“Errors Will Be Made”
INTRODUCTION
On the 22nd October this year the Trade Union Congress (TUC) released a report showing how decreasing provision of mental health services across the UK is coinciding with increasing demand (i.e. rising mental health need). Thus over the last five years the number of patients accessing mental health services in England has risen by a third (540,000), yet over the same period the number of mental health nurses, doctors and beds in the country has fallen. This has meant ‘huge pressure on the workforce and left mental health services struggling to staff services safely’, and consequently this ‘is ‘having a negative effect on patients who use these services and on the health and safety of the staff who provide them’ (TUC, 2018, p. 14).
Even more starkly, the BBC was reporting in February 2017 that a 50% rise in unexpected deaths of patients reported by England’s mental health trusts in the previous three years had occurred against a backdrop of £150m funding cut to mental health trusts over the previous four years.
It is against this background of a crisis in mental health care that AWP’s Administrative Review proposals to cut back administrative capacity have emerged. The extent of this diminishing of admin cover is expressed most strongly when comparing the before and after team structures – something described in more detail later in this document. However the headline proposals are themselves striking. There will be:
• 74 fewer whole time equivalent Band 4 posts as previous admin roles disappear and new Band 3 posts proliferate.
• an increase in Band 2 posts for which new cheaper apprentice positions are being created
• Specialist Band 4 medical secretary roles will disappear and such secretarial function will be absorbed within generic Band 3 team administrator roles.
The Trust employs approximately 350 admin staff and is looking to achieve a Cost Improvement Programme (CIP) saving from this review for 2018/2019 of around £500,000. Elimination of administrative posts, effective downgrading of staff, and for example the introduction of apprenticeships at Band 2 will in theory contribute to this cost saving. Whilst it’s complicated to calculate the scale of this cut to administrative capacity, we are looking at up to a 40% reduction. Thus, in a context of a 34% rise in patient demand across of the South West of England (TUC, 2018), when services and staff already feel stretched to the limit and staff are working regularly beyond their band and with large amounts of unpaid overtime, far fewer staff will be expected to cover the same (and growing) amount of work.
The present Unison document seeks to provide a representative sample of assorted AWP staff comments and feedback regarding the Trust’s Administration Review proposals. The staff who have contributed represent a wide range of professional roles across the Trust.
‘Listening into action’?
The initial Consultation document dated July 2018 begins with the following quote from ACAS:
“Consultation involves taking account of as well as listening to the views of employees and must therefore take place before decisions are made. Making a pretence of consulting on issues that have already been decided is unproductive and engenders suspicion and mistrust about the process amongst staff. It will be helpful to decide upon the degree of consultation first and to inform people what the decision making process will be. Consultation does not mean that employees’ views always have to be acted on since there may be good practical or financial reasons for not doing so. However, whenever employees’ views are rejected the reasons for doing so should be carefully explained. Equally, where the views and ideas of employees help to improve a decision due credit and recognition should be given. Consultation requires a free exchange of ideas and views affecting the interests of employees and the organisation.”
Considering the spirit of this passage, we would argue that there are strong grounds for questioning AWP executive’s commitment to listening and consultation in relation to the current proposals. Following the release of this initial document there was a period between 9 July and 10 August of meetings with admin staff to present the initial guiding principles of the review. Staff were then invited to send in comments and feedback. We are told in a document dated 7.9.18 and entitled ‘Administrative Structures Review: Staff Consultation Feedback’ that ‘an external evaluation of feedback was carried out to provide an independent and objective review’ and that the feedback document will present ‘a summary of the findings’. It is not clear whether this ‘summary of findings’ was itself written by the external body, or whether it was an AWP employee doing the work of summarising (it is in itself problematic that clear specification of authorship is missing). Certainly, there is no attempt to provide any detailed comparative picture of the frequency in which particular comments and feeling were expressed. There is no explanation for this absence.
However, it is reported about the feedback that
Senior managers, Doctors and the wider teams appreciate administrative support, which they feel keeps them working accurately, efficiently and productively in a timely way. There is some fear that administrative support may be weakened, pushing the burden of duties onto managerial and clinical staff. Moreover, some respondents feel a “one size fits all” approach could not serve the diversity of systems and services provided by the Trust. (p. 22)
In addition,
Respondents describe how administrators are highly valued by both staff and service users, they perform a wide range of administrative duties in community teams. …. For instance, community teams have a large volume of telephone calls, which are often from people who are in distress. These staff need to have a good knowledge of pathways available to service users. They are also concerned with staff safety and help support the lone working procedures for staff undertaking community visits. … The teams are large and have expansive caseloads, which create a large amount of work…They report this admin work is essential to ensure the clinical work is done accurately and consistently and frees up clinical staff to carry out their duties. (p. 24)
The quantity of support is also debated but it is clear that respondents feel administration enhances higher grade effectiveness and efficiency and that it is a specialist and often independent role. Thus, they are fearful of it being reduced. (p. 26)
Another respondent described an attempt to pool administrative support. The plan would include a senior administrator who would manage the work flow, allocating work and improving efficiency and ensuring work is not left during periods of leave. While a named person would remain responsible for consultant and team work, there would be consistent support/ cross-cover. This has been extremely unpopular. Another locality described how the re-development of the administrative team had a considerable impact on the quality of service provision. It improved in response to CQC warning notices. (p. 26)
Several respondents make pleas that administrative ratios are not reduced:
“I’m working at maximum capacity and still have multiple things that have not been completed and am starting to feel the strain of the post having only been here 3 months. The last person left the admin role because there was too much to do… [P]lease don’t make it any less” (p. 27)
There is considerable fear expressed by clinicians who do not want to lose any of their existing administrative support through these changes. (p. 28)
There is considerable fear that the review will reduce the amount of administrative support available to teams and specialist services. This is thought to be a false economy, where clinical staff will have to complete more administrative tasks. This cost will be due to a higher rate of pay, but also interrupt their provision to service users. It is widely felt that, where administrators are based in teams, their work is bespoke; they have local knowledge and ensure continuity and familiarity, which supports both staff and service users best. Furthermore, having a known member of staff prevents duplication of effort. … There is also fear that roles will be down-graded and experienced staff will feel undervalued and leave the service. This could leave services at risk of not being able to meet the standards required of the commissioned service. (p. 31)
Finally, we are told that additional feedback amounting to 74 sheets of A4 came back with further comments about the type of admin support required. We are presented however with only a couple of paragraphs, subtitled ‘What kind of administration support is required to support the Division and locality teams?’:
The responses in this section reiterate the sentiments outlined in the previous questions. A considerable number of senior staff have written letters of support for their administrative staff, praising their work and confirming the essential nature of their post. There is serious concern that administrative capacity will be lost as a result of the review, with changes to a hub system and how much impact it will have on the work of the specific services and for morale. There is considerable account made of the wide-ranging variety of work undertaken by administrative staff. Medical staff are particularly concerned that any loss to their support may result in being unable to meet the Royal College of Psychiatrists requirements for trainee doctors. There is considerable unhappiness expressed about the review taking place at all.
