24 hours of admin in mental health services

I recently had a Twitter conversation with Geraldine Strathdee, our National Clinical Director for Mental Health, about the administrative burden we face while practicing in our specialty. She asked me to write a blog detailing just how much paperwork (and electronic paperwork) I have to do over a set period, to shine a light on the issue. So this might not be my most scintillating blog, but I’m hoping that it’ll create some useful discussion nonetheless.

I’m writing about a typical day in my current job, but none of the content is specific to my team or Trust. I’ve done six other jobs in mental health and they’ve all carried roughly the same weight and type of admin.

The day shift

I’ve been away for a week (typical lazy junior doctor), so I get in early to check through my emails. I answer a few of the more pressing ones, which if at all vaguely important need to be copied and pasted into the electronic notes. I make a few phone calls to patients who left messages last week, typing the entirety of the conversations up too.

Then I move on to seeing some patients. Two full assessments in the morning. Not only do both need extensive clinic letters but an array of auxiliary electronic forms need to be filled out too. Each new patient needs a diagnosis under the ‘Outcomes’ tab of their electronic notes and a full risk assessment under the ‘Risk’ tab (the form has around 100 optional tick-boxes as well as free text space). Also, HONOS and clustering scores need to be calculated (two multiple choice forms which take 2-10 minutes each), so we can demonstrate that our patients are ill enough to need our help. These are all individually fairly easy forms to fill out, but when you have to do 5 for every patient, it suffocates you. I perpetually wonder why I was never weighed down by all this when I worked in general medicine (it’s because Acute Trusts pay coders to extract the information from the notes after discharge and don’t have such an unhealthy obsession with ‘risk’).

I make some more phone calls at lunch time, followed by seeing two more patients in the afternoon. It’s the same admin story as the morning’s patients. I also remember that every meeting we have with a patient needs to be confirmed on the electronic notes diary, so it gets logged as work that the team has done. This involves clicking on the appointment under the relevant tab in their notes, then laboriously copying every bit of information about the appointment (who is going to be there, what time and date it’ll be, where it’ll be, what it’s for) from the left hand side of the page into identical boxes on the right hand side of the page, to confirm it all actually happened. For every appointment. If we don’t do it, the computer doesn’t recognise that we did any work.

I stay late to finish (some of) my clinic letters and write covering letters to three other services (two within my own Trust) who I’m referring the patients to. I email all the letters to the admin team, who are wonderful. They’ll print off the letters and send them in the post (yes, including to other services in our own Trust), where the recipients will most of the time scan them right back onto their own computers. Welcome to our ‘paperless’ NHS. It’s been no different in any Trust I’ve worked in. Occasionally I find replies from these services in my pigeonhole, sent by post as well, already scanned on to our own computers by the wonderful admin ladies, who frankly must have better things to do.

God forbid you ever want anything from a GP. They have to fax it across to you, for it to be scanned and the hard copy shredded. Often they even ask for a faxed request to prove that you’re really who you say you are. It’s 2015. Email was invented before plenty of doctors were even born.

The night shift

I finally manage to get home, but I’m on call, and after grabbing some dinner I’m called into A+E to help see some new patients. Not a process which is easy on your typing fingers. Every time we see a patient in A+E, we have to:

  • write an entry in the handwritten A+E notes
  • if the patient is new, open an electronic account for them before you can do any of the above, entering their name, address, phone number, NHS numbers, and GP details at a minimum.
  • On the electronic system, fill in a brief clinical note…
  • do a risk assessment…
  • calculate the HONOS and cluster scores…
  • enter a diagnosis…
  • write an assessment letter…
  • and do a covering letter to the GP for the assessment letter.

Plus whatever extra paperwork you need to do for that individual patient, for example, a referral to social services, psychological services, or an employment support service. I have to admit, it’s so much paperwork that it’s sometimes very difficult to enjoy seeing patients. Which is a HUGE warning sign. How much paperwork do orthopaedic surgeons do when they see a patient in A+E? (not just the depth of detail on the forms, but the amount of forms?).

