Bureaucracy: the new psychiatric illness

James Gubb, 4 July 2008

It was a theme that ran throughout Lord Darzi’s final report, published earlier this week. ‘High quality care cannot be mandated from the centre – it requires the unlocking of the talents of frontline staff….where change is led by clinicians and based on evidence of improved quality of care, staff who work in the NHS are energised by it and patients and the public more likely to support it’, he wrote. Never a truer word.
But this is precisely what the system doesn’t like to countenance.

Those running it might think it does, but the reality is somewhat different. More than 800,000 jobs have been added to public sector employment since 1997, producing what the management guru John Seddon has called ‘an army of people engaged in developing specifications, writing ‘guidance’, drawing up standards, devising targets and reporting schedules and the like’.
Yet most are based on opinion and ideology, not knowledge. We need look no further than the experience of A&E. Does anyone seriously believe that the dramatic rise in emergency admissions to hospital isn’t linked to the centrally dictated 4-hour A&E turnaround target? If you don’t, here’s a fact. Twenty-six per cent of these ‘emergency’ admissions are now turned around on the same day. That’s an incredibly expensive way of solving a medical problem. And what’s more, it massively distorts clinical priority; there are many patients including those with asthma and suspected heart attacks where observation and testing need extra time.
And then there’s the exorbitant cost of recording all this data required by government. Fine if it serves some useful purpose for the organisation. Unfortunately, on estimates provided by the NHS Confederation, about 58 per cent doesn’t; i.e. has no benefit for patient care.
But most damagingly are the wider system-effects on medical professionalism; that body of knowledge and vast experience of learning-by-doing that needs to be harnessed day-in-day-out to deliver optimum care for patients. Just a simple cough can have any number of diagnosis, that cannot be dictated by guideline and protocol as the bureaucrats would so love. There is much made of the prevalence of exception reporting in the Quality and Outcomes Framework for GPs; yet I’m not sure I’d want a GP to pill my elderly relative up to the max with beta-blockers to get their blood pressure down to the required level if it meant they couldn’t get out of bed in the morning without such dizziness they’re likely to fall.
In 2006 Fiona Godlee used her editorial in the BMJ to lament that ‘the spirit of medical professionalism is slowly dying’. It smacks of a doctor’s plea for the good old days when they ruled the roost, but removing this from the equation, she is right.
This week, a powerful piece in the British Journal of Psychiatry, authored by no fewer than 37 of the country’s leading psychiatrists, provides a damning critique of the dangers of putting policy-making in the hands of bureaucrats. In the current system, laid down in the government paper New Ways of Working, a secondary care patient with acute mental illness may never even get to see a psychiatrist; rather a member of a crisis intervention team trained in non-specific psychosocial support. Important, but such support is only one part of the treatment, which should be after triage by the psychiatrist, not preceding it. They, after all, are the experts most likely to get the best course of treatment right; a proper psychiatric diagnostic assessment would look at ‘the complex relationship between psychiatric and non-psychiatric disorders and their common co-occurrence….involving biological and psychological tests and neuroimaging as well as detailed clinical assessments’; i.e. beyond limited therapy.
And how’s this situation come about? Because it’s a cheaper option that suits the government. Training more psychiatrists – the ‘superlative physicians’ – is, after all, expensive. But then so is getting the diagnosis wrong in the first place; again political imperative rules over professional judgement. And where’s the patient in all this? Lord Darzi has some work on his hands.