Category Archives: Ramblings

Digital Maturity Index?

It’s a good idea for health and social care organistaion to reflect on their digital maturity and understand where they are in relation to their peers.

The NHS Digital Maturity Index was a good proxy for what we all might reasonably recognise as digital maturity and potentially a great tool to stimulate reflection, benchmarking and change.

However, we seem to have forgotten what the likes or J Edwards Deming and Charles Goodhart have told us who said, respectively:

“Eliminate management by objective. Eliminate management by numbers and numerical goals,

Deming’s 11th point

As soon as the government attempts to regulate any particular set of financial assets, these become unreliable as indicators of economic trends.” have told us”

Goodhart’s Law

We’ve seen the same issue closer to home with the GP Quality and Outcomes Framework QoF which has been great at getting GPs to hit QoF targets, but not so great at addressing the crisis we currenty have in primary care.

Now the Digital Maturity Index has been linked to funding, career and organisational success people are understandably gaming it and it is ceasing to be a good measure of digital maturity, more a measure of gaming and political cunning that’s failing to deliver the organisational reflection that we desperatly need.

When are we going to learn?

Please! Not another “White Knight”

News has been leaked this week by Computing  of plans by NHS England to create a new post of Chief Information Officer/Chief Technology Officer to replace the role that Tim Kelsey will leave vacant at the end of the year.

On the face of it this seems to be a good idea, but my experience over many years gives me some concerns that such an appointment may not have the positive effect hoped for.

Over my 35 years in the sector I have seen a string of able people come and go in the top leadership positions in NHS IT. Generally they have been presented as the Messiah, someone with simple answers to complex problems, a White Knight (or Dame) with Silver Bullets that will result in IT or what we now call Digital, to enable a radical transformation of health and care.

A radical transformation is clearly what we need Digitally Enabled Services and Big Data are two of a very small number of tools available to us with the potential to make a major contribution to addressing the challenges in health and care readers will well understand. But, the answers to the complex problems we face are not simple, but are themselves are complex, and there are no White Knights or Silver Bullets.

As I said in an earlier blog

I’m pretty certain that the health informatics community know how to create the open digital ecosystem we need to support the emerging new models of care, but I have concerns that a lack of knowledge and experience amongst policy makers, vested interests in the care, informatics and vendor communities and a naive belief in the Tooth Fairy. Might mean we don’t achieve what’s possible.”

Leadership is critical to success, but we need leaders with a profound understanding of the domain who can harness the undoubted skills and goodwill in the care, informatics and vendor communities and who have the confidence to resist those with vested interest who insist they have simple answers.

Lets look at the characteristics of the various people who have held the top jobs over the past 35 years? In general, and there are exceptions, but these people.

  • Are intellectually very able.
  • Have a track record of doing amazing things – Although typically they overestimate the extent to which this was due to their brilliance and much underestimate the fact that they were just lucky.
  • Manage to dazzle those that appoint them, but turnout to be human after all.
  • Have limited prior experience in health or care, particularly on the front line.
  • Suffer from various degrees of narcissistic  personality disorder .
  • They don’t do “critical friend” and thus tend to get surrounded by “yes men” and sycophants.
  • They stay for no more than 3 to 5 years – Many have had the sense to get out before the job destroys them, some have not.

What do I want to see in any CIO/CTO? Well firstly it’s probably not a CIO or CTO but rather its closer to CCIO (Chief Clinical Information Officer), although it’s not exactly any of these things. They need:

  • A profound understanding of how the UK health and care system works at the front line. This is unlikely to be achieved without at least 10 years experience of working at the front line as a health and care professional in the UK or in a role directly supporting such front line staff.
  • A profound knowledge of health policy and practice and of the research/evidence base of how this might be developed.
  • A profound understanding of Health and Care Informatics – To me health and care informatics is the science of how health and care information and knowledge can be represented in a computable format an the techniques for it processing, it is not fundamentally about the specific technologies.
  • Experience of working in a politically and organisationally complex environment with the gravitas and robustness to survive in such an environment.
  • A personal and management style that can build and work with a diverse team of people who will continually challenge what’s being done.
  • A willingness to engage with unprecedented openness and collaboration with all of those in the care, informatics and vendor communities, including citizens, carers, patients and service user.
  • Enough knowledge and experience of software design and engineering to critically appraise what others tell him, but this is not a job for someone with primarily generic CTO/CIO skills.
  • Finally, they need to understand that this job is about making the best health and care systems in the world1, better by harnessing the commitment, knowledge and experience of those in the care, informatics and vendor communities that have put us in the enviable position.

