Public: Wellbeing + Features | Public

NHS: something's gotta give - either targets or services

Thu, 27 May 2010 10:06:12 GMT

Following a recent report on stress levels in the public sector, Eifion Rees reports from the NHS frontline where the pressure to meet targets is having a detrimental affect on services - and employees' health

Working in the public sector can seriously damage your health. That is the conclusion of research published recently in the European Heart Journal.

Conducted among 10,000 Whitehall civil servants, it found people who daily work three hours overtime or more were 60% more likely to suffer a heart attack than those working normal hours. Streamlining and cost-cutting have taken their toll: stress levels in the public sector are now said to be higher than in the private sector.

Public expectation

Anne Gibson, head of HR at Norfolk county council and vice president of the Public Sector People Managers' Association, puts the increased potential for stress down to an increased number of challenges. "In terms of outcomes to deliver, there is certainly a greater demand to work faster and on a more complex range of issues," she says. This is partly down to an increase in public expectation about what they should get in terms of services, fuelled by changes in the commercial world, such as online banking.

Whatever the cause, the results include greater pressure than ever on senior managers in the public sector. One NHS manager says the work-life balance in her London PCT began tipping heavily in favour of the former some 18 months ago. She regularly works 50-hour weeks, spending lunch breaks in front of her computer or in meetings, and occasionally works at weekends.

"We're expected to do whatever is required to get the job done," she says. "In most NHS organisations, people leave and their responsibilities are shared out on an 'interim' basis among colleagues – that this becomes a permanent arrangement seems to be an unwritten rule."

Contributing to the atmosphere of stress, she adds, is a tendency towards "buck-passing" and away from taking ownership of tasks. Communication is also a factor, with a feeling that some managers are being "set up to fail" by being given too much work and not enough training.

"The NHS used to be a more pleasant place to work, but over time has become more challenging and politically driven, with minimal flexibility for negotiation over target delivery. We try to keep up morale and make time to chat, but with many gaps in the service and few resources to fill them, something will have to give, either targets or services."

Reduced to tears

Or, indeed, people. One community services manager in the south of England ascribes her stress to restructuring within her organisation, overseen by an interim chief operating officer with a "very abrasive, bullying" management style. "Clinicians who are also managers, as I am, are not always valued or supported to make the development change into whatever new type of manager our leaders want," she says. Management meetings became increasingly difficult as efficiency and productivity goals were pursued, she adds, with colleagues sometimes reduced to tears.

Regularly working 10-hour days or more since September, this manager began experiencing breathlessness and incipient feelings of panic, and was eventually diagnosed with work-related stress and signed off by her GP. She believes many public sector managers are unaware they, too, may have work-related stress. "If people are on edge, anxious about their futures and unsupported in their jobs, they can't focus on patient care," she comments. "Procedures are suffering, and a growing culture of interims means an increasing focus on upping performance to the detriment of forming relationships with colleagues and loyalty to the local areas and organisations.

"The public sector has changed – my colleagues and I used to laugh a lot more and go out for lunch together, which was always a supportive time. The caring aspect has reduced as we strive to meet targets."

Stephen Chaffey, a solicitor at law firm Dundas & Wilson, says work-related stress may have legal implications, as well as impacting an organisation's "bottom line" by increasing sickness absence and reducing productivity. "While there is no UK legislation focused solely on stress, employers are obliged under the Health and Safety at Work Act to provide a safe working environment for their employees," he points out. "They will be potentially liable for a breach of that duty if an injury to physical or mental health occurs related to stress."

Management standards issued by the Health and Safety Executive offer guidance in distinguishing between positive and excessive pressure, he adds.

How personal coaching helps keep managers focussed

Jane Dudman — Wed, 03 Mar 2010 11:28:37 GMT

The way managers deal with stress can not only affect the outcome of an organisation, but also their own wellbeing, which is why personal coaching can be an invaluable tool, writes Jane Dudman

Paul Snell, acting chief executive of the General Social Care Council (GSCC), recently pointed out in Society Guardianthat the nature of leadership development in the public sector has changed.

Alongside formal leadership development programmes, he argued, it is the process of coaching and mentoring that has become increasingly linked with organisational effectiveness, personal transformation and a return on investment.

How does this translate into real leadership experience at the frontline?

