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CAMHS won't see you now

Sometimes top down beats bottom up

Parkinson’s second law states the most time is spent on the least important issues. Sounds like primary care redesign, says Dr Willie Hamilton

Parkinson's second law states the most time is spent on the least important issues. Sounds like primary care redesign, says Dr Willie Hamilton

Most of us are well aware of Parkinson's first law – that work expands to fill the time available for it. Indeed, you would think Parkinson must have been a GP, or at least married to one.

We've all experienced the law, so we know that under extended hours GPs will simply spend longer achieving precisely the same result.

Parkinson's second law is much less well known – that the amount of time spent discussing an issue is inversely proportional to its importance.

The law's illustration describes the board of directors of a power plant.

Three items are on the agenda: commissioning a nuclear reactor, building a staff bike shed and selecting the brand of chocolate biscuits for the staff canteen.

Only one person really understands the workings of a nuclear reactor, so his idea goes unchallenged, with agreement in minutes.

But everyone understands bikes, even if not everyone has actually ridden one, so here people chip in to the debate and it takes 30 minutes to resolve.

Then we come to the chocolate biscuits. We all love chocolate biscuits and all have first-hand experience of them (too much, in my case). So the debate rages for hours until finally the victors emerge, bloodied, from the field.

Does that sound just a little bit like patient-led service redesign?

This is a themed issue, in part around access, so you will have to forgive me describing the most important access issue of all – the staff toilet.

My practice finally came into possession of some more ground floor space. We could expand the nursing room, which was so small even the most devious estate agent couldn't have described it without drawing a comparison with a broom cupboard.

But there were repercussions. It became clear during the practice discussion (if that's what you can call it when it made the battle of Waterloo look like a picnic) that not only was another staff toilet essential, but that the doctors had been jolly decent so far in allowing other staff to share their facility.

I had been under the impression that a toilet existed simply to allow one of two main bodily functions. How wrong I was.

It is a sanctuary, a haven, a personal space. Maybe I should have known this – my GP brother used to play endless games of cards while seated on the throne.

This practice only ceased when once he sat so long he palsied both sciatic nerves and was unable to walk for hours. The injury didn't bother him as much as the BMJ rejecting the case report, saying it didn't have wide application. Shows how much it knows about the lavatorial habits of the nation.

Anyway, practice expansion meant our unreasonable toilet anomaly could be corrected. We now needed not just to reposition one toilet, but to build two.

And the doors had to be placed out of view of patients. It was somehow wrong for patients to know doctors need to pee.

The arguments took months – literally – so much so that I don't know if the issue was ever resolved. I left the practice.

So what did I learn? That bottom-up design of services has its place (we exist to offer care to our patients), but top-down design has its place too. If only to save time.

Dr Willie Hamilton is a clinical researcher at the University of Bristol and a GP in the city

Guest editor Dr Willie Hamilton

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