Finding someone to take this role is going to be a challenge, but it is possible. It’s highly likely that the person we need is already working in the system. The last thing we need is somebody from outside of health and care or outside the UK. No matter how able they are they won’t get to point of understanding the challenge in the time we have to meet it (2020?)

Whoever is appointed let’s make sure we don’t place impossible expectations on them. They can only succeed if they can engage with and harness those in the care, informatics and vendor communities who already know what needs to be done, their role is not to tell us what needs to be done, but to enable us to do it.

Sticking to the Knitting

I’ve written about this before, but have become increasing concerned that the pressure on NHS organisation to generate revenue outside of their core business is a dangerous distraction, acts as a barrier to the diffusion of innovation within the NHS and acts against the best interest of patients and taxpayers.

A distraction because NHS management has challenges enough without targets to generate revenues, trivial in comparison to the budgets of the services they manage, form activities which are peripheral to their core business.

A barrier to to the diffusion on innovation because NHS organisations hang on to intellectual property, in the hope of selling it, rather than making freely available to other NHS organisations and the broader UK health and care sector.

Against the best interests of patients, because it distracts people from doing their day-job and denies patients the benefits of innovation from elsewhere in the NHS.

Against the best interest of tax payers, because in many cases the target customers are just other NHS or public sector bodies which at the very best in a zero-sum game but in reality much, much worse because of the cost of sale and the massive opportunity cost from the slowed diffusion of innovation.

Those involved in the system understand and resent the situation, but politicians and policy makers don’t and have created incentives and penalties in the system that force rational people to behave in what are a sub-optimal ways.

I’m all in favour of exploiting public sector IPR to taxpayer benefit and while there are examples of such opportunities at significant scale (most often in pharmaceuticals and biotech) in many more cases the small scale of the opportunity and the disbenefits to patients and taxpayers mean we really should think again.

What makes an Open Source community?

There has been a lot of interest in the role of Open Source software in the UK over recent months, initially stimulated by NHS interest in the American VistA Open Source EHR, but now taking on a broader scope including some of the exciting home grown initiatives.

Included amongst these are a number of projects that started in a closed source environment, where the IPR owner has decided to shift to an Open Source model. From a narrow technical perspective making software Open Source is easy – You just make release it under a recognised Open Source licence and make it freely available for download. However, Open Source is about much more than the licensing model and much more needs to be done to achieve the benefits of Open Source than what the Open Source community disparagingly call a “Code Dump”.

Open Source is about an approach and philosophy that at its’ heart believes that by creating a community who can freely use and contribute to a product that we can create better software and release new commercial and social value not available from other approaches. Open Source enshrines some import  freedoms and principles which defined and maintained by the Open Source Initiative  that also provides guidance on licences that meet these principles.

To be effective an Open Source community has to be diverse and well supported; containing all of those stakeholders needed to ensure a sustainable business model for the products’ ongoing development and use in which no single entity has effective monopoly control and requires governance structures around a particular distribution or version of the source code (often called a “Distro” in the Open Source world) so that users can have confidence in the safety, security and quality of that Distro including changes and new contributions made to it by the community – Something that is particularly important in context of health and care software.

Stakeholders include:

  • Those that gain financial value from the existence of the Distro – These might be organisation that use the software or the data it generates (like the NHS, researchers and other health and care commissioners and providers) or organisation that sell services to community made possible by the existence of the Distro (including developers, implementers and maintainers) – It is this group of stakeholders who will be the main source of resources to sustain the development and use of the Distro.
  • End users of systems and those who they seek to serve using the software – It is only by involving end users in an agile user-centred design processes that we can build systems that truly unlock the potential of digital technology – Too often the poor design of tools that people are expected to use is a barrier to doing what’s important. In the context of health and care this means involving frontline clinicians, other health and care professionals, managers and administrators – Their needs are often not well understood by policy makers, senior management and IT departments. Most important of all it means working with patients, service users and their informal careers who are too often the victims of poor service resulting from poor design.
  • Academics and technologists who are able to educate the community with regard to those things they know that might enable the community to improve the Distro and/or the effectiveness of its deployment and help the community critically evaluate it use. This might include ensuring that the community is aware of existing and emerging standards, technology and theoretical frameworks of potential value to the community.
  • Policy makers and senior management who need to understand how the Distro can be deployed to improve services and how such use can both shape and support policy.
  • A vibrant market of individuals and organisations who can provide a range of services to support the development, implementation and use of the system as well as relevant add-on products and services. This market should ideally include individual consultants and contractors, SMEs, social enterprises and large global system integrators. It is vital for the health of the community that there is a competitive market in the products and service needed to improve, deploy and exploit the Distro so that user organisation have a choice of who they contract to provide these service.