John Fraser, interim head of strategy for the GSCC, has experience of personal coaching from a previous position in another regulatory body. At a highly-pressurised time, when the organisation was going through a merger, Fraser says personal coaching was immensely useful.

"I was trying to manage the transfer of business into the new framework and there was a lot of uncertainty about people's jobs," he explains. "Personally, I had taken the decision not to join the new organisation, but my focus was on business continuity, and helping the new team establish a way of working."

Fraser was put in touch with a personal coach through a scheme run by his employer. "It forced me to find some space to think about what I was dealing with," he comments. "It helped keep me focused on the critical things that needed to be done for a smooth transition and the business benefited as a result."

Dyllis Faife agrees. Now regional programme director for personalisation and transformation of adult social care in the east of England, a job she believes she owes to personal coaching, Faife says the outcome of three personal coaching sessions were very specific for her: "I got the job I have now, which I really wanted and absolutely love doing," she comments.

"I believe the coaching sessions helped me prepare better for interview and perform better, because I was clearer in my mind about what I wanted, more comfortable about the whole process and therefore about to connect in a more relaxed, thought-through way."

Emotional intelligence

For Faife, personal coaching is about emotional intelligence: "The more one reads about what makes good leaders, emotional intelligence is so important," she comemnts. "I believed in it anyway, but may not have been practising what I preach, so it was good to thing about both personal fulfilment and ways in which to have a more positive, sustainable influence."

Both Faife and Fraser used personal coach Lynn White, of consultancy WDI, who has also worked with leaders in the private sector, including David Batchelor, chief executive of risk and insurance company Marsh.

Batchelor says that one of the benefits of using an external personal coach is that it provides a valuable method of personal brainstorming difficult work issues.
"I've always been someone who looks at my own personal development, and that can either be done through one's own organisation and through external resources, such as professional exams and so on, but as I have moved up in my career, I have found that while leadership programmes are value, personal coaching is much more intimate in dealing with things at a practical level," he says.

"Whether it is about an issue with colleagues, or a business issues, of something that's affecting your organisation, a good personal coach can help you organise the way you would tackle that issue. They won't give you immediate answers, but they develop a route map for you, and give you some objective, pragmatic views. When you move to the top of an organisation, it can be more difficult to openly discuss issues internally."

Batchelor says good coaching is applicable equally well to both the public and private sectors, and is valuable not just in outlining ways to tackle issues, but also to challenge leaders' existing ways of thinking. "Sometimes you can get a bit too narrow-minded," he says. "Coaching can open your mind to the impact of what you are proposing, in a confidental environment."

Jane Dudman

Green agenda has economic advantages

Thu, 05 Feb 2009 16:36:00 GMT

The public sector has accepted the need to tackle climate change, but can't go it alone - business and the people must be engaged too

Participants at our recent roundtable concluded that, at least for the present, reducing carbon emissions would actually bring financial benefits. "I'm not convinced the green agenda will be a casualty of the downturn," said one speaker. In fact, handled well, sustainability could ease the effects of the financial crisis locally.

"The way out of the recession will be through frugality and clever spending. Those businesses that are either developing products and services that tackle climate change or have adopted them early will do well." The challenge is more about how local authorities work across the whole area to reduce emissions. "How can we help our cities move out of recession by picking up green business?" the speaker asked.

There was a widespread recognition that the Stern report had closed off resistance in the public sector to dealing with climate change. But not every public manager has grasped the fact that reducing emissions will save money and is therefore even more important in the present economic climate. "We have got to link it into cost savings.

I do not think we have managed to convince the powers that be that the two are intrinsically linked." This means that more expensive projects, such as moving to combined heat and power, may be shelved for the time being.

Spending on sustainability will be at risk in future as the effect of the bail-out takes hold. Money has been brought forward from subsequent years, so in a couple of years there will be a "catastrophic squeeze" on public finances. "We live in the most centralised state in the world. If central government is going to be in the worst financial state ever, where will that leave us?" asked one local authority participant.

In addition, there is the danger of com placency, as all the green indicators will move in the right direction because of the recession as people travel less and spend less. "There are a lot of people patting themselves on the back for cutting C02 without knowing if it's decoupled from the lack of economic growth," said one speaker.

Leadership

If the top team has the political commitment, the budgets for sustainabilty will be safe. "We all get the same cake. How we choose to cut our cake is up to us." Money can be raised in other ways - in local government, for example, through parking and charging for pest control. But this is more easily said than done.

