Intended for healthcare professionals

Opinion Acute Perspective

David Oliver: Hunt’s call to cut time spent on NHS paperwork is a hypocritical soundbite

BMJ 2023; 383 doi: (Published 11 October 2023) Cite this as: BMJ 2023;383:p2310
  1. David Oliver, consultant in geriatrics and acute general medicine
  1. Berkshire
  1. davidoliver372{at}
    Follow David on Twitter @mancunianmedic

September saw newspaper reports of the chancellor, Jeremy Hunt, asking government departments to report on how much time frontline staff in key public services were spending on “non-core work” such as administration paperwork and “red tape.”1 He reiterated this in his Tory Party conference speech.2 He argued that the time spent on such tasks harmed productivity, even with extra resources, and that taxes might have to double if it wasn’t tackled.

Such calls are not new. Most recently, the NHS England workforce plan explicitly called for productivity gains in exchange for expanding staff numbers.3 And in every spending round the Treasury calls for efficiencies in exchange for funding uplifts, or indeed to compensate for cuts. Other public servants such as police officers or teachers often complain about the paperwork burden that stops them from focusing on their core job.

NHS clinicians are no exception. We’ve led initiatives before such as the “productive wards” initiative,4 to try to reduce admin and free us up for patients. One of the concerns raised repeatedly by NHS doctors about their morale, training, and retention is the time spent on admin jobs that add little value or don’t require the skills of a qualified doctor at the top of their grade.56

Dig deeper, however, and we can see that some paperwork is essential to professional practice and can’t just be disposed of in Hunt’s virtual shredder. And much of the rest is created by the government’s own actions.

For doctors, essential tasks include writing in a patient’s notes, reviewing and commenting on results, and corresponding with patients, families, and clinical colleagues about referrals, for instance. We also prepare reports for coroners’ inquests, respond to formal complaints, carry out reviews on serious incidents and preventable harms, and prepare discharge letters and prescriptions, as well as supervising and teaching junior doctors, students, and other staff groups and documenting their progress. And if doctors are involved in medical management and clinical leadership these roles require non-clinical admin time.

I realise that some of this work could be reduced or made more efficient—for instance, by using voice recognition software or scribes, using artificial intelligence to flag abnormal results, or avoiding duplication and relying on existing documentation.78 But much of it does require a skilled professional’s expertise and accountability.

Reducing support

What Hunt fails to mention, as a previous long serving health secretary, is that he and the ministers who preceded and succeeded him relentlessly called for the NHS to cut its spending on managers and administrators, effectively disparaging their vital roles—even though they account for a lower proportion of staffing and spending in the NHS than most sectors or other world health systems.910 If you continue to reduce secretarial and admin support, especially when so much work is now done online, more of it will be dumped on clinicians themselves. Even using the term “frontline” to describe clinicians ignores the key roles played by “back office” staff in supporting their work.

The NHS also now faces very serious staffing gaps and a retention crisis due to worsening terms and conditions, plummeting morale, and a disjointed government response to the covid pandemic.1112 This means that more work falls on the staff who remain—including those in admin. Over several parliaments the government has pushed digital solutions, electronic patient records, and the move to a “paperless NHS” while repeatedly botching the implementation and contracting.1314 This has left many staff wrangling with fragmented electronic systems that are clunky, unintuitive, and not always compatible.

Then we have the slew of directives, targets, financial incentives, and regulatory requirements—some of them politically driven and based on little evidence, with no face validity to practitioners.15 Hunt’s own standards for ensuring that all patients had a senior weekend review (even when completely stable), the extra admin associated with the national “learning from deaths” programme that he introduced,16 and his own government’s requirements for medical revalidation to remain on the medical register17 are all cases in point.

The perennial soundbites about red tape, bureaucracy, and “non-core work” are designed to make headlines. But they’re not rooted in reality, and they deny the government’s own role in creating the problem.