The Distro needs a custodian, owned and controlled by the community, who will promote nurture and protect the Distro, provide mechanisms to encourage, manage and quality control changes and improvements to it by the community and commission the delivery of enhancements and other services on behalf of the community.  The custodian needs to set and maintain source code and documentation standards and ensure that documentation is available of a sufficient quality to enable a competent developer without prior knowledge of the product to work with the source code and ideally should be able to provide additional guidance and training to enable those who want to work with the software to be able to so as quickly as possible.

A key aim of the custodian is to try and keep the community together on a common Distro. Too often, short-term pragmatism results in changes to source code somewhere that breaks something somewhere else creating a “fork”in the source code tree. While some limiting forking might be healthy if too many users “fork off” the benefits of Open Source are diminished. Avoiding this requires that the custodian provides support for people to make changes to meet their needs without breaking things important to others, in a rapid agile and responsive way. However, making changes in this way will still be slower, in terms of achieving immediate local priorities, but doing so has damaging medium and long-term sequelae. The custodian has to close the gap between the two approaches and educate developers about  the benefits of doing things for longer term benefit.

Additionally , the custodian has a role in providing assurance and warranties to users that deployments based on the Distro support by organisations accredited by the custodian will be safe and secure to deploy in live health and care settings.

Enabling the custodian to deliver its’ responsibilities will require that it is funded by the community to do so. To facilitate this the custodian is probably best constituted as not-for-profit Community Interest Company (CIC) whose control is vested in the community such that no single class of stakeholder can determine its’ actions.

If we can build effective communities then the wider introductions of Open Source software in the NHS as part of a mixed economy alongside proprietary products will help drive better value and front line user engagement and commitment  across the board, just dumping source code under an open source licence (or worse some bowdlerised licence) will not.




Food England?

Listening to the Nuffield Health Policy Summit Lots of interesting stuff from Phil Collins of the Times. Talking about “command and control”, “integration and competition” and “patient centred service design”

Perhaps it would help to think of the NHS as a supply chain?

Supply chains are complex adaptive systems which consist of a large number of participants of very variable size and power. There is little or no overall control or management of the system (although individual elements may be and should be tightly managed) and the participant simultaneously compete and corporate.

Left alone supply chains just work, tamper with them and they break in unexpected and unpredictable ways. Consider how the UK food supply system works without “Food England”.

“Wicked” Barriers to Innovation and Adoption

Sometimes we just have to JUST DO IT! In the NHS we have too high a tolerance for inaction and too little tolerance for honourable failure.

I’ve just come back from the Healthcare Innovation Expo in Manchester, where there was much talk about the need to encourage innovation. I’m all for that but I think it’s widely agreed that the problem is not innovation but getting innovation that works widely and rapidly adopted.

I’m trying to help NHS England do some innovative things with Open Source and we made lots of progress over the two days at Expo, but I again encountered examples of two of the wicked barrier to innovation and its’ adoption.

I call these things “wicked” because they are both things that are genuinely important and that we must properly consider, but they also represent two of the most effective spanners that those who feel threatened by the innovations of others can throw in the works to slow down adoption.

They are:

  • Clinical safety
  • Evidence

Don’t get me wrong clinical safety is important and I support the application of standards like ISB0129, which I think is actually well put together and does a good job of encouraging a proportionate approach to clinical safety. What gets my goat though is the way in which clinical safety can be used as excuse for not doing things differently. I wouldn’t mind so much if we knew that current systems and processes were safe, but the fact is that we know they are probably not and I don’t see a good case for slowing down innovation longer than is necessary to be confident that they at least marginally reduce harm. Too often “the Best is the enemy of the Good” and the paradox is that the laudable desire to ensure that responsibility for clinical safety is nailed down and hazards are properly assessed and managed makes it desirable, to some, to stick with current systems and process where the hazards are not well understood or managed, but where nobody’s head is on the block if things go wrong.

