A common thread has been developing in this column over the past few months. It wasn’t actually planned: it just emerged spontaneously, from discussion of an apparently disparate set of issues:

* Calls for cybersecurity across the NHS are being undermined by a lack of local resources, and by a fragmentary approach to upgrades, including the patchy roll-out of basic equipment such as Windows and Internet Explorer

* Front-line staff have huge difficulties in understanding (never mind implementing) complex information governance regulations

* There’s a complete underestimation of the workload involved in putting solutions such as Patient Online into practice safely

* Local Digital Roadmaps (and more recently Sustainability and Transformation Plans), are ‘flying pig documents’, in which great ideas are proposed with little prospect of completion because of well-documented workforce and resource pressures

* Calls for seven-day working are also using manpower and resources which are already overstretched servicing five-day weeks

* The workforce, and particularly the GP workforce, is becoming progressively depleted and exhausted.

In essence, these problems have a common cause: there is a frequent, pronounced disjunction between the perceptions, intentions and emphases of those at the top of the NHS, and the realities of front-line work for the NHS staff upon whom these decisions impact.

The ice shelf

This all reminds me of the Ross Ice Shelf in the Antarctic, an area of floating ice covering tens of thousands of square miles.

The ice itself is white, extremely cold, hard and barren (except for the occasional penguin); yet the sea on which it floats is liquid, relatively warm, and teeming with life – particularly plankton, fish and (beyond the ice sheet) whales.

There’s a complete discontinuity at the interface of these two domains – the one on top being cold, static and desolate; the other warm(ish), mobile and fertile. I don’t think there could be a better analogy for today’s NHS.


Sadly, those at the top frequently seem not to comprehend what frontline workers actually need in terms of support, equipment and — in particular — specialist knowledge and expertise.  

There are two reasons for this. Firstly, the NHS has become unbelievably complicated (for a fun but unnerving view of this, see the celebrated King’s Fund cartoon).

This convoluted structure is bad enough, but the unseen problem is that it’s also interlinked by finances, regulations and targets, so that everything interferes with everything else.

In a Byzantine situation like this, it is actually much simpler and easier to be part of a unit (clinical or non-clinical) dealing with a single specialist subject area and nothing else.

For example, it’s not that difficult to understand the ramifications of information governance and consent, if that’s the only matter you have to deal with.

The tricky bit is when you have a full time clinical day job, but in addition have to learn IG, plus protection against cybercrime, plus child safeguarding regulations, plus the legalities of amending erroneous computer entries, plus…

As a GP I often wish I had a lawyer constantly at my elbow because of the draconian penalties for getting such non-clinical decisions wrong.

Front-line needs and stresses

The second cause for the disjunction is that there is often a dearth of true communication between top management and their completely overloaded frontline staff.

New ‘solutions’ for the current NHS crisis are constantly being proposed from on high, without senior management and politicians appearing to recognise that each member of staff only has a finite amount of time available.

If a GP is on a Skype call to a patient, she isn’t available for a surgery consultation, and vice versa. Offloading ever more work onto already overburdened staff — particularly in primary care — is no longer possible.

Often management doesn’t even realise how poor or irrelevant its own communications can be, nor truly understand front-line workers’ actual knowledge needs.

Indeed, NHS managers can easily forget how specialised their own specific area of expertise actually is: the “I know this — surely everyone knows it…?” problem.

NHS websites are generally hopeless: frequently they communicate in numbing detail everything users don’t need to know, but can’t seem to signpost the really important stuff.

The solution? It’s not a blame game

Given that there can be such a degree of cognitive dissonance between NHS management and its front-line workers, what is the solution?

At first sight it might seem that management boards aren’t paying attention to the information they are being given by those at the coalface, but this is almost certainly too simplistic an analysis.

More likely – as with any cognitive dissonance – it’s because those in charge really don’t perceive the significance of what they’re being told, or because the reports they receive aren’t detailed, comprehensive or brutal enough.

For whatever reason, top management often seems not to have a coherent feel for what it’s like to be on the healthcare frontline.

In fairness, information of this nature doesn’t necessarily turn up packaged in neat official reports. Instead, it osmoses in non-specifically, to be felt rather than learned.

I wrote about this some months ago – how huge amounts of highly relevant front-line information get passed on almost incidentally, during chitchat at the watercooler.

Finally, may I emphasise strongly that I’m not doing a blame game here. There are some great managers within the NHS, together with some wonderful committees and programme boards.

Everyone in the NHS is trying to work to the best of their ability. Just because the system has developed problems doesn’t mean we should blame the individuals making up that organisation, nor pull down the whole edifice.

Sea to ice

Instead, I simply want to draw attention to the enormous discontinuity that has developed within the NHS, where people and organisations at the top often don’t fully appreciate the complexity, subtlety and scale of needs of those on the frontline. Nor do they understand how easy it would be to deploy simple solutions to lessen this burden.

While this cognitive dissonance remains unremarked and unresolved the NHS and its staff will continue to suffer, delivering vastly less than their potential would suggest.

The good news is that there’s a solution waiting in the wings — and it involves a different approach to data handling. More next time.

About the author: Dr John Lockley is clinical lead for informatics at Bedfordshire Clinical Commissioning Group and a part-time GP.