The question is raised about career progression:
As previously outlined there is also much support for a route for administrator career progression route, as there is little available presently.
This forms part of ubiquitous reference in the formal proposal documentation to consistency and transparency, something applied to job descriptions for example:
It is reported that job descriptions for administrative roles are not up to date. (p. 14)
Respondents suggested there is some on-going confusion due to the variety of roles and difference in lines of responsibility. The structure could be made fairer, with consistent provision to all wards. (p. 23)
The question [of medical admin] raises considerable dispute about whether medical secretaries and administrators who have specific skills and are allocated to work with consultants and medical teams are necessary. Responses from clinical staff, particularly consultants, suggest that the continuity provided by a named administrator is extremely helpful, reducing the risk of tasks being overlooked or de-prioritised. Moreover, administrators who occupy this role speak of their job satisfaction and sense of ownership of the work (p. 25).
Whilst there appears to be frequent reference to consistency and transparency, it is left very vague what is being suggested, although at times the pressure for staff to work beyond their band is being indicated:
One respondent suggested it is important that all staff know what a member of administrative staff is required to do, so they do not request tasks to be completed, outside of the job description: “It’s also important to ensure that staff are not made to do things that they should not be doing in the future”. (p. 25)
It seems notable that the summary of the feedback at no point makes references to consequences for safety and risk. It is hard to believe that no respondents mentioned this theme – certainly subsequent feedback during phase 2 (which Unison has been copied in to) makes frequent reference to it. This raises the important question about to whether the Trust executive has seriously demonstrated a concern with assessing risks to service users (as well as admin and clinical staff) of these proposals.
The mysterious case of the disappearing staff feedback
Following this feedback document being drawn up from the initial period of consultation, the ‘Phase 2 Consultation report interim Findings’, dated 1 November, was published. This presented proposals which were supposedly developed in the light of staff feedback. It is stated at the beginning of this document that ‘it seeks to summarise feedback from the first phase of consultation and to outline proposals on new structures, ways of working and related activities and processes.’ However, after all the above-mentioned staff suggestions and concerns made in good faith, we are presented simply with the statement that, ‘The following themes/topics were frequently raised in the phase 1 feedback’, followed by a short collection of terse phrases, each graphically presented as nestling in a cloud.
These themes consist of:
‘greater consistency’, ‘Up to date job descriptions’, ‘improving reporting systems’, ‘who’s who in corporate’, ‘consistent supervision approach’, ‘more recognition for admin staff’, ‘career pathways’, ‘hub vs team approach’, ‘clarity on career development opportunities’, ‘improve IT skills’, ‘apprenticeship approach’, ‘staff anxiety about the consultation’.
So there is no attempt at any more detailed specification or elaboration, instead simply boiling down the mass of opinion in favour of not reducing admin capacity to ‘staff anxiety about the consultation process’ – not staff concerns about the actual impacts on quality and safety of care. This concern is instead mentioned later and kept distinct from the main themes, apparently having the status of a non-theme:
We recognise the potential transition from current admin structures to a new structure will create anxiety. We also recognise there will be some concerns about the potential impact on the service and quality standards.
(Section 3.5 (p. 12) entitled ‘Incorporating staff feedback from phase 1’ reads as a completely empty tokenistic exercise.). And the feedback mentioned above which did touch on the theme of improving job descriptions and career progression, ends up not as proposals for protecting staff from working above their bands and for facilitating employees’ upward career trajectory, but as a giant exercise in levelling down.
These points direct us back to the earlier ACAS statement that ‘[m]aking a pretence of consulting on issues that have already been decided is unproductive and engenders suspicion and mistrust about the process’. Also very pertinent is the recommendation that ‘whenever employees’ views are rejected the reasons for doing so should be carefully explained’ – something which has certainly not been done by those leading the admin review.
Finally, the ‘Phase 2 Consultation report interim findings’ attempts partly to justify the proposed changes thus:
Any typical hierarchy of jobs has fewer higher bands and more of the lower bands. Indeed, this is true of all professional structures across the Trust. The current situation for our administration roles does not reflect this pattern or have a clear underlying rationale.
This argument epitomises the race-to-the bottom culture which underlies the admin review. Indeed, it is a perfect formula available to justify any number of future downgrading of staff roles. If, for example, there are currently more Band 6 roles in the Trust than Band 5s, perhaps the former also should not be surprised to hear at some point that they too fall foul of the ‘hierarchy of jobs’.
Some of these points lead us to recall the restructuring in Bristol following a 2015 competitive tendering process and introduction of New Model of Working in community teams. This initially involved inappropriate levels of risk and complexity being pushed down onto lower banded staff, something which then caught the attention of the CQC and resulted in a special warning notice to ensure urgent improvements in relation to safety concerns.
PHASE 2 STAFF FEEDBACK
During a series of six well-attended staff meetings covering each of the main AWP localities UNISON reps asked staff if they could re-send feedback which had been formally submitted as part of phase 2 to us in order that we could produce our own response to the proposals. A snap-shot of this feedback is presented below.