The whole public sector needs to be on side. "Unless you understand how to reduce your own C02, what credibility do you have to ask others to do so?" However, in many organisations, sustainabilty is peripheral to the delivery of core services. There is also a tendency to believe technology will be the answer. "Ministers hold on to the idea, like a comfort blanket, that someone will invent something that will save them." So action is piecemeal.

Engagement

There's a need to bring the populace along with the public sector on this. Public engagement has not been consistent, which undermines progress. "The electorate is looking to the public sector for leadership, especially on sustainable consumption, but we are being told to 'buy, buy, buy,' and that runs counter to the sustainable agenda," one speaker pointed out.

Customers and markets still dominate. En gage ment still tends to be us telling people what we are going to do for them. "We act as if we are dominating markets and are the fount of all knowledge." This will put people off. "We want to do things with people, not to people."

Evidence from National Institute for Health and Clinical Excellence on achieving behavioural change in the health context has implic ations for sustainability too. It found that information alone did not have an impact. What is needed is "coproduction" - people need to be clear about what is being attempted and feel involved in achieving it.

This is not necessarily as difficult as might be thought. Hampshire has established a carbon compensation fund, whereby people voluntarily pay £10 a time to offset their emissions. This is added to by council funding and the money is used to alleviate fuel poverty, through insulation. Another option some councils are looking at is refunding planning fees for anybody installing renewable energy in their home or business premises. Others have set up a loan scheme under which the council finances the installation of solar panels, say; the money doesn't have to be repaid until the property is sold.

Outsourcing

The public sector doesn't have to bear the cost alone. Business has a role to play, from developing new technologies to coming up with ideas for doing things differently. But the difficulty with outsourcing will be finding the resources when the business case comes from the private sector, particularly during a downturn. And as the targets require public sector organisations to assess the carbon footprint of their suppliers, too few understand what the impact of outsourcing on C02 emissions would be, which services are suitable to be outsourced accordingly and which need to be kept inhouse.

This roundtable was sponsored by Mouchel

Bring back senior staff with long memories

David Brindle — Thu, 05 Feb 2009 16:11:00 GMT

With a younger workforce and fewer people staying in the same jobs, we're alarmingly short of those who have dealt with recession before

Whenever two or more public service leaders are gathered to gether these days, the talk inevitably turns to recession. It was just so recently when John Ransford, the deputy chief executive of the Local Government Association, met health secretary Alan Johnson. But the conversation took an unlikely twist.

Ransford was recalling the silver lining of one past downturn, when social work had attracted particularly large numbers of able recruits from the struggling private sector. Was that the 1992 dip, asked Johnson, or the slump of the early 1980s? Neither, exclaimed Ransford: it was the oil crisis of 1973-74.

Precious few of today's senior public services professionals were in any kind of managerial role 35 years ago. Not many were even working in the public services at that time. Ransford, a social worker himself, became a training officer with Kirklees council in 1974, so he saw those recruits coming in and worked with them. Some, he says, are still doing the job.
Limited remembrance

Such first-hand recall is exceptional. Generally in the public services, there seems to be only limited remembrance of hard times past. This is partly inevitable, given the unusually long period of economic bounty we have enjoyed. Ben Page, managing director of pollster Ipsos Mori Public Affairs, observed the other day that most of his (admittedly youthful) staff had been attending primary school during the most recent, 1992, slowdown. They and their generation, he reflected, were in for a very rude shock.

But hazy organisational memory across the economy is also a function of modern rates of turnover in top management and the shakeout, over the past couple of decades, of people in their 50s and 60s. As we seek to navigate our way through stormy waters, will we rue the absence of wise old men (and women) of the sea?

To get a clearer perspective on this, the first thing to say is that the public sector workforce, overall, is markedly older than the private. According to a study by the Office for National Statistics, 74% of all public sector workers are 35 or over, compared with 62% of all those on the private side. The public workforce is also significantly less footloose, average length of service with the same employer being 10.1 years against 7.7 years in the private sector.

Workers in middle age

However, this gap narrows sharply in middle age: just 30% of all public sector staff are 50 or over, compared with 26% of all private sector workers. Certainly, anecdotal and observational evidence would suggest that most local government and NHS managers tend to retire or drift into consultancy long before the present state pension ages of 65 for men and 60 for women.

