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We need to talk about admin

A colleague has been looking after her mum with advanced dementia for some years now, and when recently we talked about our respective stress levels, she told me a story that got me thinking.

She needed to buy petrol, and the petrol station was busy, and the pump she got onto didn’t work, and so she had to queue again, and then someone didn’t move their car when they went in to pay, and all in all it was just one of those really annoying experiences. And she said she could barely stop herself screaming: Do you know my mum is really sick, and I am sick with worry, and can you just get on with it, and get out of my way? DO YOU KNOW HOW HARD THIS IS?

She is a grown up and of course knows that the poor people at the petrol station, incompetent or inconsiderate though they might be, don’t know how stressed she is, and why.

My experience of much NHS admin is like this. Only it isn’t. Because the people and processes I am dealing with know what’s up in my life. Because that is why I am there. They know how stressed I am, how stressed all of us are in this waiting area, in this telephone queue, in this booking system.

Admin malaise

The admin malaise in the health and care system is well known and understood even by their most sporadic users– clunky at best, unsafe at worst. So when I pointed out to the clinical director for the cancer services at the ‘world class’ hospital where my husband was being treated how useless much of their admin was, he basically said he knew all that, and apologised for ‘the inconvenience’ this must have caused us.

The point is, this particular garage forecourt doesn’t cause inconvenience, it causes upset, and a loss of trust, and anxiety. Because if a hospital knows how hard their users’ lives are right now, and they still don’t make their letters arrive on time, or respond to phone calls, or check that all results are in before an appointment is booked, it doesn’t inconvenience patients and carers, it messes up our care.

It tells you, ‘We know that you are in pain and distress, but this is not important enough for us to get ourselves organised.’

It tells you, ‘We know that you are in pain and distress, but this is not important enough for us to get ourselves organised.’

Culture, not admin

There is the obvious link to patient safety, of course. So if you can’t consistently access a patient’s file, even within the same hospital, and then ask the confused, tired patient about the dose of morphine they are prescribed, you might as well not bother tagging on a convoluted process of checking and double checking the dispensing process in the hospital pharmacy: the prescription is unsafe. If you ask an elderly chemo patient whether they have 8mg or 8 tablets of steroids, and then rely on the hesitant answer, you are making medicine errors rather likely.

But there is another, even stronger link, in my view. If culture is the stuff we do that we feel doesn’t need explaining, then bad admin, bad IT, bad connectivity is cultural. A senior NHS England advisor told me recently of his wife’s cancer and the dozens and dozens appointments she had during its treatment. He said ‘at least a third’ of the times when they turned up at the hospital (another one of those world class ones) the appointment couldn’t be found on the system, his wife couldn’t be found on the system, or the whole system couldn’t be worked on. A third. Each time, he hastened to add, staff were helpful and sorted it out for them.

But I honestly cannot imagine having to work on a process every day all day that doesn’t work a third of the time, and that I have to find a bespoke work around for. Each time. Sounds like a problem with culture to me. One where staff know there is no point complaining, there is no point suggesting improvements. Nothing will be done. Low expectations, low quality.

Staff morale

Which leads to another massive impact of bad admin: staff morale. Because not only do bad IT and duplicated paperwork tell patients that their distress doesn’t matter much in the greater scheme of things. They also tell staff that their time, their work satisfaction and sanity doesn’t matter all that much either.

Why else would you put people with a world class education, world class reputation and world class skills in front of a bad computer interface? Lumber them with a printer that doesn’t work? Deprive them of wi-fi?

Staff are also dealing with difficult stuff, hard conversations, distressed patients, angry carers, overload, time pressure – they too need to feel that the processes they are working through are helping them to do this job we are asking them to do.

I think it is time we stop calling bad process bad admin. Because it is actually bad management and bad leadership.

So I think it is time we stop calling bad process bad admin. Because it is actually bad management and bad leadership. If you work the appointment system and you have no interest in ensuring that the consultant (whose time is a massive bottle neck anyway) has all the data in front of them to have a conversation with the patient that enables decision making, then you are not engaging in bad admin, you are engaging in bad care. Badly managed and executed care for sick and distressed people, and overloaded and pressurised staff.

If you aren’t able to organise processes that enable patients to alert staff to increasing pain, or anxiety or complexity, and to deploy a good, holistic response, then you will find these patients turning up in your A&E where you then have four hours to fix a problem you have failed to grasp for the last four weeks.

Is it fanciful to hope that sustained investment in the NHS for the next 5 to 10 years might be an opportunity to embed good transactional systems in well designed processes that value staff and patient time and enable good decision making based on good data?

Could our Secretary of State’s interest in snazzy IT be given a decidedly improvement-focussed bent? Can we stop treating these processes as mindless, useless, pointless admin – and see them as what they are: a central part of good, modern patient care? Let’s hope so.

Charlotte Augst is Chief Executive of National Voices.

This is the text of a talk Charlotte gave at our Unheard in Healthcare event.

Charlotte Augst6 August 2019

A little something else? If you found this of interest, then we’d suggest taking a look at some related items. And when you’re ready to chat, you can get in touch.