Spreading too thin

In general I’m a frugal person. I buy foods that are reduced because they have reached their best before date and most of my clothes and shoes in the sales. I collect coupons and shop around for good offers. I try to waste as little as possible, and to recycle as much as I can. So I can understand wanting to get good value for money.

On the other hand, I like doing things properly. For example, when it comes to a sandwich, I like a thick slice of granary bread, fresh from the oven, with generous amounts of toppings. As it happens I’m not a big fan of butter or margarine, perhaps a symptom of being overweight in the 1980s and 90s when fat was literally seen as a cause of fat, whilst the carbs underneath were seen as relatively healthy. But whether it is soft cheese and cucumber, avocado and salad, cheddar and chutney, hummus and roasted veg, or toasted cheese and banana, the topping needs to cover the bread, with sufficient depth to make the sandwich proportionate. If the cheese has nearly run out, I’ll have half a cheese sandwich that tastes good rather than a mean whole.

So when it comes to services, I can see the motivation to get value for money, and to ensure that resources are being used in the most cost-effective way. I’ve developed pathways, clinics and groups to meet needs more effectively, and I’m happy to delegate less complex work to less experienced or less qualified staff. I can’t see the justification for paying psychiatrist salaries to deliver therapy, when a member of staff with half the hourly rate can be an equally good (if not superior) therapist. I can see the importance of capping the cost of agency staff, so that this money can be invested in increasing the substantive workforce. And when it comes to staff who are not pulling their weight (my record being a member of staff who had spent a whole year with a caseload of four clients, whilst colleagues in the same job had five times that along with other responsibilities) I can see the need for performance management.

However, there comes a point that too much pressure for efficiency actually makes services less effective. I saw this happen gradually over the 16 years I worked in the NHS. If we cut out all the conversations between cases, all the informal supervision, all the CPD opportunities, the time to bond as a team and to reflect and process information between appointments, then clinicians are less able to be empathic and individualised with clients. If you also give people tougher and tougher cases to work on, expecting faster throughput than with the more mixed caseload that preceded it, and couple this with cuts in admin despite there being more and more paperwork to do, you increase burnout and time off sick. Add some pay freezes, lose a proportion of posts, put people in smaller premises and tell them to hot-desk or become mobile workers and they no longer feel valued. Make it a set of competing businesslike trusts rather than one amazing non-profit organisation, tender out services like cleaning and home visiting to allow them to be done on minimum wage without the terms and conditions of the NHS, allow private companies to win contracts, and keep people in a perpetual state of change, then morale falls. Nobody has any loyalty or job security and it no longer chimes with the ethics of the people who work there.

The sandwich has been eroded down to bread and butter, and then to crackers and margarine, and then to a value brand version of the same that is 30% smaller. It might look like costs have been driven down, but the price is a reduction in the quality of services, and in the wellbeing of staff. It reduces the willingness to go above and beyond that has been the backbone of the NHS, and increases presenteeism – the tendency to feel that you need to be at work longer, and look like you are working harder, without this making meaningful impact on the work you get done. The UK has lower productivity than most other developed nations, perhaps because we have longer working hours, and work expands to fit the time available.

All over the public sector at the moment I see services trying to spread their resources thinner and thinner, and I’m acutely aware that this means they can’t do the whole job. Social Services departments have barely the capacity to maintain their statutory role, so supporting families in need goes by the wayside. Some good staff find other jobs. A proportion of the remainder go off long-term sick, leaving an ever bigger burden on those that remain. Teachers are forced to teach to tests that assess primary school pupils on aspects of English grammar that graduates struggle with that have little relevance to daily life, and squash the rest of the curriculum into less time. Children’s centres, youth clubs and leisure facilities are disappearing at a time when it is clear that parenting support and exercise are critical in improving well-being and decreasing long-term health and social care costs. We’ve been feeling the cost of ideological austerity bite, even before the financial shock of the Brexit vote, so I am struggling to see how things can improve in the foreseeable future, let alone once any steps are made to implement the extraction of the UK from the EU.

It is hard in this climate not to feel overwhelmed by pessimism. Staff are not pieces of equipment that can be upgraded or replaced at the click of your fingers. I can make a plan for how to cover a remit that needs 12 staff with 7, but I can’t then tell you how to do it with 5. I can only tell you that if you want the job doing properly it needs 12, and if you go below 7 it won’t be fit for purpose. If I sticky plaster over the cracks, you can pretend that paying for 5 is enough, and that it is the clinicians who are failing, whilst we burn out trying to do twice the amount of work each. But no matter how hard I work, I can’t be in four parts of the country at once, or do recruitment, service development, supervision and provide a clinical service in a part-time job.

