Friday 9 April 2010


A couple of patients a day are seen within the acute Trust down the road by our liaison psychiatry service. I am involved in all of them, managing all referrals and seeing many folk on medical and surgical wards.

All is not good.

Again I've had a week of misery and depression and despair. Mercifully, that's not my patients. Nor my team. Nor myself. The low mood and low morale and consequent, "fuck it all!" attitude is increasingly pervading the acute Trust's wards. Staff are desperate.

This is bad.

If staff truly weren't bothered then they'd not care. They'd turn up, do their 37.5 hours a week, go home and collect their pay cheque and repeat it all next month (or a few days into next month, after taking a few days off sick, 'cause everyone does, right?). But no. They're mostly concientious, frustrated staff who want to do a good job, want to do things better but feel impotent.

As many folk have articulated, Nurse Anne better than most, the bottom line is that the medical and surgical wards simply don't have enough qualified nurses and support staff to deliver clinical and practical care, now. Modern health care needs staff to do a lot and to do it well. You need good staff simply to do the work. What else is our work? Almost all "work" in the NHS is an interaction (direct or indirect) between a patient and a practitioner. Fewer staff, fewer interactions, less meaningful activity and less purposeful healthcare. Quality falls. Care becomes shabby. Not because staff are bad but because there aren't enough staff to do the work asked of them.

Liaison psychiatry used to be about both proactive presence on wards/in A&E to improve how things were done and reactive response to referral requests to sort out specific goals or issues that had to be managed through liaison psychiatry input into in-patient care/couldn't be picked up by mental health services on discharge.

That's changed.

Now ward staff on medical and surgical wards are less interested in what liaison psychiatry assessments are. They're less interested in how formulations can impact on care plans. There's less interest in advice on how care can be more person centred to be more effective in delivering personal care/interventions. There's strikingly less interest in rationalising drug regimens and reducing psychotropic medication use. Ward staff see me on wards now and, with faces filled with desperation and despair, simply wish for me to make patients' problems go away, or take the patients away, or both.

As clinical care is causing me more concern, not because staff are bad but because the Trst doesn't have enough nurses on wards, as the election looms nearer, I find myself thinking more and more of a post I've bookmarked from a year ago by Dr Grumble on NHS spending. It's sobering stuff. It seems that the NHS spent 7 billion quid, in 2008, on Primary Care. In the same year it spent 12.6 billion quid on management of the NHS. That's excluding each hospital's management costs. Grim reading. NHS managers in Strategic Health Authorities or DoH or "support" roles cost much, much more than all we spend on Primary Care in it's entirety.

It's a scandal.

It's a scandal that's affecting patient care.

If as a country we need to save squillions, I know where I'd be making "cost efficiency savings" and I know where I'd be enriching front line care. Too many managers. Too few nurses. Loss of half the managers would only improve things in my world. That's 6.3 billion saved. Let's use just half of that to pay off national debt, since we're altruistic folk in the NHS, and ring fence just 3.15 billion for more ward nurses.

It's a policy I'd vote for.

1 comment:

Dr Grumble said...

This is what the Health Committee has recently concluded on the costs of NHS administration:

# The service has traditionally scored highly on account of its low cost of administration, which until the 1980s amounted to about 5% of health-service expenditure.

# After 1981 administrative costs soared; in 1997 they stood at about 12%.

# An estimate of administrative costs since 1997 has been made by a team at York University, in a study commissioned by the DH but never published. This concluded that management and administration salary costs represent, as a very crude approximation, around 23% of NHS staff costs.

And they conclude:

# If reliable figures for the costs of commissioning prove that it is uneconomic and if it does not begin to improve soon, after 20 years of costly failure, the purchaser/provider split may need to be abolished.