Formarrhoea

The epidemic of formarrhoea blighting adult mental health services is spreading to child and adolescent mental health. Threatening to arrive all about the same time are forms to do with risk assessment, care programme approach, outcome and activity recording, Commission for Health Improvement, child protection, assessment of trainees…and more. They will likely cause an avalanche when added to the mountain of existing forms and Government circulars already piled up on my desk. Forms are increasingly governing all aspects of clinical practice. They threaten to get in the way of doing the job.

I admit an aversion to bureaucracy that makes me resent being required to fill in or tick boxes on more forms. They bring certain images and phrases to mind. I find myself grumbling ‘Stalin, Third Reich, Kafka, Asperger, or just trust me to do it right’, whereas I know I should think ‘safe practice, avoiding enquiries, information systems, research…’ Perhaps it is due to unresolved adolescent rebellion (I was brought up in the 60s). However, I have found that my resentment is shared by younger colleagues who, when faced with yet another column of boxes to tick, actually shout out rather more obviously unpleasant things. Here is a new variety of ‘tic disorder’.

My fear is that the heart of good clinical practice, the clinician-client relationship, will be so controlled by forms and procedures that there will be little time or energy left to develop rapport. Instead of concentrating on joining the client where they are in their world in order to develop understanding, the clinician will be preoccupied by how to fill in the latest risk assessment form. The standard of good practice will be a set of correctly-completed forms and followed procedures. Never mind how you and your patient actually get on. It reminds me of an episode from Richard Gordon's Doctor at Large. Dr Potter-Phipps, a society doctor practising privately in Harley Street, had acquired a newly-invented electrocardiogram (ECG) machine that he used to impress his patients and he took it with him everywhere. The early large ECG machine was driven in a second Rolls Royce that followed behind Dr Potter-Phipps' own Rolls on home visits. One day, he returned from a man who had suffered a stroke looking worried. ‘A near thing, dear boy’ he reported to his assistant as he came through the door shaking his head, ‘a damn near thing’. ‘What, did you pull him through?’, asked his assistant. ‘Oh no, the old boy's dead. But I only got the ECG there in the nick of time’. Likewise, our patients may not get better or even die, but never mind, as long as all the paperwork is done they will succumb in good form. And I know what formarrhoea feels like from the patient end, having been hospitalised for depression. What seemed to matter most to in-patient staff was monitoring my psychiatric state, whereas I would have welcomed more understanding and input from the underlying emotional crisis I was going through.

Associated with form filling is the irritation of rubber stamping. As consultants, we are increasingly being asked to sanction, in writing, innocuous activities where previously a nod and a wink would have sufficed. Again, images of a police state and being expected to function as a bureaucrat rather than as a clinician. Recently, when faced with a particularly silly request for rubber stamping, I must confess a sneaky delight in having signed myself ‘Obergruppenführer’.

Two forces seem to be accelerating formarrhoea and all that is associated with it. First is the pressure to create risk-free public services, together with the belief that forms are the way to do it, emanating from the culture of litigation and compensation. The huge sums awarded when things go wrong, and the search for scapegoats in inquiries, creates the atmosphere of fear, pushing us to defensive practice. The overriding principle is to be seen to be doing the right thing. As long as correct procedures are followed, forget what really goes on at the coalface. It is the bad press and financial consequences of high-profile mistakes or plain bad practice of a tiny minority of our colleagues that is intruding into the good practice of the rest of us. Lest we think we are being singled out in the NHS, the obsession with risk management is spreading everywhere. It has even reached the church, I have discovered, where one might expect to put one's trust in protection from Higher Powers. In introducing my son's carol concert, the vicar informed us of the exits where we could evacuate the church in an emergency (adding incidentally, that we would all meet up outside in the graveyard. ‘Hope not’, whispered my neighbour…).

Second, there is the Government's unquenchable thirst for more information to drive their pledge to improve health services. Yet all the figures seem only to result in more surveys, reviews, and re-organisations that may give the illusion of progress, but in reality mask demoralisation and lack of clinical resources. Indeed, the Roman Emperor Petronius' famous description of this ancient political strategy could have been written yesterday rather than in ad 66: In our faculty, Professor Richard Williams very appropriately titled a recent talk on understanding government thinking ‘You can't fatten pigs by weighing them’. And the whole process seems set to continue. Recently, the Shadow Minister for Health announced the Conservatives would ‘radically reform the Health Service’ if they came to power. Plus ça change, plus ça reste…to be radical please leave the NHS alone for once or better still, raise it above the status of a football in party politics.

‘We trained very hard, but it seemed that every time we were beginning to form up into teams we would be reorganised. I was to learn later in life that we tend to meet any new situation by reorganising and a wonderful method it can be for creating the illusion of progress, while producing confusion, inefficiency and demoralisation.’

Now I have had a good rant, I can calm down and admit that of course forms can be useful in guiding the more undisciplined of us in our practice and capturing essential information. It is even possible that all the forms and policies on occasions overcome human frailty and prevent adverse incidents, although difficult to prove. Incidentally, if one is cunning, one can even join the system and design complicated forms to be used as hurdles to keep referrers at bay. I probably just need to attend a course on information management skills to cope with the overload. Or ask for a sabbatical from the Department of Health mailing list.

In the enthusiasm to embrace forms as a way to improve our services, a potential danger is being overlooked. Little attention has been given as to how all the paperwork and prescribed practice might actually increase risk for the patient. Not only does the sheer amount of paperwork due to obsession with risk management and symptom rating threaten the clinician-patient relationship, but it is also likely to result in less time for reflective and creative practice. Yet these immeasurable aspects of our clinical work might be precisely those that reduce risk, through bringing about change and personal growth in our clients. In any case, for most of us attention to risk and its management has always been integral to our practice. Also, a certain amount of risk-taking is necessary for change. For instance, family therapy can involve precipitating a crisis. Did the Chinese not define crisis as ‘a dangerous opportunity?’ In fact, the scrutiny of our practice - a major point of the whole exercise - might more accurately be done by setting up joint clinics with colleagues where we could observe each other at work with clients and provide live supervision. Likewise, less mistakes will be made in an organisation that is operating effectively and this depends on another factor difficult to measure - staff morale.

A further risk relates to what all the paperwork means to clinicians. It reminds us that our professionalism is no longer trusted and that central political policies now dictate local clinical priorities. The experience of being over-controlled, our practice fettered as we are turned into robots, guarantees low morale and problems of recruitment and retention. Why was the new consultant's contract rejected?

Finally, there is the biggest danger - that the whole paperwork exercise will actually increase risk for patients as fewer can be seen and for less time because clinicians (those who are left) will be so busy filling in all the forms. The attempted solution will then well and truly have become the problem. I have heard that a Trust is to create a post of Risk Manager to oversee all the policies and forms. How much of the extra money now being injected into mental health services will be soaked up by new administration to cope with all the paperwork? Perhaps some of it would be better spent on paper shredders.

Meanwhile, the legal profession appears to be the winner. I was reminded that lawyers are waiting to swoop on the pickings when visiting a general hospital recently. The entrance lobby is like a shopping mall and a firm of solicitors has managed to set up residence there, with the logo ‘If someone's to blame you can claim’. How the Trust agreed to this I do not know - but along with fining beggars, it is just another episode in the surreal Fellini film I have been going about in for the past few years. The remedy - retrain as a lawyer?