I was ill recently. In the end it was “just a virus” but I had symptoms enough one Saturday that I braved the local NHS walk-in centre. This is where you end up if you have the bad manners to get ill on a weekend.
It was functional, in its way. I was told there would be an hour-and-a-half wait and that is what it was. There are no doctors, only nurses, but they are skilled enough to determine whether you are likely to survive until Monday, or so I imagine. But the economics of this kind of place are such that every body through the door is nothing but a drain on resources, and no-one is making any effort to conceal this fact.
Truly it is a miserable place to be. I do not expect a medical waiting room to be jolly, but I saw not the merest hint of a smile from any staff, and the receptionist was very grumpy about my address being out of date on her computer. There is no welcome; no sympathy; no bedside manner.
If you want to find a deep root cause of problems with the NHS, I submit the inevitable hatred of the staff for the burdensome customers.
Here is another piece of evidence: when I said “thank-you” to the nurse, she replied, “you’re welcome.”
I remember being in the reception of my University, years ago and a receptionist saying to me: things would be much better without students.
I have a lot of sympathy for that receptionist.
As far as the NHS is concerned, it’s just the “insolence of office” at work. If you have a friendly, helpful, chirpy character you exude sunshine naturally. But most people aren’t like that. They (we) will do the smallest amount of work, and emit the smallest amount of sunshine, as we can get away with. The degree of insolence we display in our office is directly correlated with the degree of effective feedback we get from our treatment of the customer. If the customer’s views have no effect on us, we can get pretty insolent. If the customer can get us fired, our insolence lies deep deep below the surface, and sunshine shines from every pore.
Of course, by osmosis, the NHS, and places like it (which include other bits of the government, especially the local council, and large corporations which don’t believe you have much of a choice as to where else to go (did I mention the cable company ?) gradually accumulate a greater proportion of the naturally unsunny. Did I mention the council ? The sunny migrate to the customer facing bits of the private sector, where they are very much in demand.
But the “insolence of office” is not particular to the NHS. It lies within us all (or most of us.) It is kept in check by feedback processes, which vary according to the organisation and office in question. In the NHS, the feedback process is not connected to the customer at all – it is connected to “targets.”
To be fair, though – and i am always fair, even the sunniest nurse in a weekend NHS walk-in centre is likely to be ground down in time. The clientele in the average prison is more appealing.
I find that my major gripe with public transport in the UK is not the ludicrous cost of train fares or the inconvenience of timings, but the sheer horror of meeting a significant dose of the general public. An afternoon train to London with advance purchase (cheaper) tickets is a human zoo without anything appealing in it. Mix that with the insolence of in practice virtually unsackable State employees and you have a negative loop.
My dentist’s practice is a cheery place, and good value too. Oh yes, I pay for the practice when I use it.
‘Où il y a du commerce, il y a des mouers douces .’
‘Commerce = manners’ (and v.v.).
Montesquieu.
I wonder how big a part geography plays in all this? It certainly doesn’t seem to happen in my local general hospital – in Cornwall.
“The clientele in the average prison is more appealing”; “a human zoo without anything appealing in it”
There did seem to be something of that about the place. A null hypothesis might be that ill people in an NHS waiting room represent a perfect cross section of society; but perhaps not given the distortion of “free at the point of use”.
“…the inevitable hatred of the staff for the burdensome customers…”
They’re not customers, that is the problem. Remember “if you’re not paying, you’re not the customer”. The customer for the NHS is the bureaucrat who decides whether the right boxes have been ticked, and hands over the money accordingly. He, therefore, is the person the effort gets lavished upon.
Until the staff see someone coming in for treatment and think “Oh goody, this’ll help my bonus”, nothing will change.
A friend of mine once had cause to attend the University Dental Service (an outpost of the NHS) in some pain. Of course, he had to beg for an emergency appointment, which was very reluctantly granted – but not before the receptionist had charmed and consoled him with, “here it’s just one stinking gob after another.”
Yet my friend remains a Guardian-reading environmentalist lefty…
Andrew Duffin: “They’re not customers, that is the problem”.
Yes, I suppose this is a more concise way of making my point, though I *do* pay and I do think of myself as a customer. The staff don’t see me as a customer, agreed.
As their remuneration (or employment or pension) is in no way linked to the poor supplicants they process and they are supported by their coworkers and unions should anyone become assertive or complain mildly, it’s no surprise patients are treated like dogcrap on a shoe.
‘The sunny migrate to the customer facing bits of the private sector, where they are very much in demand.’
No, they aren’t. Most customer facing staff in the private sector are not in demand. Shops, banks and other places are full of people on pitiful wages and on short hours precisely because they aren’t in demand.