Similarly with evidence, we should of course seek evidence to support that what we plan to do will be effective in achieving whatever it is we hope to achieve, but again bleating “where’s the evidence” is a great way to throw a spanner in the work for those who lack a more cogent reason for objecting to a particular course of action. Again, I’m particularly irritated as we sometimes have little evidence that what we currently do works well and more often have evidence that it doesn’t so why not try something different. I’m also concerned when people ask for evidence for things that have not done before. Clearly, if we have not tried something before we can’t have direct evidence of its effect and the more innovative an idea is the more difficult it is to find proxies for direct evidence. Sometimes we just have to rely on professional judgment, faith or plain old gut feel and just do it. We have to take this route if we want innovation and adoption but we also have to recognise that we might be wrong, evaluate what we do and “Fail Fast”. We also have to ensure that we don’t castigate those who try and innovate when they fail, as long as they fail as fast and with as little harm as is reasonable practical; sadly in the NHS we have too high a tolerance for inaction and too little tolerance for honourable failure. Given the challenges we face we know inaction will inevitably lead to catastrophic failure and have encourage people to, at least, do something.

You can read more about barriers to innovation in my blog “What Entrepreneurs Want” over on the HANDI web sitenovation

Another own Goal from NHS Commissioning Board

It seems to me that the NHS Commission Board is about to score another own goal with it plans to seek section 251 approval to share identifiable patient data without consent reported in the Health Service Journal ( Warning: some of this article may be behind a paywall)

I want my identifiable health data shared so that it’s available to all of those who can use it to directly deliver better care to me – But I want to be in control

I am happy for my data to be shared for a wide range of secondary purposes that will help the NHS operate more efficiently, advance healthcare research, create economic opportunities for the UK healthcare industry, be used in any other way that contributes to the greater good or that someone is willing to make worth my while – But I want to be in control.

I want to told who my data will be shared with and have the right to restrict or extend the sharing as I chose  – even if this is not in my best interests.

I want my privacy to be protected and in particular I don’t want identifiable data or easily re identifiable rich datasets shared when the use of privacy enhancing technologies or more limited datasets make this unnecessary. If this is a little onerous for those who want to use my data – tough. However, if identifiable data is really needed and I consider the purpose noble I’ll probably consent – But I insist on being asked. I’ll lie and withhold information if I think it will be misused.

Trust lies at the heart of the relationship between patients, health and care professionals and their informal care networks. Using digital technologies and data differently is an essential part of what we have to do to have any hope of meeting the challenges that health and care faces. We have to work out how we preserve trust in the digital age and it is not helpful or necessary for the NHS Commissioning Board to attempt to remove patients from the decision about how their data is used or to ignore the existence of privacy enhancing technology that would enable them to achieve what they want to achieve without playing fast and loose with patient trust. I don’t understand how this sits in the context of a patient centered NHS or with the Government’s mantra “No decision about me without me”

My concern is that this is going to trigger a backlash that will result in challenges in the UK and European courts, patient asserting their right to opt out (section 251 does not trump active dissent), whereas most of us would be happy to share if we were asked, and most of all that this will destroy the trust that sits at the heart of the doctor patient relationship.

The issues exposed by Prof. Brian Jarman indicate just how important it is to make data about what happens in the NHS open and transparent to public  scrutiny.  Brian’s work shows us that Government and NHS can’t be trusted to hear or act on what the data tells us any more than they can be trusted to respect patient’s privacy.

We can do what needs to be done without the cavalier exposure of identifiable or trivially re-identifiable datasets. We have technology to manage blind record linkage so that identifiable data does not have to leave the control of the patient’s own care team.  Those working in the field have developed tools and processes that allow us to manage privacy risks in ways that reduce these without undermining the value of the data. While others are developing approaches that will make it easier to collect and manage patient consent.

I don’t want to see the progress we are making with open data, transparency and digital health care derailed by an avoidable backlash. let me be clear I’m with what the likes of Tim Kelsey are trying to do but they do need to take care.

For more information look at the exemplar work of:




For a broad review of the issues and more on Privacy Enhancing Technologies see Fair Shares for All from the Primary Care Group of the British Computer Society

Preserving Trust in Digital Healthcare will be the subject of the joint #CCIO #NHSSM Tweet Chat 8-9 pm, on Wednesday (20 March)



We Made It! Nick and Ewan’s Grand Union Canal Adventure for the Neuroblastoma Society

Just to let you all know that we both successfully completed our cycle ride down the Grand Union Canal on schedule on Wednesday raising over £6,750 (plus a gift aid supplement from the Tax Man of  more than £1,200) for the Neuroblastoma Society.

