NHS appointments are a mess

There has been much discussion recently about fining people for missing NHS appointments and the consensus seems to be that people have no excuse for missing them and it is only fair that they should pay a fine when they do so. 

My experience suggests that it is quite easy to miss them, because the appointments system is a mess, and my situation is much simpler than many people's.

I am documenting my views here so that I can easily share them as and when required, starting with the hospital's Patient Advise Liaison Service.

My appointments cycle

I have one underlying condition that is being managed by one hospital. I continue to see my GP for other things like the recent flu and Covid booster jabs.

This condition means that I need to see one consultant every three months and another every six weeks with the second visit followed by a treatment session the following day. I also have two scans every other treatment cycle, i.e. once every twelve weeks, which are done at a separate site.

That means that at any one time I have five future appointments booked.

Different appointment systems

The big problem is that there is no consistency in how these are managed:

• For the two consultants appointments I get paper letters and they also appear in the NHS app, which means that I get automated reminders by text
• For the two scans I get paper letters but nothing else
• For the treatment sessions I have an appointment card (!) which gets updated by hand each visit.

The only place all these appointments are consolidated is on my fridge where I store all the letters and appointment card in date order. 

I also put them all in my online calendar manually which is prone to error (more on that later).

Other issues

There are several other niggles in the systems that while are not significant in themselves they all add to the friction in the system and increase the chances that errors will be made. One such niggle has already caused me to get one appointment wrong, luckily I arrived a day early so no really damage was done.

Where electronic communications are used, e.g. NHS app, this just points to a message that is in the form of a PDF file that contains an image of the letter, i.e. it is not possible to simply cut and paste the appointment details in to a personal calendar. 

Many apps that I use, e.g. MeetUp, have an "Add to Calendar" function and NHS app should be able to do this too.

There are inconsistencies in the naming of locations within the hospital, e.g. letters refer to "Oncology & Haematology Outpatients” whereas the signage in the hospital says Haematology & Oncology Outpatients (HOOP)", and the two letters for the scans 

The letters for the scans give the data (dd/mm/yy) but not the day of the week, which is how most people refer to dates most of the time, e.g. it says "31 October 2024" rather then "Thursday 31 October 2024".

The two letters for the scans have slightly different descriptions for the same address. They also use different sized fonts. which may be an attempt to keep all of the main information on the front page.

I sometimes get automated reminders to my landline! I did not know that the hospital even had this number much less intended to use it. I am not sure which appointments these are for as I never listen to the whole message once I know who it is from.

Summary

Three things should happen:

1. The NHS app should be used for all appointments
2.  The app this should link to personal online calendars
3. Appointment letters to patients should be reviewed for consistency and clarity.

Change NHS: A consultation

Introduction

The new Labour Government has said that "Our NHS is broken, but not beaten. Together we can fix it." and has launched a consultation to start the process (I would have gone with money first but that's another story). 

I wanted to respond to that consultation for several reasons, notably because I have worked with business change through IT for most of my career and also I am quite involved with the NHS as a patient at the moment. The NHS matters to me and I think that my views on it are relevant.

I am putting these views in my blog so that I have a record of what I said and I can also share them easily when I want to.

The consultation is online at change.nhs.uk.

The 3 shifts

The consultation covers the 3 shifts, widely trailed before, as"big changes to the way health and care services work – that doctors, nurses, patient charities, academics and politicians from all parties broadly agree are necessary to improve health and care services in England".

These are:

1. moving more care from hospitals to communities
2. making better use of technology in health and care
3. focussing on preventing sickness, not just treating it.

The consultation then asks questions on these. I quote these questions and give my answers.

Q5. In what ways, if any, do you think that delivering more care in the community could improve health and care?

There appears to no rationale behind this idea other than the slim possibility that because more appointments are more local then fewer will be missed. Specialised services are provided through large hospitals for several good reasons from economies of scale to the frequent need to treat patients will multiple conditions.

I see no health and care benefits in doing this.

Q6. What, if anything, concerns you about the idea of delivering more care in the community in the future?

