Tuesday, March 18, 2008

The overzealous auditor - Part 2

While the Thatcher government were battling with the miners of Yorkshire, Nottingham and Kent, another industrial dispute rumbled on for over a year. It was a strike of ancillary workers at Barking Hospital in Essex and was in support of the cleaning staff who had their hours severely reduced as a result of the general introduction of contract cleaning into the NHS. The sad thing about this was that Barking Hospital had a long and successful history of employing contract cleaners before it became required to test the market.

The successful tenderers had previously employed staff on hospital rates of pay and with pension rights similar to those of NHS staff. This had been written into the contract by the health authority. The health authority limited its role to clearly specifying what was required and closely monitoring the contractors own supervisory arrangements. With the clamour to test NHS support services against the market (or "contract out") to reduce costs the successful tenderers at Barking however found they could no longer compete without severely restricting the hours their staff worked.

One saving that was being made by competitors new to the market place was to pay staff on a part time basis only thereby allowing the employer to avoid having to pay National Insurance for their employees. Furthermore the new entrants to the contract cleaning market place did not offer pensions comparable to those in the NHS. The previous contractors did in the end hang on to the Barking Hospital cleaning contract but only by severely restricting the terms and conditions of employment of previous loyal staff. Sadly it appears that when prioritising which staff would have to suffer the most dramatic reductions the opportunity was taken to settle some old scores and not everyone was treated fairly.

For other a year therefore there was a picket line outside of Barking hospital. All deliveries were challenged and in the early days ambulances refused to carry patients across the picket line. I saw a patient with one leg hopping from an ambulance to cross the picket line under his own steam and others on crutches making their way as best they could to out patients. This did not last for long however and in the end ambulances were allowed to cross. The strikers drew the line however at the health authority's own laundry van. Initially the drivers ignored the pickets and continued to collect dirty linen and deliver fresh. But they were under pressure to show their solidarity by refusing to do this any longer. I accepted their predicament and arranged for a rota of senior health service managers to drive the laundry van and do the unloading and loading on a daily basis.

This continued without too much problem for most of the year that the dispute lasted. There was a hiccup however when the laundry staff were asked to stop handling theatre greens from Barking (these are the gowns worn by theatre staff). Although we used disposables as much as we could the Theatre gowns were not then capable of being substituted. I intervened to talk to the laundry staff and shared with them what I understood the true position to be (including the fact that this action alone would stop operations at the hospital). I asked them to reconsider while I waited outside. When I returned to the meeting I was pleased to hear that they had voted to return. When I asked one of the laundry staff (with who I had worked during an induction day I had arranged for myself) how close the vote was she said "it was not close at all - we all voted to return and when Pat ( the shop steward) asked for a show of hands a number of us raised both hands!"

It was against this background that the overzealous auditor decided to launch an investigation. It had been reported to him that a laundry van matching the description of those used by Redbridge HealthAuthority had been seen regularly outside a private nursing home with which Redbridge had no contractual arrangement.

He had calculated the additional mileage that this regular trip would entail and the mileage of the planned route of the hospital van and the additional mileage was broadly equivalent to what would have been travelled to provide an illegal service to a private nursing home. He satisfied himself that his informant was correct about the regular deliveries and collections. He came to me asking that on the basis of this evidence I immediately sack the driver and launch an internal investigation into the laundry staff to see who else was involved in this fraud.

In the circumstances of the industrial action at Barking and the recent reversal of their decision to stop providing theatre gowns to Barking hospital I was concerned what effect these suspicions would have on our ability to continue to treat patients at the other hospitals in the district let alone at Barking.

I suggested to the auditor that as I was due to drive the laundry van that evening to Barking I would check the log myself and the accuracy of the odometer to be satisfied that the discrepancy was real.

Its just as well that I did! No sooner had I sat behind the wheel to note the odometer reading to record the starting mileage than I realised that the odometer recorded distance in kilometers! The form used to log distances was headed up "miles travelled".

Nonetheless I assumed that the overzealous auditor had corrected for this so recorded the start and finish readings, converted them to miles and could confirm that the odometer readings were relatively accurate.

The next day I asked to speak to the auditor and realised he had not corrected for the difference between miles and kilometers. We then quickly calculated that the apparent additional mileage each week was entirely explained by this failure to convert back to miles. This still left the sightings however.

It turned out that the neighbouring health authority (Waltham Forest) had jointly purchased a fleet of laundry vehicles for both authorities the colour scheme of which were the same and the registration numbers were in sequence. What's more the neighbouring health authority did have a contract to provide laundry services for the private nursing home outside of which the auditor had spotted our apparent fraudulent driver!