If you donated, thank you for your support. We plan to keep the Just Giving page open for a few more days and will send you one last email when we know the final total.

If you have yet to donate (perhaps you thought we would not make it) this will be possible for the next few days

We cycled from the start of the canal at Warwick Bar in Birmingham to the very end of the Paddington Arm. This is 140 miles of towpath and we cycled 160 miles in total between leaving from and returning to my home in Leamington Spa. We did about 45 miles on the first three days and about 25 on the last day.

We found the ride challenging, as significant sections of the towpath are hard going managing to be variously soft and dragging, bumpy, muddy and/or overgrown. The best sections are generally those through built up areas the worst in the countryside (particularly between Napton Junction and Braunston) although surprisingly the first half of the Paddington Arm in West London was very poor. On good sections we managed to average about 10-12 mph while on rougher sections we were down to less than 5 mph. The forecast had been dreadful, but the weather panned out better than we could have hoped and we only did about 5 miles in the rain including the last two miles into Paddington in torrential rain (if it had been like this for more of our trip I don’t think we would have made it).

Nick fell off his bike once and both of us came close to ending up in the canal on a couple of occasions (we declined my daughter’s suggestion than we should stage a canal plunge in Paddington for the benefit of Youtube) We did not suffer any bike problems with our specially purchased Kevlar reinforced tyres fending of the many thorns and some broken glass.

We said hello to everyone we passed on the towpath and those who passed by in boats. The response rate to our greetings feel significantly South of Berkhampstead confirming Nick’s Geordie view of unfriendly Southerners

We are now both home, aching slightly, a bit fitter and maybe a tiny bit less fat. Apart from a pint a lunchtime on the first day (which we regretted) we can confirm that the suggestions from some of you that we would stop for a beer at every pub were ill-founded and we resisted the temptation until the end of each day by which time we too tired to manage more than a couple of pints.

Thanks to all of those that supported us, particular Ewan’s wife Alison, for collecting us from Braunston at the end of the first day and returning us there the following morning, Neill Jones for meeting us at our dreadful hotel in Bletchley and taking us out to Bistro Blanc in Milton Keynes for dinner and Ewan’s daughter Iona for waiting in the pouring rain to photograph the end of our run. Also thanks to those who joined us on route or on Wednesday evening in London and us course all of you who generously donated to the Neuroblastoma Society.

You will find various photos on Nick’s blog

We have some thoughts of a challenge for next year, we shall see?

Nick and Ewan’s Grand Union Cycle Adventure

Please help us help The Neuroblastoma Society

Not health informatics this time, but the planned adventures of two health informaticians – myself and my old friend and colleague Nick Booth. ( who plan to cycle the length of the Grand Union Canal from Birmingham to London.

I was inspired to do this as a result of my local cycle rides around Leamington Spa, where I live, which includes a section of the Grand Union and wondering what it would be like to cycle all the way to London. I suggested this to a few friends who though if it were to be done it should be done properly and that we should start in Birmingham (adding 30 miles) and do the whole length of the canal. So that’s the plan, but all the friends other than Nick have found reason not to join us.

As you might imagine the canal does it best to take the flattest route possible, but this is not the shortest and the canal meanders a bit (145 miles compared with just under 100 for the crow) there are a few flights of locks to climb and the odd hill where we can’t follow the canal under a tunnel, but overall its downhill with a 350 feet descent.

The towpath is of variable quality and while some stalwarts do it in a day Nick and I plan to do it over 4 ending up at Paddington Basin, rather that the slightly closer original end of the canal at Brentford.

We have had nearly nine months to plan and train but while there has been some training planning really only started last weekend and planned reductions in weight and improvements it fitness have not been quite as we had hope. Both off us know we can comfortable do the required 40 miles in a day, but are not so confident about doing this four days in a row.

So to give us a motivation to finish we have decided to try to raise some money for charity at the same time. This will maximise the glory if we make and the embarrassment if we don’t and we have chosen to support the Neuroblastoma Society of which our mutual friend Steve Smith is Chair.

In July 1997, just before her first birthday, Steve’s younger daughter was diagnosed with an aggressive form of cancer. Like most people he had never heard of neuroblastoma, but learned a lot over the next few weeks and months as she was treated with chemotherapy and surgery. Her treatment was effective and she’ll be 15 in a few weeks, but the majority of the 100 or so children who are diagnosed every year in the UK are not so fortunate – more children die of neuroblastoma than any other form of cancer.

