Please hold, caller…

Communicating With Telephones Using Old Technology

 

NHS 111 is in the news again for all the wrong reasons.

Under-staffed, under-skilled, under-experienced, under-performing…all the old recognisable issues.

The report in the Daily Mail says that Ministers are demanding assurances there are enough staff for the service after reports that only one nurse was left to cover an area of 2.3 million people. The Royal College of Nursing warned that a “tragedy” could occur. According to the Sunday papers, tragedies are already occurring.

It is understandable that NHS managers want to protect the performance of the ambulance emergency services. We are all familiar with the business case for providing an alternative service for “urgent” cases, as opposed to the 999 service for “emergency” cases:

-reduce the emergency services time spent on non-emergency calls;

-reduce the response times for emergency calls; and

-make this critical emergency service more affordable.

But is it the concept of how the alternative is provided that is fundamentally flawed?

Would anyone chose a disembodied voice on the end of a telephone to advise at a critical moment in their existence, when at that moment the caller may well be stressed and fearful?

Perceived wisdom may say there is no truth in it, but there is a body of work* that indicates that any communication is made up of:
Body language 55%
Voice 38%
Words 7%

Based on this premise, the NHS 111 service can only ever communicate 45% of the whole, to callers whose anxiety levels are likely to affect their ability to make well-thought out decisions.

Add to this the “remoteness” of the operator (who are they?), which may well contribute to trust issues (are they unaccountable?) and the delays experienced (do they really care?) and you have a complete turmoil of emotions that is not helped by the telephone as a communications medium.

I don’t have any bright ideas for how else the service could be provided, but I’d be pleased to hear any suggestion you might have…

*Mehrabian, Albert, and Ferris, Susan R. “Inference of Attitudes from
 Nonverbal Communication in Two Channels,” Journal of Consulting Psychology,
 Vol. 31, No. 3, June 1967, pp. 248-258
 Mehrabian, A. (1971). Silent messages, Wadsworth, California: Belmont
 Mehrabian, A. (1972). Nonverbal communication. Aldine-Atherton, Illinois: Chicago

Excuses, excuses…

© Lori Martin | Dreamstime Stock Photos
© Lori Martin | Dreamstime Stock Photos

I’ve been having a “bit of a moment” over the last few months where the superficiality of leadership in business in general and government specifically has caused me lots of tutting and fuffing.

It’s finally dawned on me what’s bothering me and wondered if my conclusions made sense to anyone else?

I realised a while ago that one business driver in the health sector was the sheer complexity of information around the provision of health care now. The volume of data available to inform decisions is so vast and disparate that we cannot expect an individual to consider it all when reaching decisions about care journeys and pathways. When things go wrong it is always easy for others to point to yet another set of data which “should” have been considered.

Hence the growing traction of “expert systems”, that are attempting to assist front line staff in their decision making, and “management systems”, that are attempting to assist front line staff in…well, just keeping track.

But what sort of systems are available to our business and government leaders to help them to consider all that is under their jurisdiction and to keep track of it? Nothing…they are reliant on their staff to provide them with an objective view of what’s happening and they need to be asking the right people, the right questions…even down to what they are actually spending.

Now, in my experience neither of these things happen with any rigour, if they can be avoided, as it’s all takes too much commitment to basic information gathering and analysis, when there are fun things like self-promotion to be done.

The result of this failure to gather information is that whole businesses and departments can be so badly off track before those who are leading them have any idea that things might not be as they seem.

The reaction of the leadership and their staff is to spin the real reasons that the situation is so far out of control…shock, horror…thereby maintaining the status quo and protecting both set of jobs.

We’ve seen it in government departments and the private sector…in banking it seems to be part of a standardised cycle with fines every year. It is a useful technique to master if you are a business leader who wants to avoid being saddled with responsibility…

…the alternative, which seems to have fallen out of fashion is “the buck stops here”.