Apart from such changes significantly impacting on wellbeing of admin staff – fewer staff expected to cover the same amount of work, and to effectively work beyond their Band even more than currently happens – it will have a very big impact on the workload of clinical staff and consequently the quality and safety of care.
Cutting capacity –endangering quality and safety of care
As stated by one specialist nurse in the Bristol-based ADHD team,
Our admin team is already completely overwhelmed by the volume of work and this will only grow, not reduce in any way. Without them, the clinic would be unable to function.
Another member of that staff team commented:
[Admin staff] book thousands of appointments a year, including telephone clinics, psychosocial groups and assessments. They also transcribe dictations and assist with writing reports and managing databases. They are struggling to complete all of the tasks required of the team so we could not operate with a reduced administrative team without significantly reducing our clinical work to take on admin tasks ourselves as clinicians. ….
We would benefit from more admin support in the team as the number of clinicians has increased but the admin resource has not.
A member of the Veterans service commented:
I joined AWP’s veterans’ service in 2012, then called the South West Veterans Service. …. Now 6 years on and AWP’s veterans mental health services have grown to more than four times the size, though the admin staffing has grown only by 50% to 1.5 WTE.
Staff in North and West Wiltshire have highlighted how –
For both Wiltshire West Community and Wiltshire North Community two CMHT admin (per sector) could not possibly cover the current CMHT work plus medical admin for 14 WTE medics across both sectors. This would not be safe or doable.
It will be harder for overseeing band 4’s to manage several teams’ admin due to the Wiltshire geographical area is widely spread over multiple sites.
It is proposed that South Gloucestershire Intensive team goes from X1 Band 4 @ 32 hours, x1 Band 4 at 18.5 hours, and x1 Band 3 at 18.5 Hours, to x1 Band 3 f/t. A senior member of staff commented,
Clinical staff would have to spend their valuable time carrying out admin tasks and as their workload is quick turnaround, it generates a larger volume of work than other teams. Clinicians will not have the time to do the admin necessary and this will greatly impact the quality of the clinical work undertaken – this will be a high risk to the service and to the service users alike.
A significant amount of time is spent triaging [crisis] calls and transferring to relevant teams, signposting and giving advice, including speaking to people who are suicidal…. On occasions there have been no clinical staff available due to busy workloads…we have to make decisions to deal with the call. This is unacceptable responsibility for a Band 3 to have to deal with. With this proposed reduction in admin staff hours, there will be more risks of callers either not being answered or not given the vital support they need!
We also provide cover to the AMPH Service under the Section 75 agreement between the local authority and AWP. This alone is a Band 4 role and as such should be recognised. Expecting one Band 3 to cover this and all others tasks in the absence of the AMPH admin will be detrimental to both services as this is a high impact service.
We can see, however, that the proposed structure will be unsustainable, unsafe, demoralising and cost the Trust money in the long run…. If the proposed cut in admin staff is implemented the Service will be opening itself up to failing the people who need it and may result in deaths and court proceedings.
The staffing structure of South Gloucestershire Psychological therapies team is due to go from x2 Band 4 – one at 30 hours pw and one at 15 hours pw and x1 Band 3 at 18 hours pw, to X1 Band 3 at 37.5 hours pw with a Band 4 covering PTS as well as two other teams (one being off site and an inpatient unit).
One of the team admin workers commented:
In my view fewer administrators on lower bandings in future will lead to a loss of skills and backlogs of work. This will mean added pressures for consultants, clinicians and therapists who will have to pick up admin tasks. If they are doing more admin tasks they will be seeing fewer service users and waiting lists will grow. One of the aims of this restructuring is to cut costs, but clinician time costs more than band 4 admin time!
Another admin worker noted:
I am shocked at the proposal to cut admin hours by as much as 40% in some teams (perhaps more) with every team in the locality where I work having a reduction in hours/down banding. … The team I work in will have a 40% reduction in hours and a loss of 45 band 4 hours with a proposal of one WTE band 3 to cover instead. The workload will not reduce by 40% so who will cover the shortfall? Will clinicians be required to complete the tasks currently covered by admin and will this save the Trust money, given the clinicians are on a substantially higher hourly rate than admin? Just in this last week the team I work in was down by 40% in hours due to meetings attended regarding this process and sickness….the work has piled up and attention to detail was perhaps not what it should be therefore the service suffers. This will not be sustainable on a long-term basis.
The proposed structure will mean we operate on this reduction moving forward week after week, month after month reducing further at times of annual leave and sickness. I suspect sickness will increase as staff will be under further pressure and will be detrimental to their mental health….ironic when we work for a mental health trust. How will cross cover work if someone is on leave and another team have someone who is off sick at the same time – will the Band 4 be expected to cover and perhaps be in two locations at once?
South Gloucestershire Primary Care Liaison has a current structure of X4 p/t Band 3’s and X1 f/t Band 4. It is proposed to remove the Band 4.
A senior clinician stated that
Despite the reduction in staff, the workload has significantly increased recently due to the team now taking self referrals.
PCLS increased workload has a larger margin of error due to the fast paced nature of the work. Detailed tracking of each referral is needed to ensure accurate and timely triaging, assessment of risk, set up assessments, and ensure theses are completed in the correct timescale depending on level of risk. There is potentially a very high risk to service users waiting for assessments. If this work is not completed in a timely, effective manner or cannot maintain the current acute attention to detail required to track and process referral and avoid breaches, errors will be made.
A specialist practitioner stated:
I will be less efficient at both the admin tasks than our administrators and less efficient at my job; assessing patients.
Risk will increase to service users due to increased pressure and burnout amongst staff and also due to patients being seen in a less timely fashion. Routine admin tasks will be more expensive if shifted to frontline practitioners and staff within our team are already struggling with the workload. A reduction in Admin support to PCLS is a false economy and risks the goodwill of staff who are currently working extra hours unpaid as standard.
