Thursday, May 26, 2016

Airline NHS

29th February really started at a whim. Blogging. Sitting in a cafe in Paris...looking back,it was supposed to be sort of like a personal diary- reading that blog suggests there never was any great expectations that many would read it but over time, some have taken the time to read the rants, pontifications, lectures, it any which way you want- whoever you are- thank you for reading and passing on your thoughts- it has been much fun indeed...or at the very least, cathartic.

Time moves at pace..and when you are having fun, before you know, 4 years and a bit of blogging have whizzed by..and here today, I pen my 200th blog. And this one is dedicated to one of my pet bugbears (No, it's not the HSJ- behave yourself!) but the airline analogy the NHS uses when it comes to patient safety. And it's frustrating to no you ask why? It's because the airlines really do have much to teach us but unfortunately the lessons which we can learn are lost in vacuous sound bytes and tokenism towards patient safety.

To begin with, if you are going to use airlines as a barometer for safety, then one cannot pick and choose which bits are to be used and what not. The culture of learning from mistakes is one to be admired and learnt from but without forgetting the professional approach taken by the airline industry towards it.

Let's begin with training. There isn't a single airline in the world which allows its planes to be flown by those not trained. Imagine the sheer emotions if your pilot casually mentioned that he hadn't actually trained in flying the plane or indeed got a certificate to prove his or her training. There's a sheer belief as a passenger that the person flying the plane is trained. So let's turn to the NHS- are WE sure we follow this? Are YOU sure the person you are seeing is trained in the pathology you have presented with? Thereby lies the split and dichotomy.
Let's say you need your gall bladder surgery- you wouldn't expect anyone to "just do it"- in fact if it's not a surgeon, you would like to know that the person wielding the knife is would like to know and believe that the anaesthetist putting you to sleep and in charge of waking you up wasn't a Diabetologist who had wandered into the operating theatre. When we start extending that analogy to specialty areas such as Type 1 diabetes ( I know, sorry to bang on about it..but it's a safety thing- so bear with me) there is little to no quality control and very little of the rigour applied to let's say, a hip replacement.

Let's clarify myself here,this isn't just about the GP or practice nurse...if you think every single diabetes specialist is trained in insulin pumps, you must be having a laugh. But across the country, many do indeed have a go at it. Let's not point the finger at primary care regards rigour of training if we specialists ourselves haven't quite got our house in order or at the least aren't able to offer primary care the support they need. If you start using the airline as a comparator, then in many cases, clinics should be shut down till training is complete. It's another matter we can't do that in health- thus the analogy crumbles a bit.

The problem as ever is with sheer capacity- the response of the aviation industry with increased demand has not been to ask flight attendants to fly planes but also to increase number of planes and trained pilots- simply as that is key to safety. So what do we do? Do we simply brush aside examples of good practice from the aviation industry or do we have something to learn? My gut feeling is there is much to learn- but a genuine move away from sound bytes may need to be the first step. Patient safety champions are quick to point out errors, exhort learning from aviation yet slow to respond to what aviation teaches us. Human factors is an important issue for aviation- Martin Bromleys work on this is much to learn from- do we use that enough? Do we want to or do we simply want to use a cheaper workforce as part of cutting corners?

Challenging questions which need to be answered...need to be looked at genuinely. Till that happens, we will continue to have a system where a Type 1 diabetes patient, in 2016, in a first world country gets admitted to ITU because somebody didn't quite realise that insulin is what that patient needs to survive. Or forgot because it wasn't a priority. Or didn't ask someone who were trained. Or didn't have access to someone who was trained. Take your pick but either way you cut it..that patient is left wondering how someone who isn't trained to fly a plane is actually doing so.

Aviation has much to teach us- if only we are willing to look at it properly.  It will challenge not only politicians and policy makers but us as healthcare professionals as a whole. If patient safety is genuinely something important, then maybe worth opening up that can of worms. If that results in even 1 less error, even 1 less admission to ITU..then it's all worth it for sure.

