The Case For Private Businesses In The NHS

As a GP and entrepreneur, with my own software being used in the NHS, I have found that my opinion has continually changed with regards to businesses in the NHS.

I used to think as a junior doctor that a lot of the private companies dealing with the NHS were evil for two main reasons: overcharging the NHS for their services and the unethical use of patient data.

I think these two points are still valid for certain companies.  If you read some of the reviews of some of the NHS software suppliers then it’s patently obvious that certain organisations like TPP who provide the electronic health records for around 30% of NHS GP practices have stonewalled themselves from criticism.  Their software is also very dated and horrible to use as a result.

But, there are some great things about private enterprise.  One of the greatest differences between government ran organisations and private enterprises is accountability.

We live in an age where when there is outrage at a private company, real change can happen.  Just look at how the CEO of a multibillion dollar company was recently ousted for unethical behaviour.

I think that the world is changing.  People and consumers have a voice now, because of the Internet and how connected we are.  We can raise our concerns when we’re not happy and take our business elsewhere, or in my case start a business which is more ethically sound (I hope! :p ).

I feel that this is quite different from government organisations.  As private businesses become more transparent and ethical due to consumer pressures, large government organisations are appearing more and more opaque as time passes by.  Due to the lack of market place pressures they are also very inefficient and lack the focus that private enterprises need just to survive – but this is the subject of another blog post! 🙂

This Is Why We Can Change The NHS

The people at the top of the NHS, it is widely thought, have it so easy.  If they just had the sense to engage with the public and front line staff then they could make things better, cheaper and more efficient.

The people on the front lines of the NHS such as junior doctors, nurses and physiotherapists also have a widely held belief – that they can’t make change happen.  Patients are mostly the same as well.  “What can I do?”  they say.

If only patients and staff could yell at the people at the top and tell them how hard they have got it, the thinking goes, then maybe change would happen.

How can staff and patients possibly create change when no one listens to them?  When they don’t have any money?  When they’re just a tiny cog in the system?  When speak of innovation and creativity is often met with fear and disdain?

If this is the case then only the people at the top must be able to create change, they say.

The fact is that the people at the top realise that they have a budget where they have a whopping 1% devoted for software and 0% for innovation and creating change.  If the people at the top decide to innovate and blow some of their budget on something new, then it better have a big impact, it better be nationally scalable from the get-go and it better deliver on all the outcomes promised.  If they don’t deliver on this impossible promise then it’s their head on a pike!

You see, the people at the top are paralysed.  They can’t do anything because they know too much about the wrong kind of things and they are risking their livelihood if they put their name on something that doesn’t work.

The patients and front line staff, the ones that pick themselves to make meaningful work are the people who will create change.  The problems and barriers we face are not nearly as big as what the people at the top face.  This is a lie that front line staff and patients tell themselves, as taking responsibility for something much bigger than their role is a tough pill to swallow.

When I was a Junior Doctor at St James’ Hospital in Leeds, I had the great pleasure of working with the late Dr Kate Granger.  She started the “Hello My Name Is….” campaign.  The reason she started the campaign was because she had terrible experiences of doctors not introducing themselves during her illness.  On one occasion the doctor that told her that her cancer had spread left her “psychologically scarred”.

She went on to say at a speech:

“I had been moaning to Chris (Kate’s husband) about the lack of introductions from the healthcare staff looking after me. Being the practical optimist that Chris is, he simply told me to ‘stop whinging darling and if it is that important to you do something about it.’ So we did.”

It wasn’t Kate’s responsibility to do the campaign.  No one gave her authority to start a campaign.  She simply didn’t have to do it.  But at that moment, she picked herself and decided to make change happen.

She didn’t know that her campaign would end up being endorsed by the then Prime Minister, celebrities, about half a million NHS employees and result in her being awarded a MBE.

The reason why the NHS is so broken is because there aren’t enough people like Kate who pick themselves.  But anyone can pick themselves.  And it’s as simple as saying “I am going to make change happen”.

Ignorance Is Strength

I was reading some George Orwell and I came across this quote:

“In our society, those who have the best knowledge of what is happening are also those who are furthest from seeing the world as it is. In general, the greater the understanding, the greater the delusion; the more intelligent, the less sane.” 

