Back @ the EPR Arms: August 2018 Don’t let the perfect be the enemy of the good


(Please note the  views expressed in this EPR Arms blog do not necessarily represent the views of IHRIM)

I’d been doing this pilgrimage to the EPR Arms for decades now and you could almost measure how many pints of badgers I’d sunk by measuring the stretch marks on my six pack. (Party seven if truth were known!)

I was thinking about an earlier life I’d had – as an Information Manager in the hospital across the road. We thought we would have an electronic patient record by now, thirty years on and, apart from my aching back and knees, relatively little has changed. But now things are moving at a pace.

Why? Why has it taken so long? I would find out tonight as I was about to meet our Uni lecturer who tells me he’s very clever. Time will tell eh?

‘Clang’ went the bell on the door. Don’t know why on earth that was considered necessary. Sounds more like an episode of ‘Open all Hours’ than a busy warm and cosy pub.

I held the door open for a group of exiting clinical coders (James, Jane, Laura and Barbara) who looked stressed, as usual, and had called in for a quickie before going home.

‘I’ve got yer a pint of Badgers’ shouts Norm across the busy pub. Footy on the telly so it was noisier than normal.

‘Cheers – who’s on the box?’

‘United I think’ not deliberating on which United. ‘I don’t do football.’

‘So Norm, tell me something. I’ve had this quotation rolling around in my mind now for days. I can’t work out where it comes from, but its something like “Don’t let the perfect be the enemy of the good.” Any ideas?’

Norm did what what all like-minded folk do when asked any question. He sucked his thumb, chewed his finger nail, closed his eyes as if deep in thought and then he Googled it!

‘Well it says here that it is ‘allegedly difficult to attribute this simple statement to an individual. A number of philisophers and famous authors would claim to have made similar statements’:

Shakespear said ‘Striving to better oft we mar what’s well’

Voltaire ‘The best is the enemy of the good’

and not forgetting Confucius: ‘Better a diamond with a flaw than a pebble without’. Why do you ask?’

‘Well,’ I continued, ‘I think it has taken us a long time to get this technology stuff sorted in the NHS. Maybe we tend to over-think things.’

‘In what way? Isn’t it complicated stuff anyway?’

‘Yes it is, but we could incrementally get to where we want to be.’

‘What like?’ asked the Uni lecturer.

‘Well, it may not surprise you to hear I have a tale to tell in this space.’

‘Crack on then lad.’ said Norm holding out his now empy glass for a refill. ‘I’m all ears.’

‘Well, I was an Information Manager in a District General Hospital in the late eighties.’

‘Across the road there?’ Norm pointed with his empty glass in case I hadn’t noticed his proximity to drought status.

‘Yes - this hospital was ahead of the game with computerisation, (that we now call Digitisation). In fact, it was one of the Resource Management Initiatives (RMI).’

‘Resource what?’ tilted the glass a bit more cleverly demonstrating a lack of spillage.

‘RMI was another of these technology related programmes that seems to have been lost in the mist of time. Many nuggets of good practice could be found during a number of NHS technology projects but sadly ignored when the ‘new kids on the block’ enter the fray.’

‘So what did this RMI thing do then?’

‘It was a way of costing everything that happened in a hospital. It was a way of ensuring resources were better managed.’

‘Losing me’ said Norm.

Not as clever as he thought eh?

‘OK let’s imagine to run a hospital costs £100 million a year. Where does that money get spent? How much on staff? What kind of staff? How much did the labs cost? How much was spent in the operating theatres? How much per night does it cost to stay over in a hospital bed?’

‘Wow. This is scarily like the American ‘here’s your bill’ model’ said Norm taking the refilled pint that I’d been able to order in between sentences.

‘Clang’ went the bell and Andy the Finance Director rushes in. ‘Pint please. Badgers!’ he joins us.

‘Evening!’ he shouts. Stressed! Another one.

‘Y’or right?’ we say, knowing full well he was as far removed from right as he would ever be. We didn’t get a detailed response, nor did we expect one.