Pharming the Health Sector

I’m always wary when I see the words “NHS” “drug companies” and “partnership” in the same sentence. Call me an old cynic, but conflict of interest springs to mind. We are purposeful beings and there is a purpose to everything we do no matter how remote or obscure it might seem to others. Just as there are always two sides to every argument, one man’s meat is another man’s poison, etc.…there are always two sides to the coin:

Safety education for medical staff v converting more sales;
Promoting correct drug usage v converting more sales;
Encouraging economic medicine management v converting more sales.

© Alexey Lisovoy | Dreamstime Stock Photos

© Alexey Lisovoy | Dreamstime Stock Photos

The recent article by Margaret McCartney in the BMJ makes reference to medicine management programmes paid for by the drug industry, and of course such a well-researched piece caught my imagination.

Apparently, a 1995 parliamentary enquiry called for “greater restraint in medicines promotion, particularly soon after launch.”…which I must admit I read as “soon after lunch”…but then as I said I’m just cynical.

So, how have we arrived at the current position? I think it has to be because NHS staff value the services they are receiving from Pharma and Pharma are prepared to provide the services for the return on investment they are making. The basic business of supply and demand, then.

And what are the services that NHS staff value? It seems to me that medical staff are being provided with information based on data, often gathered from their own patient cohorts, which happens to indicate the need for increased/changed drug usage. The key here is that the data evidences the need and it is difficult to disconnect the statistics from the clinical decision-making process which is more subjective based as it is on skill and experience. It is hard for anyone to ignore information about a possible risk without worrying that that risk might occur and they would be “to blame”.

NHS Informatics groups already know what is prescribed, why, when, how long for and to whom. What is missing is the bit before and the bit after…the inputs and the outcomes, such as what did the patient present as their symptoms and when the course of treatment was over did they recover or is it on-going? There is much talk of the “Patient Journey” but in terms of information in the NHS we are a long way off joining the dots.

So, if the NHS was able to provide end-to-end informatics on drug usage e-prescribing solution could be developed and medics wouldn’t need to accept the drugs companies conclusions. Bearing in mind the complexity of all the factors that need to be considered these days when prescribing, it’s only a matter of time before this type of system becomes essential to protect the prescribers.

Perhaps Big Pharma could make an altruistic move and use the existing funding that they have already set aside for the creation of an independent NHS “drug squad” to review prescribing and ultimately to implement an e-prescribing system that works.

Care.data could have been the NHS’s ultimate repository of patient data, making a useful contribution to the institution that provides care free at the point of use. Could we re-task them?

Cradle to Grave – the New Battleground?

© Robert Bayer | Dreamstime.com

© Robert Bayer | Dreamstime.com

It all started when I was on the Tube last week and a woman in her 30s gave up her seat to an elderly man on walking sticks, he thanked her and took the proffered seat…next to the child, whose mother didn’t think it necessary to get her little girl to stand for the man.

I suppose when you think about it, the question is “Does this show a lack of respect?”

From the mother, from the child? To me it seems to be the norm these days, in a Britain that is too cool to stand up (no pun intended) for what are now see as old-fashioned values.

In Britain in the 1900s, respect was demanded by those who held the power, money and status, but it was likely to be a sham respect, not earned by the actions or manners of the one demanding it. In the 1940s it was all about “being a lady” or a “real man”, and good manners earned you respect and “genteel” was something people aspired to. Following the levelling of society’s powerful and the upper classes in the World Wars, being polite and respectful developed a bad rap to be rebelled against and was becoming viewed more as “putting on airs and graces”.

Is it any different abroad?…probably not. There seem to be many people like me, stuck in the past, who don’t get the modern vibe around the culture of self, self and more self.

Showing respect for others these days seems to be a sign of weakness, almost as if giving respect selflessly, detracts from the giver in some way, maybe even making them look naïve or a bit dim.

Once respecting others becomes an act that attracts a personal cost, where do we go from here?

How about the case this week of the 6 care workers sentenced for ill-treating residents. The son of the abused resident said of the convicted “there was no respect”. The strong generations now having their day, seem to have little if any respect for older people, who might be viewed as just living longer and longer and using up resources that could be conserved.