Thursday, May 19, 2016

Time out

Thought would use this blog aimed at all the junior doctors- with a simple message. Take a Time out.
Social media has been a curious cocktail since the "Deal" was announced- and conjectures, theories,mischief has flown around in equal measure- with to be honest, most folks having no idea what actually consist of the detail.
So to all junior doctors, take a time out. Shut yourselves from all external opinions and wait for the actual details to come out. As a senior clinician in the NHS and some experience of the system, would ask for calm, time and patience.
This isn't about the BMA or the DH- this is purely about YOUR future- and it is up to you to take the time and understand the details when it comes out. History- and indeed science is littered with examples where the abstract of a paper hides many a fact of the actual paper- and what you have isn't even an abstract but a press release.

I am not a member of the BMA- but for a moment, pause and appreciate the effort put in by Johann. Throughout all this, his composure has been much to admire, he has been resolute- and then he has also gone back to the table. Whether he has achieved what you want- well, let time and the details inform your choice.

Mischief abounds on social media- the desire to rile junior doctors is there- if you counted the number of folks with chips on their shoulders, you could open a local chippie. You, as junior doctors, are clinicians, scientists- apply that to the details and see whether the new deal helps to achieve your perspective- whether that be patient safety, equality or indeed quality of life.

For me personally, the contract was about hours worked, safeguards and indeed equality for all- not a 2 tier system based on whether you took a break due to pregnancy- and if these are looked at, I am happy. I don't know whether I am yet- because I await the details.
Think about the initial contract, see where you have got to- and then decide whether the negotiation team has achieved what you wanted. Not everyone will be happy- but it is about the majority view.

This is not about "winning"- this is about working in a safe environment for both yourselves and the patients- so wait for the details and see whether this achieves it or not. Of course, politicians will spin what they want to- but thats their job. We all know what a 7 day service needs- it certainly isn't a junior doctor contract change.
To achieve a turn around from a government and get back to table- from a bunch of junior doctors, who -lets face it- most folks didn't give 2 hoots- is nothing short of remarkable. Forget the ones trying to rile you- a generation of NHS staff and many many patients are very grateful not only for the resilience shown but the ability to go back and negotiate.

So- to all of you folks- without whom our health system would stop functioning- and to whom I am always grateful for the help you provide, its Friday. Stay off the Facebook forums, the angsty twitter chats…..take a time out. Enjoy your weekend- wait for the details- then get a nice drink, sit down with it- and make your decision- as an adult, as a clinician, as someone who is reading a paper, not a press release.

You have all earned our respect. Enjoy that…bask in that for the moment- and then make the decision that feels right to you- not influenced by anger or being riled by someone.

Best of luck x

Wednesday, May 11, 2016


Was it ever thus? Or is it that the power of social media has just made it more apparent? The culture of silence that is. Or should I say contrived silence? It's very difficult to pinpoint but whichever topic you choose, the culture of silence pervades through the NHS.

Many reasons abound for it..whether it be the fate of whistleblowers, whether it be downright bullying, whether it be political expediency or even the blame culture we all live in. No blame, no shame? The cruel harsh world of social media offers no such clause, it's stark, it's brutal, it's in your face and sometimes, not too far from a lynch mob- and not just the NHS but pervades through all sectors of life now. Sometimes overt, sometimes with a wink and a nudge...either way, the personal finger pointing promotes further silence.

We seem to have created an atmosphere where silence is the easier way out, the one path without much I know the healthcare philosophers will have some glib quote to suggest how patient care and vocation should trump all...but let me put this to you..if being honest and breaking silence puts you in hot water, either via someone baying for your head or resulting in an end of career....none of those philosophers will actually stand by you, will they? It's YOU on your own, so the natural instinct is to say "Hush". Nothing wrong there, vocation doesn't pay the bills nor the mortgage.

