a nurse with a syringe

This is(n’t) going to hurt

Another day, another trip to my doctor for a blood test… yep, getting old requires taking my aging body in for maintenance with what seems like increasing frequency. But my day was brightened by an excellent interaction with the practice nurse extracting another armful. Here’s what made it great:

  1. A cheerful greeting.
  2. She acknowledged that this was the second test in a few days.
  3. We had a conversation about singing with choirs and performing on stage – two of my favourite topics.

Let’s unpack this because although the whole thing took less than 5 minutes and seems quite inconsequential, it carries important messages about great customer experience.

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The subtle simplicity of great customer experience

Leaders need to let people bring their “best selves” to work

If anyone’s noticed the gap in my writing on the KnittingFog.blog website they’ve been kind enough not to mention it to me – or a more likely explanation is that its low traffic (if it were a country village it would be a loner’s delight) means that no-one has noticed anyway.

I’ll put it down to the pandemic effect – not that I or anyone close to me has caught COVID-19 – but just that in the way in which priorities have shifted means that some priorities drop and then have difficulty getting back to their former status. Moreover, writing about my own customer experiences has been as limited as my shopping trips to the local stores: sources of god, bad or indifferent CX have been in short supply.

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What the NHS can teach us about customer relationship management

When you think of the UK’s National Health Service (NHS) then excellent customer relationship management is probably not the thing that springs to mind. Talk to any UK citizen and for all the genuine positive feeling about the NHS – witness the recent “Clap for Carers” and happy 72nd birthday celebration – there will be a good sprinkling of people with awful tales of long wait times, misdiagnoses and all manner of poor interpersonal reactions.

I’m maybe lucky in that most of my interactions – and as we’ll see, there have been quite a few – have been positive, but I’d like to highlight one series that has much to teach the commercial sector about customer relationships.

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Whose clock are you on?

Customer journey designs ignore the customer clock at their peril

Unless you’re afflicted by a particular neurosis you probably don’t spend every minute of the day counting down the time to your demise and wondering how you’re going to spend it. Yet time-efficiency and utilisation are beloved of management consultants, personal growth coaches, line managers and productivity experts the world over.

But often we’re using the wrong clock.

In the last week I’ve had two very personal examples of whose clock I’m on. Regular readers will know I’ve been a customer of St George’s Hospital in south-west London for more times than I would prefer to have been this year. Most of the time I’ve had some great experiences – under the circumstances – but my most recent visit caused me to reflect, not on mortality as much as time-efficiency.

Oh doctor, I’m in trouble

Following a routine day surgery procedure to correct a cardiac arrhythmia problem, I awoke in the middle of the night a few days later with a severe pain in my chest. Not, I was glad to notice, anywhere near my heart, but causing me some breathing difficulties. Following a few hours snatched sleep I embarked on a customer journey that went something like this:

08:00 Book same-day GP appointment online

09:15 GP appointment

10:00 Ambulance to hospital

10:20 Accident and emergency department – blood tests and electrocardiograms

11:50 Chest x-ray

12:05 moved to acute medicine unit

14:00 First meeting with doctor

15:30 Meeting with doctor and consultant – diagnosis and treatment

16:00 More tests

17:15 Medication delivered by pharmacist

18:00 Travel home

18:45 In my sick-bed!

A journey that lasted over 10 hours to diagnose and commence treatment of what appears to be a lung infection, most likely picked up on my first visit.

Every touch point in the journey was excellent – there were many others not documented that were also very good – but there was a lot of time in between them.

Always crashing in the same car?

Experience number two: I’m lying in bed the following afternoon when my wife phones to tell me she’s damaged the car – and two others – in a car park about two miles from our house and it can’t be driven. Another – longer – customer journey kicks off:


14:30 My wife calls our insurers and speaks to a very helpful and reassuring person on the other end of the phone at Admiral

15:15 My wife returns home – a lift from one of the other drivers, proving that the world is full of kind people, even if you scrape their cars

16:15 Call from recovery firm to confirm details for picking up the car

16:40 Call from recovery driver to ask where the car key is

16:50 Taxi to car with key


08:30 I call the repair workshop – would it be possible to pick up a courtesy car? Apparently, the car hadn’t yet been delivered by the recovery firm and would most likely be on Monday and a courtesy car couldn’t be made available until the damage had been assessed.


14:00 I call the workshop again.

“Yes, the car was delivered about 40 minutes ago so they’re doing the assessment”

“So, can I come over and pick up a courtesy car?”

“It takes about 48 hours to submit the assessment and have it approved, then we can let you have a courtesy car.”