Roles and responsibilities are also different between the same team in different localities;
The teams in South Gloucestershire and North Somerset are allocated a Band 4 Administrator and two Band 3 administrators for PCLS.
In Bristol there is no PCLS team. Triage does some of this work, screening patients and arranging initial appointments, however the remaining administrative work is done within the Recovery teams i.e. tasks such as re-arranging cancelled appointments, processing the follow up appointments, discharges and managing the care-pathways process etc. There is no provision for this work within the proposed structure for Bristol.
Another difference between localities:
The teams in South Gloucester and North Somerset are allocated a Band 4 Administrator, two Band 3 administrators and one Band 2 administrator for functional Older Adult work, in addition to two Band 3 administrators for their dementia service.
In Bristol, the functional older adult work has been merged with the general adult work. In addition, the Dementia & Wellbeing Service run by Devon Partnership does not offer care for complex patients, or those experiencing a combination of functional and cognitive problems.
Therefore the bulk of the service offered to older adults within Bristol is provided by the Recovery Teams. There is no provision for this work within the proposed structure for Bristol.
It is proposed that Bristol Central and East Assessment Recovery Team changes from X4 B4 admin including two medical secretaries, and X1 Band 3 and 1 Band 2, to X2 Band 3 admin, and X1 Band 2 (apprentice), and one Band 4 lead admin position open to any admin in Central A&R, Central Crisis or Early Intervention to apply for. A medical secretary commented:
Currently the six full-time administrators employed by the team work to full capacity. Given that the team currently has over 850 referrals open to it, with nearly 1300 contacts undertaken by clinicians in the past four weeks, and 60 staff, this isn’t surprising. If the amount of admin support for the team was cut in half, logically half of their workload would have to go back to the clinicians and managers of the team instead; this would be over 112 hours of administrative work (assuming that all clinicians and managers complete administrative work as quickly as a trained and experienced administrator can).
Job descriptions
There is consistent theme regarding the current complexity of workloads and feeling this has been misrepresented allowing the trust to fudge current job roles into a generic role which is not fit for purpose. There are concerns over lack of knowledge of current roles and hence difficulty in being able to define and rewrite such roles. A generic band 3 admin role is not adequate to reflect each teams roles, functions and complexities.
South Gloucestershire South Psychological Therapies team state;
It is difficult for me to accept that one day I will be coming into work on a band 4 and the next I will be working on a band 3 when my work will not have changed one iota. The Job Descriptions may be new but the actual day-to-day work will be exactly the same.
Another admin:
I feel band 4 status is essential due to the sensitive and sometimes distressing calls we receive, the ability to triage calls and work unsupervised and the fact that we are a training team with a Consultant and trainee Doctors to support.
You are expecting band 2 and 3 to take the day-to-day calls from patients who may be in distress and potentially suicidal. These calls are currently covered by staff who have generally worked their way up to band 4 gaining years of experience both within their role and from life generally. Do you think this aspect of the work will be held safely by staff who are new to the service and potentially inexperienced?
Examples of calls taken:
Patient called to speak to therapist who was unavailable- I spoke to patient asking if she was safe, had a family member or friend to speak to, or needed to speak to someone else instead. She said she felt like she was walking on a tight rope and may fall off but by speaking to me felt steadier and could wait to speak to therapist. I told her to call back if things changed and she was struggling again. She fed back to therapist that all she needed was someone at the end of the phone to re-assure her.
Patient discharged but struggling with decision and calling numerous times to speak to therapist….administration had to keep boundaries whilst remaining compassionate.
Patient struggling and going through a spell of crisis…..because admin provide continuity when answering the phones we were aware of patient’s current presentation and act accordingly without undue delay.
We have got to know the patients on the caseload and know when to act on calls immediately and when they can wait, continuously assessing situations….this is based on life skills, instinct and expertise and cannot be taught overnight but from years of working within a mental health setting.
In terms of inpatient services, there has been concern over the lack of a ward clerk job description and how the new generic admin roles do not reflect their current duties. Thus one admin worker noted that,
Ward clerk duties are wide ranging and complex, and they work with a large degree of autonomy. The role bridges the gaps between different services and interfaces, and includes health and safety measures (ensuring maintenance of PIT alarms, registering staff, ensuring these are used and returned), being responsible for up to £1,000 petty cash for service users and staff groups, monitor Reportzone for breaches, missing data, which is not shown on the proposed job roles.
North and West Wiltshire CMHT admin have expressed dissatisfaction with the criteria for the new Band 4 role and highlighted inconsistencies with regard to qualifications for this role;
No jobs are deemed complex or to have value in progression of knowledge/skill if not a managerial role. [This shows] complete disregard for the complexity of role when actually completing admin tasks instead of managing them.
Removal of the medical secretary role means lack of regard for specific qualifications some people have to complete this role (Medical Secretary qualification) leading to down banding for doing the same job. At the same time requiring the new band 4’s need to have RSA III or NVQ3 in Business Administration or equivalent as an essential skills to apply for the job.
Whittucks Road is a stand alone unit who currently have x1 Band 4 and feel a Band 4 should remain in-house. One senior practitioner noted that,
Whittucks Road has medical cover for only 2 days per week (1 Consultant who works for this service 2 days per week, 1 Specialty Doctor 1 day per week and 1 GP for 1/2 a day once a week). The band 4 secretary is essential in providing up-to-date communication between the medics and the ward i.e. to update re MHA deadlines, feedback from nursing staff and the ward manager re patients on the ward, and an important link to the community teams and other wards so that patient care is met within the accepted timeframe. This would not be achieved if the band 4 were not based on the ward.
A band 4 administrator/secretary is required on the unit as there are no junior doctors to assist with the administration of discharges and meeting the protocols around Clozapine, liaising with the pharmacist, completing MHA paperwork (reports and papers), drafting of Ministry of Justice reports and emails. A band 4 secretary is needed for ward round, to take minutes and use systems needed to obtain up to date information as there are no junior doctors to do this. This is felt outside of a generic band 3 role.