There rarely if ever is a healthcare professional in the NHS who doesn't see poor care..the question is....does every single one of us flag it, raise it, take the cudgels up and improve that patients journey or the next one? The answer is possibly no. Let's take my area of specialty....there rarely is a diabetes specialist in any shape or form who isn't aware of what happens to patients with diabetes admitted to hospitals ( I am not even talking about weekends)...many of us have been part of reporting errors, highlighting poor care, simple basics being missed...hand on many of us have tried raising each of these errors and kept going? How many of us at some point haven't been asked to hush as there is no money/stop causing a racket/isn't a priority? Have we then colluded for poor care continuing? Have we chosen the easy way out? Have we decided due to one reason or another to not raising it anymore, to keep quiet? Tough questions aren't they?

There is a reason why journalists finding scoops bemuses me to no end. Because any doctor or nurse worth their salt could actually find you better scoops -except that in the present system, you do so and you are a whistleblower. Finding scoops is easy- just try putting FOI of errors and actions can criticise many an event. In the cold light of time and through the sharp focus of a retro spectroscope, judgement is easy to pass.Patient errors are not too uncommon- what we need to find out what stops us from raising them...what promotes the culture of hush. It's a fine line between accountability and a witch we as a society balance that divide well or does the freedom of social media offer us all opinions without control?

The present contract fiasco is another private, there are few who will admit it's a good thing- at last check, bar David Dalton and Chris Hopson , no one has associated themselves with a public statement. To be clear, I respect them for that- whatever your views on it, at least they have been clear about their views...the rest have either chosen to stay silent or make oblique vague references to working together, having group hugs and all sorts of waffle. So here's my question...if the top echelons of the NHS are adapting the Hush approach, what message does it send to the rest of the staff?

The sadness is that these errors are actually gold dust, complaints are important and we must, as a system, understand why keeping quiet doesn't help anyone...perhaps society also needs to give the NHS staff a break when errors happen- if there is willingness to put ones hand up, learn and improve care, that must be seen as a positive. I am keen to try and improve patient safety- especially for those with diabetes- in hospitals. And I would strongly encourage staff to not walk past the next error, not shrug their shoulder but to raise it, whatever be the due process. If that turns to be a dead end, go further up..if still that doesn't work, I would like to know. I would like to understand what stops a type 1 diabetes patient from being given their insulin in 2016 in a first world country. I don't want a fancy hashtag for that...I want folks to genuinely believe it's worth speaking up.

Hush isn't really an option and in a small way, if I could help to break that cycle, please- do bring it to my attention- if all other avenues seem exhausted. One can only promise to try.

Sunday, May 1, 2016


What next is pretty much the question on everyone's lips. Many theories, many conjectures, many thoughts…but to be honest, when you are in uncharted territories, all bets are off. So all guesses, including mine, are all, at best, guesses- some tinged with reality, some in hope, some in despair- and some as ever with an agenda lurking in the background. Many blogs have appeared where patients feel left out of the discussion- as far as the government is concerned, they did have a discussion- it was in their manifesto- to have 7 day services. That discussion went quite well actually- it was called the General Elections.

So what will happen next? The strikes have happened- the seniors moved things around, cancelled stuff, stood by their juniors and to, what appears, the utter incredulity of some, no major safety issues cropped up. The scaremongering was anyway a bit silly- most seniors on the ground knew it would be ok- and to be fair, as did most NHS managers. All it needed was a bit of planning, cancellation of some activity, teaching etc- and there were enough personnel around to cover what was needed. I have no idea what happens next- more strikes, more the mix of that the Euro referendum - all of that makes this all pretty unpredictable- who knows- maybe both sides may have an epiphany and decide to go have a beer…though to be honest, the chance of that happening and Lance Armstrong coming back to competitive cycling appears to be at par-at the moment.