14:15 I call the insurers to make the point that this is stretching the definition of courtesy a little bit but also, since I’m an accommodating sort of person, to say that we can manage without a car until Wednesday morning so if they could compress the 48 hours that would help. They call the garage who agree to provide the estimate by Tuesday p.m. All happy(ish) – for now.

Clocking off

There are two clocks in operation in my examples: a customer clock, representing my preferred time for the journey and a supplier clock representing when I’m not in control of the time the journey takes. In my healthcare journey, once I had made my booking and arrived at the doctor’s surgery I had pretty much ceded control to the various suppliers. In my car insurance example, we were in control of some elements (getting the key back to the car) but the overall – and rather unsatisfactory – timing of at least 4 days to become mobile again is predominantly dictated by the other actors in the process.

Any customer of the UK’s National Health Service (NHS) is accustomed to delays: in my case I had written off the day (and a few following it as it turned out) so although the waiting was tedious, I was aware that there were other higher priority cases using the resources. (This, incidentally, is one of the characteristics of a service owned by the public: you feel a bit of “we’re all in this together” and make allowances.)

Customers of insurance companies could, however, get a much better service. I have made a note of the difference between a hire care (provided by the insurer and available immediately on some policies) and a courtesy car (provided by the repairer and only after establishing that the car isn’t a write-off). Next time around I will pay more attention to this fine detail when selecting an insurer.

Takt and discretion

The idea of a customer clock isn’t a new one. In Lean manufacturing approaches the idea of “takt time” – literally the “beat” of the customers’ demands for products – is a key one in establishing how a manufacturer’s production line should be optimised. This works if you have customers with reasonably predictable patterns of behaviour like, say, an insurance company, less so if you’re a busy general hospital with a vast range of customers and conditions to service as well as specialised resources responding to multiple demands.

The key thing for suppliers is that, whilst they may have their own timings for the stages in their customer journeys, optimising these may end up sub-optimal for the customer. The tendency is to optimise the delivery of a service, but customers want the delivery of outcomes. In my hospital journey my desired outcome was wellness, or at least a signpost towards it, and whilst the time spent was longer than it could have been (in a world with less demand) it was delivered.

In my insurance example the outcome is “get me mobile again!” and the time taken to deliver it is at least 4 days longer than it could have been. I’ll be making a mental note to check out Direct Line when renewal comes around as their positioning shows them as problem solvers not just insurers.

The closer you can get to understanding the customer’s clock as well as your own, the more likely you are to attract and retain customers.


Six days after the ambulance episode I headed back to the hospital for a check up and was delighted to get through initial checks, x-ray and consultation with the doctor in less than 45 minutes. I barely had time to draw breath – now much easier – between appointments, so proof that when all goes according to plan, the NHS can approach customer time.

Jerks at work can seriously affect your health

And other aspects of performance can be affected as well

According to recent reports the cardiac surgery unit at my local hospital has a mortality rate almost twice the national average and the main reason given is a “toxic atmosphere” and bickering between two rival camps of surgeons. Since I’m an outpatient at the cardiology unit in the same hospital this is a source of both personal and professional concern for me. On a personal level it’s slightly worrying since I am expecting to have a minor cardiac procedure there later this year, and on a professional level it’s another demonstration of how people who behave like jerks can mitigate the best endeavours of an otherwise doubtless highly competent team.

It’s uppermost in my mind at the moment, not only because of my supraventricular tachycardia but also because I have just finished reading Robert Sutton’s excellent book “The No-Asshole Rule: Building a Civilised Workplace and Surviving One That Isn’t”. In what amounts to a manifesto for removing jerks (my preferred term, although Sutton devotes a substantial intro to his rationale for using “asshole” – he’s American obviously) from workplaces.

The most convincing argument for me is the concept of TCA (Total Cost of Assholes) which shows that it’s not just the ‘soft’ cultural issues that are impacted, there’s a direct cost impact as well. When you count up the reduced productivity of the people affected by bad behaviour and the time spent appeasing, counselling or disciplining the perpetrators, together with the management overhead, legal costs, settlement fees etc. you find that it’s just not worth recruiting the brilliant salesperson, surgeon or CEO in the first place.

House calls

But, I hear you ask, don’t we have to tolerate a bit of jerkiness or assholery from leaders just to get things done? This is a tricky question and one which Sutton tackles head-on: you occasionally need to be direct or even downright rude to make things happen – he refers to this as being a “temporary asshole” – but maintains that being a full-time jerk or “certified asshole” is, in the long term, counter-productive and injurious to business performance.