What about those at the end of their life…often treated with indifference in the health sector as seen in its discredited use of the Liverpool Care Pathway and more recently in a new report claiming that hospitals continue to fail patients at end of life.

To take this to its inevitable conclusion…with the assisted dying legislation paving the way for an “acceptable” solution, and with respect for others on the slide, will we slip into a future we weren’t expecting?

The future “cultural war” to be waged is likely to be young v old, as the scary prospect of a world populated by millions of old people, who need care, but aren’t valued, overwhelms a generation who were never taught to respect older people anyway.

Sixties sci-fi at its most horrific.

Legs 11 (1)…thoughts on the NHS lottery

It's a lottery out there...Don’t you just despair over the constant stream of NHS bad news? It’s like a lottery out there if you’re sick…
The main cause of recent Press hysteria is the NHS 111 Service…and yet reading the various articles there is no consensus amongst journalists about what really is the problem. Of course, there is “The Computer System”, that baddie from the sci-fi genre of the 50s and 60s. If you are my age you will recall that computers are violent towards humans and are looking to take over the world.
There is no grasp that today’s services are brought to us through many systems working together (or not) and in the case of the NHS 111 Service I imagine there to be Call Centre Systems, Triage Systems, Patient Record Systems…which has failed us? Or are we blaming them all?
The BBC talks about high call volumes. Is that the Call Centre system causing the long wait? Or is it the staffing levels?
While the Daily Mail sees the Triage System as possibly the main problem…or could it be that staff with only 10 days training, who are so desperate they admit “I don’t know what to do”?
Reports of IT crashes are common in all reports and maybe that was a reference to the Patient record System…or maybe not. Or could it be that as usual a Government project of this size is suffering from flawed planning, know-nothing procurement, poor project management and inadequate testing?
All of the above I suspect, the bigger-is-best policy wreaks havoc again, it never changes and it never will until leaner, meaner, providers are given the chance to prove themselves on Government projects.
I feel a twinge of sympathy for the solution designers as, having worked for years within Government, call volumes have probably been vastly underestimated. The NHS 111 Service is designed for “urgent” calls; the NHS 999 Service for “emergency” calls. However, if you give the public an easy option, they will take it…and hey, who wants to wait two weeks to see a GP?

Love like you’ve never been hurt…outsource like there’s no one watching

The Virgin rail deal and the G4S security contract for the Olympic Games has brought government procurement to the attention of the general public…people who would not normally have outsourcing outcomes on their radar.

Over my career of 30-odd years in the public and private sectors, I’ve been involved on both sides of the fence as contractor and outsourcer…poacher and gamekeeper. We used to say, “this is not our core business, let’s find someone to do it for us”. The assumption would be that a contractor whose business it actually was would have the skills and expertise to be able to do the work cheaper and better than we could.

In those far off days we used to have the concept of the “Intelligent Customer”…this was a tiny group of knowledgeable staff who stayed within the outsourcing body, able to oversee the work of the contractor and to monitor performance.

Roll forward 30 years and as civil servants became more relaxed with having “someone else” do the job the concept of the Intelligent Customer seems to have disappeared…along with any pretence of monitoring and management of outsourced delivery.
Channel 4 News asks “Do you know who runs your world?”…and the answer is probably “No”.

Government departments are now just “kitemarks” with approved contractors wearing the “badge” of the organisation they have replaced….the skills have been lost in government and there is no going back.

Very few people realise that they are now dealing with private business operators and their rights to question the service and get a response have vanished. Transparency is one of the biggest issues…freedom of information does not apply.

Some of the biggest companies…G4S, Serco and Capita have been awarded business to the point that they are bigger than many government departments. The supply chain is deepening and so many public sector staff have been transferred to the new business providers that the culture has been imported along with them…they are becoming indistinguishable from the civil service they have replaced.

In fact, they could well be in a similar position to that of 30 years ago…asking themselves “is this our core business?”

If the difference between public and private sector workers cannot now be seen by the public how blurred has the line become for those who remain behind in government? How close are the links? And can the taxpayer ever know what sort of deal their getting?

