NHS trusts spend £2m to stop staff speaking out – Telegraph

“It is simply not plausible that the man [David Nicholson] who was supposed to be running the NHS was seemingly unaware that employees threatening to speak out were being offered golden goodbyes in return for a vow of silence. As the accounting officer who has presided over this culture he is either complicit in a systemic cover-up or has failed to ask questions. If he knew about them he has misled Parliament. The culture in the NHS needs to change, he has to stand down now. What patient safety concerns have been covered up [by these gagging orders]? How many lives have been put at risk?”

via NHS trusts spend £2m to stop staff speaking out – Telegraph.

Is David Nicholson the Fred Goodwin of the NHS? It is difficult to resist the comparison.


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“Health workers beat dementia patients and mistreated others on hospital ward.” – Trial is told. | Mail Online

“Jurors heard the healthcare assistants were arrested after student nurse Lucy Brown whistleblew on them following a placement on the ward last Spring.”

via Health workers beat dementia patients and mistreated others on hospital ward | Mail Online.

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Commissioning board chair makes GPs ‘playing golf’ jibe | News Article | Pulse Today

“The head of the NHS Commissioning Board has hit out at GPs for being ‘out playing golf rather than treating patients’, as he called for a ‘profound cultural change across the NHS’.”

via Commissioning board chair makes GPs ‘playing golf’ jibe | News Article | Pulse Today.

So the chap who’s in charge of helping GPs become world-class healthcare commissioners bollocks them for playing golf not treating patients eh?

Well that escalated quickly.

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A&Es further hampered by staff having to get wretched ‘Friends & Family’ test completed…

Twitter: ‘Your Humble Servant ‏@yrhumbleservant  “Tales emerging that A&E crisis being worsened by staff having to take time out to get Friends and Family Test filled in by patients.”‘

Sounds entirely plausible.

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A Sticking-Plaster For A&E: the ‘Walk-In Centre’ fail…

If your A&E department is over-flowing with ailing but not expiring citizens who have had the nous to realise it is the one place in the whole of the NHS that is open in the evening or at weekends; who calculate that a 4 hour wait to see a junior doctor is better than a 2 hour wait just to get through on the phone to their GP receptionist during the week; who with the patience of Job and a small picnic packed by Nan are prepared to sit it out until seen: then ‘Something Must Be Done!’ Something, at the very least, must be done to separate the critically ill and injured wheat from the mildly dyspeptic chaff.

Nursing triage is now a standard place to start – though whether it is a good place to start is moot – an initial prioritising discussion of history, presenting signs and symptoms, and, one hopes and prays, having the ability to make an instant yet sound differential diagnosis between little Johnny’s runny nose and indications of possible meningitis: ‘Red’ for “Immediate threat to life. Treat now!”, down to ‘Grey’ for “Worried well. Let them stew.” That sort of thing. Nurse-led triage, though, can only be an effective tool when the totality of patients-in-waiting fits within the intended remit and flow of A&E, not when the rising headcount in the waiting area pushes it beyond its safe competence and capacity.

One response to pressure on triage is to increase its resourcing by number and by clinical experience and expertise, the evident risk being creating a secondary department within a department, which any half-decent systems theory would acknowledge as being inherently contrary to efficient and effective ‘flow’. Another option, now widely in operation, is the ‘Walk-In Clinic – located within A&E but a separated provision of GP-led primary care that can attend to the many for whom primary, not secondary, health services are all they really need and, in truth, want. The not unreasonable reasoning seeming to be: “They’ve come here to A&E only because they can’t access a GP out-of-hours, so let’s give them just that.”