Healthcare provisions is already fragmented, e.g. dentistry and optometry, and having separate centres for other services risks further fragmentation with the need to visit several centres for one condition.

Small units are likely to be inefficient, e.g. a surgery facility at a GP surgery will either be over staffed to ensure that it meets all demand or under staffed at some times leading to more waits.

People often have multiple needs and being co-located means it is easier to address them at the same time, for example, to get an unplanned x-ray for a patient. When working on Business Transformation we called this "one and done", i.e. fix everything on one visit.

Small specialist units will focus on the one thing that they do and will lack the patient's full context to provide the best service. This happened to me when a private surgery unit missed the possibility of skin cancer and this went undiagnosed for a few years. This fragmentation may kill me.

Q7. In what ways, if any, do you think that technology could be used to improve health and care?

Again, the described benefits of this are weak at best and they are all claims made about other large IT projects that spectacularly failed to deliver. I have worked on some of these and the example of Horizon at the Post Office is fresh in our memories.

The idea that patients need only tell their story once misses two very important points, each specialist needs to hear and questions a different part of that story and that story will change over time (do you smoke, what medications are you taking, how active are you, how stable is your weight etc. etc.) and so it must be retold for accuracy.

Using AI to review scans is an obvious thing to do but it is hardly transformational. The only way that this could help significantly would be if we took lots more scans but that would be an additional cost on the NHS.

Technology is too often portrayed as a magic wand, it is not.

Q8. What, if anything, concerns you about the idea of increased use of technology in the future?

I am concerned that the benefits are overstated and could not be delivered without substantial additional investment (beyond the basic hardware, software and networks) in things like data cleaning and ID cards.

The basic technology, e.g. exchanging packets of data between systems, is easy but does not help because the data quality is pretty low and inconsistent and so sharing it will only make things worse.

I have worked on large IT systems with simpler data, e.g. spare parts held in stockrooms, and every project had to start with a large data cleaning exercise and even that does not solve all of the problems as some of the answers are unknown, e.g. a supplier code does not match any code used by any supplier. Similarly in systems involving people you will often find several dates of birth of something like 01/01/1900 where people have made up data just to get past that screen. Or, even worse, used a special data as a code for something else that has been long forgotten but which is useful.

There will be significant inconsistencies in the data between systems. To pick another example I have direct experience of, there is not a standard list of Nationality codes so things like the Census and Schools (both part of UK Government!) use different lists. These lists also change over time so while a younger person may be identified as, say, Bangladeshi their parents may be just Asian. I picked this as a simple, easy to understand example, other parts of health data are far more complex and far more prone to inconsistency. Agreeing standard lists will help but will take time and will make the data cleaning longer.

And one key part of the data is missing, a unique identifier for each person. Who remember's their NHS number or carries a card with it on? A national ID card system could help (after a lot of time and money) but there will always be gaps, e.g. recent arrivals.

I would be very surprised if you could get the data at sufficient quality to share in less than eight years and employing thousands of people for that long is expensive.

Q9. In what ways, if any, could an increased focus on prevention help people stay healthy and independent for longer?

This is where the focus should be, though not necessarily for the reasons given. We should enable people to be healthier so that they can live more fulfilling lives, not just to save the NHS money. People play sports for fun not to keep out of hospital.

The consultation gives no idea of the scale or ambition of "tackling the causes of ill health" but these need to be bold to first address recent declines in population health (e.g. obesity) and then to significantly improve them.

That means being brutal with manufacturers and retailers over things like smoking, processed foods, alcohol, etc. We know many of the major causes of ill health and should address these seriously.

Going back to school lunches for all school pupils and breakfasts too for primary pupils would be a major boost to wellness and is probably the easiest and quickest option the Government can implement.

In 2023, there were 132,977 casualties on UK roads. We must do a lot more to address this, including stricter enforcement with harsher penalties and redesigning roads to manage out traffic.