The civil service may be rather different. The latest data suggests that very slightly more civil servants in senior grades are 50 or older (2,330) than are under that age (2,320). The issue here, though, is that the Whitehall culture now encourages staff to move departments - and take secondments - to get breadth of experience and to get on. Only 23% of senior civil servants have been in their posts for four years or more and the average time in post is only 2.9 years.

This is compounded by increasing recruitment from outside the civil service: of the 2007 intake into the senior civil service, 62% came from government departments but 21% came from the private sector and 16% from other parts of the public sector. While this is much to be welcomed in terms of opening up Whitehall to fresh talent and thinking, the potential downside is that nobody remembers where the policy bodies are buried.

The effects of this churn in civil service staffing have already excited comment in relation to the Treasury's response to the banking crisis. It has been noted that fewer than one in seven of the department's officials (of all grades) are 50 or more. Unfavourable comparisons have been drawn with the formidable grasp of economic history displayed by Vince Cable, the Liberal Democrats' Treasury spokesman, who has been an economist for more than 40 years.

In coming months, we can expect similar criticism that the Department for Work and Pensions has forgotten how to deal with mass unemployment, that Communities and Local Government has lost the blueprint for neighbourhood regeneration, or that the Department for Business, Enterprise and Regulatory Reform cannot put its hands on the dusty file marked "Job creation".

Jonathan Baume, general secretary of the FDA, the trade union for senior civil servants, says the union has long been warning about the loss of effective organisational memory. "How many people were around in the early 90s, never mind the early 80s, and have the experience and knowledge we need now? The key questions are 'What did we do at the time? What did we do right? What did we do wrong?'"

Of course, many of the people who know the answers will still be around somewhere. Some will be consultants; others will be non-executive directors. Others still will be on the golf course. Time to send out the search parties?

David Brindle is the Guardian's public services editor

David Brindle

Abusive behaviour against public sector staff is rising

Thu, 08 Jan 2009 16:22:00 GMT

Abusive behaviour against public sector staff is rising and action is still piecemeal, writes Anna Bawden

Many public sector workers will be relieved the festive season is over - far from being a time of goodwill to all, for those working in the NHS, the police and social services, it is a time of heightened danger of assault by inebriated clients or members of the public.

As drunkenness increases during the Christmas and New Year celebrations, so too does the risk of violence against public workers. According to the British Crime Survey, victims believe that in 40% of assaults and 31% of threats at work, the attack was alcohol-fuelled.
But December is not the only dangerous time. In fact, violence is an occupational hazard for large swaths of the public sector. According to figures from the Health and Safety Executive, public sector workers are the most likely to be victims of serious violence. As the graph shows, six out of the 10 sectors with the highest rates of violence were in the public sector.

Of the more than 6,000 incidents reported to the HSE, almost 1,468 were against care assistants and home carers, 731 were against police officers, 627 were against nurses and 467 were against prison officers. Proportionally, staff in the Prison Service, the police and the NHS are in most danger (bus and coach drivers are also at risk but are mainly private sector employees).

The HSE's figures are based on incidents reported through the regulations on reporting injuries, diseases and dangerous occurrences, so they only include cases where the victim needed at least three days off work. The data does not capture minor assaults and many cases are not reported. The frequency of violence is actually much, much higher.

The Prison Service's own figures show that for the year to April 2008, 12,773 staff were assaulted, while the latest data from the NHS Security Management Service (SMS) reveals that there were 55,993 reported assaults against NHS staff. Recent research by Incomes Data Services for public sector union Unison found 71.5% of custody staff had been threatened with physical violence, more than 60% had been victims of minor assault and one fifth had been so badly attacked as to need medical treatment. Police community support officers, forensic services, traffic wardens, police station receptionists and security staff are also at particular risk of assault.

In local government, social workers, residential care assistants, library staff and day care workers are most likely to have experienced threatening or violent behaviour. Data from 2005 surveys found 3% of respondents reported having been victims of violence requiring medical assistance or first aid, while 14% said they had been physically threatened.

Tough measures

While some public sector professions do involve an element of risk, unions and other commentators feel much more could be done to mitigate the danger to staff and pose the question of why public employers have made so little headway in tackling the problem. Dave Prentis, the general secretary of Unison, says: "It's disgraceful that violence against nurses, paramedics, social workers and other public sector workers is on the increase and we need tough measures to deal with it. No one should have to put up with violence and abuse just for doing their job."