After quietly tiptoeing out of A+E, I make it home for a nap. But in the early hours of the next day, I’m called out again to assess someone who has been brought in on a Section 136 by the police. I see them, and they need to come into hospital. And as is absolutely usual, there are no beds.

The phone calls begin- to the consultant, to wards who might be able to spare a bed, and inevitably to the bed manager and anyone else who needs to give the green light to an out-of-area bed. Every phone call is accompanied by a note on the electronic system, in addition to the assessment entry (and risk entry, etc. etc.) and the handwritten section paperwork. Thankfully an SHO is around to do the drug chart and the blood test forms. I email the patient’s usual care team to tell them what’s happened. Eventually a bed is found, and the transfer paperwork needs to be readied – so you’ve guessed it, everything needs to be printed off, and either faxed to the accepting hospital or put in an envelope with the patient.

And with that done I go home, get some ice on my typing fingers, and catch a few hours of sleep before the emails start rolling in again.

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About Alex Langford
I am a psychiatrist (now an SpR) based in Oxford after 3 years working in South East London. Before I went into psychiatry, I used to be a general medical doctor, and I also have a BSc in psychology. I'm particularly interested in improving the public face of psychiatry, evidence based medicine, teaching and patient rights. Don't mention cricket unless you've got the next fortnight free to discuss it.

7 Responses to 24 hours of admin in mental health services

  1. Sue mccracken says:

    Try all the poss 50 odd outcome measures in CYIPAT

  2. Marisa says:

    I’m glad you wrote about this. Apparently tedious but in fact very important topic. I suggest you add indicative times – how long does it actually take to write up an initial assessment, or even each ‘brief’ phone conversation. Add it all up and you will be surprised how many hours per day that amounts to!

  3. nickyhayward says:

    Well put across, Alex – and if you were putting all this on a pie chart it amounts to perhaps a third of your time with the patients?

    I sympathise. I worked in NHS admin for several years and have extensive lived experience of MH crisis services as a carer. After years of feeling I was banging my head against a brick wall from the other side of things, I too became really unwell and experienced aspects of the broken system first hand. Now I work as a ‘lived experience consultant’ and blogger, lobbying for change.

    The last three years I attended scores of interminable meetings and conferences, and engaged in numerous ‘consultations’. You hear a lot about how change has to be incremental, and little changes.

    The two bed presentations I saw in that whole period were from Sunderland Crisis Team and the Open Dialogue team from West Lapland. Interestingly, each team had decided their current service was ‘crap’ – their word, not mine!

  4. nickyhayward says:

    … Sorry, hadn’t finished. Must have pressed something!

    They realised they had to go back to the drawing board and start afresh.

    Result: both teams are low on paperwork, innovative with technology, spend a high proportion of time with clients and family/friends and get excellent results … I was going to say on paper, but you know what I mean.

    My thoughts: Question the diagnostic system; spend much more time with people – relating;prescribe much, much less as a system (you’ll be dealing with a lot of drug-induced/ problems there too); explore Open Dialogue/soteria-type approaches as a system: essentially talk to people and listen to them, and listen much more to survivors/supporters. Ditch tokenism. Work in true partnership with us. Be bold. Design a whole new human-friendly system for both clients, supporters and staff. The ‘system’ is broken and isn’t working for anyone. Let’s face it.

  5. Pingback: 24 hours of admin in mental health services | LYPFT Planning Care Network

  6. What about patients being dragged into the system. 24/7 on drug testing. Slave labour. No pay no time off and someone else decides who can visit, where we live, what we eat. If we can go get some fresh air or (whilst I was on a section) passive smoke.
    Proving someone is ill may take a lot of paperwork. What about changing the focus on what the patient needs ie counselling if anything rather than taking away all their human rights and then complaining about the paperwork – you can just make it all up anyways, mine did. He wasnt even qualified. Just lied about assessments. In scotland we pay £300 an hour for solicitors to attend mental health tribunals. Nothing for them to do. There are no rights to defend. mine didnt even ask what his quals were. The police told me he has none when I asked what they were. Noone has ever got done for a Section 318 offence. Lying on forms.

  7. Pingback: Going digital, is it what we need? | RMGirlUK

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