Sadly, our popular myths and stories often feature heroes and heroines with significant personality defects who nonetheless solve the crime or carry out life-saving surgery as a result of their controversial insights. In the latter case, we’ve often discussed in NextTen whether we’d prefer the fictional Dr House as the surgeon you’d want to diagnose your mystery illness rather than someone more “touchy-feely”…

The heart of the matter

But back to St George’s – and real life – the newspaper reports of the “dark atmosphere” in the cardiac surgery unit are frustratingly light on detail and, as always, there may be other reasons for the high mortality rate: as a teaching hospital St George’s often has the more complex cases to deal with. But what struck me was that out of a team of 39 people there was a view that the environment was toxic, but nothing appeared to have been done about it.

It appears that management are now taking action but ensuring a healthy workplace – in all senses of the word – requires that those on the receiving end of sustained jerk behaviour are able to raise their concerns and have them dealt with rapidly and constructively.

It’s not exaggerating too much to say that, in this case, it could be a matter of life or death.

Small changes can make a difference: a birthday present to the NHS

Time taken to establish a rapport with customers is not wasted

I don’t think the best way to celebrate the National Health Service’s 70th birthday is by having an extended stay in an A&E department waiting room but that’s what happened to me the other day so I’m sharing it with you as it illustrated an important lesson in customer experience:

Establishing rapport is absolutely critical

When you enter any kind of customer journey, the first impression you get is crucial – how many times have you been left standing around on entering a restaurant or had difficulty distracting counter staff from their apparently more important conversation with their co-workers? Think about when it works well: a prompt and friendly greeting and offer of help puts you in a good frame of mind to enjoy the rest of the experience.

In this regard, accident and emergency departments are no different from restaurants, retail stores or your local bank branch: all interpersonal elements of the journey should be geared towards making you feel as good as possible, even though you might not be feeling that great to start with.


Last Monday night in my local A&E was not the best time to visit: when I arrived, the waiting room was packed, and I resigned myself to a slow journey through the various tests and investigations I was in for.

However, on the plus side I was able to observe a critical opportunity for improving patient experience that was missed on every occasion. Every time a medical practitioner from nurse to consultant called a patient they did the following:

  • Stand on the edge of the room and call the patient’s name (not all that clearly but the patients could just about hear).
  • Once the patient had started to get up, immediately start walking to their treatment/assessment room.

It’s this latter step that began to bug me: I’m pretty agile but at one point I “lost” the medic who had called me and had to find his room. Not, admittedly, a massive crisis, but consider if I had mobility issues or had limited mental capacity and became easily confused it wouldn’t be the best start to my treatment.

Without fail, the patients were left following in the medic’s wake and it struck me that in doing this – I think the assumption was that they needed to read the patient’s notes before they arrived in the treatment room – they were missing out on a crucial opportunity to greet the patient and escort them to the room. Typically, this step in the journey takes only a few seconds but it would create, I think, a significant difference in patient satisfaction if they were introduced and had a very short rapport-building chat on the way to the room.

I’m one satisfied customer despite this as, at each stage in the journey, I was treated with all the care and consideration you would want. Even though it was a busy night, and everyone could have been quite harassed or under pressure, it didn’t show.


Not one to let a piece of ad hoc research go to waste, I have written to the hospital’s feedback line to offer them my advice. It’s hardly free consulting, but you could consider it my birthday present to the beloved institution as it celebrates its 70th birthday. I’ll be interested to hear if they think it’s worth a go but however much I love the NHS I’ll be happy if I don’t have to have first hand experience of any improvement that results any time soon.

Is management consultancy a waste of money?

Not if you link it to performance outcomes

There’s an old management cliché that goes something like “50% of my marketing spend is wasted but the problem is I don’t know which 50%”. When it comes to spending on management consultants it could be that 100% of your spend is wasted if recent research into their value in the National Health Service (NHS) is to be believed.

The reality, however, is a little more complicated.


A research project took place last year carried out by the University of Warwick Business School, Seville University and the University of Bristol to evaluate NHS health trusts’ spending on management consultancy. It was an open-minded investigation into the impact on overall efficiency but when the findings were published they made for another money-wasted-in-our-NHS story in some newspapers. The academics found – against their expectation it has to be said – that the more that health trusts spent on consulting the less efficient they were. It was said that the money – some £640m in 2014 – could have been better spent on more doctors and nurses.