These two sentences in effect perfectly sum up what is wrong with not only society, but also with large organisations.

My own experience in the world of medicine echoes this sentiment.  I am always struck by how front line staff are all able to perfectly describe what is wrong with the NHS and can offer dozens and dozens of solutions to improve things, to make things more efficient and to make things better for patients.

However there are certain people (the “Inner Circle” as George Orwell calls them), who move away from actually seeing patients, see the healthcare system as a whole, see the challenges that we face socioeconomically, see the future (or think they can see the future) problems and so on.  As a result, these people end up knowing nothing about what actually needs to be done.

What does this mean for people on the front line?

Well, for the first time ever, thanks to the decreasing costs of technology, it means you can choose to pick yourself and create work that actually matters.  Work which is informed by actual reality.

Is it any wonder that incumbents get disrupted?  They are blinded by their own size and informed ignorance.

NHS Startup Part XV – “It’s Up To Us Now.”

We launched a new phase of our app for our patients and Primary Care services this week.  The build for this phase was huge and we have been steadily working on it for the previous four months (designing, building, testing, messing up ad nauseum).

I think we’ve really nailed what we intended to do.  As we collect more data, it should show that we’ve increased how efficient things are running at the practice, that more revenue is being made and that patients also prefer our new app to the existing means.

My main fear for this launch was actually the practice and the number of staff that work there.

As our app continues to expand and increase in its abilities it requires a concerted effort by everyone at the surgery for it to really work to its full potential.

I was initially worried about this.  Up to now, a small number of staff at the practice have been doing everything and they didn’t even need to do much to make the app as successful as it has been.  Now everyone in the practice has a small part to play to make it really grow and have a bigger impact.

Could they do it?  Would they do anything wrong?  What happens if they simply don’t want to?

These were the questions running through my head.  Although the launch itself went without a hitch, I was leaving the surgery still thinking that someone may mess something up.  That’s when someone from the team said:

“It’s up to us now”

At that point I just felt a massive sense of relief.  I truly do believe that the team are all bought in now.  I realised that giving people something to do with regards to my app isn’t bad.  It’s actually good, because now everyone is bought in and involved in the mission.

I guess being a leader is about leading from the front, aligning people and then creating change.  Maybe I was trying to create change from the back and by not leading all this time.

One thing’s for sure though – if someone does mess up.  I won’t be upset or angry.  I’ll be grateful they tried.

Epic Rant – The Maiden And The Hare

I was going through my subscribed list on WordPress the other day and noticed that most bloggers I followed have stopped blogging after only a few posts.

Three questions spring to mind:

  1. I wonder if these bloggers would quit if they had tens of thousands of followers and likes on their posts?
  2. I wonder if they would continue to blog if they could possibly be a successful blogger if they continued for 7 plus years.
  3. I wonder if they would continue to blog if I could guarantee that they’d be a successful blogger if they continued for 7 plus years.

I bet the answers to these questions would vary massively.  Most people want a guarantee.

This is why people fail.

They fail because they quit.

People fail because they want a guarantee of success.  If they don’t have that guarantee then they tend to not stick it out through the rough times.  They don’t stick around for the times when no one gives a damn about what they have to say and don’t give a damn about what they’ve done so far.  And why should others care?  People aren’t as special as they tend to think of themselves.

“At first, then, exhibit the coyness of a maiden, until the enemy gives you an opening; afterwards emulate the rapidity of a running hare, and it will be too late for the enemy to oppose you.” – Sun Tzu, The Art of War

In life there has to be a time when you keep your head down, obey orders and commands to learn your craft.  When I graduated from medical school, I accepted that I knew very little in comparison to other doctors who knew a lot more than me.  Voicing your opinion on how things should be run and organised as a nobody makes you come across as a douche bag.

I’ve spent over a decade involved in healthcare (from the time I started medical school up to this point in time) and before that, I was surrounded by medicine because so many of my relatives are doctors.

Only now am I writing a blog and starting a healthcare company.  Before this time, I kept my mouth shut and studied my craft.

It is shocking the number of people who don’t put in the grind and hustle and yet expect the world to take note of what they have to say.  Let me tell you something – the world doesn’t care unless you’ve provided something of actual value.  No one will listen to you unless you have credibility, which will be apparent in your actions, character, network and public standing.

