Published: 14/04/2005, Volume II5, No. 5951 Page 33

The most memorable of my school assemblies - and there were not many, believe me - was when my headmistress uncharacteristically quoted that well-known philosopher Charlie Brown: 'Sometimes I sits and thinks. And sometimes I just sits'.

Last month provided few opportunities to 'sit and think'. For senior managers and trust boards it was the month of deadlines - the last opportunity to balance the books, deliver the targets and generally ensure all was in the best possible shape before submitting to another round of star-ratings.

This year the pressure was compounded by the need to negotiate much of the local delivery plan at short notice.

But the end of the financial year is also putting increasing pressure on clinical staff. Most of the better performers in the NHS are now pretty lean organisations and inevitably the increased 'productivity' is delivered by clinicians on the front line. They are working to maximise elective surgery in the face of barely receding winter emergencies.

Meanwhile the deadline for having an appraisal is approaching and There is the need to agree a new job plan. Not to mention the request to attend a focus group on Improving Working Lives, which interestingly is not mandatory for foundation trusts - perhaps the concept of improving working lives is an unaffordable luxury in this new world order.

Recently the time to just sit has been superseded by guilt and deadlines or the inevitable invasion of clinical work. This is not a moan - the doctor-patient interaction is why I went into medicine. But the rapid growth of treatment options, their complexity, demographics and patient expectation, counterbalanced by an increasingly restricted junior workforce requiring greater supervision, has also had its impact.

Sorry, no time to stand and stare today, must get on with saving lives.

In an attempt to create some space in my clinical practice I have been trying to change the way I follow up some of my patients, the aim being to spend more time with those who need it and streamline the care of well people in remission.

Things were going quite well until the key nurse specialist on the project was involved in a serious car accident. The whole thing foundered and left us realising the danger of building an initiative around one individual.

So how do we manage this problem of lack of breathing space?

Perhaps the only option is to learn to prioritise. We need to decide what is do-able and what is not, then educate the public to change its expectations.

For my personal therapy I am reading Going Sane by Adam Phillips (at least when I can stay awake after climbing into bed).

Mr Phillips is a psychoanalyst who has written on a range of subjects from evolution to kissing. His discourse is on how we can make space for a sane and well-balanced attitude to life - a guide to dealing with the madness of life.

Whatever the change that starratings deliver to the Healthcare Commission's new inspection regime based on Standards for Better Health, can I make one small request? Make it integral to the way we work all year round.

do not impose time frames that allow a last-minute sprint and create intolerable pressure. Reward organisations that have achieved sustainable change - in culture, working practices, delivery and patient focus. Then, perhaps, some of us can just sit occasionally and find the breathing space to innovate and improve. .

Professor Hilary Thomas is medical director of Royal Surrey County Hospital trust and professor of oncology at Surrey University.