Rationalisation = greater efficiency?
Whether rationalisation improves efficiency was a problem discussed in several of the interviews. As one informant said, 'I spend a lot of my time saying it's too overcrowded here, things are moving too fast, there's so little capacity here that we are […] overstretched. I want to reduce it [the speed] and I think that would be more effective' (B). The pace of work was a recurrent topic. Other informants supported this argument:
'What annoys me most about all this is not when it's busy and you're working hard, but when I'm having to spend time being inefficient. Spending ages trying to get hold of people, placing patients, lots of unnecessary work. Like for example spending several hours trying to get hold of people or not being able to find a bed straightaway instead of helping out in the department' (D).
One informant pointed out: 'There's a belief that we only need to work in a smarter way or be more efficient and work more with the logistics. In my opinion, that's what we do all the time […] we don't often get around to other things like enhancing quality' (A). According to the informants, the pressure on capacity created demands for better organisation whilst the increasing pressure also required time for prioritisation and patient logistics, time which could have been spent on patients.
The informants made it plain that some patients were resource-intensive because they had to adapt to the 'streamlined production lines' of the hospitals. While these could not be adapted to the patient, the patient was unable to adapt to them. As one informant pointed out: 'The age of the patients we operate on is increasing all the time, and these older patients have a low tolerance level for surgery, and many become psychotic afterwards and are in a state of delirium. Then they have to be monitored continuously and we need to hire extra staff for them, which is very resource-intensive' (C). Due to the lack of beds and increased patient throughput, patients also required more follow-up as a rule. Elderly patients in particular were described as a challenge in the quest to meet the hospital's needs for efficiency:
'The patient arrives and at our hospital things must move fast. So they often come in on the day of their operation. They have taken care of things at home and are ready, and they come along with their daughter for the operation. And things must go very fast. Primarily because we need to get them out again quickly because we have little capacity but also because there's the continual pressure of statutory requirements. So some poor old soul is thrown in at the deep end as soon as he arrives. We operate on him, but he falls ill afterwards because he isn't really well enough to be operated on and he's insufficiently prepared' (B).
The patient's practical, physical and mental preparation was described as of key importance for the success of the operation. Some patients were admitted the evening prior to surgery because they needed help and major surgery was involved: 'It's also very important that [patients] sleep well. If they're unable to carry out the preparations they're supposed to, they must be hospitalised'. When preparations were left to patients and their family, the health personnel no longer had control of whether they had been carried out.