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Morale is a reflection of staff involvement and concern. It means low sickness and absenteeism rates, low staff turnover, low accident rates, excellent time keeping, minimal industrial disruption and dedication to the job.

Management are interested in the workforce and plentifully in evidence on the shop floor.

Investment is about the buildings and plant-clean, well maintained and serviced, up to date, well ventilated and at an equable temperature.

It includes investment in people-training, staff benefits. Many things in health care require a “learning curve” when performance is determined by experience.Thus practice makes perfect and lack of practice also reduces quality.

This area of training and learning is contentious but accepted if tomorrow’s consultants are to learn their trade. Also contentious is the number of procedures an individual consultant need perform annually to maintain optimal skill.

An organisation needs to work around the optimal rate where there can be pride in the work done and in the quantity. Too much or too little work probably reduces quality and raises cost.