Buy Cheap, Buy Twice

© Vangelis | Dreamstime.com

Sir Richard Branson seems hopping mad…and well he might, after losing what had become his “baby”, the West Coast rail contract, after 15 years. Speaking as a Northerner who has lived with West Coast travel through the Virgin years, I can say that the service has gradually improved…the constraining factor seems to have been the track not the trains.

Sir Richard claims that the contract has been awarded on the basis of price, which he thinks will be unsustainable as happened in 2007 and in 2009 when the Department of Transport had to take back the East Coast line because the companies awarded the contract could not afford to run it.

Will this contract fail as many have in the past? I expect it will. I used to get the train into work (if I couldn’t avoid it) and remember the announcements while we were stationary at platforms where staff were trying to crush commuters onto already full trains…”we are not going anywhere until you all move up together”. FirstGroup who have won the bid said that they expect the number of passengers to rise…where do they think these passengers are going to come from?

Government purchasers never seem to realise that cheapest isn’t always best…maybe you’ve heard the old saying “you don’t get sacked for buying X – (enter the name of an international supplier at X). Procurement is mostly about risk transfer…getting the job done cheapest and with minimal risk to whoever is procuring.

A recent example is the G4S fiasco. This is probably a case of the procurement team confusing “blame” and “accountability”…they can blame G4S but they themselves will always be accountable.

Look also at the LSP contracts placed by NHS Connecting for Health…litigation and counter-litigation virtually guaranteed from the start.

SMEs are more likely to be awarded public sector contracts in Scotland than in England and as an SME I’m not surprised by that, considering the level of knowledge amongst the buying community…”big” is seen to be the safest way forward.

But then what is safe? Government have agreed mechanisms to identify suppliers who don’t deliver…which is astounding this late in the game. Most of the population knows how to pick and choose their “suppliers” based on performance…

Parents need to meddle, if we are to medal in 2016

A levels are out at last…how exciting!

Well maybe not as much as it was in my day, when everyone went back into school to see their results posted, catch up with friends, talk to teachers about the next steps…all sounds a bit Boys’ Own Paper or Jolly Hockey sticks compared with today.

I had reason to phone our local secondary schools a few weeks ago to see if I could post a notice for this year’s leavers and thought Results Day would be a good time to catch them…not happening I’m afraid. Recorded messages told me the schools won’t be manned again until September.

I’m guessing this is about keeping the results private, in the wake of our 1980s educational changes to ensure that nobody ever fails…something that I hope will be overturned if we are ever to prepare our youngsters for the real world and for working with others in a team.

That the “everyone wins” culture in state schools is bad for achievement is also supported by Bristol MP Charlotte Leslie.  She has joined the debate on why more medal winners are from private schools and whether it is the achievement-driven policy that works…she should know having had first-hand experience…and my belief is that you get what you pay for with a private education…longer hours, newer equipment, highly paid coaches, etc.

Encouragement to win is a big one and Radio 4’s Woman’s Hour had Judy Murray on today talking about how parents could handle their child’s talent for sport and there’s no doubt in my mind that it’s a bit easier if your parents are encouraging and can afford to buy you the kit.

But the Government appear to be actively discouraging sport in public sector education, still selling off playing fields despite the campaigns to stop the rot…
…while showing us that standards are improving? Yes, 98% of all marks today are passes this year.

On the subject of exam results in general, what on earth is a “CC” or a “D*D*D*” for goodness sake? How are employers like me who are a long time out of education to compare results?

Don’t get sick…just yet

Last week, alarmist headlines warned readers of an NHS ‘killing season’…a period when the average mortality rate increases in UK hospitals due to the intake of newly qualified medical graduates. To counteract this dip in the quality of patient care, the Department of Health has published details of a plan to better provide trainees with the skills they need to hit the ground running. But is it enough…after all it seems the Department of Health are happy to inflict on us medical staff who can’t speak English, so are we any worse off under inexperienced doctors?