My current role at Whittucks Road meets the new band 4 job description (job purpose, skills and abilities), except for supporting admin staff recruitment as currently no need for this.
The manager of Whittucks Road added;
I rely on my Administrator to support me when I am investigating complaints and other sensitive matters – will the proposed Band 4 be available to me for this?.
A practitioner in South Gloucestershire PCLS noted the positive effect having a Band 4 in the team has had on the teams functioning;
The removal of band 4 positions on the ground/frontline work and only having these as management positions, belittles the intensity, complexity and skill base needed for people currently functioning in a band 4, with positions changing to generic band 3 roles.
And another viewpoint:
As far the new job description appears, it seems there is a further layer of management and delegation, but the numbers of staff on the ground needed to complete the work (which they currently do autonomously) would diminish to add a further layer of management which is not required.
Specialised services have expressed concern over the lack of research into current roles and lack of consideration to how complex these currently are:
How are you going to ensure there is parity across all same banded roles when there has been no consultation on what each person on each banding actually does? Once it is rolled out are we able to refuse to do things we currently do that is no longer a part of our job descriptions, for example?
There has also been concerns over lack of accountability if people work generically and do not have dedicated workloads/responsibilities. This is highlighted by a practitioner in South Gloucestershire:
This model does not explain how the tasks that will not be able to be completed will be picked up, or who will take responsibility for the inevitable risks that will arise.
Medical secretaries
Specialist Band 4 medical secretary roles will disappear and such secretarial function will be absorbed within generic Band 3 team administrator roles alongside a reduction in admin staff numbers in each team.
Current medical secretaries work solely for dedicated Consultants and their trainee’s. This role takes all of their working hours, and more, tending to work late without extra pay or time owing to ensure critical work is completed. If they are expected to now work generically in a team with reduced admin hours but include additional tasks to their existing role, there is a question of who will be expected to pick up the work the medical secretary’s currently do.
As one medical secretary stated;
The job is too varied to have floating rather than dedicated support. It is not just a typing pool.
Bristol recovery teams provided a list of current roles completed by medical secretaries:
What kind of ‘medical admin’ support needs to be provided to Consultants and medical staff?
• Speciality specific, with local experience and knowledge of the job
• Organising clinics
• Provide an efficient outpatient appointment system. (RIO + Outlook diaries)
• Managing diaries, including meetings, leave cover etc
• Typing/transcribing dictation
• Safe, effective, accurate transcribing, knowledgeable (medical terminology, diagnosis, risks, medication, physical health etc)
• To receive, sort and prioritise daily correspondence for all the doctors organising such action as appropriate and ensuring clinical reports/requests are brought to the attention of the medical staff to enable action to be taken.
• Managing patient phone calls and triaging – providing a point of contact to liaise between for service users, carers, medical staff, primary care, social services, non-statutory organisations and other members of the staff both within mental health services, the trust and other organisations.
• Understanding the risks and importance of monitoring psychiatric medications as well as in depth knowledge about procedures and specific forms required. These medications include controlled medications, Lithium, depots and Clozapine
• Speciality specific knowledge of the MHA (Mental Health Act), liaison with, eg MHA admin, Criminal Justice Services etc.
• Aware of the relevant legislation and the legal implications of requests for information.
• Coordinating and chasing essential physical health monitoring
• Instituting check on requested investigations, liaising with neuroradiology and other specialist departments as necessary, to ensure referrals and requests to these departments have been actioned in a timely way. Following up the whereabouts of scans i.e. CT, DAT scans in time for appointments.
• Collating FP10 prescribing as per Trust requirements and appropriate submission on a monthly basis.
• To ensure Community Prescription sheets/Polar Speed and Depot scripts are up to date, scanned to RIO and sent to pharmacy and Polar Speed within deadline of expiry date.
• Dealing with emergencies and urgent situations when knowing who to contact and what to do is essential
• Working independently to a degree, including prioritising, taking initiative, remote management skills, supporting quality improvement activities – our work is personally managed not supervised.
• Assisting with teaching activities eg assistance with Power Point presentations, handouts etc.
• Support of doctors in training (requirement by RCPsych and GMC)
Medical Admin support provided must be in keeping with guidance/ requirement of –
GMC
RCPsych
Deanery
• Responsible for inducting junior doctors into the administrative systems. This includes completion of forms for RIO and W drive for the team and advising them on the admin systems so that they are quickly familiar with the systems used by the team and are able to contribute to the clinical work. Our secretaries liaise with other professionals during the induction process to ensure that the junior doctors join different members of teams in order to enhance the learning experience early on in the job and facilitate good team working from the outset.
• To support doctors in any of their additional roles e.g.appraisal and supervision ensuring we provide and receive supervisions, support our educational supervisor and clinical supervisor roles, training programme director, south west executive committee.
• Supporting doctors in their 360 Appraisal.
Bristol Central and East Recovery query the efficacy of having generic admin to support Consultants and the decrease in banding to Band 3:
Trying to manage doctor’s requests across a team of three administrators, all of whom can change doctor diaries, would be an incredibly and unnecessarily complex proposition. The job descriptions for Band 3 administrators do not nearly cover some of the complex issues that medical secretaries work on, which are more suited to the generic job description of a Band 4 administrator- including involvement with R&D projects (usually with some consultant involvement), the management of senior manager and clinician diaries, dealing with often highly-sensitive meetings and investigations (with Consultants required to create reports for the Ministry of Justice, Coroners, and more), organising complicated meetings (with doctors often asked to weigh in on multidisciplinary and other complicated matters), helping with complaint responses, CQUIN and audit support
Central and East Recovery also express concern over current difficulties employing Consultant psychiatrists and feel this will make it harder to recruit:
It appears difficult to recruit doctors to our team currently (when one 0.6 WTE doctor left the East Stream of the Central & East Assessment and Recovery Team, it took months before a replacement locum consultant was willing to take the post, which presumably cost a fortune to get in place); it seems that if doctors aren’t offered specific medical secretary support at a band where they can take initiative and offer real, substantive help on complicated matters, that the team will struggle to recruit, or even keep, new doctors in the future – in fact, we’ve been told by doctors that several colleagues are already looking for new roles as a result of this.
