there is a strong bias in our current government to push towards privatisations of the NHS, and in fact this is already happening in parts. I worry that private organisations’ mandates to “deliver shareholder value” i.e. generate profits will result in a conflict with other benefits such as safety, quality of care, or safety of healthcare workers. If a profit must be made, common sense suggests that costs must be reduced as well as outputs maximised, and while efficiencies can deliver some of these, we must be wary that costs are not hidden (e.g. work done but not paid for) and benefits are not sacrificed (e.g. less tangible aspects of patient care).

TRIZ suggests that we should push towards a utopian future – but also live in the real world. A clear understanding of the Ideality we are willing to move towards will help us make better decisions – and understand where other people are trying to drive us towards.


Learn more about TRIZ here.


Lilly Haines-Gadd

TRIZ facilitator, trainer, 'TRIZ for Dummies' author and MD of Oxford Creativity - a TRIZ company based in Oxford, United Kingdom. www.triz.co.uk

Lilly Haines-Gadd


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