Good thinking, maybe. But how does it work in practice, does it do what it says on the tin, or do we wretched patients kick the can all over the place until it is bent quite out of shape? First off, word soon gets around that here’s a GP resource for which you don’t have to phone to book an appointment days in advance: just pitch up when you fancy – with Nan’s sandwiches once more for the inevitable wait – and you will be seen eventually. Maybe just by a locum, but then you get seen by a different GP each time when you go to your registered practice so what the heck? It’s conveniently there in the evening when you get home from work, and if Sunday afternoon telly is particularly tedious you might as well go and be bored there as anywhere else: you’ve run short of the blue pills and if you can get home in time for X-Factor with your renewed prescription it’s a clear win-win.

So within days – hours – of opening your wonderful, new and problem-busting Walk-In Centre it is stuffed to the gills, not only with those people who would have been unnecessarily cluttering up A&E and whom you’ve been able to divert there, but also by a whole host of others who probably would have stayed at home but who now grab the chance to get sorted soonest.

Perhaps you’re beginning to feel like the Sorcerer’s Apprentice – just wishing you’d never started to mess with a system you don’t really understand and certainly are failing to control. What, though, are you going to do to attempt to manage demand for the ‘Walk-In Centre’? You’ve built a waiting area for 20, but now over 60 people at any one time are lining the corridor all the way back to the door off A&E.

Something, yet again, must be done! [This is, I hope you gather, a real example of a hospital on the edge of East London – and collapse – a few years ago.] So how do you stop people simply walking in to your Walk-In Centre? Why, easy! You introduce an appointments system! [I kid you not.] When people phone up to ask about the Walk-In Centre, you instruct your receptionist staff [true story] to tell them that they must make an appointment before coming down. This is both truth and lie: there is an appointments system because you’ve introduced one, but no one has to use it – if they know better – because both processes are running in parallel!

So now your corridor is stuffed half with people clutching a ticket for an imaginary timed appointment, and half with people who’ve just walked in off the street on the off chance. Both sets have, anyway, to queue in order to sign in with the Walk-In Centre receptionist, who can only tell everyone what she’s been told to say – people will be seen in strict order of arrival, no ifs or buts and if that’s tough then it’s just that – tough. (Fancy that job? No, nor I.)

The systems analyst has a decent metaphor for the situation: you’ve laid a carpet, but not flat: there’s a trapped bubble of air lifting one section. So you stamp on the bubble and, hey presto, it’s vanished. Or, rather, not. It’s simply moved somewhere else. Solution – lift the carpet and re-lay it flat second time around. Answer – lay it flat in the first place!

If too late now for the answer, what’s the solution? I don’t claim to know, though Jeremy Hunt does: it’s all GPs’ fault for abandoning out-of-hours care. The system having been dismantled under Labour is to be mantled (apologies to P G Wodehouse) under the Coalition. A review, with proposals of how to effect this volte-face is due at the end of the month. I, for one, am totally confident that the report will be replete with whole-systems thinking and proposals – fully acknowledging the challenges and complexities of reversing course – and will make it perfectly clear that whatever is done will have dire and unintended consequences if not designed, planned and delivered around the real world of how people and patients have learned to behave in order to make healthcare systems work for them. Has to happen one time I suppose.

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Friends & Family Test: the NPS system in commercial operation…

NPS (Net Promoter Score) is all the rage in hospitals these days. The essence of the question posed to about-to-be-discharged patients is: based on your experience would you recommend us to your friends and family?

Developed as a measure of ‘customer loyalty’, initially by Fred Reicheld in 2003, it’s intended to be an effective way of knowing, not only whether existing customers will stand by you, but also whether they will – or will not – tell their loved ones and buddies to spend their money at your store too. (Not a million miles then from the old retail nostrum: “If you liked us, tell others. If you didn’t, tell us.”)

Whether or not the NPS works as a lead indicator of future success, as well as a lag indicator of past performance, is moot in the commercial sector, with its place, purpose and value in health care services distinctly unclear if not downright controversial. (Would you want to be the nurse who hands such a questionnaire to someone about to be discharged after a RTA in which they were seriously injured but also their child killed? No of course not, you wouldn’t dream of being so crass. But how then do you capture such an important *patient experience*, or is it simply not to be included in the aggregated feedback about whether your hospital in total is a star or a dog?)