The hackles of the management consulting industry were duly raised and the consultants’ own City Livery Company, the Worshipful Company of Management Consultants organised a debate in May with the researchers, the Chief Executive of the Management Consultancies Association (MCA) and a large number of company members (including me) who turned up to get to the bottom of this apparent slur on their competence.


The researchers – Professor Andrew Sturdy, University of Bristol, and Ian Kirkpatrick, University of Warwick, kicked off the debate with a summary of their approach. Andrew Sturdy has been focusing on evaluations of the value of consulting for a number of years, most of which has relied on qualitative evaluations of value, and therefore relished the opportunity to get some more quantitative data. The data was quite extensive and covered 120 hospital trusts’ consulting expenditure over a four-year period, correlating that with changes in each health trust’s financial performance.

Source: Policy Bristol

And the numbers do not lie: apart from a minority of trusts where efficiency improved, amounting to one third of the top 25% of consultancy users, the impact on the overall population was negative. I won’t go into the statistics used in detail but, on face value, they don’t paint a great picture.

Alan Leaman, from the MCA, had the task of responding to these results. He pointed out that, even though the press release had equated consultancy expenditure with spending on doctors and nurses this was an inappropriate comparison – and much along the same lines as those campaigning for a leave vote in the Brexit referendum suggesting we would have £350m a week to spend on health after leaving the EU. His main objections, which the researchers did not dispute, covered three areas:

  • The data sources are quite crude, and the figures included the costs of interim staff, including Chief Executives
  • The outcomes from consultancy work were much wider than efficiency and included improvements in care quality, inventory management, procurement, IT and relationships. In some cases, consultants had identified areas of underspend that had been corrected.
  • No hospital is an island – the best work comes when hospitals are joined up with other care providers.

(We have also covered examples of joined-up approach in earlier articles on The Next Ten Year – see our article on Asheville for example.)


With questions open to the floor an introduction from the chair setting out what he described as “Queensberry Rules” the stage was set for some furious debate. However, anyone expecting a punch-up would have been disappointed – I’ve seen more argy-bargy at my local residents’ association meetings – as the contributions were considered and thoughtful.

Everyone agreed that more detail was needed to be able to highlight areas of good practice in procuring consultancy services and that data quality could be improved. It was also recognised that the NHS – subject as it is to a high degree of imposed change – may not provide the best conditions for effective consultancy. Imposed change tends to create resistance: imagine the level of resistance if the change team you are meeting with might result in your redundancy and appears to challenge your accepted ways of working. In this environment, good results are going to be scarce. One questioner asked whether consultancies should decline contracts that were set up not to achieve results – the temptation to take fees without accountability for the results being key here.

Poor work in some areas was certainly acknowledged, particularly where firms had deployed consultants with little knowledge of the sector or had used standardised approaches. It was also possible that the wrong types of consultants were employed in a number of cases. It was commented that there McKinsey seemed to be a surprisingly popular choice of consultant. Strategy consultants such as McKinsey are very different from more operational providers and there seemed to be a temptation to go for a prestige brand rather than a more considered outcome-driven appointment. Expensive, inappropriate and ineffective – in my mind a bit like buying a Ferrari to go off-roading.

Buying better – think F.A.S.T.

As a customer success specialist, NextTen has taken the opportunity to define how we can provide services differently – using our culture and leadership expert Gordon Tredgold’s F.A.S.T. approach (Focus, Accountability, Simplicity and Transparency) I offer some principles for engaging third party service companies better:

  • Review your own capability for change (transparency) – many of the NHS trusts in the study had their own change departments – many of which were quite effective. It might be a valuable, if challenging, piece of work to compare internal and external projects and the results they delivered. I have frequently found – once engaged on a project – that organisations already have highly expert people with an acute understanding of what needs to change and whose voices have sadly been ignored. (This is also increasingly the trend for Customer Experience.)
  • Start small with quick wins (simplicity)– a good discovery project can flush out areas of potential change with the potential to deliver a good return on investment and identify the capability of the organisation to deliver it themselves.
  • Invest in capability (focus) – rather than do the work for the client organisation, it’s much better to start education-centric and work out how the consultants will transfer and build capability so that you can manage the change after the consultants have left the building
  • Link to measurable results (accountability) – as was pointed out in the debate, it’s not beyond the capability of most buying organisations to have some form of performance-related clause in their contracts. The questions over performance data in aggregate in the NHS doesn’t mean it can’t sensibly be used in specific cases.

None of the above is rocket science: it’s good practice for any significant investment. What seems to cause the confusion and misapplication of consultancy is the apparently “intangible” nature of the benefit delivered. As a way of getting beyond this, the work of Professors Sturdy and Kirkpatrick is an important start to an essential debate.