Part of the problem is the perception by some staff that their employers do not take violence seriously enough. Around a third of victims of workplace violence or abuse do not report it. While in some cases, the individual may feel the incident was too trivial, 14% said they did not believe management would have done anything even if they had reported it. The public sector also has a patchy record in terms of monitoring the extent of the problem. While the NHS collates data centrally, there are no comparable figures for local government or the civil service. "If we are going to stop the violence we must have accurate, up-to-date information about the number, nature and where these attacks are happening," says Prentis. "A national database is a vital first step towards knowing the extent of the problem and how to better protect the workforce."

Preventative action is also piecemeal. The exception is the NHS. Following concern that hospital staff were being subjected to excessive danger, the Department of Health established the NHS SMS five years ago. As well as monitoring and collating data, it also promotes conflict resolution training, which is mandatory for all frontline staff in the NHS. Around 90% of trusts now have a dedicated local security management specialist who is on the frontline to deal with issues as they arise. The SMS provides them with support and guidance.

Taking action

Next year, the health department is paying for 30,000 personal alarms to be issued to frontline staff in trusts. Although that is just a drop in the ocean, given that there are 750,000 frontline workers in the NHS, it is better than nothing.

The NHS is also getting tougher with those who attack staff. Criminal sanctions have risen from 51 in 2003-04 to almost 1,000 in the past year and a total of nearly 3,500 since the SMS started work. It has brought 29 private prosecutions against individuals who have assaulted NHS staff, where the police haven't taken the matter further. "If the police won't take action we will consider bringing a private prosecution with the health body. It is important to send out a message that we won't tolerate violence," says Richard Hampton, head of security at the SMS.

"Clearly it is unacceptable that any public sector worker should face abuse or violence while they are doing their job. It is important that where at all possible, incidents are prevented rather than relying on action after the event. The responsibility lies with both employers and staff to ensure that risks are identified, action agreed and importantly taken to ensure that staff can carry out their duties free from fear of abuse."

Ultimately, while prevention is always the best option, there may be a case for giving all public employees the same legal protection as police officers by making it an offence to assault a public sector worker.

A healthy break

Anna Bawden — Thu, 04 Sep 2008 14:53:00 GMT

New proposals aim to give citizens the right to healthcare in countries across Europe, but how will this work?

The EU is trying to clarify citizens' rights to healthcare outside their own country but a draft directive raises a host of questions about payment and reciprocal responsibilities.

The directive would move the EU on from today's health agreement, which provides automatic reimbursement for emergency treatment for EU citizens wherever they may be. Until 2006, travellers had to take the E111 form with them to qualify for emergency care. It's estimated that 1% of the EU's total healthcare costs are incurred by people being treated outside their home country: that's about £8bn, and much of it is explained by movements across particular borders, between Germany, the Netherlands and Belgium and between Germany and Austria.

In future, the EU envisages a union-wide health economy in which would-be patients could travel to seek care in the knowledge their home healthcare system would cover (some of the) costs.

The proposals are an attempt to clarify patients' rights following European Court of Justice rulings. In a landmark case in 2006, Yvonne Watts successfully argued that Bedfordshire primary care trust should cover the £4,000 cost of a hip replacement operation she had sought in France, because otherwise she would have faced "undue delays".

Payments

The directive would entitle patients to receive non-urgent healthcare in any of the 27 EU countries and be reimbursed up to the amount their care would have cost to provide at home. So for UK patients, if treatment was no more expensive than it would have been under the NHS, they could reclaim the full cost of healthcare received in other EU member states, although they would normally have to pay for their own travel and subsistence.

Treatments unavailable at home will not be reimbursed. So if the National Institute for Health and Clinical Excellence has not approved certain drugs, patients would have to meet the full cost if they received them abroad. Similarly, spa treatments and massages available in some countries' health systems would also not be covered.

Patients will still need to get a hospital referral from their GP first. Afterwards, they would be free to seek outpatient treatment abroad without any need for authorisation. But for care involving an overnight stay, they may need permission to have treatment abroad. If the numbers of patients going abroad would "seriously undermine" the stability and smooth running of services, member states could insist patients obtain prior authorisation to receive healthcare in another country.

