Published: 25/07/2002, Volume II2, No. 5816 Page 18
However much money we spend on healthcare, we are reliant on the quality and efficiency of clinical work. Crisis services, acute hospital care or nursing homes are merely structures to allow an effective interface between staff and clients.We are well advised to show affection for our clinicians, since managerial jobs depend on their work, and so does the future of this government.
This is recognised, and the recent Human Resources in the NHS Plan strategy shows all options are considered.Model employers, the skills escalator, modernisation of pay, learning, regulation and workforce planning are all on the table, and improving staff morale is central to the strategy.
But there is a contradiction in government policy that undermines the positive intentions - the steady increase in regulation and performance-management, mentioned again in the comprehensive spending review.
New money will be linked to targets, inspection and audit.A sentence in the introduction of the HR strategy makes the point more subtly: 'While the Department [of Health] will continue to set the strategic framework and national standards, the real power and resources will move to the NHS frontline.' This in itself appears innocent and laudatory, but frameworks and standards are imposed in increasing numbers and the work of frontline staff is measured locally in growing detail to allow central scrutiny.While with one hand the strategy acknowledges this tension and promises to remove unnecessary bureaucracy, with the other it reiterates the many new regulatory bodies, which impose yet greater demands for detailed data.
But local staff collecting the data are clinicians.And filling in forms has an (unmeasured) opportunity cost. For example, clinicians might instead treat patients!
I am not picking a fight about audits on clinical activity or targeted inspections.Nor, in fairness, do clinicians.
Government has a duty to know the NHS performs efficiently.
What concerns me is the layer on layer of data expected to be recorded by clinical staff.
Increasing the layers of hierarchy creates requests for yet more data from borough managers, trust directors, the primary care trust, strategic health authority or DoH.
Each wants more information from all the layers below - and it all ends up with clinical staff.
The key message is that data collection is not identified by staff as relevant to their clinical work, but as externally imposed. The consequences are predictable.
Anyone trying to collect data will know that it is hard to achieve more than a 50 per cent return.
The quality doesn't bear thinking about.When I recently discussed administrative demands with clinical staff it aroused strong emotions. They claim that, typically, about 40 per cent of their time is spent on form-filling.
Clinicians accept the need for accountability, but not if activities are simply perceived as pointless obstacles to efficient clinical work.
We know that poorly implemented performance management damages morale, and therefore productivity.We also know that performance management not owned by clinicians does not improve practice. Clinical staff get their job satisfaction from patient contact and control over their work.
On top of this are the direct costs and inefficiencies of formfilling. The NHS plan conservatively requires an additional 12 per cent growth in the mental health workforce.
However much money enters the system, we are unlikely to recruit such numbers fast, since there are so many competing workforce priorities. The HR strategy rightly emphasises the need for retention by the creation of positive incentives such as flexible working practices and child care.
But perversely, working conditions are being created which, a strong evidence base shows, are demoralising and inefficient. If we could reduce non-clinical time by 25 per cent, we would have taken a big stride towards alleviating our recruitment problems and improving morale.
I recognise the widespread illusion that collecting everything means knowing everything. I understand the fear of letting go.
But what do we know now, with confidence, about activities at the clinical interface? If the aim is to shift power to the frontline, we should place responsibility for quality control there, and only demand data that is both necessary and collectable.
Dr Matt Muijen is director of the Sainsbury centre for mental health.