An example in NPS practice from the commercial sector with some reflections:

This morning one had a necessary falling out with one’s mobile telephone provider, vis the length of their contract and its baleful effect. The call-centre worker was charm personified, but utterly unable to help: rules being rules, rules is all she has to go by. Customer, though, is not a happy bunny and says so: not about her, no not at all, but the bloody system and its wretched inflexibility.

Half an hour later the NPS kicks in. Texts start to arrive asking whether – let us call them Vodaphone – would be a company I would now recommend to others. First off – how has this come into being? Did the machine kick in because of key words I used (‘F*** that for a game of soldiers’), because she pressed the ‘Customer down!’ button, or by some other means? Is there also an equivalent for happy bunnies, or do they only pounce on the grouches? Are they even interested in improving their service, or is this just another means by which they monitor and control their front-line staff? That last is crucial to the hospital case.

So Text One is the standard opener: “Based on this experience, how likely would you be to recommend Vodaphone, from 10 (definitely would) to 0 (definitely wouldn’t)?” Truth, of course, is I neither would nor wouldn’t. If Vodaphone want to pay me to advertise their wares then let them. Otherwise I’m keeping stum. Everyone round these parts knows already which is the only mobile with a decent signal, and it isn’t Vodaphone; so the conversation would never, in any case, occur.


Comes to mind, though, that Text One was in fact the second, not the first, received on the matter; it being preceded by an invitation to participate in the process to which the only available  response was a silent ‘Yes please’. “Hello [bit informal, but let that pass]. We’d like to ask you 4 questions about your most recent contact with Vodaphone. All texts are free and the 1st question will follow shortly.” Not “We’d like to ask you, is that all right with you?”, but “We’re going to bother you whether it suits or no”. Backs. Up. Put.

Then comes: “Did we resolve your issue on this occasion. Please reply with either Yes or No.” What does that say? It says most clearly that Vodaphone expects all its contact to be ‘failure demand’ calls. That is, something has gone wrong and the customer wants it sorted. See John Seddon passim for why that is entirely the about-face way to proceed with any organisational learning or management of performance.


Then the killer: “How satisfied were you with the adviser who handled your query, from 10 (very satisfied) to 0 (very dissatisfied).”

Please note – the only moral reply to such a question is a resounding ’10’. Nothing else will do. The worker may have been rude, impossible to understand let alone do business with. It’s not their fault OK? Call centres are a latter-day vision of a Dante-esque Hell and all within the tormented souls. You can also be pretty damn sure that a low score here will cost the individual their wage (in fines) or even their job. They didn’t create whatever your problem is: chances are either you did or the company’s systems did. And if you can’t acknowledge the one, don’t let the company systems blame the hapless front-line worker for the other.


Next: “Thanks. Finally [it isn’t] please could you tell us the reasons for your ratings?” Pay me and I’ll fix your systems for you. Haven’t time or the intention to bash out some text that will simply scanned for key words – profane or other – and then entered into the database.

“That’s for me to know and you to work out.”

Finally: “Thanks for the sarcasm buddy!” No, sadly not. At least that would be a human-to-human moment. Instead the inevitable “We really appreciate your help. Your feedback will be used to help us continually improve our service to customers.”

Well hang on! I, frankly, couldn’t give a fig about *customers* plural. This customer is displeased. How about improving your service to me?! How about rewarding my feedback efforts with a bit more flexibility in your contract duration?

Now the absolute lulu, the avalanche of icing on this cake – 30 seconds after completing this discourse a spam text arrives “We sue for you!” One of those shyster companies wanting to know if you’ve just had a bum deal and are chasing a bit of compo. Call me the most barking of cynics, but I bet there’s a deliberate leak in their algorithm that routes the seriously discontented to the shysters. Easily done, and if it can happen it just did.