This would require clear evidence that preventing treatment abroad would damage national health systems and authorisation could not be refused if patients would face excessive delays.

Major problems lie ahead, especially over the calculation of costs. States with social insurance systems such as Germany and France will find it relatively easy to calculate reimbursements. Others would have to establish tariffs and systems to calculate what citizens are entitled to claim back. In the NHS, indicative prices exist for some procedures (at least in England) but not for others. "What would be the level of reimbursement for care," asks Anna Dixon, director of policy at the King's Fund, citing non-hospital treatment for which there are no tariffs; block contracts are the norm, so it is much harder to calculate a price per item.

It's not just the NHS which lacks the database the directive would require. Spanish health is financed through local taxation and central government funding. Delivery is devolved to the 17 regions. Denmark finances healthcare through taxation set at 8% of income. The bulk of this is then distributed to five regions, with the rest going to 98 municipalities.

Costs vary as they do in different parts of the UK. An implication of the EU move is that Scotland and Wales and Northern Ireland would have to calculate how much patients should be reimbursed. Scotland has tariffs for some elective procedures, while Wales and Northern Ireland have none.

The growing prevalence of day patients who are admitted to hospital for minor surgery but do not stay overnight will also be problematic. The directive also only distinguishes between in- and outpatient care, so it is not clear whether day patients would need authorisation to go abroad or not.

Discrimination

The directive could lead to allegations of discrimination. Why should NICE rulings be applied to patients from England if a non-approved therapy is available in, say, France? If patients have to pay upfront for their care in a Belgian hospital, this could mean that only those who have the money would be able to go abroad for treatment. Health systems would have to establish mechanisms to pay each other directly; with many countries operating devolved health services, the complications are endless.

The EU seems to want to establish free choice for patients - a political proposition that is highly contentious in some countries. The directive proposes that patients receiving care abroad could have more expensive care and pay the difference themselves. That trespasses on a hot political debate in England about top-ups.

As things stand private patients must pay the full amount for care. But if the directive allows them to receive rather more or better quality healthcare abroad and be reimbursed for what they would have received in the NHS, it will become increasingly difficult to argue that the same principle should not apply at home.

The clinical professions are accredited differently in the various countries; there are different minimum standards of care. What happens if a patient's treatment abroad goes wrong?

Perhaps anxieties are overblown. If the directive becomes law, it may have few takers. According to the website treatmentabroad.com, last year only 28,000 people from the UK received elective surgery and other non-urgent hospital treatment abroad. As each patient typically spent over £3,000, it would have cost nearly £97m to reimburse them.

Health collaboration is strong in certain areas. Strasbourg has arrangements with Liège and Luxembourg to exchange trainees, teaching, research and patients; Maastricht, Aachen and German speaking Belgium also treat each other's patients, as do hospitals either side of the Italian/Slovenian border. Keith Pollard, director at Treatment Abroad, says some medical tourism is also common to countries where care is cheaper, such as from Germany and Austria to Hungary.

A recent study by McKinsey argues that globally, 40% of those travelling abroad for healthcare do so to get access to the latest treatments and technologies. A third seek better quality care than they would find at home (particularly those from developing countries) while many simply want quicker access to orthopaedics, general surgery or cardiology.

Treatment Abroad says for UK patients, anxiety about MRSA is an important factor behind the decision to go abroad, alongside waiting lists and the cost of private healthcare in the UK. In countries with long waiting lists such as Northern Ireland, Wales and Spain, the directive could in theory help to cut them.

There may be financial benefits for lower-cost health regimes. "If you go to a country that is cheaper, the NHS will be quids in because it reimburses at that rate," says John Bowis, one of London's representatives in the European Parliament. Hungary is already popular among patients from northern Europe for dentistry.

The directive might strengthen private insurers such as Bupa and PPP. They already operate internationally, so would be in position to advise local health systems about healthcare in other EU states. And they may also move into providing "navigation" services, helping patients and GPs choose where to go for foreign care.

Pollard estimates that around half those who have gone abroad for treatment used an agent and half went under their own steam. "The market is very fragmented," he says. "There are a lot of one- to three-man bands acting as go-betweens." The directive would create opportunities for bigger players to set up medical tourism intermediary services, be they travel operators such as Thomson or insurance giants.

Anna Bawden