Medical Morale
Standing Medical Advisory Committee Advice (3/2002) - November 2002 |
TASK: The Chief Medical Officer, Professor Sir Liam Donaldson,
invited SMAC to consider medical morale.
INTRODUCTION: SMAC is a unique, broad based committee consisting
of practising doctors from all sectors including primary care, community,
secondary and tertiary hospital care and universities. We also have as
ex-officio members the Presidents of the Medical and Surgical Royal Colleges.
DESIGN: In considering the current state of medical morale
members were invited to suggest issues impinging on medical morale on
both a local and national level. The Chair and Vice-Chair then commissioned
papers from member s on selected issues.
PAPERS: Each commissioned paper is attached : Appendices
I- X in Portable Document Format 
(29pp 76Kb)
DISCUSSION: Members met on 13 November 2002 and discussed
the key issues raised in the papers. Nigel Edwards, Policy Director
at the NHS Confederation, gave a presentation to inform discussion.
SMAC reached the following conclusions:
ADVICE: Is there a problem? - Yes.
(i) Published evidence suggests that stress and its
effect on the workforce is a matter of increasing concern in the health
service (Appendix I).
What are the causes and contributing factors?
- Shortage of resources in the NHS
(ii) Poor funding of the NHS compared to Organisation
for Economic Co-operation and Development countries especially between
1979 and 1997 (Appendix II) has resulted in widespread shortages.
(iii) Erosion of secretarial and clerical support
resulting in inefficient use of clinicians’ time and skills (Appendix
III). The provision of high quality, individual. Administrative support
for every doctor would make an enormous difference to both morale and
productivity.
- European Working Time Directive (EWTD)
(iv) There are clear signals (Appendix IV) that EWTD
is already having adverse effects on the overall quality of inpatient
service with no clear plan of action emerging from the government to deal
with the consequences.
- Strategies without implementation
(v) Flooded by strategies to improve the NHS there
appears little emphasis on implementation. Many strategies have the enthusiastic
support of the profession but this will be difficult to sustain without
implementation giving rise to disenchantment and disillusionment. (Appendix
V)
(vi) Lack of control over clinical practice ultimately
leads to poor morale. This may be considered in terms of:
- decisions made for doctors without a rational explanation that affect
their working practice. Appendix X describes the potentially demoralising
effect of employing international clinical teams without discussion/rational
explanation with resident clinical teams; and
- increasing clinical and non-clinical workloads. Appendix VI discusses
the effect on morale of the increasing roles a clinician must take
on to meet targets, clinical governance and training issues and how
these impact on morale.
(vii) The cause both of stress and also of diversion
of a large proportion of clinicians’ time away from direct clinical care.
Although the right of the patient to complain is extremely important and
supported by the committee there appears to be no safeguard against vexatious
complaints ( Appendix VII)
(viii) Whilst there has been much work to improve training
over the past few years there are still issues concerning the extent to
which doctors are equipped by their College training programmes for non-clinical
management tasks ahead. This lack of training predisposes to low morale
as there can often be feelings of inadequacy in such areas (Appendix VIII).
- Undervalued by Managers and Government
(ix) The consultant contract is discussed in terms
of its effect on family life, retention of staff and how much the clinician
feels valued (Appendix IX).
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WHAT CAN BE DONE?
Immediately
Make targets more clinically appropriate
- Allow sensitive and locally appropriate application or interpretation
of targets. For example – patients who refuse treatment should
be excluded from targets.
- Provide a guarantee to doctors that they would not have to do
anything clinically inappropriate. For instance, targets should
not be achieved locally by encouraging clinicians to do minor
surgery rather than concentrate on major.
Better support for professionals
- Ensure that managers are encouraged to prioritise administrative
and secretarial support for doctors to release clinical time.
Resolution of contract
- Early resolution of the intentions of the ‘Consultants Contract’
is needed.
In the medium-term
Empower staff
- Empower doctors and professionals for the role which they have
to play. For instance, train them to develop personal strength
and resilience and for those managerial tasks they will have to
undertake.
- Undergraduate and postgraduate medical training should better
equip doctors for organisational life but in doing so it should
be recognised that doctors still have to be doctors. This means
that that they should not spend any more valuable clinical time
than necessary doing managerial or administrative tasks.
Professionalise supporting roles
- Medical secretaries and clinical administrators provide specialist
functions and should be viewed, valued and developed more professionally.
Co-ordinate Policymaking and ensure the sum total is achievable
- DH should routinely consider the potential impact locally of
the sum total of all of its policies and whether together they
are achievable and consistent. For instance, it may be unrealistic
to expect full implementation of four NSFs, the ICT strategy and
achievement of targets at the same time as being structurally
reorganised.
Ensure organisational focus on quality and outcomes
- DH should encourage organisations to focus on healthcare quality
(health, patient pathways) through using process measures with
a clear link to health outcomes where outcome measures are suitable,
available and appropriately risk adjusted.
Ensure the best clinical configuration to meet needs whether
inside or outside NSFs
- NSFs, and similar directives, need to fit the varying needs
of geography, population and epidemiology – not the other way
round. Configuring services around one NSF will inevitably destabilise
other services. Local discretion in implementation needs to be
maintained.
In the longer-term
Change the culture
- It is clear worldwide that doctors will need to relate to the
public and to managers in new and different ways particularly
now that information and evidence are more freely available and
possibilities of intervention are ever increasing. Conversley
perfection in health matters can never be achieved, resources
are finite and the general public must share responsibility for
their own health.
- A new compact/concordat is needed between the public, politicians,
doctors (and other professionals) and managers. We understand
that discussions are underway and we would welcome participating
in these.
- Clinical leaders should be encouraged to participate in the
development and understanding what the compact/concordat means.
- Training will be needed for all those implementing and supporting
the new compact/concordat.
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