The closest I have got to experiencing the demands on Accident and Emergency (A&E) is watching the TV series MASH, but recently I was right in the middle of it!

Waiting for attention I was interested in the way that the staff were managing the wide range of medical problems that were rolling through the door. There were: people holding limbs in great pain, a head covered in sticking plasters, two to three people bright red and coughing, a queue of wheel chairs with legs in plaster, and somebody hobbling around in too much pain to sit down. In the background Ambulances were rushing in and trollies were rattling along corridors. All of this activity is, in a management sense, ‘unplanned’ e.g. people could arrive at A&E anytime of the day or night with a wide range of problems. I started to wonder how a typical A&E is organised and operates to manage the situation and to meet the 4 hour waiting target.

A few days later I was waiting in another queue this time in my local coffee shop. As I slowly moved along I did a quick sum¹ to work out how long I would have to wait and came up with the following calculation:

If the queue had been longer then I would have waited longer. Or if there had been more staff serving then the quicker the service and the shorter the waiting time. To apply the same approach to A&E I took some statistics from the data published monthly on A&E performance where the average number of people attending A&E per hour is approximately 12 / hour ( on average there are 8,500 people attending A&E for each hospital in NHS England per month ). I also assumed that a typical A&E department can manage 10 cases per hour then the using the same approach as a the coffee shop I calculated:

which was close to my experience in A&E. The calculation confirms what we would expect: if the A&E department’s capacity was increased by adding more doctors and nurses then the waiting time would reduce. Similarly if the number of people attending A&E was reduced then the waiting time reduces.

Of course the calculation is too simplistic to be applied to the complex operation of an A&E Department because it assumes average quantities. But trying to answer the question: Why can it not be applied ? - highlights some of the underlying factors that are adding to the complexity of its operation.

Starting with the average arrival rate of A&E attendees, A&E statistics show that there is a wide variability during a typical week. For example Monday is the busiest day at A&E with attendance 13% above the daily average and also 13% above the next - busiest day, Sunday. Also, in 2013/14, 24% of A&E attendances arrived by ambulance or helicopter who require immediate attention. All of this starts to show the variability in the arrival rate of people requiring medical attention.

Similarly the wide range of patient’s medical problems will affect an A&E department’s capacity to manage their diagnosis and subsequent treatment. For example if there was a major emergency situation, say a train crash or a flu epidemic, then the capacity of A&E would be overloaded. Another area is diagnosing the medical condition. For example 3% of patients attending A&E have severe life threatening conditions and must be seen immediately. Also, if about 40% of attendees are not seen within an an hour of arrival at A&E their condition could deteriorate to life threatening.

There are many more factors affecting the performance of A&E for example the well publicised bed blocking and transfer to social care which can increase the time seen by the doctors and nurses. Other factors are not so obvious for example the impact of weather - when average daily temperatures hit 20°C compared with 5°C, trips to A&E rise by nearly 20%. However, very cold weather does also cause longer waits.

Although the assumption of using average quantities to describe the operation of A&E is over simplistic, asking the question “why do the assumptions break down ?” can gives a better understanding of the underlying factors that contribute to its performance. Based on my experience, the way that the staff manage the range of the medical problems that come through the doors of A&E is much more impressive than the TV characters Hawkeye or Trapper John!

1. More formally the calculation is an example of Little's Law which states that the long-term average number of customers in a stable system L is equal to the long-term average effective arrival rate, λ, multiplied by the average time a customer spends in the system, W. For a different and more detailed discussion on the application of Little's Law to staffing levels in A&E see: Little’s Law: The Science Behind Proper Staffing

Over the years I have been involved in group sessions to develop solutions to business problems but when I heard about a session using a bear I had to find out more.

Many years ago the Pacific Power and Light (PP&L), now Pacific Power, had a problem with ice building up on the power cables which supplied their customers in the Cascade Mountains. During the autumn and spring the build up of ice on the cables could over stress the lines causing them to break. The normal solution was for a linesman to climb the towers and shake the power line. It was a very dangerous job with a high chance of the linesman falling off the towers.