Steve’s been a member of the Neuroblastoma Society for a few years now and is currently the chair of the Trustees. The charity raises funds for research into the causes and treatment of this disease, aiming to ensure a happier outcome for more children and their families. Over the years the Society has made grants exceeding £2.5M, a great effort for a charity which depends entirely on volunteers.

The Society is the biggest single funder of research in this field in the UK and a lot of this work just wouldn’t happen without it. The next grant round kicks off later this year and Steve and his colleagues are trying to make sure they have £1M available.
The more you donate the more difficult it will be for us to give up after the first 3 miles and the more we are likely to suffer so please give generously.

Just go to

So please dig deep and donate now.

Life without a Moblie Phone

Both my adult children have recently had their phones stolen. Both were bereft.

This lead to the following email to my son with some reflections on life without a mobile phone.

Hi Silas,

How are you finding life without a phone?

Interesting to reflect on this. You were born in to a world where very few had mobile communications, but I had a car phone by the time were you were two and you had your own mobile at 14, so pretty much all of your independent life you have had a mobile phone. You are of the first generation in this position and it has certainly changed the world.

As a teenager most of my friends had a phone at home and then browse around this website- Palm Beach Roofing Expert for their future home roofs and building although there was a significant minority without one (we didn’t have one until I was 12, and your mother had long left home before her parents installed one) I spent most of my time at university and in the few years after in shared houses with no phone.

Mobile communications was for a few restricted uses and much restrained by cost, the technology, available radio spectrum and regulation. The only way for an individual citizen to get legal mobile communication was as an amateur radio enthusiast and this required a licence that necessitated passing technical and Morse code tests, but did give you access to SW radio which with the aid of a big enough aerial and a shed full of kit allowed global communication (SW will propagate in the ionosphere, so with the right conditions you could get voice communications with Australia).

Radio telephones using VHF were restricted with civilian licences only available to the likes of taxi firms, private security operators and GPs These things operated with a base station with a big aerial and could manage a few 10’s of Km range, but only very short distances mobile-mobile without relay through the base station which required manual patching by the base station operator.

One of first publically available national radio telephone service came with deregulation in the early 1980’s which allowed Securicor to open up their network of base stations (set up to communicate with their armoured delivery vehicles) to anyone who could afford it. This service still requires manual intervention to patch you through to another user and the operator could also patch you through to the POTS and would do things like make a restaurant reservation for you. The kit was such that it really needed to be installed in a car, but it was possible to get a luggable unit. However, this technology was very expensive and really only affordable by rich individuals or businesses with imperative need for mobile communication. I worked with someone who had a Securicor phone and I made my first mobile call on it in 1983.Shortly after Securicor partnered with BT to set up the Cellnet mobile network.

The introduction of cellular phones in the mid-1980’s started the mobile revolution as it massively increased capacity and provided automated switching between mobiles and with the POTS. The first phones were luggable and really needed a car installation, but I used one of these on the train for the first time in 1987. Also at about this time the first phone designed as a hand portable appeared this was the size of a brick with a 6 inch aerial (it battery life was also about that of a brick) This was a great favourite with City Boys and is probably the most iconic artefact of Thatcher’s “loads-a-money” deregulated Britain

With my car phone in 1987 I was amongst the first to have a mobile It cost over £1,500. However over the next 10 years prices fell, the technology improved (and importantly went digital allowing SMS messages), network coverage and devices improved and by the mid 90’s mobile phones had become affordable by the masses.

Before than life was different. Mobile phones in the future might use alarm control system for better security and to avoid circumstances. Meeting up with people required that you knew where to find them (people were much more tied to home or office) or prior arrangement (mainly made by fixed line phone.)When you were out and about it was difficult to communicate and the only way it could be done was with complex arrangements using call boxes and other fixed line phones to relay messages. There was much hanging about and prematurely terminated activities when pre-arranged rendezvous got out of step with changing circumstances and you never knew if you had just been stood up, forgotten or if some disaster had befallen the person you were supposed to be meeting.

In your world all of this has changed and it’s a double edge sword. On one side you get the peace of mind of easy communication and you are freed from the need to tie yourself to particular locations and pre-arranged plans, while on the other side you are expected to be always available, always contactable.

All in all the connected world seems a better one to me, but it is interesting to discover what we do when these things breakdown, particularly those with no experience of different ways.