Joe’s View: On Christmas bonuses and rate limiting steps

My uncle Jimmy was a bloody good roofer back in the days when ‘bloody’ was still a swear word. Hard dangerous work, especially in the run up to Christmas, back when we had proper winters and health and safety had yet to be invented.

My uncle Jimmy told me roofers are key to the building process. Until the roof goes on, the plasterers and the sparkies and plumbers and decorators can’t get started. The roofer is the rate limiting step.

One year, long ago, the foreman offered Jimmy a 10 shilling bonus to speed things along and get four roofs finished before Christmas. He would normally finish three in a week but, if he worked flatout at breakneck speed, he could manage four.

It was Christmas and the money would help, so he agreed. It was dark and snowing as he laid the last tile on the last house on Christmas Eve and stood back to admire the four houses as the snowflakes covered up his craftsmanship. He trudged through the snow to the site office to collect his pay packet whistling Silent Night.

The next day, Jimmy and his wife were due to join us for the big, setpiece Christmas dinner which it was our turn to host. The doorbell rang and I raced to the front door on my imaginary horse, wearing my new cowboy suit and pointing my cap gun at the new arrivals.

To my surprise it was Aunty Irene, on her own. My dad asked where Jimmy was. Irene replied that he had got up very early in a foul mood and had muttered something about having to go to work.

It was in the days before mobile phones, so people were able to tolerate not knowing where Jimmy was for a couple of hours. But when he hadn’t showed up by the time the Queen was on the telly and we were getting ready to serve dinner, clearly Irene was starting to worry. So my dad offered to jump in the Hillman Minx and drive down to the building site to see if, however implausibly, Jimmy was still working on Christmas Day. And, sure enough, he returned from the drive with Jimmy.

The cost of losing support of the rate limiting step

Over dinner, Dad described, to hilarious effect, the scene he’d been confronted with at the building site. The ground around the four houses was no longer white with snow, but black with the shards of thousands of broken roof-tiles, with Jimmy atop the last house furiously smashing the tiles with a lump hammer, steam rising from his body into the freezing air as he laboured furiously at his vandalism.

Finally, with all four roofs now laid open to the skies, Jimmy came down the ladder and silently jemmied the lock off a decorator’s lock-up and – sweating and breathing hard – daubed: “Merry Bloody Christmas, love Jimmy” in red paint on the front door of the foreman’s office.

“What’s all this about, Jimmy?” asked Dad.

“Bloody foreman. Promised me an extra 10 bob to do an extra house this week and then welshed on the deal. E’ll never try that again. It’ll cost him a week’s wages for a roofer now and the wages of all the sparkies and the decorators and the plasterers and the chippies, all sat on their arses for a week.”

Uncle Jimmy understood his own worth and that some people are key to an enterprise and without them it is difficult to proceed. The price of not paying them to do a little bit extra when they are already working hard can have massive, unforeseen and expensive consequences. It can seem smart to save a little money, but losing the support of someone in control of the rate limiting step of the enterprise was the schoolboy error of Jimmy’s foreman.

Names, numbers and addresses

The NHS has a rate limiting step in the digitisation of healthcare. We look to other industries that have achieved massive digital efficiency savings – industries like banking and the airlines – and the pattern is the same in all of them. Step one is the opening of a digital channel of communication with the citizen.

This has generally been by the collection of the customer’s email address and mobile phone number. The NHS is probably the only organisation in the world not routinely mandating the collection of such information. Why not? Well, frankly, the doctors and nurses are too busy to read email from their colleagues, never mind from their patients.

However, busy people can be persuaded to take on further work in the short term if it makes life easier in the long run and offers a significant Christmas bonus. The long term benefit of collecting patients’ phone and e-mail contacts will definitely not be exchange of emails between doctors and patients – that’s just shifting work between channels.

The long term benefit of two factor authentication

The long term benefit is using the patient’s details to set up two factor authentication and give the patient an account, a username and a password. Then much of the current admin burden, currently often shouldered by expensive clinicians, can be handed over to the patient, easyJet style. The patient can also begin the shift from patriarchal medicine to tech-supported self-care which is necessary to make the NHS affordable for the next 70 years.

And the short term Christmas bonus? Well, the place to do the gathering of email addresses and mobile numbers is obvious. General practice. Why? Everyone has a GP and they all have electronic records. But general practice is on its knees, right? Yes, but they are smart and will understand the long term gain – and God knows they deserve a Christmas bonus.

The National General Practice Digital Channel Shift Bonus Scheme

How big a bonus? Well, it’s going to be a lot of extra work on a one-off basis. So let’s say we spend some of the annual NHS postage stamp budget – £79,000,000 annually in England – on the National General Practice Digital Channel Shift Bonus Scheme. Let’s pay a pound per patient to general practices. In England we’d have 20 million pounds left over to spend on making sure the digitally disconnected or illiterate were properly included.

We are the NHS and we don’t leave anyone behind, but we could save £79,000,000 in every subsequent year because we would no longer have to write to the patient. Nearly a billion saved over 10 years. Every region could have the equivalent of The Great North Care Record for that kind of money.

Yeah, I know. It’ll never happen and we’ll probably be having the same conversation next year.

Merry Bloody Christmas. Love, Joe.