Over the years, the National Health Service hospitals have internalized a set of metrics that allow measuring the activity of each institution. These days, all over the hospital, it is common to hear: “I have to do more first consultations”, “The CA is bothering me with the average delay”, “The case-mix of my service is very high ”, “Our percentage of outpatient surgeries is fantastic”.

Although many of these indicators have existed in hospital management for several years, in 2002, the introduction of program contracts dependent on this family of indicators changed the perception and demand on health institutions and professionals.

Nothing that did not exist in the exercise of liberal medicine, or private medicine, on behalf of others, where the remuneration of professionals, particularly doctors, almost always depended on the number of acts performed, with advantages and disadvantages, the latter almost always associated with the performance of clinically unnecessary acts.

It won't do any harm to the world if we use productivity indicators. In fact, this measurement led to the growth of surgical activity at the Public Hospital, with an increase of more than 74% in the number of surgeries performed between 2005 and 2016, and the outpatient consultation, with an increase in the number of consultations performed in more 30%, with almost 4 million more consultations per year.

This increase in activity was clearly reflected in the improvement in indicators of access to the Public Hospital, measured, for example, through the median waiting time for surgery, which dropped from 8.6 to 3.3 months (2005 to 2016).

However, the real impact of assimilating the productivist jargon has yet to be assessed in its entirety. In particular, the almost exclusive use of this type of indicators can contribute to less attention on other areas that deserve more and better attention, such as clinical quality and the humanization of care. On the other hand, this path leads to a hyperspecialization of professionals and health teams, abandoning the holistic view of patient-centred health care.

Moreover, the performance evaluation solely focused on productivity, both institutional and professional, leads to the progressive removal of high quality professionals and the reduction of non-medical health professionals and structural specialties for Public Hospitals such as Internal Medicine.

Inexperienced management teams and too focused on "numbers", with little sensitivity to the complexity of the Hospital's core - the health professionals - will easily make the mistake of believing that everyone is replaceable and disposable, especially those that "small numbers" feature.

It is also important to consider that, by only demanding attention to productivity indicators, we may be contributing to the induction of unnecessary procedures.

The induction of demand by health services is well studied and it is important not to evolve into models very close to us, in which the unnecessary performance of surgeries, complementary means and consultations prevails.

We should pay special attention to the less positive examples from other Western countries, where volume prevails over quality and safety, there is extensive documentation, for example, on the overproduction of CT scans, MRIs, varicose vein surgeries, cataract surgeries, tonsillectomies, placement of knee and hip prostheses, or the implantation of cardioverters.

Thus, the Public Hospital should not be hostage to production indicators or professionals from additional production. As in the past, it would be a mistake to return to a remuneration model based on overtime work, so it will not make sense for the strategy of retaining professionals and improving access to go exclusively through the use of “by piece” payment for teams.

The sustainable development of the Public Hospital depends on our understanding of its responsibility regarding the health of the population and patients, its real shareholders. In this field, there is much to be developed with a view to introducing and valuing indicators that consider clinical, population health and patient experience outcomes.

Indicators and “statistics” will always be instrumental and not an end in themselves. As in so many other matters, success will always depend on competence in its use.

Better Management, More SNS.

Article published in the April 2018 issue of Hospital Público.