The overzealous auditor - Part 1

When I worked in Ilford for the Redbridge Health Authority I had responsibility for planning and support services. It was in the management of support services like cleaning, laundry, gardening and staff accommodation that I came across a most comic character. He was the chief internal auditor and both smoked a pipe and wore an occasional deerstalker hat. I'm not sure if he also played violin but there could be no doubt he imagined himself to be a modern day Sherlock Holmes. Unfortunately while he had much scope for launching investigations he did not share the fictional character's clarity of thought so would do the most inappropriate things at the most inappropriate times.

I am saving my own experience of this for a second installment but in this one - by way of introduction - will relate another of his adventures as reported to me.

This concerned his investigation into the relatively high consumption of steak at one of the hospitals in the district. I think it was at Goodmayes the psychiatric hospital which is where his own office was based.

For one reason or another his suspicions were aroused that the culprits were the catering staff employed in the main kitchen and that the increased high consumption was not down to any other factor such as the recent addition of an adolescent unit which might just have skewed the figures away from previous trends.

He therefore arranged to arrive early one morning before any other member of the kitchen staff had clocked on. With an assistant to verify his findings he was going to observe their behaviour and hopefully catch someone red handed. This meant he needed to have somewhere to hide. Apparently there was no shortage of cupboards and larders where dry food was stored so he chose one of these to hide in with his assistant.

After an hour or so both remained unobserved and yet had seen nothing untoward. Getting a trifle annoyed at this the overzealous auditor struck a match and began to draw on his pipe. In the confined space his assistant who was too afraid to criticise his boss tried to stifle a cough as he was not used to being in such confined and close proximity to pipe smoke.

The assistant later reported later - to the amusement of others - that at first the kitchen staff wondered who was coughing and realising it was not any one of them initially continued with their preparations for breakfast and lunch.

About 10 minutes later however they noticed smoke coming from one of the dry store larders.
As they approached they could pinpoint the stifled coughing as coming from the same place.

"Is there anyone in there?" - they asked but the overzealous auditor unaware of the smoke trail signalled to his assistant to remain silent by placing a finger up to his mouth. The assistant duly complied. A few coughs later - "Look we know you're in there if you don't come out now we're going to ring the police" said the suspected kitchen staff. Still there was no response other than inside the larder the overzealous auditor was gesturing even more demonstratively to his assistant to keep quiet in the belief that the kitchen staff would go away.

It was only when the kitchen staff shouted that they had no option but to open the larder door and use the fire extinguishers to put out the fire that the auditor emerged, pipe in hand and with his assistant following on dutifully behind. Some excuse was blurted out about needing to check stock levels and having got locked inside the larder when no one was around to help get them out. In this way the overzealous auditor extricated himself with - he supposed - his dignity still in tact. In reality of course the kitchen staff had worked out the real reason he was there. In more ways than one therefore the overzealous auditor had truly "blown his cover"

The first codified laws of cricket -1744

A couple of years ago I came across a most interesting book which I bought 2nd hand in Alnwick Northumberland. It was edited by Neville Cardus and John Arlott and consists of reproductions of cricket prints. In an introduction Neville Cardus reproduces the first codified laws of cricket from 1744. Others I have shared this with since have been equally entranced and fascinated by the clarity of thinking and the essence of fair play that permeates. I hope you too will read and appreciate why the phrase "its just not cricket" still has meaning to this day.

The First Codified Rules of Cricket - 1744

Laws for Ye Bowlers 4 Balls and Over

Ye bowler must deliver ye ball with one foot behind ye Crease even with ye Wicket, and when he has bowled one ball or more shall bowl to ye number 4 before he changes Wickets, and he shall change but once in ye same innings.
He may order ye Player that is in at his Wicket to stand on which side of it he pleases at a reasonable distance.
If he delivers ye Ball with his hinder foot over ye bowling Crease, ye Umpire shall call No Ball, though she be struck, or ye Player is bowled out, which shall do without being asked, and no Person shall have any right to ask him.

Laws for ye Strikers, or those that are in

If ye wicket is Bowled , its Out.
If he strikes, or treads down, of falls himself upon ye Wicket in striking, but not in over running, its Out.
A stroke or nip over or under his Batt, or upon his hands, but not arms, if ye Ball be held before she touches ye ground, though she be hug’d to the body, its Out.
If in striking both his feet are over ye popping Crease and his wicket put down, except his Batt is down within, its Out.
If he runs out of his ground to hinder a catch, its Out.
If a ball is nipp’d up and he strikes her again, wilfully, before she comes to ye Wicket, its Out.
If ye Players have cross’d each other, he that runs for ye Wicket that is put down is Out. If they are not cross’d he that returns is Out.