Managing out traffic is a win-win as it reduces traffic accidents and also encourages people to use other and healthier means of travel. In the early 70s I went to an edge of town secondary school and hardly anyone went there by car, we need to get back to those days.

Q10. What, if anything, concerns you about the idea of an increased focus on prevention in the future?

My concern is that the Government will back away from the big necessary changes under pressure from lobby groups claiming that it is trying to implement a "nanny state". If these measures are to work then they must be bold.

Here in America at Orange Tree Theatre

I try to support Orange Tree Theatre as it is one of my nearest and while its programming is not always to my taste there was a lot going for Here in America, the phrase "multi award-winning plays for the RSC and National Theatre" as did the presence of Shaun Evans the star of Endeavour.

That said, Orange Tree Theatre is proving to be quite popular these days and when I finally got around to booking my options were limited and I had to settle for a high stool in the third row, Lower Floor C30, at £35. The late booking also meant I ended up with a distanced performance (first introduced immediately post-Covid) which was just as well as my third row seat would have had poor visibility if not for the spaces in the first two rows.

Here in America looks at McCarthyism through the eyes of playwright Arthur Miller and his frequent collaborator director Elia Kazan. Their discussions, and actions, were mostly around whether to give the names of other possible communist sympathisers when they were interrogated. 

And that was about it. The play was essentially a documentary on a specific part of the proceedings of The House Committee on Un-American Activities and while it was interesting to hear the views of Miller and Kazan it was a story with little drama.

I also felt that in setting the play wholly in America in 1952 the opportunity was missed to say something about the echos of McCarthyism in modern politics, such as the way that all criticism of Israel is called unpatriotic, despite the very obvious genocide and war crimes.

The lack of any real drama or message was a shame as the production was very good in all other aspects. I very much appreciated the theatre of the show and the skills of all those bringing it to the stage but I was left wondering what the point of it all was.

The River at Greenwich Theatre

There are certain things that I look for when selecting a theatre performance to see and the name Jez Butterworth is one of these. 

It helped that it starred Paul McGann and was on at Greenwich Theatre which I had liked on my first visit to see Vincent River in 2024 (yes, the two plays I have seen at Greenwich Theatre are Vincent River and The River). A front row seat (A27) for £21, thanks to concessions, was an offer that I was not going to refuse.

Greenwich is fairly central but it still took a mainline train, a Jubilee Line train and a DLR train to get there. Luckily the connections were good (though having to climb up the emergency escape steps at Cutty Sark was not great) and I got there in good time for bit of a mooch and a coffee with cake before heading to the theatre where I had a pint of local Meantime beer before the show.

The story to The River is superficially simple, a middle age man has short term relationships with multiple women that follow the same course but while the story is simple the storytelling is anything but and that is what makes The River rather special.

The main technique is to interweave the stories of two of the women so we see similar scenes played out with the two female leads, Kerri McLean and Amanda Ryan, with one leaving the set to be replaced by the other repeatedly. The stories are non-sequential so, for example, we see one woman ask about a drawing she has found and then we see him doing the drawing. This is all done very nicely so that it is not too complicated to follow nor too clever for its own sake.

Making sure that everything was perfect, the stage was very effective as were the sounds (mostly of a river) and the lighting. Greenwich is quite a small theatre and it was punching above its weight here.

I said that the story was superficially simple and some time later I am still thinking through some of the deliberate loose ends and uncertainties. A play that makes you think afterwards is a good thing.

The River was a thoroughly engrossing and stimulating production which I enjoyed greatly.

Goldrush at The Half Moon (6 Oct 24)

Once upon a time Goldrush were called The Honeyslides and I saw them whenever they played at The Half Moon in Putney (which was every six months or so) and I have been carrying on that tradition under their new name. The only difference over the years of seeing them is that they had a new dummer this night and the occasional female backing singer has not been at any of the recent concerts.

There have been other small changes, Luke (on the left) now plays piano too, some of the songs have changed and the music technology has had several upgrades but their concerts essential remain Neil Young and Crazy Horse playing Live Rust, and that is all I could ever ask for.