So where does that leave us with a hospital point-of-discharge NPS survey?

1. Would you want to be bothered by and with it anyway; or are you simply thrilled/relieved at going home, wanting to concentrate on packing, on checking you’ve got your meds, on remembering post-discharge instructions, on working out what you now need to do to catch up on all the things left undone while stuck in a hospital bed?

Crucially, would you want even to think of your loved ones in the same situation? You’re going home with a cancer diagnosis, you’re probably desperate to know whether your faulty gene has been passed on to your children (been there, felt that guilt and shame); you want to be forced to think about that right now – your sprog having the same ghastly chemo you’ve just endured – and to give that terrible feeling a proxy score on a bit of bloody paper?

2. Would you want any feedback you give geared towards whether or not you would ‘recommend’ the hospital to others. Aren’t you more interested in having your own, personal experience recorded? What does it mean anyway, and how often do conversations in the ‘Dog and Ferret’ begin: “Anyone know where’s good for gallstones?”; or “I’m thinking of crashing the car next week. Their A&E any use?”

3. The whole NPS thing is predicated on whether or not there is any choice in the matter. If not Vodaphone then who? In that case the answer is simple and it is ready. There are other mobile providers – hundreds – but only one that works around here. So if I could get out of my Vodaphone contract I would and head straight to O2. That I can’t is my beef. As for hospitals – what do I know? Very little in truth. What I want is assurance that my local gaff is the best it can be; that it is safe, clean and knows its trade. If somewhere in Birmingham is better on all counts, what earthly use is that to me? Local hospitals for local people. That is that ticket.

4. If I do sound off about the place, who’s going to catch it in the neck? You can bet it won’t be the CEO, it’ll be the Ward Sister who may well be doing everything she possibly can to keep the place going as best it can, with insufficient staffing numbers and junior doctors who are still at the “Is it an arse or an elbow?” stage of their medical learning. What if I just say ‘No ta, can’t be arsed’? Does Sister catch in the same neck if her respondent rate is below target? Probably, but this is my worry? It is, again, but why should this guilt trip be laid on me when I just want out?

5. Does my ‘happiness quotient’ really tell them anything useful? Will there be any depth analysis of the data, any looking for root causes, or will the forms simply drop into a performance management box for counting towards scores on the door? Isn’t this all a bit post hoc anyway? Never mind about any future trade I might put their way, have they bothered to ask me whether I’ve been happy with my stay? That may be but the dreaded lag indicator – but it’s what matters to this and to every patient.

Maybe though hospitals could learn from that spam text. Perhaps they should allow – decent and legitimate – compo claiming firms space in their front lobby in case anyone does leave spitting feathers and forceps. That would be the risk management equivalent of the ultimate car safety device: take out all of the seat-belts, the air-bags, the anti-lock brakes and the SIPS; replace them all with a just dagger mounted on the middle of the steering wheel with its point towards the driver. The perfect way to reduce ‘failure demand’, not bits of NPS paper.

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Commissioning.GP | News | GP News | Conflicts of Interests Concerns See CCG Delay Project

‘Under the CCGs current guidelines regarding how the group manages conflicts of interests, Prof Chester should have left the meeting when they began debating the topic, and should not have voted. Vanessa Lodge, the CCG’s board nurse member told The Surrey Comet, “We are not clear yet about our policy on conflicts of interest. We have not got that in place yet.” She added that the policy must come first so the board can make sure it acts “for the right reasons”. The board was told that clarification will come in the next two weeks.’

via Commissioning.GP | News | GP News | Conflicts of Interests Concerns See CCG Delay Project.

– You’ve lost me. Should have left the meeting, the implication being he didn’t. Should not have voted, the implication being he did. So why not certain about ‘policy on conflicts of interest’? Damn well should be before starting to hand out massive slices of the commissioning pie!

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