Bristol Consultants concur:
In Bristol the Consultant group all oppose these changes fiercely without exception. Several Medical Leads also submitted information as part of the consultation and none of this has been taken into consideration. In Bristol we are having longstanding problems with recruiting and retaining our medical staff and this is only going to make our posts even less attractive. This will lead to further agency locum costs and wipe out any marginal savings that you are suggesting within a matter of days.
They also expressed grave concern regarding potential outcomes of pursuing the generic admin ‘pool’:
Large adult wards need protected and dedicated admin resource. The use of a hub for typing tribunal reports is not practical and will lead to potential late submissions with potential directions (including fines and court proceedings) against our senior medical staff. This is totally unacceptable. I feel that inpatient consultants need a dedicated individual based on the ward to comply with very short deadlines around Section 2 work, for example.
Bristol Consultants also reiterated the importance of having a dedicated medical secretary for community consultants work:
The role of the doctor in the team comes with specific administrative demands such as written and oral communication using medical language with other doctors such as GP’s, such as prescribing medication, the governance of this, overseeing the monitoring of physical health consequences of medications such as Clozapine, providing reports for mental health tribunals and other legal documentation such as CTO12 forms in timely fashions to ensure community patients who are restricted by the MHA aren’t treated illegally. Much of the practicalities of this are organised by the medical secretary freeing up clinical time for the doctor to spend with more patients or in supervising fellow clinical staff to manage their patients safely.
With these critical aspects of the role of medical secretary identified, please can you provide more information about how it will be ensured that these roles are fulfilled if we are not using the specific training associated with the title of medical secretary?
Feedback obtained by Unison which describes the experience elsewhere of medical secretarial duties being absorbed into a generic admin role has shown a marked deterioration in the quantity, quality of work, patient safety and satisfaction in people’s jobs.
We received the following communication from an AWP employee regarding her observations during her time spend working in Stroud health services:
In Stroud staff were ‘successfully’ downbanded and pooled medical secretarial work was created.
Consequences – work was missed as ‘cherry picking’ from pooled work took place.
Consultants did not receive the individual care which meant that specialised knowledge was under utilised by secretaries, new employees did not have the same interest, and patients were unwittingly affected, as secretaries would know what results to look for and chase up, whereas new Band 3 staff picking up pooled work did not understand the nuances. Therefore standards and quality were affected, morale sank further and knowledge & skills lost as people left or resigned. (Affects recruitment and retention).
Unsure if this applies in quite the same way with psychiatry as in medical but suspect it may have some bearing.
With regards pay protection – 5 yrs was offered however lost pay protection if increased hours.
In Gloucester Royal Hospital they used ‘time waiting’ or ‘marking time’ where if increase hours drop to a lower band, and if someone left at a higher band they were replaced with a lower band. Similar to pay protection.
Basically – in a nutshell – it was not worth it, for staff morale, consultants and patients. Now staff still try to keep to ‘their consultants’ rather than ‘pooled work’.
North and West Wiltshire highlighted concerns regarding stopping the medical secretary role and proposal of the generic pool of admin staff could lead to:
Lack of accountability and ownership of duties using the ‘pool’ admin approach (ie. some staff will carry a job through, others will do the minimum). Clinical staff will become frustrated trying to find someone to complete a task if already preoccupied with something else and unsure who to leave it with to ensure gets done.
Lack of accountability to complete processing of and documenting prescriptions for 300 service users [within the memory service]. It would be difficult to keep consistent recording/reminder records for each service user without a nominated person allocated to this role.
A North and West Wilts administrator also made the following comments about negative safety implications:
The new proposed job description for a Band 3 administrator makes no reference to prescription administration which is an essential role in the current medical secretary role.
This includes ordering FP10’s, updating & amending the prescription spreadsheet (which is used to record and monitor all prescriptions for proof of appropriate use which is a CQC requirement), arranging prescription requests and chasing these up to ensure completed, recording and uploading prescriptions on RiO including monitoring when they are next due in some teams such as Swindon memory team, fax & post FP10 prescriptions to pharmacies, post FP10’s to Service Users and ensure logged, fax & post Community Prescription cards to AWP Pharmacy for dispensing. Errors in this service could lead to someone’s mental health deteriorating as not prescribed medication on time, could lead to medication duplication/errors which could have greater consequences on patient safety, and if not recorded appropriately, not adhere to CQC guidelines.
A Bristol Consultant also highlighted that:
Some medics have extra roles requiring extra admin support. This includes Medical Leads, Postgrad Tutors, Undergrad Tutors. The extra roles involve admin support for rotas, securing locums for vacancies, teaching and academic programmes, annual leave, MAG minutes, mortality reviews, job descriptions, supervision and many more.
I also think the 1 band 3, to 2 Consultants plus trainees will be very stretched, and not work unless we get some sort of effective digital dictation capability.
Staff would need to check and recheck requests/deadlines and reports for Ministry of Justice or the Mental Health act are completed more often to check someone has taken responsibility for this and followed it through. This becomes more difficult to find out if someone starts a job, but passes this into someone else to complete. It will be easier for deadlines to be missed which could lead to critical incidents regarding renewal of sections, including CTO’s not being request/completed on time.
A consultant from PCLS and recovery team stated;
The loss of the function as medical secretaries will also be very difficult to absorb…things easily get missed and lost if the admin staff can not provide continuity
And another practitioner mentioned:
How do you prioritise one Consultant’s work over the other? This will cause friction and tension with our Consultants.
Concerns are also raised over lack of awareness of conflicting work from several Consultants in the team:
if there is no dedicated worker, who prioritizes the Consultant teams workloads and decide what needs completing first? Who is aware when something has been completed or still outstanding? Who would be accountable if mistakes are made?