Batt Foot or Hand over ye Crease

If in running a notch ye Wicket is struck down by a throw, before his foot hand or Batt is over ye popping Crease, or a stump hit by ye Ball though ye Bail was down, its Out, but if ye Bail is down before, he that catches ye Ball must strike a Stump out of ye ground, Ball in hand, then its Out.
If ye Striker touches or takes up ye Ball before she is lain quite still unless asked by ye Bowler or Wicket-keeper, its Out.
When ye Ball has been in hand by one of ye Keepers or Stopers, and ye Player has been at home, He may go where he pleases till ye next ball is bowled.
If either of ye Strikers is cross’d in his running ground designedly, which design must be determined by the Umpires, N.B. The Umpire(s) may order that Notch to be scored.
When ye Ball is hit up, either of ye Strikers may hinder ye catch in his running ground, or if she’s hit directly across ye wickets, ye other Player may place his body anywhere within ye swing of his Batt, so as to hinder ye Bowler from catching her, but he must neither strike at her nor touch her with his hands.
If a Striker nips a ball up just before him, he may fall before his Wicket, or pop down his Batt before she comes to it, to save it.
Ye Bail hanging on one Stump, though ye Ball hit ye Wicket, its Not Out.
Laws for Wicket Keepers

Ye Wicket Keepers shall stand a reasonable distance behind ye Wicket, and shall not move till ye Ball is out of ye Bowlers hand, and shall not by any noise incommode ye Striker, and if his hands knees foot or head be over or before ye Wicket, though ye Ball hit it, it shall not be Out.

Laws for ye Umpires

To allow 2 minutes for each Man to come in when one is out, and 10 minutes between each Hand.
To mark ye Ball that it may not be changed.
They are sole judges of all Outs and Ins, of all fair and unfair play, of frivolous delays, of all hurts, whether real or pretended, and are discretionally to allow what time they think proper before ye Game goes on again.
In case of a real hurt to a Striker, they are to allow another to come in and ye Person hurt to come in again, but are not to allow a fresh Man to play, on either Side, on any account.
They are sole judges of all hindrances, crossing ye Players in running, and standing unfair to strike, and in any case of hindrances may order a Notch to be scored.
They are not to order any Man out unless appealed to by any one of ye Players.
(These Laws are to ye Umpires Jointly)
Each Umpire is sole judge of all Nips and Catches, Ins and Outs, good or bad Runs, at his own Wicket, and his determination shall be absolute, and he shall not be changed for another Umpire without ye consent of both Sides.
When 4 balls are bowled he is to call Over.
(These Laws are Separately)
When both Umpires shall call Play, 3 times ‘ tis at ye peril of giving ye Game from them that refuse to Play.

The observant student, considering the above first written Constitution of Cricket, will note that there is no reference to leg-before-wicket. Maybe the game was all the better for the lack of this rule. - Neville Cardus in The Noblest Game.

Memories of the old White Hart Lane

I suppose I might be considered a fair weather supporter because it was not until the year after Spurs won the double in 1961 that I began to watch and support them. I was 12 at the time and with a group of friends would board the special supporters trains that ran along the eastern line to Liverpool Street stopping at White Hart Lane whenever Spurs played at home. Ever since I have supported and in latter days just "followed" the team. This has been through both good times ( generally when the year ended in a 1) and bad - its always been entertaining ( that's the Spurs style) but most of the time exasperating as well.

It was a toss up whether by car from Harlow (New Town) the local team was Arsenal, Spurs or West Ham. Many families hailed from North London and brought their past loyalties with them. But I was born in South London and was only 18 months old at the time we moved. Tooting & Mitcham FC would have been the club to support had we not moved I suppose.

Anyway, by public transport, White Hart Lane was the nearest ground for us to get to. The train fare was reasonable and we could generally sit on the way out but the return journey was a different matter. We would walk for about 10 minutes from the station in Tottenham to the ground and then join the queue for the juniors turnstiles. I seem to remember we paid a Bob ( 1 Shilling "in old money" or 5p ) to get in. This was considerably less than the adult price so made the up to 2 hour wait worthwhile. If we were late however we would pay the full amount as otherwise we could not be sure of standing somewhere where we would see much of the game. Once in the ground with our programme (often bought outside the ground), bags of Percy Dalton roasted peanuts - still in their shells - we would then join the rest of the crowd and try to get down to the front.

In the early years we would bring small wooden boxes - which we had made ourselves - to stand on to get a better view above the adults around us. Sometimes the grown ups took sufficient pity on us that we would be passed down to the front. All the way around the stands in those days was a low iron railing consisting of overlapping semicircles painted white. We would establish our position by pushing our small arms through the gaps and holding our hand together tightly.

This was most important because these were the days when everyone stood. The capacity of the old ground was around 62,000. Highbury had a capacity in those days of around 75,000 and Wembley was 100,000. All these capacities reduced when all seater stadiums were introduced after the Hillsborough and Bradford stadium disasters.