On an individual project level, starting with critical customer outcomes is the most effective way of driving effective estimates of benefit. If these can’t be defined the project isn’t worth doing. Once they are, the principles above will ensure an effective use of whoever your service provider is.

In short, you can use consultants to add value. And still keep hold of your watch.


Net Promoter Score – what’s the point?

It all depends on the context

An unwanted set of medical visits last week resulted in an equally unwanted set of follow-up texts.

My local hospital trust “would like me to think about your recent experience in the Emergency Department. How likely are you to recommend us to your friends and family if they needed similar care or treatment? Reply 1 for Extremely likely, 2 for Likely, 3 for Neither likely nor unlikely, 4 for Extremely unlikely or 6 for Don’t know. Please reply today, your feedback is anonymous and important to us and helps us to improve our service…”

There was no follow up question in their survey – clearly they were just wanting a number.

My GP’s surgery then did exactly the same.

Yes, the much-touted and widely-discussed Net Promoter Score (NPS) was at work again!

Well, actually the experience and the care in both cases were great but I didn’t reply, but because the context of the experience means that I think NPS has no significance in isolation. If I had responded with 8 but with no opportunity for follow-on comment how can they react? If the hospital looks at their scores how can they do anything meaningful unless they have some view of what aspect of my experience is not great in the my opinion.

No choice

It got me thinking what do people use NPS for? Picture the scene if you can: someone close to you is suddenly taken ill. The LAST thing you are going to do is say “Hmm, let’s take you to XYZ Hospital, they have a really great patient experience and I’d heartily recommend it!”

If you lived in my neck of the woods you would only have one choice in an emergency, assuming it didn’t require an ambulance: the nearest hospital. And that’s in London – an area not short of “competitor” hospitals; elsewhere you most likely wouldn’t have a choice.

Similarly, signing up for a GP is not like having a bank account or a phone service: you tend to sign up long-term and don’t like to switch unless you move house. You might recommend individual doctors within a practice to your nearest and dearest depending on your experience but that’s not the question.

I asked a GP friend of mine who’d moved from my surgery to another practice whether they were using a similar measure. “Oh yes” she said, “we do the scoring as specified and then we have to send the results to the Department of Health.” As far as I can tell there is no follow-up or any expectation to do anything differently. The score was being used little more than a traffic light to gauge the surgery was performing above a minimum threshold.

So, what’s the point of NPS?

Despite its misapplication in parts of the National Health Service, the measure is partially useful, but it does not deliver quite the impact it claims:

  • If I have a great experience from supplier A where various competitors are readily available, I’ll form an emotional attachment to the supplier that provided it. I might quite like Supplier A but part of the attachment is based on confidence they can do the job and trust that this will happen consistently.
  • I’ll be more much likely to tell someone that I recommend supplier A and much of the time I will give them a 9 or 10. In this scenario NPS accuracy is working.
  • I might be using NPS after a visit to a retailer. If I got what I wanted, and the assistant had smiled at me nicely then I would be more than happy to give a nice round 10. Then I would most likely forget I had ever been there and I never raise it in conversation again. The scoring system is not working so well.

Because it’s focused on measuring my reaction to specific events NPS is not a complete picture. The experience I have had needs to be part of a journey towards a particular outcome. To use my recent healthcare example, that journey won’t be complete until I have had a follow-up appointment and further treatment, if needed, a process involving referral and booking into the appropriate clinic. My satisfaction (not likelihood to recommend) won’t be determined until my desired outcome – good health, reassurance about future health concerns – is achieved.

And it still won’t involve me recommending any form of medical treatment, no matter how great the experience is.

Building on success

At NextTen we find it’s much more helpful to talk about customer success which we define as a combination of fulfilling the customer’s desired outcome and providing a good experience. Using these two dimensions we can build a customer advocacy matrix. High advocacy companies combine a great customer experience with a great outcome delivery, although it’s possible to achieve business success with an OK or even below-average experience as long as you deliver the customers’ desired outcomes as low-cost airlines continue to prove.

  • Ryanair and Spirit: poor customer experience but great profitability.
  • Kingfisher Airlines: great experience but went bust!

Context is everything

NPS can certainly tell you if you’re in the high advocacy quadrant of the matrix, but you’ll need additional qualitative data to understand why you’re there, or if you’re not, where you need to improve. And if your market context isn’t one where high levels of customer choice or switching occur then you would be better off measuring something meaningful like the number of and reasons for customer complaints.