Maybe the problem is that I am stubborn. I won’t just toe the line whilst covering my eyes and ears and going lalalalalalala when it comes to everything that isn’t being done. Like my exit point from the NHS, there comes a time where I’d rather leave than do things badly. And where the only efficiency available for me to recommend that fits the prevailing rationale is to pay two cheaper staff instead of my time. I’m teetering on the edge of the plank they’ve made me walk, and I’m increasingly tempted to jump. Maybe in retrospect they’ll recognise how much was getting done with such limited resources.

4 thoughts on “Spreading too thin

  1. I couldn’t agree more. I also think that we can be a victim of our own success, when a skilled member of staff does the job of 2-3 people and make it look easy, which makes others pile on more work. It’s only when they leave that the gap becomes visible (or the service is so far gone, no one cares anymore).

    Part of me thinks there will be a “flight to quality”; where individuals will refuse to be fobbed off by nominal support from someone semi/un qualified. I have seen that in those with resources opting out of IAPT by asking for insurance or private treatment, or GPs demanding for “proper” psychologist/ psychiatrist. Maybe there will be a tipping point and the shift will happen?

    Liked by 1 person

    • I hope so. It is better to focus on the positive of being perpetually in demand for the quality services we provide, than on the situations in which we are being expected to do more and more for less.


  2. Crow says:

    Why is it “better to focus on the positive” while the positive gets so small it is barely visible and, in some cases, is a mere fantasy. Why do so many professionals enable crippling government policies by working longer hours, cutting services for patients, reducing desperately needed training, etc (as you very clearly mentioned above)? While we all continue to bury our heads in the sand and say “our poor hands are tied” and hope in the fantasy that things will get better if we just wish hard enough, then governments etc will continue to push to reduce services and funding cause they can always find other things to spend the money on. Do not be deceived….they will NEVER say “O dear, look what we have done to these poor people. How could we be so cruel? Here, have some more money.” It’s NEVER going to happen. Wake up. Psychological Therapies are asking severely disturbed clients to get well by Brief time-limited therapy, by 8wks of computerised CBT courses, by Peer Support methods (blind leading the blind) and abandonment & accusation when they are deemed “treatment-resistant” if the inadequate methods don’t “work”. The professionals who tell people that “you just don’t want to change” are the self same ones who themselves don’t want to change their behaviour either, but rather seem quite happy to buy into and mediate the whole austerity ideology, no matter what the cost, at least if you go by their behaviour.

    It could be argued that we don’t want to prevent child abuse, because where would the mentally ill of the future come from and what then would become of our jobs? Your jobs will be surplus to requirement as patients are increasingly being required to “heal themselves” or die trying.

    While professionals choose only to fight for their own terms & conditions (Junior Doctors strike), while patient care is becoming ineffective, even harmful and risky, then you cannot convince patients that you authentically care about them. While you bury your head in a professional bucket of sand and quietly ignore or allow increasingly harmful malpractice to continue, content to collect your wages at the end of the month and hoping to merely survive to retirement them you have become a shame to the human race and to your profession.

    You cannot continue to tell people you care about them while walking away from them and doing little to protect them from the harm of yet more cuts. We just don’t believe you any more. Junior doctors proved that they are willing to fight, but ONLY for their own terms & conditions and NOT for patient care. You CAN effect change but you CHOOSE not to bother. A shame on all of you.

    The suicide rate has increased massively (6000 to 7000 in ONE year) and no one bats and eyelid. I guess it’s just seen as collateral damage – acceptable losses. It’s not happening to me so why should I care mentality.

    A final thought…..when the NHS was finally established in 1948, the group of people who actively stood against it were……DOCTORS!! That says it all.


    • I completely disagree. Nobody goes into therapy without wanting to help people. Nobody would want child abuse to continue, and very few people accept (let alone like) the rationing of mental health and social care services. But some help is better than none. And whilst people are trying to make supply fit demand they don’t have the time or emotional resources to look up, band together and fight the bigger fight. The whole of the UK political system is broken by swathes of people who are ignorant, short-sighted, selfish and/or disenfranchised. But it doesn’t mean that the good people have buried their heads in the sand or walked away from the needs of their clients. What makes you think we can make change any more than you can?


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