Many people have written about the atmosphere that existed in the old football grounds before they were all seater and it is now something that few people will experience. When Spurs played one of the other top teams the attendance in the ground would near "capacity" which for us small ones meant we would not be able to move independently until we got out of the ground after the match.

When the action on the pitch moved to the corners we would strain along with those around us to see what was happening out of sight. Never mind that we would not be able to see any better because everyone else was doing the same - we could not help ourselves. Goal mouth action would somehow cause everyone to want to get nearer to the action so we could move 2 or 3 steps down the ground because of the crowd behind pushing us there. If we stood behind the many crash barriers every 8 to 10 steps or so dotted around the "stands" we might find ourselves almost being crushed as we could not move down any more. Even without these incentives to get a better view there would be times when the crush of the crowd would make it difficult to draw breath easily without wriggling around.

On one occasion I can remember the crush being so great on leaving the ground after the game that our feet did not touch the steps as we left. We were wedged should to shoulder with grown ups and "hitched" a free if somewhat terrifying ride down the steps. The trouble with this was on reaching the bottom and before our feet again made contact with the ground some of us would be herded to the right ( and away form where we wanted to be going) while the others were herded left. The fight to regroup for those of us forced to walk against the stream was very tiring.

On the way back to the station the new cheap Japanese transistor radios would blare out the strains of Sports Report and because all team played on the same day and at the same time we would listen out for other results. Cheers and groans would break out from the travelling hordes from time to time in response to what were picking up on the radios held to the ears of those we were passing by at the time. Those that had not managed to hear clearly would soon be informed by others who had what all the noise was about. I well remember one of these moments it was after an away game at Upton Park against West Ham. Dave McKay a Spurs stalwart who had broken his leg the season before was returning for the reserve team after almost 12 months out of the game. We juniors decided to stay in the ground until much of the crowd had left. During the lull before the storm we listened to Sports Report on nearby transistor radios when it was reported that in his first game since breaking his leg Dave Mckay had been stretchered off in a reserve game and it was believed he had broken his leg again. Even in a half empty stadium this news led to a deep communal groan that was eerie because it was as if we had no individual freedom of thought but were just a collective herd.

That feeling was most exaggerated on one occasion at White Hart Lane and is the memory I wanted to record withthis posting. It was the first home game since another old stalwart of the double winning team lost his place to a young upstart we had not heard of. The stalwart was the Scottish goalkeeper Bill Brown, the young upstart was Pat Jennings from Watford.

There was a lot of animosity toward Pat that day. That was until early on in the game with the ball heading clearly over the bar he jumped one handed to catch it. For a split second the background rumble of crowd noise was replaced with the beginnings of discontent - we could all see it was heading out for a goal kick so why try to stop it and perhaps give away a corner. The growing discontent was never fully voiced however because a strange thing happened that first brought the ground to a split second of utter silence (the silence of disbelief) followed by a tremendous crescendo of cheering. The young upstart had jumped one handed to stop the ball a foot or so above the bar ( or so it seemed to us) - the ball just seemed to stick to his single glove which he curled around the ball and safely brought it down into both hands ready to thump it back into play.

We could not help it - we all grumbled as one, then were all briefly silent in disbelief and finally cheered at the top of our voices to welcome a new hero to the old ground.

Lies Damned Lies and Health Service Statistics - Finally its official

Was it serendipity?

An hour after posting my reflections on "how many times can you die?" I spotted this:

Report slams Department of Health statistics

The Department of Health's statistical releases have come under stinging criticism following a new report from the Statistics Commission, the official watchdog that will be disbanded at the end of this month.

In an analysis of government releases, the quarterly NHS inpatient and outpatient waiting times statistics failed against all six criteria, namely clarity, accuracy, objectivity, professionalism, use of simple language and ease of use.
18 March 2008

Here is a link to the report itself.

To see the evidence go to page 47 of the PDF file ( that's Page 41 of the report) and you will see a traffic light style assessment. It's easy to spot the Dept of Health quarterly statistics line - its the only one where all 6 indicators are red.

It seems a pity that the supposedly independent official watchdog had to wait until it had a couple of weeks of existence left before issuing such a damning indictment - I suppose execution really does concentrate the mind!

So how many times can you die?

No this is not a morbid anticipation of my admission tomorrow for a hip revision operation but both a reflection and memory prompted by a news item on the BBC web site this morning : http://news.bbc.co.uk/1/hi/england/staffordshire/7301688.stm about a hospital which has a level of deaths outside the normal range and is about to be investigated. Already it appears that the appearance might not reflect reality and may be down to the way data has been recorded.

