I am fascinated when the pursuit of efficiency tries to bash the human situations it uncovers into submission. A few years ago I became obsessed with incontinence. In the ‘patient story’ slot at the start of our board meeting we had heard the case of a woman whose life had been totally ruined. An operation had been carried out to repair an unfortunate condition but had resulted in profuse and permanent incontinence. As a result, the woman, in her forties, previously smart and in a good job, no longer felt confident to leave the house, so she gave up work, didn’t want to see anybody because she was afraid she smelled awful, and was living with depression and poverty. She wasn’t complaining, you understand, and everybody was very sympathetic, but it was all just very unfortunate. I was appalled.
Now as you know, chairs of boards have virtually no power to get anything done. They are supposed to guide, reflect, support, steer, challenge etc etc etc. Execs are extraordinarily busy, and there are few things more annoying than a non-exec getting under their feet, and I do sympathise with that. Also we were in the middle of trying to save a great deal of money and get off the naughty step with the regulators. So my obsession with incontinence became something of a quest. I went to speak to the urology surgeons to find out how often operations caused incontinence, and how often they could resolve it. Also to find out how the surgeons felt about the fact that something they did could have such terrible effects on women’s lives. We had some brilliant urology surgeons and they care very deeply about their patients, but in a large institutional machine, everybody’s duty of care ends at a specific point, and theirs tended to be after the operation. I talked to the incontinence nurses, who set the patient up with whatever services they can when it is discovered that incontinence is here to stay. The nurses care very much, but they don’t have control over resources, and the pipeline is always filling up their diaries so they can’t really spend much time thinking about what happened to people after they’ve left the hospital, unless their condition brings them back to hospital regularly. I discovered that the main thing we did for people was sign them up for free incontinence pads.
We were on a big efficiency drive at the time, and amongst other things, I was interested to know why we were running a large fleet of vans and drivers, which were costing us quite a lot of money. I went to see the recently appointed manager in charge of the relevant bit of the structure. He and I got on very well, and he confided to me that he had slightly illicitly brought a piece of software from his previous job in fleet management for a big private sector company. He wasn’t supposed to install it on his work computer because the NHS was understandably paranoid, but when I asked him what the vans were doing he brought his own laptop in to demonstrate. One of the biggest cargos we were sending around our patch was huge boxes of incontinence pads, and he showed me that there was a mysterious blip in the routes when most of the vans congregated at a particular spot at the seaside around lunchtime. He had deduced that the van drivers were all meeting for fish and chips most days as a refreshing break from their day delivering incontinence pads, even if they had to drive ten miles to meet up with their chums. He was keen to design much more private-sector style efficient routes and start monitoring performance more fiercely.
Talking to patients it became clear that the pads themselves were a bit of a nightmare. In order to make the van delivery worthwhile, several huge boxes at a time of the bulky items had to be delivered, making storage in a small house a really ugly fact of life. The pads were very old fashioned compared to the slimmer and more elegant versions available at every supermarket. I went to see the finance people to find out why, if we were prepared to pay for pads, we couldn’t negotiate a voucher system which could be spent online or wherever people shopped, but that would have required a national decision. And it would have made most of the vans and the drivers redundant of course.
The NHS spends nearly £2bn a year on incontinence, and invidividuals top it up with £750m a year spent on additional pads. Hundred of thousands of people in the UK have restricted lives because of incontinence, yet in at least 60% of cases huge improvements could be made through surgery and targeted exercise programmes. Lots of research is carried out, and great voluntary sector organisations like the Urology Foundation (https://theurologyfoundation.org ) do their best to raise the profile of this affliction which affects so many people.
I couldn’t get the picture out of my mind of the woman we saw at our board meeting, and so many thousands like her. I think of all the separate parts of the strand I explored, each of which was trying to be compassionate and efficient, but weren’t able to combine together to make a improvement to that woman’s life. And I wonder whether the van drivers have now been deprived of their sociable fish and chips in the interests of efficiency. This year, World Continence Week is 17th - 22nd June. It’s probably not in your diary, but put it in - it’s worth a bit of reflection.