Be the maiden and then the hare.

Rant over.

Innovation With NHS Software

There are two ways in which Enterprises assess how valuable a piece of software could be to their organisation.

The first is whether it can save money.  Save on staff costs, inefficiencies, wastage etc.

The second is whether the software can make the organisation more money.  This is an order of magnitude better than saving money and you will face a lot less resistance if you can create something which can increase revenues.

I think that this is one of the reasons Primary Care in the UK has so much more technology and innovation than secondary care.  Surgeries in the UK are ran like small businesses and the better the health outcomes and indicators that a practice can achieve, the more money they receive for their business.  Hospitals get allocated money on an as needed basis.  They don’t get rewarded with money in the same way Primary Care Businesses do.

If this is the case then where is the incentive for companies to make innovative products that make things better?  Companies are only incentivised to make things cheaper in Secondary Care.  The way to make things cheaper is usually to keep doing what you’re doing at a cheaper price point.  Doing something new means large implementation costs.

Unless increasing efficiency is baked into your product / service then I would say that the best course of action may not be to go for a market where innovation and making things better is not rewarded.

Is there a market where there is money and an opportunity for your startup?  Then that’s the market you should go for.

If Marcus Aurelius Were A Doctor

When a man kisses his child, said Epictetus, he should whisper to himself, “To-morrow perchance thou wilt die.”- But those are words of bad omen.- “No word is a word of bad omen,” said Epictetus, “which expresses any work of nature; or if it is so, it is also a word of bad omen to speak of the ears of corn being reaped.”

The above is a meditation by Marcus Aurelius.  It’s not the most well known, but when I first read Meditations, this one really stayed with me.

Accepting that life is finite, although jarring is empowering because it allows you to focus your finite time on aspects which you do have under your control.

I’ve found that a lot of doctors cannot accept the fundamental truth that they cannot predict or control what will happen to their patient.  When a patient walks out of your room he or she may die.  It happens all the time and most often it’s the patients that you least suspect that get unwell.

What I find interesting is that a lot of doctors try to counter the inevitability of their patients dying by becoming emotionally involved.  I have seen some of my colleagues cry and go into depression because they get so involved.

Patients themselves may want their doctor to be more emotionally invested in them.  They may prefer and consider doctors who are more emotional to be the better doctor.  But just because they may prefer something doesn’t make it correct.

I find that a lot of people in the general population would prefer to not take responsibility for their health and outcomes in life.  If their doctor becomes invested in them, they feel that they are able to give the responsibility of their health over to their doctor.  This is patient disempowerment rather than empowerment in my opinion.

In 90% of cases a patient should not expect to give over complete responsibility of their health over to their doctor.  A lot of patients have actually tried and failed to sue their doctor because of this false expectation.  When a mother sees a GP about their baby and is told that the baby has a viral infection, but if things deteriorate to seek medical attention – we are telling that mother that nothing is certain in life and actually, there is a chance that this could turn out to be meningitis.  A doctor can only go by the clinical picture in front of them and come to a logical clinical decision.  It is up to the mother to act responsibly and do something if the child becomes more unwell.

Another sign of how dependant patients become / how unrealistic their expectations are is when patients complain about seeing several different doctors before getting to the correct diagnosis.  Patients don’t realise that if this is the case, it’s extremely likely that the way the patient presented was atypical as is evident by several different doctors coming to an incorrect conclusion.

Doctors should not become emotionally involved and accept full responsibility for their patients health.  Sure, we can empathise with our patients.  But what we mean by empathy is that we get where the patient is coming from, we try to understand the patients life circumstances and try to formulate a management plan which the patient can tolerate and live with.  Empathy does not mean becoming emotionally invested.  This is actually a very quick way to allow unknown biases to sway your medical judgement and provide poor care.

“All men are made one for another: either then teach them better or bear with them.”

I wonder what Marcus Aurelius would think about becoming emotionally attached and accepting full responsibility for their patients health.  I think the above quote sums up the correct attitude you should have as a doctor.  If the patient listens you can teach them about a healthy lifestyle, how to manage their medical problems as best as they can and so on.  (And always document what you have said!)

If patients do not like what I can do for them with the tools that I have available at my disposable then it is none of my concern.