I suppose the United Kingdom will not collapse completely in my lifetime, but it’s hard to imagine it can keep going much longer.
Consider the following snapshot of interaction with the National Health System.
For background, my wife and I live in Birmingham, the second largest city in the UK, with a population of around 1.2 million people.
Last Saturday, my wife woke up with very severe back pain, so that she couldn’t walk without holding on to something.
Our general practice (GP) surgery is closed during the weekend, as seems almost universal in the NHS, apparently as a result of the “core hours” part of the NHS contract with GPs.
We therefore had to phone the national 111 helpline.
This was a series of “press one for …” options, that ended up with a five minute conversation with an operator, who said that someone would call back within two hours.
After around two and a half hours, a specialist nurse called up, talked to my wife, and agreed she needed to be seen urgently.
Here’s where the frustration ramped up quickly.
The specialist nurse gave us a numeric code and a phone number. She told us to call the phone number and give the code, and they would give us an appointment.1
At once, at about 3.30pm, we called the number the nurse had given us, and the person answering said in fact we had to go to a website — http://badgeruts.uk — log in, and then book ourselves an appointment with the given code. He explained that there were three places we could book an appointment, in the Birmingham areas of Aston (centre North Birmingham), Erdington (North), and Solihull (South East). One of these (I forget which) releases appointments at 6pm, and the other two release appointments at 4pm. He warned us to be quick because the appointments go fast.
So we went to the website, which, entertainingly enough, redirected us to a site called Drive Thru Care.
Have a look at that site. It’s a really clunky old interface. Luckily my wife had logged in before, so we went straight to the Log In phase, and this took us to the booking phase, where things got nasty.
Sure enough, this phase offers us the options of the three sites above offering appointments. Sure enough, on choosing one, we got a year 2000 vintage web interface, where we click on a box to confirm the patient is not bleeding to death or suffering a heart attack, enter the date of symptom onset, and type a summary of the problem. Below, sure enough, is a series of 24 or so appointment boxes for Saturday, either labeled “Booked” or “N/A” — nothing we can select.
We know from the helpful phone call that some appointments will be released at or around 4pm in two sites.
Does this website auto-refresh when the appointments become available? Looking at the low quality of the site, we have to guess no. So we refresh the page, at which point the page clears all our previous information, so we have to fill the checkbox, date and summary again. And refresh, and again. And again. And again. We can copy / paste the summary, but still, it takes a few seconds to refill each time.
Meanwhile, for reasons inaccessible to us, more appointments become “Booked”. Presumably wondering how someone got these appointments without going through the same process is part of the entertainment. I noticed that the total number of slots decreased by one — again, for reasons unknown. We wait, refresh / retype / paste, refresh / retype / paste, every few seconds.
At last, a little past 4pm, a series of slots appear, and immediately about half of them appear to be “Booked”. We very quickly select one of the six or so remaining, retype / paste, click “Book”. Error, the slot is no longer available. Refresh. One slot left. Select, retype / paste, “Book”. We get the last slot.2
I guess there was about 40 seconds between the slots appearing and all of them being booked. We got a slot only because we are very good at using computers — we know to refresh, copy / paste the long stuff, and do it very quickly, with keyboard shortcuts, on good WiFi.
Aren’t we the wrong people to prefer for urgent care slots? I mean, yes, we needed a slot, but why do we get it for being in the top few centiles for fluidity and speed in using web interfaces?
Given how fast the slots went, I assume that a large majority of people who should have got slots, did not get slots. Before we succeeded in getting the last slot, we had spent maybe 20 minutes on the phone, 2.5 hours waiting for a phone call, and about 20 minutes on the website. A specialist nurse had agreed we needed an appointment. Given our experience, I’d have to guess that a small proportion of people in that situation got a slot — maybe 15%, maybe less. So now you have 85% of your patients, and particularly those patients who not very skilled with clunky web interfaces, who need to be seen, have spent maybe 40 minutes working on getting an appointment, and waited more than three hours since contacting the health services, and they get — nothing.
What should have happened?
By looking at the web interface while we were waiting, I estimate that there were around 100 Saturday evening slots available across the three urgent treatment centres. Bear in mind that these three centres cover the UK’s second largest city, with a population of 1.2 million.
It seems most unlikely that 100 slots were enough for the demand.
OK, say that the NHS just doesn’t have enough money or staff to provide more than 100 evening appointments. How should these slots be distributed?
Not, I think, by making your sick and needy patients run an obstacle course of outdated web technology, and giving the slots to the winners.
And in fact, how hard would it be to allocate the slots by answering the phone?
Remember that we already had to phone somebody, to tell us to use the website, and to give us the miserable but useful advice on how to play the system to get an appointment.
Let’s take my guess of 85% pre-screened people not getting appointments, and 100 appointments. That’s about 670 people who need appointments, of whom only 15% are going to get one. Let’s pay 10 doctors to answer the phone on Saturday afternoon. They each take about 70 calls, and then negotiate to allocate the 100 appointments. Give them an average of five minutes to talk to each (already pre-screened) patient, giving them each around six hours of work, and allow time for negotiation, and between calls, for an eight hour shift. Let’s say the average GP gets paid £87K per year; this would give an hourly rate of about £50. So the cost of this service would be about £4000 per weekend day. For the UK’s second largest city.
And at least, that way a) the patients get a better assessment and triage service, and b) the selection of who gets an appointment would be based at least plausibly on clinical need, rather than skill and speed in using poor web interfaces.
On the other hand, the advantage of the current system is there is no person to whom one can direct one’s anger — one can only marvel at the extraordinary but terribly familiar incompetence of NHS IT provisioning, and tell one’s friends. Put simply, our leaders appear not to be much worried if we fall into existential rage as long as that rage is impotent.
To recall the context — my wife found it difficult to walk and was in severe pain. Now we would have to get downstairs, get into a car, drive for 30 minutes, wait in a waiting room, walk to a treatment room, be seen, walk out, drive back. This was going to be (and in due course was) very unpleasant. The obvious thing to do is to offer a home visit. These do not appear to be possible with the current NHS system. Anyway, back to process that exists.↩︎
To complete the story, we drove for 30 minutes or so to the urgent treatment centre (UTC) in Solihull Hospital for our allotted appointment time. We were seen after about 20 minutes, and the appointment was — OK. At which point my wife is still in a lot of pain, and I leave her at the treatment centre entrance to get the car. When I try to get out of the hospital car park, the Pay Station to which I am directed is comprehensively closed, the phone number given there is the main hospital number (press one for …), and neither I nor another two drivers can get through the barrier without a paid ticket. By discussion and exploration, we find two machines where we can pay our tickets, but the machines won’t read mine, and are cash-only for those it can read. Jogging around the building and asking, it turns out we have to go the hospital main entrance, and ask security. Who take my payment, and send me back to the car park to buzz me through. It appears the hospital does not expect its patients getting after hours treatment to park in their patients’ car park.↩︎