There had been many attempts to come up with a solution but the company was struggling, so they turned to a professional facilitator who suggested that a diverse group be assembled to look at the problem. A group was assembled that included the linesmen, supervisors, accountants and people from the mail room.

Over a coffee break one of the linesmen recounted the story of how he come across a black bear who was not happy that he was trespassing on his territory and ended up chasing him for over a mile. To try and stimulate the group, the facilitator retold the story. One person suggested that training the bears to climb the poles to shake the ice off the lines. Ideas followed about how they could be tempted with pots of honey placed on top of the poles. Elaine Camper picks up the story: “.. one of the more senior, more sarcastic linemen said, ‘You know all those fancy helicopters those fat cats in the front office fly around in all the time? Why don’t we grab one of those and fly from pole to pole placing the honey pots on top just after an ice storm. That way the honey will be there when we need it, and, besides, it will do those fat executives some good to walk for a change.’

Still another period of laughter followed. Then one of the secretaries spoke for the first time. ‘I was a nurse’s aide in Vietnam. I saw many injured soldiers arrive at the field hospital by helicopter. The down wash from the helicopter blades was amazing. Dust would fly everywhere. It was almost blinding. I wonder if we just flew the helicopter over the power lines at low altitude, would the down wash from those blades be sufficient to shake the lines and knock the ice off?’

This time there was no laughter - just silence. She had come up with an answer. By valuing diversity and by encouraging divergent thinking, the resource had enabled the group to come up with a possible solution to a problem all wanted solved.”

There are a number of lessons from this story that can be applied to any group session for developing solutions to business problems. The fist step is to design the group session with an aim in mind. In the case of PP&L the aim was to find a way to knock ice off the power lines without using linesmen and at a tolerable cost. Next step is pull together enough people with different backgrounds, either professionally or it could include people with non-business experience. With a diverse group it will produce many different perspectives of the problem and could result in a radically different solution. The final part of the design must include enough time for people to relax and have fun which will let the ideas flow.

The problem to be solved must be described in simples terms, so that it is easily understood by a diverse group of people, therefore it needs to be devoid of any technical terms. The importance of the problem needs to be emphasised. In the case of the ice forming on the power lines apart from the linesman going out into bad weather, with the potential of falling off the power transmission towers, meeting up with a bear in a bad mood adds to the health problems!

Now the tricky bit. Managing different groups of people in a meeting is very difficult. For example people with a technical background will immediately start work on designing a solution, which will leave the rest of the group behind. For the session to be successful many voices need to be heard therefore those on the periphery must always be brought into the discussion. It is important that the facilitator works around the groups of people that huddle around the coffee machine during the breaks to pick up on little stories and feed them back into the meeting. All participants need to be encouraged to throw off their inhibitions and be creative in their contributions to the session.

After the session a criteria must be developed to assess all of the ideas, even if there is one that is head and shoulders above the rest. The criteria can be used to rank the ideas so that if the obvious solution doesn’t work then there are other solutions to investigate. A good record of the session must be kept so that every solution is captured just in case they need to be returned too, for example if there is a change in technology that makes one of the ideas more viable. It is important to follow up with the participants of the session, thanking them for their contribution, and letting them know how the solution is progressing towards implementation.

The group session was a success and PP&L used a helicopter to blow the ice off the power cables. It is a solution that many other companies around the world have adopted and improved. But if they hadn’t found a bear during a coffee break then they may never have found the helicopter.

See the attached video for a helicopter blowing snow and ice off a power line using a steam hose:

I am interested in a wide range of subjects: the philosopher Wittgenstein, baking, poetry, mathematics, fishing. Quite a mix. But I claim no in-depth knowledge in any of these subjects. However, when I meet people who are passionate about a subject they inspire me to add it to my already long list!

