I have to admit; when I lost the Duchess I was pole-axed. I knew it was coming but nothing prepares you. To be honest I still don't think I am at the end of the journey. Perhaps I never will be.
How the parents of William Mead, the 12 month old, whose pneumonia turned to an undiagnosed sepsis and killed him, are managing I can't bear to think.
Their story is rehearsed enough in the papers; you don't need me to spell it out. The death of a child. A tale of missed opportunity culminating with the blame dumped on the desk of NHS 111. Somewhere there is a call handler beside him, or herself with angst and regret.
It is an awful business. With all the arrogance of hindsight, it's easy to say we knew something like this would happen... the trouble is, we did.
The story starts with NHS Direct a national, nurse-led, non-geographical advice and information service, set up in 1998. It worked, had high approval ratings and did the job.
Until...
Until the misguided stupidity of Andrew Lansley. For, it was he who ordered the well-functioning system be broken up and sold off.
His arrogant foolishness knew no bounds. A system that was costing around �57 a call was put on the market with an indicative price per call in the mid-�20's. Half price; the system parcelled up and auctioned.
The consequences did not require Mystic Meg. Unskilled staff supported by under developed algorithms, with clinical staff present as vapour, meant miss-handled emergencies, waits, queues, mistakes and management blur.
Mayhem followed. The papers had a field day. Who knows how many lost their lives in fall-short-care? We will never know.
The service received the usual bungs and beatings. But, for all that William Mead won't celebrate his second birthday, won't have his first day at school, go to Uni, worry his Mum with late nights and stag parties, get married and make his Dad a Grand-Pa. The family have had their future stolen.
Stolen by management at the margins, political point making; he may not be the only one.
There are still too few clinicians at the front line of NHS111, too little room for common-sense, too much bureaucracy. If algorithms and strangers on the phone worked we could replace GPS with voice mail. Be like the gas board or the banks. Healthcare isn't like the gas board or the banks.
There were other missed chances to save this young life. Somehow a GP failed to 'spot the whole picture' during multiple face-to-face consultations. What chance has a call handler got?
The Tinkerman, whose life appears to be the punishment of Sisyphus, sweeping up the detritus of the Lansley years, is quoted in the �walled Times as saying he "wants to improve the simplicity of the system". How can you improve simplicity? It's either simple or it isn't. You must design for simplicity.
He also says NHS111 needs more medics on the phone... welcome to the lost land of common-sense. At the time of the sell-off I said, we said, hundreds of us said. People working in the call centres said. It has taken the death of a child to make the Secretary of State say, you can't replace front line skills.
At the heart of this disaster is the silent killer 'sepsis'. Diagnosing is difficult as the signs and symptoms can be caused by other disorders. Docs often order a battery of tests to pinpoint it; impossible to do on the phone.
This is a tale too often told in the NHS; better training, access, listening to patients and their relatives.
I will never get sick of saying; the front-line of care is where we do our business. Where reputations are made and lives lost. If you want to; circle the wagons, buy your bog-rolls cheaper, sweat the assets and make a pound do the work of two... but protect the front line, fund it properly and make it fun to work there.
Politicians must learn; staff doing the job usually know best how to do the job. Some may have an axe to grind but the majority will have a good point to make.
Politics is too often a monologue. Politicians need to learn the value of a metalogue.
Staff are not the enemy; they are allies in austerity, partners in efficiency, supporters in quality and the best friends you can have to deliver sensible policies.
