Receiving bad news

As doctors we sometimes dread breaking bad news.  There are even courses you can go on to learn how to do it. 

Receiving bad news is much worse!  The usual sequence of bereavement reaction is felt, i.e. denial, anger, acceptance etc.  This remains true when the ‘bad news’ is personal criticism.  I felt this when reading the Medical Director’s response  (p36) to ‘Can Gerry Robinson fix the NHS?’  It came across as defensive and was written, I guess, when emotions were still raw and the bereavement process had just begun.  Denial and anger were very evident. 

I see such responses throughout the NHS.  More time and energy is spent defending, managing and rubbishing criticism than is spent addressing the issues.  I have met people whose entire working day seems to be managing how they appear to be doing something useful rather than doing it!  They must live with a constant fear of being found out.  Awful. 

Of course, TV programmes are entertainment but the central message of Gerry Robinson is true.  The challenge is how to respond positively when the circus has left town and the dust has settled.  In management speak, this is often described as ‘embedding’ a change.  It is pretty easy to initiate a change and maintain it for a few weeks whilst resources are heavily directed on it but, like holding a hard-won military objective, it’s incredibly difficult to make the change permanent. 

Doctors are particularly skilled at playing the long game, i.e. going along with an imposed change for a time, whilst knowing all along that they will revert to the status quo when the ‘managers’ have lost interest.  Everyone else knows it too. 

In later posts, I’ll suggest ways to ’embed’ change.




Having just upgraded my blog to a new version, I find all my images have gone AWOL!  I’ll try and rectify over the weekend.

There are always hazards when attempting something new!

  “There is nothing more difficult to take in hand, more perilous to conduct, or more uncertain in its success, than to take the lead in a new order of things.” (Machiavelli, 1469-1527)



The Marketing Mix

marketing mix Public sector employees, especially clinicians, can struggle with the concept of ‘marketing’ what they do.  In the NHS, there still exists the feeling of being overwhelmed by demand and the last thing you would want to do is attract more patients!

However, applying marketing tools to your service can be highly revealing and beneficial.  Consider the traditional way that goods are marketed; the 4 ‘P’s:

Product:  the thing you are selling

Price: the price to the consumer

Promotion:  any special offers or high-impact advertising

Place/distribution:  where you offer your product, how you get it to the consumer

At first glance, these 4 don’t seem to fit with providing a health service!  But give a moment’s reflection and you’ll see where they make sense.  For example, under ‘product’, how could you let patients ‘sample’ your product before they ‘buy’?  Is there information easily available about your hospital or service?  Do they know what to expect, or what’s coming next?

Even more interesting is the extension of the 4 ‘P’s to 7 ‘P’s of services:

People:  the staff who provide the service and interact with the patients

Physical evidence:  what’s the impression given by the surroundings?  What have I brought home with me to remind me of my visit?

Process:  has my experience been seamless?

So, for instance:

People: it would be hard to overstate the importance of the personal interaction in the user’s assessment of the quality of the service.  Production and consumption occur simultaneously, so the user associates the quality of the service by the behaviour of the provider.  In the NHS, there is very little training and control of the providers’ personal behaviour; the focus tends to be on the technical competence, rather than the ‘bed-side manner’.

Perhaps it’s time to systematise the training of customer contact skills in the NHS, especially the frontline staff?



Also known in its abbreviated form, disintermediation, this means ‘cutting out the middle man’.  It has become a popular phrase as electronic business has developed.  As you can imagine, electronic business and commerce has the great potential of getting rid of middlemen.  In healthcare, this means bringing the patient closer to the professional.

The essential quest of medicine is to bring a patient with a problem over here, to a doctor with the answer over there.  In other words, there is a doctor somewhere with the answer to the patient’s problem; if only we could get them together quickly and easily.  Usually this involves multiple steps, if it happens at all.

Well, that’s where electronic systems come into their own.  They offer the prospect of bringing problems and solutions together, i.e. knowledge.  This type of activity is traditionally done by third parties, e.g. a GP.   However, it’s pretty much up to chance if your particular GP knows the answer to your problem, or even knows where to get the answer.  (Samuel Johnson, 1709-1784 said, “Knowledge is of two kinds. We know a subject ourselves, or we know where we can find information upon it”).  Unfortunately, the NHS in the UK insists on maintaining the intermediary, even when s/he is patently unnecessary.  Think about this, you can’t access a specialist in the UK without going first to a generalist; what waste!

Middlemen everywhere will cry, “But we add value!”  Well, maybe; but not all the time.  Often they just add cost.  And a lot of the value they do add can be equally, if not better, done by electronic systems.  For example, an algorithm-based questionnaire can ‘shape’ a referral to the best locality.  Decision-support software is already available for GP’s, why not make it available to the patients themselves, thereby cutting out the expensive middleman?

Soon the distinction between knowing a subject ourselves and knowing where we can find information on it will become meaningless.  Look out middlemen!