They are polite because they’ll be sacked if they are not.
NHS staff are never going to get sacked for being poor at customer service, which is why menial admin and reception staff in particular at hospitals and clinics are often brusque and unhelpful.
” I was told there would be an hour-and-a-half wait and that is what it was.”
And I’ll have a bet, if you phoned them next week or next year, the wait would still be advised as & be an hour & a half.
Theoretically this is impossible. If the supply staff to attend to patients exceeds, demand the wait should tend to zero. If the supply is less than demand, it tends to infinity. If demand is variable, wait may shrink or grow around the 1 1/2 hour mark, but it can’t be constant.
Of course, what they’re doing is queue managing. A queue enables them to move demand through time. Perfectly reasonable, if it lets them maximise the efficiency of staff. But there’s a cost. And the cost is being borne by the patients. Opportunity cost. So how should we value this?
Well. given that Rob was attending at the weekend, it was likely in non-working hours. Now we value non-working hours higher than we do working hours – because if we didn’t, we’d be working earning money.
This still going to apply if it’s say a child being accompanied by a parent . The child mayn’t be working but the parent could be. Or if they don’t work, they value not working higher than working. Estimating that the pay of NHS walk-in centers is unlikely to be less than the average of those attending, the cost of that queue to the public is going to be at least one & a half times the total earnings of the walk-in center staff, for each hour they’re employed. Possibly, given necessarily accompanied attendees where both are employed & other factors, much more than 1 1/2 times.
Not a cheap policy is it? If you’re the public.
On the double thank-you question, I agree that it’s evidence of the positive sum nature of trade. In my crappy bar job (which I hope not to have for much longer as I inch towards a long-delayed graduation) I employ the double thank you every time. However, it’s not because I acknowledge the symbiotic nature of trade (although I do). It’s because I don’t know how else to respond. The English way is “My pleasure.” Well, sorry, but it’s not my pleasure to serve you. It’s my job. The alternatives? “You’re welcome.” Well, sure, but I’m not American. It’s hard enough to restrain myself from saying, “Help yourself,” when customers ask if they can “get” something. I’m certainly not going to tell them they are welcome. They already inferred that from the fact that we’re open for business and inviting their custom. “That’s all right.” Meaningless. “Think nothing of it.” Too 1940s. I have fallen into the double thank-you habit simply because it’s the only response I’m comfortable making.
bloke in spain: fascinating, and all perfectly obvious now that you have pointed it out.
I found upon ending up in an NHS ward, brusque and unhelpful (and sometimes quite literally unintelligible) was the default. However in A&E and even admin staff, I actually found people competent and quite agreeable. I do wonder if it varies by postcode as the Chelsea & Westminster Hospital is a fairly nice place, unlike many of the shitty depressing dismal 1960’s/70’s built horrors the NHS inhabits.
When I was a kid I learned a basic rule that I have found very helpful in understanding these things.
“He who pays the piper calls the tune.”
That along with my mother’s other favorite saying “if wishes were horses, beggars would ride” are all in all a pretty good summary of economics, I’d have to say.
Novus: “No worries?”
A profoundly Australian reply to “Thank you” actually.
A couple of years ago, for the first time ever, I went private. The consultant advised me that I needed an MRI. There were three choices:
1. In the nearby NHS hospital for £900. Timescale, within a week.
2. In a private clinic for £450, the same day.
3. In a nearby MRI machine that had just been set up in an office block, for £225, the next day.
I chose 3. Service was excellent.
Consultant looked at the scan and said that I could be treated as one of his NHS patients. Told me to take the scan to the radiography department in the nearby NHS hospital and get them to add it to his system.
Tried to do this in a radiography department almost completely empty of patients. It took me three separate goes to get anyone to speak to me, let alone understand what it was I wanted to do — despite them knowing the consultant and his clinic. Nine exceptionally unhelpful people (who ranged in scope from moronic all the way through to hostile and antagonistic) all tried (and failed) to work out a way of doing this. None of them understood their own computer system.
While they were failing to do this, I listened to one of them having a mobile phone conversation which, I tell no lie, consisted of her telling another person that, “People just didn’t understand, or value people like her. She worked in the NHS because she really, really cared about people.”
She was the one who showed absolutely no interest in helping me.
In the end, I took the scan downstairs to where the consultant had a secretary who was single-handed dealing with a roomful of about sixty people waiting to see another consultant. Despite being completely snowed under with phone calls and paperwork she smiled, said, “can I help you?” Took the disc off me and sorted it out.
Private v Public.
