Please hold, caller…

Posted on September 30, 2015 by gaynah

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

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Excuses, excuses…

Posted on August 24, 2015 by gaynah

: © 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”.

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Cradle to Grave – the New Battleground?

Posted on July 18, 2014 by gaynah

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.

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Legs 11 (1)…thoughts on the NHS lottery

Posted on April 4, 2013 by gaynah

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?

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

Posted on October 10, 2012 by gaynah

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?

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Buy Cheap, Buy Twice

Posted on August 30, 2012 by gaynah

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…

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Don’t get sick…just yet

Posted on July 9, 2012 by gaynah

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!

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Change the Record

Posted on June 6, 2012 by gaynah

Earlier this week Health Secretary Andrew Lansley published the Department of Health’s long awaited Information Strategy whitepaper “The Power of Information”. It details plans to take all patient records online by 2015…but haven’t we heard all this before?

Back in 2002/3 the National Programme for IT (NPfIT) was born. It promised to do much the same thing, as part of the overall revolutionary plan for NHS interoperability. We all know what happened next – at the last count the Programme had spiralled to £12.4 billion and was officially ‘axed’ in September 2011 with us being years older and no wiser. I accept that we are a little closer than before to the goal of a standardised, electronic system for patient records across the NHS…but what needs to change to make Mr Lansley’s vision a reality this time around? Here are some pointers:

Break down barriers to change – the NHS Spine has been in existence for many years…it’s not the technology that’s holding us back but the attitudes. However, things are moving and nearly 15m Summary Care Records have been created. It is interesting to note that a patient’s ability to “opt out” was a huge sticking point…to date only 1.29% have chosen to do so.
Identify patients by one unique number – incredible as it may sound, a patient’s NHS Number is not always the primary identifier for an individual across all sections of the NHS. This needs to change so we move to a one patient, one record system. This is a key message from the Information Strategy.
Clean up ‘dirty’ data –in the last couple of months we’ve had news that 20,000 pregnant men and 95,000 ‘ghost patients’ remain on the NHS books. This needs sorting and much of this process can be automated. As an example, Quicksilva’s orQestra® system is helping our customers to verify NHS Numbers…in one case resulting in a 1.1% improvement in verified records in the first month…when you’re talking about 1.3m records, that’s getting us there.
Pharmacies need to be encouraged to provide electronic transmission of prescriptions using barcodes – the Electronic Prescriptions Service (EPS) shows promise, but is far from the universal standard. Greater take-up will improve the quality of the data online and remove the need for routine appointments, a significant overhead for GPs.

No one can pretend that any of this will be happening quickly. One of my main concerns is that there is no optional central guidance as to what solutions can be used to deliver on the Strategy. Mr Lansley has instead called on GP surgeries and hospitals to use “imaginative solutions”. It’s true that the top down approach of NPfIT did not work but I think more guidance is needed for those healthcare providers who cut their IT budgets leaving them with no-one to help them make important decisions which will affect their future in competition with the private sector.

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NHS Data – which one are you, again?

Posted on April 27, 2012 by gaynah

Last week’s news that the NHS has saved £6.1 million by removing about 95,000 ‘ghost patients’ from its GP lists sounds impressive, but it only exposes the tip of the iceberg. Removing these outdated records from GP lists is a step in the right direction, but there are other pressing reasons why a concentrated clean-up of patient data is needed.

The quality of data supporting the NHS has been poorly controlled for years and now that healthcare information is beginning to be shared between care providers the true extent of the issue is set to be highlighted. With NHS Trusts under relentless pressure to measure and publish quality outcome indicators and with the increased accountability that directly affects their budgets the need for clean, accurate and accessible data is more important than ever.

To enable health care providers to identify which patients they are actually treating the NHS maintains its Personal Demographics Service (PDS). The PDS is where data on every recorded NHS patient is held; it’s used by hospitals and other care-providers as the most up-to-date repository of patient identity available. However, matching the details a patient has given about who they are against the hospitals own database and then verifying with PDS is not always straight forward.

If patient A is recorded in one database as living on ‘Salisbury Road’, and on another database as living on ‘Salisbury Rd’ then to a computer you have a failed match and there is an error, whereas to a human user the records are clearly the same and perfectly usable. However, where the flow of information is electronic, and interpretation performed by computers the situation becomes very much more polarised and a minor error can lead to the failure of the referral mechanism, resulting in a patient being unable to book treatment, or to unknowingly receive treatment under a separate identity. Such situations are often propagated as treatment staff, having recognised registration problems, will often not have the authorisation to make the changes needed.

It is not surprising then that A&E departments find themselves treating unknown or non-NHS patients which results in the hospital not being able to claim back the cost from the Department of Health. As part of the NHS Reforms hospitals will become reliant on their own income to fund treatment. Without being able to verify who they are treating, hospitals will lose out to “ghost patients” and “health tourists” meaning they won’t be paid and won’t have the cash available to maintain their service levels. It is vital to address wider data quality issues now, before the Reform Bill changes the NHS beyond recognition.

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NHS Bill – the devil’s in the detail

Posted on April 11, 2012 by gaynah

Last month I commented that the NHS Bill risked losing hearts and minds and drew some parallels with the way differences of opinion on NHS reforms have been handled in the past, that is, by just ignoring them. Well, the reality is now upon us and whether we like or not, the thing is signed.

Many of the arguments against the Bill have been deeply emotive with health sector groups denouncing the Bill with evangelistic fervour…an ideal scenario if you want to dilute and detract from the smaller voices warning that the Bill is privatising health care by the back door. If you’re wondering whether this is the case or whether I am just scaremongering, then maybe it’s worth considering that this Bill has been ushered hastily through at a time when surveys show record levels of satisfaction with the NHS.
Being a “business person”, you’d think I would see the sense in privatisation and in most markets I can, but how can directors of private companies put patients first when their statutory duty is to put shareholders first?

These questions are the ones that generate a most unhealthy response in me:

Once hospitals are forced to take the Foundation route, they become independent of government and subject to GATT rules (showing my age) and EU competition. What will happen to them should they start to fail?
What will happen to the supply contracts currently in place with NHS orgainisations that are being scrapped? We’re talking about everything from cleaning to catering to IT and building maintenance. Will they be novated?…or worse, who’s left to manage the suppliers?
Even before the bill was passed, we had an example in Hounslow where the new GP consortium has appointed a multi-billion dollar American company to vet patient referrals according to a set of rules. How is this improving patient choice?
What happens when GPs start running out of money to commission services? If I should suddenly get ill in March, would I have to wait until the new financial year in April until I get hospital treatment?
Where will the 1 million staff work whose jobs are set to be privatised by 2014?
Most patients do not see GP practices as private sector organisations, but they are, and at least in the past we have had referrals to hospital staff to provide treatment for the patient independent of profit considerations.

This Bill will take that safeguard away…and personally I would rather be treated by an NHS not-for-profit organisation than a “multi-billion dollar American company”.

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