An example cropped up recently when I was attending a fly fishing show. The show was full of stands selling hooks, feathers, furs, tying tools, books and many other things that I wasn’t aware that I needed to tie a fly. In amongst the stands were tables where experienced fly tyers patiently answered my very basic questions. In the middle of one hall there was a large square where fly tyers were seated demonstrating their skill. As I slowly walked around them, asking myself whether I would ever reach their level of skill, a small group had gathered around one tyer so I joined in. He was delicately tying a fly that was so small we were all straining forward to try and see. At each each stage he explained why he was selecting the materials, how he was using the tools and enjoyed answering questions. Later in the day he was giving a talk about the history of the type of fly that he was interested in and how its design had developed over the years from the introduction of new materials, tools and techniques. The talk was packed and in my opinion it was the best of the day. After the show I bought the fly tyers book which opened my eyes to new things to be learned and is so well written that I am sure that a non fly tyer would enjoy it: The North Country Fly – Yorkshire’s Soft Hackle Tradition.

People who are passionate about their subject can crop up unexpectedly. For example we had a company install a new garage door. The company owner took us through the manufacturing history of our old doors, what was wrong with them and the advantages of the new doors. He also took into account how the new doors would affect the overall appearance of the house. He was passionate about garage doors and we felt that he could have spent most of the day discussing them! On a more regular basis we buy cheese from a stall in our local market. The stall holder will take time to explain the history, recipe, and the importance of cows milk to the quality of the cheese and will let us sample the different types. Although it can take over five minutes to buy a piece of cheese we always feel that we have learned something about the art of cheese making and look forward to our next purchase.

Passionate people concentrate on the ‘why’ as well as the ‘how’ and pick the correct level of communication for their audience. They have a command of detail, including the history of their subject as well as being knowledgable about the people who are also involved in the same area. They tend to be self motivated and whether they have a university degree about their subject is secondary. They are also passionate about sharing their subject. But it is interesting to note that the passion of a person can be blunted by the media. For example, I am sure if I met Sir David Attenborough or Prof Brian Cox then their passion would be more effective whereas on the TV or Radio it is not at the same level as some of the people that I mentioned above. Therefore it is important to meet passionate people face to face. Another subtle difference is between somebody who is enthusiastic and a passionate person. An enthusiastic person can come across as excitable and showy about a subject and seem to be trying to sell it whereas a passionate person brings their subject to life.

In a world that seems to be full of experts and enthusiasts who are just a few clicks away who spout facts we need more passionate people who can renew our energy for subjects that we are already interested in or increase our interest and motivation into new subjects such as fighting climate change.

Holding my breath I knocked on the door. Waited. I knocked again. This time a softly spoken “yes” came back; I gripped the door handle and I went in.

The head of the Mathematics Department, the Prof, looked up and carefully put his Parker pen down. He was the first real mathematician that I had met. His room was lined with large glass fronted bookcases that bulged with mathematics journals. The only window in the room and it let the autumn light shine onto his desk. I was in awe. He sat upright in his neatly tailored light tweed jacket that he filled. As he started to tidy away the papers from the top of his desk and he looked up. I had never been this close to the Prof, he was usually several rows away in a lecture theatre, and the neatness of his black hair and the strong cheek bones made him look younger than he probably was. His intense eyes passed through his dark rimmed glasses and held me under scrutiny.

After completing an Engineering degree and a “year out” to earn some money I had decided that I really wanted to study Applied Mathematics. I enjoyed thinking engineering problems and then using mathematics to develop practical solutions. The course at Cranfield Institute of Technology ( now called Cranfield University ) was a two year conversion course that was developing me to Masters level in Applied Mathematics. But I was now in the orbit of real mathematicians and struggling.

The Prof had was an expert in partial differential equations which he had studied at Cambridge. These equations cover a wide range of applications but his speciality was in working out how molten steel flowed in castings. The technique of casting is used to shape components used in the everyday objects that we use from printers to aeroplanes.

