Intended for healthcare professionals

Soundings Soundings

Patients not paper?

BMJ 1998; 316 doi: (Published 18 April 1998) Cite this as: BMJ 1998;316:1251
  1. Trisha Greenhalgh, general practitioner
  1. London

    Dear Mr Dobson,

    Thanks for your letter, postmarked 1 April, asking me for my good ideas for improving the NHS. I gather you sent a copy to every member of staff to mark the 50th anniversary of this great institution. Considering that the NHS is the biggest employer in the world apart from the Russian army and Indian railways, you must have licked a lot of stamps.

    As you indicated in your letter, this exercise is highly likely to generate thousands of sensible and practicable ideas, which nobody in any strategic position has previously thought of. I was impressed with your promise to keep your civil servants engaged “for as long as it takes” on the task of opening all the responses and sending a personal reply to each one of them. That made me feel very special and valued.

    For my part, I'd like to tell you a story. A couple of years ago I was invited to apply for the post of non-executive director of my local health authority, on the strength of my academic credentials and my work in the field of clinical effectiveness. I received a letter of appointment, signed personally by your predecessor, on very thick yellow notepaper.

    Soon afterwards, a nice man from the health authority, whose full time job it was to deliver boxloads of paperwork to the members of its 40 or so committees and subcommittees, brought a consignment of “essential papers” to be read before my first board meeting. Once I had organised the various reports and briefing papers into box files, the pile stood taller than my 4 year old son. My monthly board meetings, and the five committees that protocol required me to sit on, generated a similar volume of papers approximately every six weeks.

    A year later, when we had house guests to stay, I realised that the spare bedroom had become a repository for some 150kg of largely unread paperwork. By that time, I had formed the opinion that the machinery of the health authority was so singlemindedly geared to the production and reproduction of its own internal reports and memorandums (and the reduplication of similar material from central office) that it was exceedingly difficult to focus its well meaning and hardworking members on any task that did not involve the multiple handling of pages of bullet pointed jargon.

    With great regret, I resigned from the health authority a year ago. I did, incidentally, continue my clinical effectiveness work for it. Indeed, I would like you to note that I resigned from the board in order to be able to continue that work. But since the public office (and the modest salary) went with the paperwork, I have lost both, and, in a gesture I found deeply symbolic, I was required to hand back the swipe card that got me into the “important” parts of the authority's offices.

    Mr Dobson, my good idea is this. Why not challenge the culture that allows a senior official to produce an internal memo whose sole purpose is to spawn additional paperwork for public employees, photocopy it a million times, and suggest that all NHS staff stop what they are doing and respond to it?

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