Medics across the trust have highlighted specific concerns over the loss of the medical secretary roles and how this could affect recruiting Consultants during times where this is proving difficult. If consultants prove more difficult to recruit, or go off with stress the cost of a locum will be detrimental and vastly more than the cost of the administrator remaining on their current band.
Lack of the medical secretary roles would affect the future of having trainee doctors working within teams,
The accreditation as a medical training post will not be continued if adequate admin support can not provided.
And Bristol Consultants echoed this;
These changes are also disregarding what is required in job descriptions approved by the Royal College of Psychiatrists and training posts by the local Deaneries. This will impact on existing posts where individuals are likely to seek representation from the BMA and also any new posts going forward as the job descriptions will not be approved by the College.
The proposals you are suggesting are going to impact negatively on our services and will make our training posts extremely unattractive. We are likely to lose trainees quickly and this has longer-term ramifications in attracting the next generation of consultants.
This has also been reflected by team managers who feel trainee doctors are a beneficial resource to over stretched teams but cannot continue without having a designated medical secretary;
We would be unable to manage Trainee Doctors as the Band 4 is essential to ensure the organisation and workload from this group is managed properly
Concerns regarding administrative lead role
Recovery teams in Bristol provided the following feedback regarding admin staff reporting to the Band 4 admin manager and then to the Band 5 administrative Lead or report directly to Consultants, ward managers and service managers. Staff were unanimous that:
• roles should be co-located with the clinical (MDT) team for each Service – this is essential for knowledge base and relationships with clinicians and patients, performance and governance, patient centred care and streamlined governance.
• We do not support the concept of central hub working. Face to face contact with the individual team is essential for above reasons, also motivation, team spirit, sense of ownership of the service, morale and staff retention (AWP is allegedly an ‘Investor in People’)
• Our Admin services are already stretched with an ever increasing workload – any potential reduction could risk compromising patient safety.
• Our view is that the roles should report to Consultants, ward managers, service managers/team leaders as applicable for their Service and not admin reporting to other admin.
• If admin are no longer using the medical secretary role, who will prioritise and ensure all the Consultants’ work is completed? Would the Consultants liaise with the band 4 administrator who is not on site, who will then try and delegate and prioritise workloads which is then handed down to a pool of administrators – who decides who will be completing what is not directly allocated to specific Consultants?
• It would make more sense, be more streamlined, be less room for error or miscommunication and reduce the likelihood of work being lost/not completed if Consultants continue having direct contact with a named person on the ground. These staff are currently self-managing in liaison with the Consultant, therefore the additional managerial role is not required and causes more room for error.
A Member of the ADHD team advised:
I believe that the admin staff would be best managed by our team manager rather than from an admin hub, because the processes they work with are specific to the team and require close management because of the rapid developments occurring within our service
Issues regarding gender pay gap
A respondent from South Gloucestershire South psychological therapies team made the following comment:
There is information about the gender paygap on Ourspace as follows: ‘The overall pay gap data for AWP indicates that on average, men in our organisation have an hourly rate 14.9% more than women.’ Can you tell me how the new proposed structure addresses or improves this, given that at present the majority of administrators are women?
There is a very important question here. We note that the AWP’s 2017 Gender Pay Gap report states that,
The aim of the Gender Pay Gap reporting regulations is to enable those authorities with 250+ employees to identify and narrow the gap in the difference between the earnings of men and women by identifying any gender-based pay inequalities and to enable them to make plans to investigate and remedy these.
Valuing admin staff, their well-being and career prospects
Admin worker in S. Glos:
From a personal point of view, this process has had a detrimental effect on both my mental and physical health with stress levels in and out of work rising because of this review. I currently feel supported by my team colleagues and sincerely hope that the service we all deliver will not be jeopardised or, more importantly, broken if you drive these proposals forward to a reality.
Specialised services administrators commented that:
Jobs will be more repetitive, with less varied jobs, which de-skills and devalues people. Admin will probably need to feed in to the “high value complex task doers”, which ultimately is a repetition of work and is degrading to others already in post doing the job.
Whittucks Road staff advised:
Changing what is the NOW band 4 role to a Band 3 role is completely and wholly devaluing and demoralising.. The work generated by the clinical/management/nursing team currently will not change, regardless of the banding, therefore in my view, the current Band 4 role is not redundant at all.
Although the re-banding has been sold as providing greater structure in progression of bands, staff do not agree with the function this purports:
The proposed structure means an effective downgrading of the majority of band 4 admin posts as across the board there will be 73.85 WTE fewer of them. This means if people don’t wish to move into a more managerial role, their ‘career’ stops at band 3.
South Recovery team practitioners stated that:
you have made a core part of our team feel isolated and completely invalidated.
JOB RE-PROFILING AND AGENDA FOR CHANGE
It is not clear that the proposals have considered the requirements of Agenda for Change (i.e. national NHS Terms and Conditions of Service), Annexe 24 part ix, which states:
where a workforce re-profiling exercise results in a member of staff being paid at a lower pay band, as established through job evaluation, then the member of staff should see a commensurate change in their role (or the work they undertake,” and ask the employer to identify what tasks or duties down-banded will no longer have to undertake in each instance.
The proposals appear to be a very large-scale re-profiling exercise of administration roles. Annexe 24 requires that such exercises are conducted with the affected staff along with their Trade Union representatives. This clearly has not happened.
The proposals cover a very large number of staff and a considerable number of discrete teams of administration staff. This response has shown that although there was a general discussion and involvement with staff it did not look at the detail of each individual role. The differences that each individual member of staff experienced was raised during the Phase 1 discussions. The response contained in the proposals appears not to have addressed the individual differences but rather moved towards a generic role for all staff.
A further requirement of Annexe 24 is that if there is re-profiling, and especially if there is a down banding of a role, then the employer has to be very clear as to what the differences in the new role will be. In a down banding situation the member of staff will be undertaking different and less responsible tasks then before. There is no indication or recognition in the proposal of what the proposed differences will be and how current tasks will be carried out; clearly in some cases not by the current workforce.