Despite the number of times that reviews of performance end up generating lots of heat but very little illumination it is still very necessary.

Lest we forget:

Beverley Allot,(http://www.guardian.co.uk/uk/2007/dec/06/ukcrime.health)
Bristol Children's Cardiac Deaths, (http://www.bristol-inquiry.org.uk/final_report/report/Summary3.htm)
Harold Shipman (http://news.bbc.co.uk/1/hi/uk/3391871.stm) and more recently
Colin Norris (http://news.bbc.co.uk/1/hi/england/west_yorkshire/7276700.stm)

should all remind us of the need for continuing vigilance.

After 2 years training as an NHS Administrator my first substantive post was a lowly administrator in charge of the general office of Pontefract General Infirmary in 1973. It was not at all what I had expected. There was an element of "man" management but to my mind much too much time spent on financial matters such as collecting all the cash from tills and petty cash floats throughout the hospital and explaining each week to disgruntled staff why the pay they received was less than they expected. The weekly petty cash accounting ended up with banking a vast amount of coins and cash and producing the necessary paperwork that showed everything balanced and could be reconciled with receipts issued by tills or various departments who either disbursed or received cash to/from patients and sometimes staff.

Just across the corridor from my office was a medical records outpost where the junior doctors would turn up and sign cremation certificates. As this was outside the normal range of their hospital duties they received payment on a per item basis. This was jokingly referred to as "Ash Cash". Depending on how much had been disbursed I would need to top up the float kept in the department and get a receipt signed.

Being somewhat sceptical I asked if "ash cash" might prove to be an incentive to provide less than the best care for some patients and although my suspicions were dismissed there was something in the way that they were dismissed that made me ask a supplementary question about whether any junior doctor seemed to sign a disproportionately high number of such certificates. There was also something in the way they responded that made me ponder this more - I think they had suspicions but could not bring themselves to speak them out loud - and having a penchant for data analysis I suggested to the Chief administrator that I might be allowed to record the times of deaths and locations to see if there was anything out of the ordinary and if there was whether this could be correlated with staff rotas. I was told that this was not something that hospital administrators needed to be concerned with and to get back to counting up the petty cash.

I was reminded of this a year or two back during an email exchange with a good friend who is the Chief Executive of a hospital in Melbourne. It caused a shiver when I realised that had I been allowed to pursue this weird request I might well have turned up evidence of Dr Harold Shipman's early murders of hospital patients, as he was one of the junior doctors working at Pontefract General Infirmary at the time and had already started on his destructive ways .

It always seemed to me important to retain a healthy scepticism about the purity of motives and abilities of hospital staff. After all they would share all the human frailties as the rest of us and "statistically" it was likely there would be some who were dangerous and needed to be identified early for remedial action to be taken.

Many years later I was approached by Jeremy Laurance, then of the Times to assist in the interpretation of hospital mortality statistics which were about to be published for the first time by the Department of Health. I was at the time an academic in charge of what I liked to call the "Informed Management Unit" of the Nuffield Instiute for Health Studies at Leeds University. ("informed management" as distinct from the "uninformed mismanagement" that I experienced around me in the NHS at the time).

I took the raw data which was standardised for age, sex and casemix and sorted it into a descending order and then plotted quartile scores onto a map of the UK. Of course I expected to see a picture resembling a well mixed fruit cake with the top quartile Standardised Mortality Ratios scattered throughout the UK. Instead I saw a significant clustering of the highest levels of hospital deaths along the M62 and down the northern section of the M1. In addition although somewhat less distinct was a concentration around the North East London and into Essex.

The article was held up from publication by one day because of the IRA bombing of the Baltic Exchange in the City of London on 24 April 1993, but the next day the map, sorted table and some comments from me appeared in the front page leading story. I had tried to tell Jeremy that from previous experience the explanations might lie in poor data, poor coding and classification or could be telling us something we did not know before.

When asked to speculate further I did say that possible reasons for high hospital mortality might reflect the underlying poorer health of the populations (quite likely given the industrial nature of the areas concerned), fewer resources, a greater willingness to undertake high risk cases or might reflect the poorer skills of the doctors attracted to work in the areas concerned. This analysis sounded more alarming when the relative position of the 4 possibilities was reversed and as a result it appeared that I was pointing the finger at the skills of doctors first and foremost!

A few days of senior NHS staff commenting on the figures particularly in the "worst" areas and hospitals followed. One leading Regional Medical Officer was quoted as saying that they were not worried about studying hospital mortality and the chief executive of one of the hospitals concerned said she had never seen these figures and did not routinely question them. Within a week the whole issue had "blown over".