‘I was just telling Norm about Casemix and the RMI stuff!

‘Flippin Eck lad, that’s going back some. That was- what - late 80’s early nineties.’


‘So, what exactly was it then?’ piped in Norm who had been patiently waiting.

Andy took over, ‘Well, we had a big database – called the Casemix box. We then costed absolutely every penny spent by the hospital which allowed us to attribute it to every patient.’

‘What? You gave them a bill?’

‘No – it was purely for us to manage our resources. So in the lab they costed everything and calculated an accurate cost of a test. In Radiology – the cost of each specific X-ray or scan etc and in the end absolutely everything we spent in the hospital would be costed and every patient’s episode would be an ‘aggregation’ of these costs.’

I joined in again. ‘Yes – like we calculated how much theatres cost to run: what equipment was used, cost of surgeons, theatre porters, anaesthetists, scrub nurses etc this allowed them to calculate a cost per minute of time in the theatres’.

Andy added but more importantly, we also re-organised the hospital at the same time. We created Directorates and all this information was fed into those Directorates enabling the management of these resources closer to the clinician and patients.’

‘Sounds very sensible. What went wrong?’ Norm re-engaged.

Jim explained ‘As you can imagine it was a very complex process and, to be honest, we went OTT. We should have just used a ‘Wet Finger’ and guessed – We could have had ‘broad brush’ costs. Eg Lab tests were cheapish, moderate or expensive. Sadly our lab scientists don’t do guessing. ‘Think this is going to be a four pinter’; said Norm going to the bar. ’Carry on – I can hear you. So, what happened? Where’s this Casemix box then?’

‘Switched off. It became a data collection nightmare. Because we didn’t have mature clinical systems, we had to employ a team of data entry clerks to input manually lots and lots of data e.g. drug charts from each ward were manually updated overnight on the Casemix box to get all the drug information (which had all been accurately costed too!) This was ‘cos prescribing wasn’t being done on computer. Clinical Coding wasn’t done in real time (i.e. while the patient was still there.) So clinical coding was done after the patient had been discharged.’

‘So I still don’t get it. How did this help you run your hospitals then?’

‘Well, if absolutely everything that is done in a hospital is costed, and you record everything that you do to a patient, you can then start working out how much each episode costs, how much say a hip replacement costs on an 80 year old compared to a thirty year old. You can better plan and resource future episodes. You can, and we did, use it for clinical audit answering questions like how effective and how efficient are we?

‘Thin end of the…’

‘Possibly. But not the intention’.

‘But what’s this got to do with enemy of the good?’

Well, feeding this big casemix box was our PAS – Patient Administration System. That captured basic but very useful admin data. We knew that Nellie had been admitted from Westgate Rd Surgery (Dr Bowers) at 9.18am on Monday 14th of March.

We could have generated a letter or email informing the GP practice that Nelly had been admitted urgently to Ward 10 at 11 am.

We could then easily generate a letter or email even, to tell Dr Bowers that his patient Nelly was discharged on Thursday the 17th March and that she was not dead! We thought that information would be of benefit to Dr Bowers - to let him know his patient had been admitted and she was now back at home- and still alive!’

‘So why didn’t you?’ asked Norm.

‘It was argued that the ‘discharge’ letter was too scanty and should have said what Nelly came in with, what treatment/intervention she had had and what drugs she was discharged on and if any follow up was required. The system didn’t capture clinical data at that time and was decades off having the drugs available electronically. So we did nothing. This simple message to the GP never happened.’

In the search for perfection we failed to deliver the useful.

Yes – perhaps the Bard was right when he said ‘Striving to better oft we mar what’s well’’

Let’s not wait till we have the complete solution. Real clinical and organisational benefits can be derived from relativley simple changes now don’t you think? What simple changes would you like to see in your organisation? Email me in confidence: This email address is being protected from spambots. You need JavaScript enabled to view it.


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