Driven from efficiency to distractionBMJ 1996; 312 doi: https://doi.org/10.1136/bmj.312.7033.784a (Published 23 March 1996) Cite this as: BMJ 1996;312:784
- G E P Vincenti
I once came across a comment by Gaius Petronius, written in the first century AD. “We tend to meet each new situation by reorganising, and a wonderful method this can be for creating the illusion of progress, whilst producing confusion, inefficiency and demoralisation.” When I read this my thoughts turned to the reformed NHS, but recent clinical situations have served to broaden such concerns.
A teacher came to see me the other day, worn out by the stress of trying to cope with the new educational reforms. His application for early retirement on health grounds was being questioned. I have seen many like him, crushed by the demands for ever more work and ever higher standards of performance. At first he had been pleased to comply, then as things became more stringent he had taken to bringing home increasing amounts of paperwork, until in the end he was working to midnight every night. The final straw had been a recent visit by the school inspectorate, whose report suggested that he be given increased responsibilities and tasks. He just could not give any more and decompensated into mental illness. When he went on sick leave his symptoms improved dramatically.
That same week I had seen a senior police officer, a fire officer, a nurse manager, and a local government civil servant. Like the teacher, they had all been suffering from work related stress. The same pattern of increasingly impossible demands had overwhelmed their stress coping strategies. All reported feeling submerged beneath a tidal wave of paperwork and endless meetings. They felt unable to devote sufficient time to the basics of their job, be that teaching, policing, firefighting, or managing. None of these people had typical vulnerability factors for mental disorder. They had no history of previous psychiatric problems, nor was there any significant family history. They all enjoyed a supportive relationship with their partners, and none had pressing financial concerns. They all drank alcohol in moderation. Admittedly, few exercised regularly these days, their work schedules did not permit it.
To my mind, recent reforms within a variety of public services are in danger of driving out not just those who are under-performing, but talented people who give valuable service. There seems an expectation these days that one can achieve ever higher targets, but surely there is a limit. Even in high jump the bar is raised only by a small amount each round, and in the end even the winner knocks it down. Competitors are discouraged from harming themselves as they try to achieve the next height. Within the public sector, at least, there seems to be no thought given to how high the “bar” should be set, and I detect that an increasing number of “jumpers” are landing awkwardly. If too many people take premature retirement on health grounds, however, pension funds will be unable to cope. I suspect that more of my patients will have their application for an early pension turned down, with disastrous results for their health. Unfortunately, the stigma of mental illness is such that they are likely to be blamed for their misfortune. When adverse working conditions lead to physical ill health legislation is often introduced swiftly to correct this. Somehow I doubt that any action will be taken to limit the psychologically damaging effects of efficiency drives in the public sector. I fear that we are in danger of drifting from public service to public slavery. None of this is new, as Gaius Petronius observed nearly 2000 years ago. The Roman Empire in which he lived, collapsed into chaos and the dark ages, strangely enough through overexpansion, demanding more and more from its increasingly overstretched legions. There may be a lesson there for us today.—G E P VINCENTI is a consultant psychiatrist in Northallerton