2 years later when I was working in Riyadh I received a call from Jeremy who wanted to repeat the analysis on the "latest" figures to be issued by the Department of Health. I was flattered that he had tracked me down and wanted my assistance again. I arranged for the "latest" figures to be posted out to me and began my analysis only to discover they were exactly the same figures provided earlier. When I returned to the UK I visited the Department of Health Web site to obtain the next years figures and found they were no longer produced.

When I enquired why they were going backwards and no longer publishing hospital mortality figures I was told that they caused so much trouble when they did that they decided not to again. Now as it happens they were right to do this because further enquiry elicited that the reason for the clustering of high standardised mortality rates was related to the IT systems in use in the districts concerned.

The NHS had a few years earlier undergone a necessary upheaval in the way it recorded hospital activity. In the past, output (not outcome note!) had been recorded as discharges AND deaths - it did not matter in what state a patient left their bed as long as they did leave it. Some patients would in the course of a year be admitted many times to the same or different consultants for the same condition. As a result new data definitions and categories were designed to provide more meaningful information. So in future we could differentiate between consultant episodes and patient episodes. One patient episode might involve one or many consultant episodes.

What had happened in the early years of this reform was that some IT systems allowed coding staff to record the same patient death in hospital against all the consultants they might have seen as an in patient. In other words if a patient had been seen by 3 consultants ( say orthopaedic on admission, cardiac after a heart flutter and a general physician because of some other problem that required medication) and then died before being discharged, this counted as 3 deaths not one. Other hospital coding staff were recording the death either only against one consultant or ensured that the summarised reports of hospital deaths used patient episode data not consultant episode data.

When the Department corrected for this the highest mortality rates were more randomly scattered throughout the UK.

However despite these coding and classification problems (and they will always be there because its human nature to be well meaning but confused) the need for continued vigilance remains. If this recollection is read in years to come (as I hope it will) no doubt you will be able to extend the examples I provided earlier of why this is important to do and to get right - if for no other reason then to make sure that you really do only die once!

Monday, March 17, 2008

The wonders(?) of early NHS Computerisation

In the mid 1970’s The DHSS managed to get approval to spend money on 3 experiments in Hospital Computing. 2 London Hospitals were to set up computerized In Patient systems and a Northern Regional Hospital was to set up an Out Patient System (A much more daunting task in may ways because of the much larger number of potential patients whose details needed to be part of its initial patient index.)

The Public Accounts Committee a few years later enquired what the outcome of this expenditure was. The ambitious Out Patient project (not surprisingly) had failed and one of the 2 In Patient projects had achieved nothing - in fact the money assigned by Parliament to the DHSS for this project had been swallowed up in the day to day running costs of the hospital concerned. Red faces all round among the senior civil servants accountable to the PAC for the use of public monies! The only project where they could point to the money still being used (however successfully) for the purpose intended was the London Hospital Whitechapel. Its Chief Administrator had the vision of the computer replacing the telephone system for the ordering of tests and feeding back the results in place of the paper trail in situ at the time - a praiseworthy objective. This site and its IT staff were held up as gurus and were much consulted by DHSS Civil servants for years to come not because they had achieved what they set out to do but because they had not given up and were still there…. trying.

One of the expected benefits to have emerged from the computerization of records and order requests was a reduction in the numbers of clerical staff employed to file and recover medical records. A few years in to the project it seemed a good idea to evaluate if this aim had been achieved. I got involved peripherally around 1978 when the Chief Administrator of the hospital had been appointed Regional Administrator and had in fact ordered that the highest priority capital development for the City & East London Area should be the urgent replacement of this Computer system (on which by then the hospital had come to rely). In those days of supposedly rational comprehensive planning, major capital developments would be proposed evaluated costed and scheduled into a rolling 3 year programme. It was not unusual for major patient centred developments to languish in year 2 of the short term programme for 3 to 4 years before funds were eventually allocated. It upset a number of people then when the computer replacement had to be number one for expenditure in the next year, not having been in the programme before. As a result a visit was made to see why the hospital had become so dependant on the computerized system that its imminent failure, unless replaced, was a danger to patient care.

The visit ascertained that the 20 evaluation staff had for many years been so busy fighting fires with the system that to all intents and purposes they were additional medical records staff and when added to the clerical staff who were recognized as such meant that the hospital employed nearly 3 times the number per 100 beds than any other hospital in the country. So much for replacing inefficient paper based systems. However not to be daunted, in the afternoon the Computer Manager showed the visitors the impressive high speed printers pumping out hundreds of post paid cards to patients notifying them of a clinic cancellation. Now this must be better than the previous system of notifying patients of late cancellations thus saving them the waste of time and expense of arriving only to be told the clinic was postponed.

