What is quality? What's a quality service?
For a start, quality is what you do when no one is looking...
... and, achieving it? Five steps;
- Figuring out what you're doing,
- deciding if you want it,
- putting things in place, to make sure you get it,
- all the time, every-time,
- until you don't want it any more...
Simples, but there is a bit more.
When I'm driving home, late at night, I swing through Bagshot, stopping-off for fish-n-chips. It's a gourmet experience beyond description, for under seven quid. Then again, so is Le Caprice. Like beauty, I suspect quality is in the eye of the beholder.
A Swatch watch is reliable, fashionable and thirty quid. A Rolex is three grand. They'll both tell you when it's three o'clock. We buy stuff that says things about us. Don't confuse fashion and status with quality.
- Does it work; do what it says on the tin?
- Is it easy to use?
- Does it work all the time, every time?
- Does it comply with the necessary regulations?
- Does it go on working for as long as you think it should?
- Can it be refreshed, repaired or upgraded?
- Does it look good?
- Do I want to be seen with it...?
I'd add one more; is it seamless... joined up?
I have just had the most awful experience I have had in my years in and around the NHS. I'm embarrassed. It happened to me and I can get over it but a lot of people must just give up.
Patient transport. Trying to organise it for a neighbour. Normally I'd take this lady to hospital but I'll be away.
A former teacher, bright as a button but scarcely mobile. Out of the house she is wheelchair bound.
For some reason, she knows not why, out of the blue, she received a letter from the hospital asking her to attend on a Saturday at 0830hrs, for imaging. She had an operation some time ago and feels fine.
No one asked her if it was convenient.
It's impossible. She depends on rising services and they never attend before 0930hrs. Rescheduling, maybe but it would mean her getting up at six in the morning.
A phone call and a lot of palaver got the appointment changed to another Saturday, later in the morning.
- Getting a scan follow up... quality.
- On a Saturday... for working people... quality.
Next, how to get there. The hospital appointment-lady doesn't do transport. That's the responsibility of the GP. The practice says it's nothing to do with them; ring patient transport at the hospital.
Patient transport at the hospital doesn't do out-patient transport, that's somebody else...
... they're not sure they can do it on a Saturday... oh, no... yes... sorry, we can.
There follows an intrusive interrogation about family support, living allowance, benefits entitlement, NHS number, the condition, the reason for the visit, mobility questions, transfer assistance... that no unregulated stranger should ask on the phone.
'Well you see, some people pretend they need transport, but they don't, they just don't want to pay for parking....'
Really, I wonder why!
Then the cracker question; 'How long will you be at the hospital?
Dunno, how long will a scan take, is there a queue, are they fully staffed at weekends.
'Please ring the scan department and ascertain how long the procedure will take... so we can arrange pick-up for the home journey'
'We are unable to give a time as it depends on the mobility of patients, other pressures and demand...'
I ring the transport people and lie;
'It will take an hour...'
Discounting the time it takes for everyone to answer the phone, the job-weary brittleness of the tone, the duplicated questions, the fact I have to lie and the whole dammed horrible, demeaning, clunky, nasty experience... the final straw;
'It's not free, the GPs have to pay for this you know...'
Actually they don't. We do, it's our money.
It's a quality service to have a scan at the weekend. It's a quality service to be able to get transport if you are a signed-up member of the Blue Badge club. It might be a quality service to commission a dedicated, expert transport service... maybe.
String it all back to back and you break the basic rules; introducing service interfaces.
Where there's a join there's something for people to trip over. Components may be kind and excellent, the end-2-end experience... horrible.
It's not the first time my neighbour has been in this predicament. The same palaver.
Artificial Intelligence would have learned my neighbour needs transport, early appointments are no good and she needs a wheel chair and would calculate the average time it takes to get through scanning on a Saturday.
Artificial Intelligence would have remembered her NHS number, her address, her status and made the arrangements without bothering five people, seven phone calls, office and back office overheads, heating lighting, employment costs and bits of paper.
Bring on the machines.
Have a good weekend and console yourself with this story.
My heart sank. A ten year plan. No, no, no!
To make it worse, twenty-two chief executives and others are to be distracted from running their tortured organisations... conscripted into work-streams, in the futile pursuit of compiling a ten year plan...
... our most talented, who have problems enough, battling ludicrous regulators, balancing books and holding back the tide of demand.
They are all clever but none so clever as to be able to presume the future. I know of no NHS plan that has survived its course.
Yet, once again, we are to blunder into the future. Once again, 'a plan' to shout about... creating just enough noise to hide the truth; we have no idea and cannot have any idea, what the future may hold.
Planning for ten years means we have to divine;
- ... the outcome of Brexit...
- ... and the upshot of three general elections, possibly four.
- Economic performance, international trade and the value of the pound.
- The tax-take, GDP and the ability to sustain investment in public services.
- The exit, or otherwise of key industries.
- The cost of stockpiling drugs and devices.
- Movements in the labour market.
- The financial sustainability of the university sector, much of it, over-borrowed.
- Care and medicine as a career choice; engulfed in a global shortage and a collapse in recruitment.
- The impact of technologies, the NHS usually a slow adopter.
- The inability to reimagine service delivery - entrenched contractural frameworks.
- The impact of developments in pharmaceutical products, the cost and our ability and willingness to pay for them.
- The impact of innovative Apps and their disruptive impact on service delivery, payment and contractural frameworks.
- Regulation; killing enthusiasm for innovation.
- Public patience with a perceived, failing service; middle-class migration to the private sector.