I was good at applying formulae to solve mathematical problems but was hitting a brick wall with his homework. I started to take the Prof through my attempts at solving the problems, explaining the different formulae that I had tried to apply. Suddenly he sat back in his chair and in a frustrated voice said “Your not an Engineer now, you’re a Mathematician!” His outburst came as a shock after all I felt I was a mathematician wasn’t I on the course! We started going through the first problem and he pushed me to think harder about the properties of the problem: what were the equations telling me ?, could they be rearranged to see a better solution ?, could they be simplified to get a start on the solution ?, had I solved similar problems in the past ?, could I solve one small part of the problem and then build my way back to solving the original problem ? We moved through each problem and with his encouragement I started to learn that it was more important to understand the problem and play with ideas about solutions rather than simply apply formulae. Closing his door behind me I felt that I had been shown the first steps in becoming a mathematician and that the real work was ahead.

I still keep up with the latest developments in applied mathematics and when I start to think about an engineering related problem a sense of excitement begins as I let my imagination play with the equations. At the back of my mind is the Prof’s words steering me away from beaching on the shores of applying formulae.

Recently the paper shredder has been working overtime. It has been chewing its way through bills, bank statements and a few drawers worth of career documents: CVs, pay slips, bonus letters and redundancy notices. Stopping frequently to let it cool down, a thought emerged about my career and the path it had taken - had it been worth it ? Then I remembered the advice the philosopher Wittgenstein gave to Maurice Drury, one of his ex-students.

Wittgenstein met Maurice Drury in 1929 during his period as a philosophy lecturer at Cambridge University. He actively encouraged his students not to become professional philosophers, and in Drury’s case after graduating he became a psychiatrist. They met as often as circumstances allowed until Wittgenstein’s death in 1951.

During one visit they went for an evening walk when Drury, who was a newly trained doctor, doubted his career path, because of his “ignorance and clumsiness.” At the time Wittgenstein brushed off the conversation as Drury’s lack of experience. Later that evening he wrote him a letter giving advice about his choice of career. After a section where he admonished Drury for “thinking about himself” when he should be “thinking about others e.g. your patients”, he wrote:

“But not because being a doctor you may not go the wrong way, or go to the dogs, but because if you do, this has nothing to do with your choice of profession being a mistake. For what human being can say what would have been the right thing if this is the wrong one? You didn’t make a mistake because there was nothing at the time you knew or ought to have known that you overlooked.”

Wittgenstein’s approach to solving philosophical problems was to untangle the misuse of words. In particular, it is using words where they have lost their meaning that leads to philosophical problems for example: is truth the highest good?, are computers conscious? and can he can feel my pain? Wittgenstein’s solution was to show that the use of words such as “truth”, “good”, and “conscience” were being misused and once shown then the problems disappear.

In their conversation Wittgenstein picked up on Drury’s use of the word “mistake” and questioned if he had used it correctly. The word mistake is used in the context of knowing the action that should be taken. For example when I take a route to visit a friend and arrive late because I took a wrong turn I may say “Sorry I am late, but I made a mistake and turned left instead of right at the traffic lights”. I am using the word mistake correctly because I am describing where I went wrong. Therefore within the context of visiting my friend the word mistake is being correctly used and its meaning is clear to both of us. However, in the case of a career to use the word mistake correctly would mean that I would have known what the correct career route was, and nobody knows that because we can’t read into the future. Drury made the best decisions he could within the circumstances at that time.

Wittgenstein’s advice to Drury is not the standard career guidance that floods the book shops and web with ‘Ten Steps To Success’ type headings. Instead, he untangles the misuse of a word that leads to Drury’s frustration about his career choice. As the shredder grinds through the last staff appraisal, Wittgenstein’s career advice has questioned whether I was asking the right question!

To read the full letter, click here.