At the sight of the mammoth pile of personally addressed cancellation notices being spewed out from the noisy printer, all present agreed it was a most impressive illustration of the benefits to patients of the computerization of records and maybe even offset the additional running costs of the system. That was until one inquisitive visiting nurse picked up one the cards and read it loud to everyone. The essence of which was to notify an individual patient that the clinic they were due to attend had been cancelled and that a new appointment had been made for 3 weeks time …. unfortunately their appointment was for 10:15 that morning and the earliest they would receive the notification would be the next day!

A couple of years later it was argued that a lower cost solution at St Bartholomew’s hospital using mini (not mainframe) computers and supported part time by only 3 Medical Physics staff, should be discontinued and instead St Bartholomew’s should make use of the London Hospital Whitechapel system (described above). I was to attend some user group meetings at the London Hospital as the representative of Barts.

The cheap and cheerful system at Barts was able to make use of printers that could print lower as well as upper case, which meant that any patient correspondence looked decent. The London’s mainframe printers however could only manage upper case and letters were not always aligned. (I knew this because I had received such letters from the hospital notifying me that although I had already waited 1 year for a hip replacement that because of consultant staff disagreeing about where to do such operations in the future all lists had been abandoned and once they had sorted it out I would be allocated to a new waiting list and could expect to still wait a further 12 months.) When I asked if we could continue to have lower case letters used in correspondence with patients I was told that this was too expensive for the mainframe printers and we would have to get used to Upper Case only, like every one else using the system.

I was however more shocked to find the discussion at the user group taking a bizarre turn when a consultant representative asked the Computer department to produce a 3rd copy of the daily Lab Results print out. It appeared that each patient specific report was printed out in the Labs and sent by internal post to the medical records department where it would be filed in the patient’s paper record. (This could take a week or two). To assist in responding to urgent requests a bulky fanfold print out of each day’s results was retained in the Path Lab so staff could refer to it to respond to doctors wanting urgent results.

Although this seemed to work well someone had the bright idea that a second copy of this daily printout should be located in the Out Patients department to be consulted when required, thus avoiding the frustration of ringing the Labs to get an urgent result only to find all phones were engaged. This worked quite well but because of the underlying delays in getting results onto the patient’s records some medical staff had decided they should cut the required results from this 2nd copy of the batch report of daily Lab Test results and stick it in the patient’s paper record themselves. However the extracted report was not always cut out neatly and might include part of the report from the lines above and below. This meant that those results could not be read in Out Patients as they had been “vandalized” by colleagues.

The meeting I attended therefore considered whether to provide a 3rd copy that would not be cut in this way to ensure that urgent results could be accessed. Everyone (except me) thought this was an excellent idea and a good use of the limited computer development funds.

Of course these days, with networked computers, results can be called up on screen by those authorized to view them “any time, any place any where” so it might be difficult for some to imagine this crazy state of affairs. However this pattern of “patch and mend” and then patching the patches does reflect that side of human nature that seems more comfortable with incremental adjustments than any rational reappraisal of systems to evaluate if they achieve objectives – so I trust that this account rings true into the future because we continue to experience similar behaviour in many other fields of human activity.

The Hospital that was Stolen in the Night!

In the Ilford District of East London there were a number of small “local” hospitals providing what would now be provided by a single “District General Hospital”. One of these was in Dagenham and was sited relatively close to the Thames on land that was rich in gravel which would be excavated once a new Hospital opened thus allowing the small hospitals to close.

This particular hospital had been erected by the Army about the time of World War 1 and consisted of around 8 temporary huts. These had a low brick wall and rounded sheets of corrugated metal to provide walls and roof. The inside skin of the buildings consisted of wooden lathes and plaster fixed to the same low brick walls. This was typical of a fair proportion of the 1948 building stock of the NHS as in the 2nd World War the Americans built something similar but used single story brick built out houses. These hospitals were classed as EMS (Emergency Medical Service) hospitals. Dagenham hospital was one of the last remaining 1st World War EMS hospitals in 1984. It was located at the end of a narrow badly lit lane between houses on a 1950’s housing estate – so few people even knew it existed. An ideal place to house elderly patients who had few people to visit them then!

Despite all of that the interior of the huts were great for the nursing care of elderly patients. The width of a typical ward was around 30% greater than today’s designs and with regular licks of paint and a willingness to pay for the wasted heat that escaped through the uninsulated buildings actually provided comfortable patient accommodation.

As was the nature with NHS capital programmes at the time the new buildings kept getting postponed so that in my time we could no longer put off doing some remedial work at the hospital to make it last about another 3 years. Unfortunately this proved impossible as the structural survey, we felt needed to be carried out to make sure any remedial work could be done safely, was itself deemed dangerous. The report I received stated that normally the integrity of the external cladding would be best inspected from inside by probing through the internal lathe and plaster skin. However Structural engineers soon realised that the internal skin was in fact holding up the rest of these buildings so it was deemed unsafe to disturb them….. oops and a case of fingers being crossed!