@Stuck-Record
> 1. In the nearby NHS hospital for £900. Timescale, within a week.
> 2. In a private clinic for £450, the same day.
> 3. In a nearby MRI machine that had just been set up in an office block, for £225, the next day.
In the NHS hospital a patient is a liability.
In the private clinic a patient is an asset.
Novus: How about “sure thing”? Too American?
Welcome to the wonderful world of workers who, essentially, can’t be fired and KNOW IT !!!
They also are aware that that is is difficult, if not impossible, to go to another supplier of the ‘service’ they ‘supply’.
This, it seems, invariably leads to, for the most part, a ‘screw you’ attitude.
“Think nothing of it.” Too 1940s.
The modern version, and what I would recommend is “de nada.” Marking you out as an internationally travelled sophisticate who is only working in a bar because he owns it, and wants to gauge customer satisfaction first hand.
This.
Many in London might assume this was either “piss off” in some heathen tongue or perhaps a garbled reference to mythic subterranean inhabitants of Ireland.
On the topic of this thread, it is another example of English being a language that has been stripped down to the bare bones and finds itself lacking a suitable word or term. This problem simply doesn’t occur in Russian (the response being universal), and the French have both a formal and less-formal response to a “merci”. I have often thought English could probably do with a polite form of “you” (or the reinstatement of the informal, whichever got dropped) so that people don’t need to incorrectly use “yourself” when they feel “you” is too brusque.
Many in London might assume this was either “piss off” in some heathen tongue
What would count as a heathen tongue in London these days ?
Anything other than our native tongue, er, tongues: i.e. English, Polish or Punjabi 😛
@Jerry
> Welcome to the wonderful world of workers who, essentially, can’t be fired and KNOW IT !!!
Honestly, I don’t think that is entirely fair. It is the truth but not the whole truth, in fact not the main truth. I think a lot of doctors and nurses went into the profession with a true desire to help people. The problem is that the people who control the budgets respond to incentives, and the paymaster is not the people who walk in the door, as I say, those people are considered a liability since they don’t bring any money with them. The people who bring the money are the ones that need to be satisfied. That corporate culture is communicated down to the public facing workers and is at the root of the problem.
If we are talking about fear for your job, it is true that nobody in the NHS gets fired for being mean to the patients, but people do get fired in reductions in force and hospital closures. These are decisions made by politicians and bureaucrats, so keeping your job is about keeping politicians and bureaucrats happy, not the public.
This is combined with the fact that the place is full of sick people. People can be unpleasant at the best of times but when they are sick they are particularly unpleasant. Most people are decent, but the ones who aren’t make up in spades for the ones who are. So the well of compassion that the medical staff have, which comes from being decent people rather than being incentivized, is quickly depleted.
Which again comes down to the excellent, profound even, comment in the OP. “Thank you!”, “You’re welcome.”
Indeed. Much as I oppose the very existence of the NHS, I have not had only bad experiences. Indeed many of the doctors and nurses were first class folk, and on the several occasions I have crash landed in the Chelsea & Westminster A&E, I have generally been pretty impressed by the people.
But not so much when I ended up in a ward, which is like transitioning from a First World Battlefield (A&E) full of heroes & heroines, to a Third World Slum (the ward) inconsistently run by a mixture of barely intelligible malingerers and an occasional overworked heroine.
Fraser – you are correct. My statement was perhaps a bit too broad ( I tend to be guilty of that from time to time ! )
Health care is a field where many of the actual care providers are motivated by a desire to help others. My experience has been in other areas with exposure to mostly ‘unionized government employees’ who couldn’t care less about you, your problem, or anything else regarding you.
MANY gov’t employees are not there because of some desire to ‘make a difference’. They are there to get a paycheck ! The KNOW that they. essentially, can’t be fired and they KNOW that you have no recourse whatsoever. ( who are you going to go see to resolve a problem with your car registration, or your Social Security check, or your tax return ?? )
In many cases your are treated indifferently at BEST.
I have maintained for some time that gov’t is the ’employer of last resort’ populated in many cases by people who simply could not hold a job in the private sector.
Sorry to sound mean but we’ve just had a large piece of our economy
( medical ) taken over by the government and if history is any indication it’s going to be a mess as time goes on.
To paraphrase a former president – because there is no P&L or ROI concerns in gov’t ( hey, we can always hit the taxpayers up for
more !! ) – I seriously doubt the government could make beer for less than $50 a six-pack !
” Indeed many of the doctors and nurses were first class folk, and on the several occasions I have crash landed in the Chelsea & Westminster A&E, I have generally been pretty impressed by the people.”
