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How "shared care" is like a ticking time-bomb...

By Dr. Colin Coulthard |


Imagine for a minute that there was a ticking time bomb that needed defusing. It’s just like in the movies, a jumble of wires, some sticks of dynamite, and a rather obvious digital countdown on the side of it. It’s ticking ominously closer to zero. If you defuse it in the wrong way, the bomb goes off.

Now imagine, that you have an expert who knows how to safely defuse this bomb. The expert does this regularly, many times a day, and knows what to do like she knows the back of her hand.

So my question to you is this. If you were locked in the room with this bomb, how would you want it to be defused?

Option A

This is where the expert walks into the room, swiftly snips a few wires (usually the red one in the films) and safely defuses the bomb.

Option B

The expert employs a skilled technician. The technician’s skills lie elsewhere in maintaining electronic circuits. This technician has very little experience of specific types of bomb but knows something about bombs in general. The expert has sent the technician detailed instructions about this type of bomb and how to defuse it. The instructions are quite long and detailed, and take a large amount of time to read and understand. The technician also has many other sets of instructions that she needs to read. The expert guides the technician by shouting instructions to her, and the technician sends pictures of her progress in defusing the bomb back to the expert. The expert then uses these pictures to decide on the next step. She then shouts more instructions back to the technician. This process is repeated until either the bomb is safely defused, or everything goes BOOM!

Oh, and the technician has five other bombs that are similar but different to defuse at the same time. Each separate bomb needing different instructions from different experts simultaneously.

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Lessons learned vol II

By Dr. Colin Coulthard |

At itamus, we’ve just realised that we’ve made a mistake. To be more specific, as I am in charge of business strategy and all that entails, I’ve just realised that I’ve made a mistake. Actually, it’s one in a series of mistakes that we’ve made.

Now you may be thinking that this is a bad thing. It is not. It is only by making mistakes that we make progress, so I thought that I’d document them here.



This is the first mistake I made. If you want to make a profit, you need to have a business model that scales. This means that your unit price needs to be greater than your unit cost. That way as your volume increases your profits will outweigh your fixed costs and eventually you’ll be in profit. If you can scale enough, you can make a large profit.

However, as a start-up, this can lead to a tactical error.

The mistake that we’ve made, is thinking that we could go straight to ‘at scale’ production without paying our dues first. Every company needs to pay its dues. Facebook started off as a web page with a set of yearbook photos for Harvard. Google started off as a PhD project.

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The hidden costs of "working at scale"

By Dr. Colin Coulthard |


“Working at scale” is the solution to all our problems. It must be; both NHS England and the Royal College of General Practitioners says so. So surely it must be true?

Well, er, no.

To this author, “working at scale” is a strategic error, that is likely to make things worse, not better. It’s an availability bias-type error.

Apologies in advance, this is quite a technical blog.

Availability bias” is the psychological phenomenon whereby things that are easy to remember or visualise are given undue weight over things that are not so easy to remember. A good example would be side effects from medication. When we don’t have side effects from medication, we don’t remember because nothing happened. When we do have side effects from medication, we do remember, because something did happen. This means that people find it easier to remember the times that they had side effects compared to the times when they didn’t. This has the effect that many people tend to overweight the risks of side effects from their medication when making decisions.

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The health-tech start-up scene. All fart and no motion?

By Dr. Colin Coulthard |

When I was a trainee in A&E, in the last millennium, we had a ward sister in charge, and she was a legend in her own lifetime. Every other word out of her mouth was a swear word, and she had a particular turn of phrase. One of her favourites, was when she’d dealt with a threatening patient she’d say “Don’t mind him, he’s all fart and no motion.” Meaning that he’s all talk and very little action…

Recently I’ve been weighing up the pros and cons of staying in London. At the moment both of us are working part time as locums to support ourselves. The rest of our time we’re devoting to itamus. The problem for me, working in London, is that the amount of money I need to earn to support myself here is significantly higher than it is elsewhere in the country. This means that I’m working for seven sessions a week in order to keep afloat. This limits the time that I can spend on developing our business, and I think that this is holding us back.

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The huge hidden threat to the NHS...

By Dr. Colin Coulthard |

At itamus, we’ve recently had a revelation. We’ve realised that trying to innovate within the NHS is almost impossible. This is a problem for us, but it’s an even bigger problem for the NHS.

In our opinion, the only way that the NHS is going to survive is through the changes recommended in The Berwick Report. This means a change of culture in the NHS, towards a process of continuous improvement, with safety first, effectiveness second and patient experience third as the guiding values.

The demands on the NHS are growing and changing rapidly, and the NHS needs to be “agile” to be able to deal with these demands effectively.

For continuous improvement to work, organisations have to be prepared to take constant small risks to find out what works. The mantra is to “experiment cheaply” and yet in our experience, this is the opposite of how many of these organisations work.

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What is "time management" and why is it so important?

By Dr. Colin Coulthard |


Time management is fundamental. It is fundamental to effective systems, and it is fundamental to healthcare. And yet it is something that is neglected throughout the NHS.

As a trainee, I was lucky enough to have some (three whole hours!) time management training as part of my vocational training scheme. And yet, that was the exception rather than the rule. Time management as a whole is something that NHS staff have little to no training in. As a result, many of us are feeling the effects acutely.

Time management has been shown to help resilience on an individual basis. It has also been shown to improve efficiency on an organisational basis. So what is it?

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The Duty Doctor: a cautionary tale of function creep in GP land

By Dr. Colin Coulthard |

function creep. noun. 1. the gradual widening of the use of a technology or system beyond the purpose for which it was originally intended, esp when this leads to potential invasion of privacy.

This is a phenomenon that we are all too familiar with in GP land. Something starts out as one thing and then gradually mutates into another. Services are commissioned, and then gradually over time the funding reduces, and we find that we’re expected to continue to provide them as it’s now just part of our job.

However, the concept of the “duty doctor” in a GP practice is an excellent cautionary tale of how an ad hoc modification to a complex system can lead to unintended adverse consequences. If you want to find out more then read on…

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