An NHS administrator at an urban community health trust explains the pros and cons of having managers, rather than clinicians, running the NHS
“There are many different facets to my job: I do general IT support work in a community health care NHS trust, but I also mediate between managers in the local clinical commissioning group – which pays our trust to carry out medical and social services in our borough – and clinicians in the trust. In this capacity, I work with nurses and health visitors on the clinical side, and senior managers on the managerial side.
I have not been in this role for very long, but have worked in different parts of the NHS for around five years. Over this time, I have seen some dramatic changes in the organisation. When I joined, most NHS bodies were managed by clinicians; now managers all seem to come from the commercial world. That’s had a mixed impact: many aspects of our trust are now being run much more efficiently, and there is less scope for staff to let productivity slip. But clinicians don’t always approve of putting business managers with very little medical understanding in charge of running medical institutions. They find it hard to accept being told how to do their jobs by people who know so little about the subject.
One way in which the new, more commercial approach has had a positive impact has been a new mapping system, through which health visitors are allocated their appointments. Before this was introduced, health visitors – who drive from appointment to appointment – were ascribed jobs solely depending on which borough they work for, even though someone from a different borough might be closer to an address. With the new system, admin workers can track the health visitors and allocate the closest addresses to their itinerary, making the whole process more efficient.
Health visitors now also have to keep a daily diary, detailing all their movements throughout the day; the data is discussed at weekly meetings. This reduces scope for them to skive – but I’m sure the vast majority of health visitors wouldn’t anyway.
Recording each and every one of their movements also protects them: being able to prove where they were means they can’t be blamed for things that weren’t their fault. Unfortunately the requirement to put all the data into a centralised system is a huge strain on clinicians’ time. Whereas before they could take handwritten notes while with a patient or in the car, now they have to wait until they get to a computer at the office.
They can’t cut down on the number of appointments to get the extra clerical work done, either. Managers have set clinicians a target of spending 50% of their time with patients. It’s been made clear that if that target isn’t met, the CCG will commission private companies for those services instead. This constant threat does spur people on to work harder, but also dampens morale and leads to severe stress.
One trust in England is already commissioning private firms to deliver large parts of its health and social services. The government is privatising the NHS through the back door, but very few people outside the service seem to have noticed.
The 50% patient-facing time target is just one of many goals that clinicians and clerical staff are accepting begrudgingly. Sometimes, the statistics required by managers are so unattainable that staff just make them up. For instance, managers want health visitors to record the ethnicity of every patient; but some they feel awkward asking, or don’t want to ask as a matter of principle, so they tick the box for ‘other’ – making the data very inaccurate.
There are similar problems with the information about new mothers. Health visitors record whether mums are breast-feeding or smoking during the new birth visit. Now managers have said they must also provide the same data six to eight weeks after the first visit. But due to a severe lack of health visitors, it isn’t always possible to repeat visits after six to eight weeks, so data is often just made up or copied from the first visit. There is a culture amongst managers of ignoring any suggestions that the targets might be unrealistic and could lead to inaccuracies in the data.
Clinicians rightly ask: ‘What’s the point of all these managers?’. They don’t see managers working with them to improve patient care, and they’re increasingly made to do things based on financial rather than clinical motivations. It doesn’t spell out a promising future for the NHS.”