Having just seen my father go through the last 6 weeks of his life in the clutches of the NHS, I’ve been giving a lot of thought to this post. Perry’s right that the NHS has some first class people in it. But maybe that’s part of the problem.
Everyone you deal with seems confident that individually “they’re doing their best”. It’s the central narrative of the NHS. But when I used to run a public facing business I was never interested in whether individuals were “doing their best”. It really doesn’t matter whether they’re doing their best, worst or indifferent. What matters is whether the customer’s getting what the customer expects.
And that’s where the NHS falls down so badly.
From what I saw, all these people “doing their best” seem to pay little regard to how what they’re doing interacts with all the other people “doing their best”. I lost count of the times one lot of them weren’t coordinating their activities with another lot of them. A fine example was the “incontinence assessment” commenced two days before he died – when he was no longer incontinent because he’d been unable to take much fluids for a couple of days. When we needed an “incontinence assessment” or better still an incontinence solution, was about three weeks ago when he was lying in his own piss. Which was when the person “doing their best” said they were going to ask for an incontinence assessment. Of who or what, who can know. But whoever it was, “doing their best” as they no doubt were, doesn’t seem to have been alerted to the need. At least in anything approaching real time.
Now, as someone who ran a business, this sort of thing is what I spent a great deal of effort making sure didn’t happen. Constantly instilling in people that what they did only had relevance in in the overall picture of what everybody did. That everyone is personally responsible for seeing their actions coordinate with everyone else’s. That when you pass something on, you check the next bit happens.
I can’t get away from the suspicion the NHS ” aren’t we great” narrative deters people from being that most important thing – self critical. To not presume one’s “doing one’s best” in the larger picture.
Just to add, I do think the NHS narrative is responsible for a lot of the “attitudes” mentioned above. They really are convinced that they are more valuable & important than the public they’re supposed to be serving. They’re constantly told they are. So the public should be grateful – profoundly grateful – that they deign to deal with them – their every moment being so valuable.
The NHS seems ok at running specific departments. And if your problem requires more than one department, you are may well be fucked, and not in a good way. Wards are where this becomes very apparent, because there you need various different things.
It is a bit like going into a restaurant. You get served your first course really quickly (you told them it was an emergency) and it is pretty damn nice. The chief was good at his job and the service was efficient and quite friendly.
But now you have had some food, the waiters leave and are replaced by surly Nigerian waitresses called ‘care assistants’ who barely speak English.
An hour later you get your second course. Which is fairly nice but cold.
You need to go to the WC, but end up pissing under the table because the waitress who could tell you where the loo is located went on a tea break. Other waitresses ignore you.
Two hours later you get your desert, which was supposed to be chilled but has warmed up. But at least it tastes nice. Eventually the wine you ordered with your main course arrives, an hour after you left the restaurant. It might well have been nice wine, but who knows?
The NHS is a bit like that.
I’m not sure, Perry. It’s more you’ve wandered into a caff & the bloke behind the counter’s Heston Blumenthal. So you ask for a bacon sandwich & he fries a couple rashers of smoked back, butters a pair of white slices & dumps the result in front of you. It’s not a bad sandwich, as sandwiches go, but it’s not done with any enthusiasm or good grace & if you want a cup of tea with it you have to go to the caff in the next street. Where you get served by Marco Pierre White.
I have no knowledge of the NHS, but as far as replying “you’re welcome” or “thank you” to “thank you” goes, it makes neither more nor less sense than saying “thank you” in the first place does, to someone who’s only doing his job. Neither the comment nor the reply is anything but a noise that shows you and the clerk are both aware of each other as human beings: mutual gruntings would do as well. That’s not to say comment and reply are meaningless, only that the meaning is in the speaking, not what’s said.
Horsefeathers. There’s every reason in the world to be grateful to somebody who’s “just doing his job” if he does it well, and the more so if he he puts his back, brains, and a little extra effort into it. To say “thank you” is the minimum expression of courtesy and respect that is part of his payoff for doing a good job.
The principle is the same even without the “extra mile,” if the job done is adequate. (Note: adequate means the job is done well enough to get the desired result. It doesn’t mean the guy showed up, mowed 2 sq. inches of your 1.5 acres, and called it Done. I speak as an expert on being stiffed in this manner. Snarl.)
Anyone who’s suffered through incompetence or “80% of the effort gets 20% of the result” [sic!] from workmen from lawn-mowers to salesmen to “financial advisors” to lawyers to doctors, ought to realize this without even thinking of it.
And “You’re welcome” is very much a matter of, at a minimum, courtesy and respect for the “thank you” human for showing courtesy himself.