When matters of life or death necessitate quick, accurate decisions and treatment of the highest quality, the NHS offers the best healthcare in the world. It’s only when the bureaucracy has a chance to catch up that things start to go badly wrong. A recent family trauma showed us the very best and worst of the NHS, all in the space of the same treatment.
Have you seen one of these? It’s the NHS ‘friends and family’ test. I think it’s the most inappropriate customer satisfaction survey of all time.
And the competition for that title is pretty damn strong.
Before we get to that though, let’s rewind 7 days from this survey, to the point when my Dad suffered a massive heat attack on the 2nd tee. Some brilliant CPR from two of his golfing friends couldn’t restart his heart, but kept essential oxygen flowing around Dad’s body. A third friend dialled 999 and the first paramedics arrived on site within 6 minutes. They were soon joined by two further ambulance crews and a Doctor, who arrived by air ambulance.
This is what John Seddon would call “pulling value from the system”. The right resources were delivered to Dad, when and where he needed them. No questions asked, no cost restrictions applied, just the unifying purpose of doing whatever was necessary to save a human life.
Dad’s heart had stopped for 40 minutes before the 6th attempt with the defibrillator kicked it back into action. The first hurdle had been overcome, but he was still in critical danger as the ambulance took him to the nearby Royal Berkshire hospital and stage two kicked in.
Dad was rushed into surgery, where it was discovered that he had three blocked arteries. Three hours, three stents and another go with the defibrillator meant that Dad had survived to live another day. The consultant later told us that the surgeon must have “balls of steel” to have even attempted the procedure that he did, but that, I guess, is the point.
From the moment that Dad collapsed to the point when he exited surgery, the people treating him were allowed to freely use their skill and expertise. There was a clarity of purpose that focussed everyone on the same goal – to save a human life. No one needed incentivising with a target, no one needed to stop and ask for sign-off from senior management before continuing treatment and no one stopped to check whether Dad had the right insurance before sending out the air ambulance. Despite the lack of bureaucratic intervention, it is important to note however, that those in charge of the situation had complete control and their teams worked in perfect synchronisation. Amazing!
This pattern continued when Dad was passed into the Intensive Care Unit, where they placed him into a coma to allow his brain time to recover. There, the purpose shifted to “make recovery as complete as possible”, but you still had that same sense that everything happening around Dad was contributing to that purpose – nothing was done that didn’t need to be done. The staff were, quite simply, fantastic.
The same was true of the staff in the coronary care unit that followed ICU – still the same focus and excellent levels of care. The pace of care was dropping though and this was critical. As the pace slows, bureaucracy makes it’s move, overtaking the staff and introducing wasteful nonsense into the workflow. It seeps in without anyone noticing, until it strangles the excellent work completed at the front line. Here are the examples that I witnessed:
1. The ludicrous customer satisfaction form
It takes a very special mind to come up with something so inappropriate as to ask a patient recovering from a heart attack whether they would recommend the ICU and CCU to family and friends. On his release from hospital, it would have been nice if Dad had been able to remember what his care was like that morning, let alone what it was like over the last week. Never mind eh, as long as he ticks box 1, then that’s ok. How much resource is being wasted on collecting this information? What improvements have resulted from collecting it? How many frontline staff could be paid for if it was dropped?
2. Patient discharge procedures – part one
The consultant gave Dad the all clear to go home at around 9.30 in the morning. We were told that there would be a small delay whilst the dispensary prepared his prescription. Five hours later, we were still waiting. This triggers problems for both the hospital and the patient. For us, it meant sitting around on a congested ward, with no one able to tell us what time Dad would be able to leave. For the hospital, it meant that Dad was left needlessly occupying a bed, when there was a queue of patients waiting to come into the Coronary Care Unit.
3. Patient discharge procedures – part two
As the hours ran by, Mum and I needed refreshment. We let ward staff know we were going for a coffee. As we came back out from the hospital cafe, we were stunned to find Dad walking towards us, carrying his worldly belongings with him. Bearing in mind that Dad had been instructed not to move far from his bed up to this point, walking several hundred yards to the Discharge Suite whilst carrying his own bags seemed completely at odds with the care that had preceded it.It struck me that the “pull” system of providing the resource when needed had disintegrated at this point. The people working in the system were generally still great, but the system had shifted focus away from purpose and onto targets and segregation of duties. Communication had suffered and the level of care had dipped considerably. The dispensary were unable to meet the demand placed upon them, the ward were unable to communicate with the dispensary and the porter services were unaware of Dad’s need for a wheelchair.
The ward staff had kindly informed us about the aftercare that Dad would receive, including home visits to check on his progress and reassure my Mum. Sounds good, doesn’t it? One small problem though, Mum and Dad live 20 miles from the Royal Berkshire Hospital across the border in Surrey and home visits are not permitted over that distance. To a large degree I can understand this – if someone from (say) Newcastle fell ill on holiday in Reading, then you wouldn’t expect staff from the Royal Berks to offer home visits afterwards. However, the drive to Mum and Dad’s house is just over 30 minutes, so is distance or bureaucracy the barrier? What’s more, the care cannot be transferred to Dad’s local hospital, so he misses out completely on the promised visits.
So, back to the key question – how likely are you to recommend our ward to family and friends? Well, if you suffer a heart attack anywhere in the country, the standard of care at the Royal Berks is simply superb and I cannot praise them highly enough. However, I do see some problems in recommending it to family and friends:
- I would rather that my family and friends didn’t end up in ICU at all if that’s ok
- If you suffer heart problems, would you whip out the customer satisfaction results for all UK hospitals and ask to be taken to the Royal Berks ahead of more local alternatives? Of course not, so what is the purpose of “recommending” one hospital over another?
- If you do decide to use the survey results to dictate where you receive your care, it is quite difficult to influence the hospital you’re taken to when you’re unconscious
- Unless you live close by, the Royal Berks are unable to provide you their best levels of aftercare, so who would I recommend it to?
It makes no sense for hospitals to compete against each-other for our care. It makes perfect sense for everyone to expect consistently good care at whichever is the nearest hospital when you become Ill. Yes, I understand that some hospitals will offer specialist care, but the choice to “pull” on those specialist services rests with the care provider, not the patient.
So I would ditch this useless question and replace it with one more like this:
How can we remove pointless bureaucracy to let staff focus on purpose, just like they are allowed to in emergency situations?