This is the tenth part of the BMJ Leader blog series written anonymously by “Magical Meander”, a medical manager working in the NHS, to help align perspectives and build understanding of medical management across these two professions.

Why does central heating always break on the coldest day of the year? After a few recent experiences of waking to no hot water or heating, my daily routine has adapted to checking both and holding my breath. So far so good. But only after 5 visits by the company who insure my boiler. This fascinating experience led me to think about a number of parallels to healthcare.

Firstly, before the fifth visit, I received a call from a senior booker at the insurance company. He noted the increased frequency of call outs and explained this had triggered his system to choose a senior engineer to visit on the next occasion. This is somewhat similar to ED programmes that run frequent flyer programmes. Where a patient triggers a ceiling of visits additional input is mobilised e.g. if the frequent flyer is visiting due to frailty issues – social care, OT, physio, care of the elderly and mental health teams leap in to prevent the next visit.

Not unlike the NHS this excellent intervention did not go smoothly. Having just put the phone down on the booker. I had an app ping to tell me that my appointment had moved from the next day to the following week. Not great given I had arranged to work from home on the original booking date. 2 hours of calls later I was none the wiser as to what had gone wrong. I was however furious. I had been told that no-one could deal with my issues because the team were going home. Fair enough, except that it was 4.30pm. Finally only after I became very determined, did the team locate a senior manager who explained that senior engineers worked via a different booking system and so I should just ignore the recent app message. All too often I fear this is exactly the sort of uncoordinated experience of altering appointments that patients experience. My own recent attempts to rebook a scan and a linked appointment echoed this sort of lack of technological input and admin staff not enabled or knowledgeable to act as a sensible link.

So the next day came and I waited and waited. 2 hours late the senior engineer appeared. Again a familiar NHS flavour. He was cheery and kindly acknowledged my knowledge-less diagnosis and didn’t make me feel stupid instead he bravely carried on with his own thoughtful assessment and management of the issues. The engineer was really wonderful – he stayed hours, he went off to get parts. Again how true of the NHS. When patients finally get to see the clinicians they need to see, these teams go above and beyond and all too often patiently deal with patients half knowledge derived from dodgy websites or social media, with curious interest and respect.

As the engineer left he explained to me the main issue was essentially a block in the pipes (AKA lime scale) or in my language a thrombus. He also explained that I could purchase a filter to prevent re-accumulation i.e. fixing the problem was covered by my insurance, but preventing it was not. How true this odd set up is of the NHS as well. The NHS will pick up the end result of years of accumulated problems: smoking / drinking / or even not taking preventive medications e.g. statins. But it will not all too often fund prevention fully. Prescription payment exemptions exist for specific conditions e.g. diabetes, and yet not for the preventative drugs that might stop the need for treatment medications. That means that the very people we should be supporting, those we know have the ability to change their life course, we do not instead we ask them to spend on prescriptions (albeit a small amount). Equally whilst some programmes exist to tackle obesity or smoking all too often prevention schemes are cut when the money gets tight. This is even truer when you look at prevention more broadly i.e. money spent beyond healthcare on education, housing, roads etc. True it is hard to justify savings in the future against cost now, especially when  this leads to higher overall costs now and so to spend money on prevention would require either more budget or cutting services to those with needs now.

So  it does seem daft that I am left paying my monthly insurance premium and knowing that if pipes fur up again this will be fixed. But for want of a little investment this could all be prevented. True I could pay for the prevention but that seems counter intuitive. Surely we need to think about incentivising me to do this. If I paid for the filter and received a cash back for a call out free period – would that work? Translated to healthcare if either individuals or the state paid for prevention better and rewarded those who did not use healthcare would that drive a revolution to healthier lives? If that sounds unreal in Israel the government has announced a proposed plan for unvaccinated individuals who have the vaccines now will be eligible for a reduction in income tax in the future. I haven’t seen the economic data on how many vaccines need to be given to prevent an ICU admission and the cost benefit comparison to income tax earnings by the state but this hints at a change of mindset and one that after my instinctive choices with heating feels intriguing to me.

Magical Meander

Magical meander is an anonymous blog written by a medical manager working in the NHS and published every six weeks on BMJ Leader Blog.

Declaration of interests

I have read and understood the BMJ Group policy on declaration of interests and declare the following interests: none.