SUMMARY: DANGERS OF SEEKING MENTAL HEATH CARE ON THE CHEAP
Overall the vast majority of the staff feedback which we have heard directly or received in written form is strongly critical of the admin review proposals, for the reasons raised above. The proposals constitute a serious attack on and devaluing of admin staff, many of whom who have built up very significant bodies of knowledge and skill over a number of years, and now find themselves thrown backwards, on reduced pay, and their well-being jeopardised by a significantly increased workload. And the result of this, including the downgrading of medical secretaries, is to seriously undermine and endanger the quality and safety of mental health care delivered by clinicians. In this sense service users and their family/loved ones will have to pay a large price. If many staff are already fully stretched in terms of workload pressures, the risk of making errors – with potential catastrophic results – is increased.
Unison believes that there are very good grounds to call into question the genuineness of the consultation process itself. This partly explains the very high levels of frustration and anger displayed by administration staff. This strength of feeling was clearly on display during the different staff meetings which Unison reps organised throughout the Trust, and most recently in the Day of Action lunchtime walk-out. The large level of support from all different sections of clinical staff, evident again in the Day of Action, indicates their awareness of the wider damaging repercussions for their own practice.
More particularly, and in summary, some factors which we feel have not been taken into consideration are:
1. Job descriptions and job functions – currently working above bands e.g. arranging and scrutinising MHA documents and deadlines met for legal frameworks.
2. People completing the same role as a Band 4, coming the following day as a Band 3 but the work and its complexity remains the same (whether in an allocated job or ‘generic’ position).
3. Ward Band 4’s are already overwhelmed completing the current Band 4 role – will their more complex work be removed from their role? If so, how can one =Band 4 manage several teams/wards and complete all their complex tasks whilst not directly on the ward/in the team.
4. If the new Band 4 role is managerial, who will be completing the work on the ground now that at least one member of staff has been removed from the team? This will make the remaining staff more overworked and does not reduce the complexity or amount of work they already do.
5. Specialised Services highlight the redundancy of the ‘generic’ admin role, as each team has differing complexity and specific skills necessary to be cohesive. They have very specific service users and situations which means relying on the ability of and knowledge of the admin staff to facilitate the efficacy of the team.
6. There needs to be more people ‘doing’ the work, not more ‘delegators’. All band 4’s currently appear to self manage, work autonomously, and already supervise lower band workers, therefore the proposed added layer (alongside the additional role of Administrative Lead) appears unnecessary and takes resources away from frontline staff.
7. There is no detailing of how the current workloads will be completed and by whom, or how detailed and critical jobs e.g. managing legal documents such as Mental Health Act paperwork which is currently part of a band 4 role, will be administered.
8. Admin staff, consultants, managers and other team members have stated they feel that current Band 4 administrators in their team should remain at their current banding due to:
• the complexity of their roles,
• expert knowledge base and skills needed to complete the job
• accountability and management of formal and legal systems e.g.
o managing mental health act paperwork,
o ensuring KPI’s and audits are met to meet CQC requirements
o avoiding breaches and fines
o talking to distressed and high risk service users sometimes without a qualified to support them, and having to give advice and assess if an immediate response is needed
o reduce, help manage and prioritise consultants and managers workloads (a consultant may have up to 200 clients working 3 days per week therefore cannot manage/be aware of all deadlines/competing tasks).
o Having an allocated medical secretary for consultants is a requirement from the Royal College of Psychiatrists, therefore non-negotiable
o Without a dedicated administrator, junior doctors cannot work on wards or in the community. Teams can be reliant on their support due to being overworked and caseloads rising.
Bristol Consultants at Petherton have requested the medical secretary role to remain at its current banding. They reflected that one better
way to save money is to increase productivity and efficiency in our most expensive staff (the senior clinicians) and in order to do this we need a strong admin support network to make this happen. What you are suggesting is going to have a very negative impact on how teams will work and this will lead to a poor service user experience and poor quality service.
We have endured the fallout of a series of poor decisions with regards to our Estates and we are absolutely clear in our minds that these proposals are sending us in that same direction. This is both deeply frustrating and extremely disappointing.
If [the loss of medical secretaries] is not happening outside of Psychiatry, why is it happening here? We have concerns about the parity of esteem for our patients.
A Bristol Consultant noted that:
The end result will inevitably be, expensive people (such as medics) who are terrible administrators, taking even more time away from patient interventions to talk to a computer – this is not Lean practice – and ultimately patients will lose out
Another Bristol Consultant stated:
Your current proposal is to reduce the Bristol Recovery team administrators further to one Band 4 post, two Band 3 posts for Recovery and one for Crisis team. This would reduce the level of administrative support to a critical level increasing the risks of errors considerably and causing problems such as:
• not arranging appointments in a timely fashion;
• “losing” patients in the system;
• delays in communicating with GP’s, with the consequent increase in risks regarding medication management and increased costs due to slower transfer of prescribing to GPs;
• reduced efficiency in doctors activity as we are not good administrators and are very expensive if used to arrange appointments, type letters etc.
• loss of the ability to monitor staff activities such as completing care plans, arranging appointments regularly, recording demographics, monitoring team caseloads, referral and discharge rates etc.
In short the proposed structure is deeply inequitable compared with other parts of the trust and reduces the administrative support available in the teams to a dangerous level.
NEXT STEPS IN UNISON RESPONSE
Following a series of well-attended meetings across the main localities of AWP administrative staff voted unanimously for a series of activities that could give expression to the strong feelings of opposition to the administration review. This includes the plan to conduct an Indicative Ballot of members in January in order to gauge their willingness to partake in some kind of industrial action. In order to not move towards industrial action we would need to see the proposals being withdrawn, the process restarted or the proposed new structures very significantly amended.
REFERENCES
TUC (2018) Breaking Point: the crisisin mental health funding. Available at: https://www.tuc.org.uk/sites/default/files/Mentalhealthfundingreport2_0.pdf
UNISON Response to AWP’s Administrative Structures Review Proposals
12th December 2018
work and mental health 