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Personal Views Personal views

Baubles are a waste of time

BMJ 2000; 321 doi: (Published 07 October 2000) Cite this as: BMJ 2000;321:905
  1. Charles Essex, consultant neurodevelopmental paediatrician
  1. Coventry

    My car needed a new exhaust pipe. As I had time to wait I read the chairman's 10 point customer satisfaction guarantee displayed on a large sign behind the counter (I want to deliver a quality service to my customers so I am interested to see what other organisations say and do). I watched other customers. Most ignored the sign. A few glanced at it, then ignored it. What they wanted to know was, “When will my car be ready, will it be done properly, and how much will it cost?”

    Having a policy was more important than who wrote it or what it said

    I kept a clinic session free (waiting list up, activity levels down) to attend a seminar about the Charter Mark Award, an award that public services can apply for. One criterion for the award is that a department should monitor its performance and publish the results so the users of that service can see them. I visited a unit that had been awarded a Charter Mark. The waiting times from referral letter to appointment, and from arriving at the clinic to being seen, were displayed on a corridor wall. People walked past. Nobody stopped. Nobody looked. The unit was fulfilling the criterion. Even if the results had been displayed in a more visible place, such as, say, the waiting room (which was probably what those who designed the award had in mind), would it have made a difference? What had that criterion got to do with the quality of the service offered? Surely, what people want to know is not how soon 90% of patients were seen but when their child is going to be seen.

    I send letters to parents and, with the parents' permission, copies to other relevant parties. These letters are a record of the consultation and reinforce for the parents what has been said, with important information about diagnosis, prognosis, and changes in treatment regimens. I think this makes an important contribution to communication between doctors and patients. Judging by a survey I did, the parents think so too. Over 80% of the letters were typed by the end of the next working day after my clinic, and 100% within five working days. Then my trust signed up for the King's Fund organisational audit and one of our secretaries was allocated to complete the paperwork from our unit for the audit. Because of this, my letters to parents were significantly delayed (the audit does not measure this but I do). The audit was supposed to improve the quality of service we deliver, yet it impaired it.

    With less than 48 hours to the deadline for the trust's completed audit submission, our secretary was told that we needed a written “nappy changing policy” for our unit. At such short notice, she was going to write it although in the end someone else did so. The staff collating the paperwork from different departments needed a policy document to fulfil the audit criteria. Having a policy was more important than who wrote it and what it said.

    At advertising awards, advertisers congratulate each other on how subtle and sophisticated their adverts are. They seem to miss the point as to whether the adverts actually get the message across to the majority of punters or increase sales. The Charter Mark Award and the King's Fund organisational audit were thought up by an administrative mind set. The organisers have lost the plot. These awards have “paper” standards: do we have written policies and protocols? Do we carry out various bureaucracies? Whether we treat patients and colleagues well (such as giving them more than 48 hours' notice to write a document) seems less relevant.

    Do any of these vast paper exercises improve the quality of service we offer? It is of no interest to me (or the users of our service) if the audit describes us as the best or the worst unit in the country. The question we ask our customers is, “How was it for you when you brought your child?” If they are dissatisfied did we deliver a poor service? Can we improve that? Or does their dissatisfaction reflect a different upset which they focus on the process rather than on their feelings about themselves or their child?

    To believe that because we are good and caring people, what we do will inevitably be good and caring is naive. We fall short of the standards we set ourselves. We are human, fallible, with feet of clay; we have finite emotional and physical energy; we have finite resources. But to believe that creating a bureaucracy, with protocols and procedures, the solution favoured by those who seek to control, will lessen risk and deliver a quality service is specious. I know my colleagues and most parents appreciate the service we offer. Yes, I'd like wider recognition for my team for the quality of our clinical practice, but not at the expense of creating paperwork which is meaningless to the people we serve. A bauble is a “trifling piece of finery; a stick surmounted by a head with ass's ears.” These awards are administrative baubles.


    • If you would like to submit a personal view please send no more than 850 words to the Editor, BMJ, BMA House, Tavistock Square, London WC1H 9JR or e-mail

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