We need more than a quick-fix solution…we need to be pre-empting both problems earlier on and providing sustained support to junior staff in the UK by better nurturing their skills and attracting, retaining and developing the very best home-grown talent from the start.

At present, it is reported that patients admitted to British hospitals in an emergency on the first Wednesday in August have, on average, a 6% higher mortality rate than those admitted on Wednesday the previous week. The Department of Health’s measures to eliminate this ”blip” look to smooth out the change-over period in August by introducing strategic, targeted training which aims to better prepare trainees for the reality of life on the wards.

The Department of Health has stressed the importance of a better transition period: “Our aim is to ensure that all junior doctors spend a minimum of four working days shadowing the job that they will be taking up and completing a Trust-based induction.” It’s this kind of exercise that will lessen the shock-to-the-system reaction which seems to be fairly common when juniors first have to face the literally life and death situations that they come up against on duty…another shock to them must be the hours they are suddenly expected to work and the exhaustion that results. Most of the working world has already worked out that by helping new starters to become more familiar with their new working environment, combined with a thorough handover of their responsibilities, they will be better prepared for flying solo.

Indeed, it’s encouraging to see that trials in Bristol of week-long shadowing and additional teaching have reduced mistakes made by new doctors by 50%. If this is truly representative of the benefits, I’d say that we’d be short-sighted to set this kind of skills development at just four days. The plans put in place so far are a great start, but more can be done both in advance and in the longer term to not only bring these statistics down, but to ensure that the very best doctors are providing the very best care in our hospitals.

To attract home-grown talent we need to be encouraging Britain’s young people into medical training, from an early stage. Over the past eight years, nearly 200 UK nationals have headed abroad to train as doctors and dentists at medical schools in the Caribbean alone. We need a system in place that can attract and retain the skills we have in the UK in a world that has become globally competitive for such talented individuals.

It’s important that we’re looking at the longer term effects of the culture too when shaping the way we go about training juniors. A recent report highlighted that during their training junior doctors do not feel valued by their superiors or the organisation as a whole: managers (83.3%), the chief executive (77.7%), the organisation (77.3%), the NHS (79.3%). These figures are not a surprise when you poll at the bottom of the heap…same in most professional sectors I would say.

So what’s in store for all of us who might fall sick next month? It’s thought that 7,000 junior doctors will voluntarily begin the new induction scheme later this month, before they start their posts in August. Compulsory from next year onwards, this personalisation of skills development is a big step towards improving patient care at this crucial time. Whilst more can be done to improve training, it is certainly a good sign that at least things are moving to bridge the massive gap between being a student and becoming a medical professional…safer too!

What’s wrong with Special?

All the Same

© Alexey Lisovoy | Dreamstime.com

I’m at a loss to explain it…why is this government working so hard to eliminate anything that is different?  Same old, same old, seems to be their template for the future.

Once we Britons were known for our originality, if not eccentricity, and we provided the World with thousands of innovative inventions that have shaped everyone’s lives.  We’ve always celebrated “the different”… be that people or things…and these islands have always been home to the special, the unusual and the anomalous.

Now “anomaly” is spoken of as equal to wrong or unfair…something that must be wiped out or at least ignored.  It is becoming “the norm” for Government to seek out and dispose of anomalies.  As evidence I cite:

The Pasty Tax – said to remove an anomaly in the application of VAT on hot food but which puts up the price of the workers’ lunch.

The Heritage Tax – the chancellor says this will avoid the anomaly of not having VAT on repairs to old buildings, but zero tax encourages the owners of listed buildings to keep them serviceable for the Nation.

The Abolition of the 50% tax rate – the chancellor believes that everyone should have the same top rate.

I suppose these instances have highlighted the current trend to make everything the same…and the Government would probably argue, make things fairer…but then a state where everyone is the same and there is nothing worth striving for is surely the life of a drone?

This is not a new situation, though…just look at the way we run junior school sports days (no winners or losers), allocate university places (by quota) and fill jobs (by quota).  We are on the road to everything of equal value…and with it…mediocrity.