A couple of years after I left I spoke to the acting general manager who told me how he had been called at his home over Christmas to be told that the by then deserted hospital had been stolen!Apparently some enterprising entrepreneurs had driven lorries unnoticed down the badly lit lane to the disused hospital and stripped the huts of their metal cladding and any other recyclable material they could find. So sometime between Christmas and New Year the hospital disappeared or was stolen.

The acting General Manager pondered whether he should report the “loss” to the police and decided it was not necessary as the entrepreneurs had actually saved the authority some money. The Authority was in the process of inviting tenders for the clearing of the site so that it could then be sold with mineral rights for gravel extraction without encumbrance. The health authority had in fact been prepared to pay someone to do what these unknown “public spirited” opportunistic East Enders had done. He thought it was a great Christmas present for the health authority

Why a "Prisoner of Hope"?

On his last Sunday morning TV program (Breakfast with Frost) the eminent presenter David Frost interviewed among other worthies Sir Desmond Tutu - the former Archbishop of South Africa. If you know your history you will know that Desmond Tutu was able to comment on the scourge of Apartheid in South Africa in a charitable and forgiving nature that was a powerful form of non violent resistance. He possessed a most engaging smile and laugh (in fact at times it seemed nearer to a giggle).

Sir David turned to Sir Desmond and stated " You have always struck me as a supreme optimist". Sir Desmond thought for a couple of seconds smiled and responded."You know that's not right. Throughout my life I have neither expected the best or accepted the worst - I have striven to improve things becasuse I have always been a prisoner of hope - that's what has kept me going".

I like to say to people that that was the moment that Irealised that the Archbishop must also have been a liflelong supporter of both Spurs and the England Cricket Team.

When I reflect on my own response to difficulties - such as poor health or having to suffer well meaning but confused fools involved in the provision of public services - I think I have survived by being a Prisoner of Hope. I still get attracted to new atempts to achieve meaningful public engagement only to be disappointed yet again. I suspect that despite my intentions to hold back next time I will get drawn in again in the future only to be frustrated.... until the next time of course!

What I hope to achieve by blogging

As I face yet another couple of fairly major operations, with the inherent unintended consequences that are entailed, perhaps its not surprising that I have been increasingly aware of my own potential mortality in recent months. I have therefore given some thought to what I might "leave behind" me when I am gone. I started a while ago recording reflections and memories and leaving these on my computer. Other reflections remained just transitory thoughts that were never committed to paper. My daughter writes a very entertaining blog and more recently my son has recorded his travels in South America in a most amusing manner. I doubt my own literary style will be anything like as appealing and can only hope that like insanity it might be something that can be "inherited" from your children - well we'll see.

So with these thoughts in mind one project that I returned to a few years ago was to update the family history for the benefit of my 2 children and any grandchildren that might come after them. This has been a rewarding experience and appealed to the social historian in me as I uncovered evidence of the effect of the industrial revolution on former hand loom weavers and agricultural labourers on my wife's side of things. For my part the ancestral line is somewhat truncated by virtue of pogroms and holocaust. This makes searching through eastern european records - where surnames become transliterated whenever borders were crossed and sometimes radically changed to better appeal to a British ear - a little more challenging! Nonetheless tracing both lines back to relatively recent times (200 years ago) does show a common agricultural small village experience supplemented by rural crafts.

The process of compiling details of over 1000 relatives and sharing these with family members through a web site has been rewarding. At times I have slept with clues to someone's past life turning over in my mind and woken up early to explore some new channel of enquiry. This was far better than reading Agatha Christie - I found myself actually writing new stories not just reading them. Other family members have appreciated the results of these enquiries which is in itself rewarding but I hope is only the tip of an iceberg of future family members who will be grateful for my efforts.

Another response to possible early mortality was to invest in wood turning equipment and to try my hand at turning the wood at Quiet Knoll into bowls coasters, egg cups and other potentially useful things that might be passed on to family members to come. Fortunately we have an ample supply of deciduous fruit and flowering trees. Some like Laburnum have a tendency to quickly blunt tools but compensate by producing lustrous finishes with contrasting dark heartwood and occasional flashes of lighter sap wood. I will in time include pictures of some of the results on this blog so you will be able to see for yourself. My grandfather was a wheelwright and I still posses some of his woodworking planes and spokeshaves although I have not used them since I was experimenting as a child. Sadly I disposed unknowingly of a small hammer that he is pictured holding in the one photograph I have of him in his workshop.

So my audience is not only the occasional visitor to this site but family members in the future who I may never know but I hope will feel that they will know me through what I leave behind.