- Proprietary software versus open-source, integration and interoperability; desegregated procurement.
- The financial failure of local government and the knock-on effect of adult social care.
- The inability of regulation to influence safety; no universal understanding of 'quality'.
- The collapse of the care-home and domiciliary care market.
- Pharma and device launches in England, ending - it's only 3% of the EU market.
- The birth-rate and the dependency ratio.
- The future of social housing.
- Lifestyle choices over-taking healthcare responses and the lack of impact of PH.
- The legalisation of Class-A drugs, or not.
- The end of the high-street model; people unwilling to travel for services they can access on a screen... an on-demand economy.
... shall I go on? This is just a quick brain-dump. I wonder what the list would look like if we all sat down and thought about it.
There is not one person in the NHS, England, UK, Europe, the world... who can plan, strategise, create a ploy, determine a pattern, take a position, or have a perspective on any of this. Anyone who says they can... is fool or a liar.
What's the answer?
Ed Smith, the former chair of NHSI talks of three P's and that's a a good place to start; purpose, people and process. A consistent view of;
- What do we want to do,
- where do we find the people to do it and
- how are we going to help them do it.
Strategy leaves us in the trenches, planning is impossible and analysis only tells us what's what... not, what's next.
All we can sensibly do is to try scenarios; narratives, set in the future, say, 2030 or 2035... how the world (and our world), changes if certain trends were to strengthen or diminish, or various events were to occur.
A couple, maximum 3 scenarios, representing different possible futures, associated with different trends and happenings... used to review or test a range of ideas, policy options and questions. The conclusion generally being that different plans are likely to work better in different scenarios.
The RAND Institute first developed scenarios in the 1940s. A famous example of scenarios is the Mont Fleur exercise carried out in post-apartheid South Africa. There's more here. Derek Wanless, sort-of, used scenarios in his seminal report on the future. It is still current but no one is listening.
Ten year plans are not a job for serious managers, they are employment for a colporteur.
Why anyone would try is beyond me.
However expected death might be, it comes with its own intimate regrets, sadness and grief.
When death comes unexpectedly the shock of the loss is unimaginable to anyone who has not experienced it.
When death comes to a child, unexpectedly, the grief must be unbearable.
When the death of a child comes unexpectedly, as a result of mistakes, the companions of death, anger, guilt and blame arrive with a vengeance.
Jack Adock's parents can never be reconciled to his unnecessary death in one of our hospitals, in Leicester. How could we expect it to be any different. Bereavement is a test of faith and they can have no faith in the NHS.
There are no words that can be said by anyone in the NHS that will relieve their suffering, exasperation, hostility and exhaustion. There is no explanation, account or confession that will satisfy them. The NHS killed their son. We must never forget that.
It is a heavy burden for the hospital, the Board, everyone who works there and not least Dr Hadiza Bawa-Garba. It is an agony for the family.
It has taken tribunals, regulators, lawyers and judges to decide the question at the heart of the appeal;
'... whether the Medical Practitioners Tribunal was entitled to take account of systematic failures at the hospital, and failures by other staff who worked there, when deciding what action to take in relation to Dr Bawa-Garba.'
There's no disputing the facts. The doctor admitted her errors. The hospital was under pressure, IT failures, key staff were absent and the chaos people were working in, I'm guessing might be replicated a hundred times across the NHS.
There but for the grace of god...
The Court of Appeal has decided that the Tribunal is entitled to take account of such matters when deciding a doctor's fitness to practice.
Dr Bawa-Garba had been convicted of;
'gross negligence, manslaughter for failures on her part in the care of Jack Adcock, which led to him dying significantly sooner than would otherwise have been the case.'
Because of this conviction the Tribunal reviewed Dr Bawa-Garba's fitness to practice. It decided that the doctor should be suspended for one year.
The regulator, the GMC, appealed the decision of its own Tribunal, in the High Court.
The GMC claim to do three things;
- keep patients safe (they obviously can't deliver that),
- uphold confidence in the profession (that seems to have gone by the board)
- and set standards (where were their standards in a chaotically busy, understaffed hospital on the day Jack died).
As a patient I judge the GMC to be of little use to me. In all logic, they are unable to deliver their objectives.
If that's true, it's of no use to the professions. My fate as a patient is inextricably bound to the success of the professions.
If the professions cannot admit their mistakes and learn from them, how long is it before I am the next mistake and you are the one after.
Time and again I have railed against the GMC. If this case is not to be their undoing, nothing will. The GMC have sheepishly indicated they will not appeal.
The regulatory framework belongs to the Masonic generation and there is a fundamental, glaring conflict between the GMC's duty to me as a patient, keeping me from harm and upholding confidence in the profession.
They can't do both.
It is trite and often said without sincerity and truth but we must, absolutely must create a climate where we are grown-up enough to realise; our NHS that cares for a million people very day, in every type of complicated extremis, under pressures few professions work under... must learn from its errors.
We don't wan't carelessness, we don't want negligence, we don't want fools. We don't want hospitals crumbling under the pressure of demand.
We don't want to turn honest people into crooks but we do want to learn when honest mistakes are made, errors of judgement, not intent. Systems stressed to the point of dysfunction.
Doctors are different from you and me. They come to work every day with the risk they could cause harm, or even death. When it happens and we must expect it, we must know why and how.
It is the highest form of self-respect to admit when we are wrong, learn and make amends.
It is only from the errors of others we can ever be right ourselves.
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Reproduced at TrainingPrimaryCare.com by kind permission of Roy Lilley.