But heck, everyone's having a go at conjecturing- so why not me! Trusts are not stupid- they know, beyond everything, they do need their staff to run things safely. Given a choice- most executives will choose patient safety above fiscal discipline (aka being tight with money)- the reason? They rarely do their job to balance books- they do want to make a difference. Want an example? Pretty simple- the reason the NHS is still running reasonably well in spite of all pressures is because its happened at the expense of the money side…the billion dollar question is how long that is sustainable.
Anyway. so Trusts won't be stupid- and they will find loopholes in the contract to ensure their juniors find it reasonably acceptable. Roy Lilley's suggestion of "local negotiations" will happen- but not publicly- and variations will emerge- but by using the new contract.
That will result in gaps- which will need filling. The locum caps will be breached- has to be - in fact there exists a clause of breaching it for patient safety- and it will continue to happen at pace. If Trust X decides to hold to the cap, a neighbouring one will breach it…all about who wants patient safety above the issue of money. Tricksy eh?

What will that do for 7 day service? Nothing to pretty much nothing- why? Because the whole 7/7 had nothing to do with juniors but heck, who cares about technicalities. All that aggro, fights will result in little for patient safety, the finances will continue to take a hammering - so we are stuck where we are. And then comes the most important bit…to keep the NHS going, what you do need is a lot of "extra"…"extra" bits that are not paid for, bits that come from vocation- and angry disgruntled people don't give you that. Thats not special for a  medic, but is the same for the chap seeing you drinks at a bar too…he will stay on a bit extra because his boss made an extra effort to make him feel valued

So how would that happen? Well- it will require the medical leaders to do so…the question is whether they have the trust to do so? Would the juniors trust those who have either stayed quiet or openly forced the contract? Would those seen as, rightly or wrongly, furthering their career be trusted to put an arm around their shoulders…or will it need a new generation of leaders to do that? Tricksy indeed. How would Dalton fare when he stands up to speak to juniors and regain their trust- who knows indeed?

So, in short, a forced contract, achievement of bits of government manifesto,more financial troubles, need for new leaders to rejuvenate the workforce…that's my prediction for next 6-12 months
Or I could be completely wrong- and it could all be sorted by that one single beer between Johann and Jeremy.  Or the next battle with consultants will erupt with further embitterment, angst…and all those attempts at "working together"? Take one further hit.

Imagine…all of this potentially avoided by an open honest discussion with the public…something along the lines of "We genuinely want to improve 7 day service- however, we don't have enough money for it- so lets discuss what needs to stop or reduce"

Now…THAT wasn't so tricksy..was it?

Saturday, April 23, 2016

Three at a time

So here we are- a national role in diabetes. 7 years as Clinical Director, work with CCG as secondary care advisor, work with Kings Fund, CQC..a model of care- which for all its faults- is at least seen as a template to work on….the opportunity and the ask was perhaps at the right time. Working alongside the present National Clinical Director of Diabetes, Jonathan Valabhji…the opportunity is there to make some changes. The billion dollar question as ever is will I be able to? How restrictive will the trappings of central NHS be? How much freedom will I be allowed? The thing however is that self doubt is not really in my genetic make up- so after a fleeting few seconds, to me the job became pretty simple- you make of it what you want to, right?

Thank you to many patients, carers, colleagues for the kind words received, the hopes placed and the suggestions but I don't intend to change the whole world of diabetes overnight. A great tip for me when I set out on my management journey back in 2009 was always to focus on 2-3 things for starters. Get those right- then move on to the next phase. Try too much, you struggle to achieve much…so have mulled over many things, lots of conversations with my to-be partner in crime, Jonathan- and I think I am honing into 3 things…I suspect if we can get those things right, we will have progress.

Priority A: 

Improve Type 1 diabetes care: With my background, this was pretty much a given. I have always maintained that in the term "diabetes", we have meshed everything and done a huge disservice to all types- Type 1; Type 2, genetic ones- they are distinctly different with distinctly different needs and skill mix- if powerbroker/Commissioners don't know that or fail to recognise that, we will never ever improve quality of care for anyone.
Part of that will involve increasing profile, raising awareness, getting all to agree to appropriate pathways (and that has indeed been part of the reason for setting up the #talkT1and #TAD talks. Lets get the basics right.
Giving basic foot checks t folks with T1D isn't complicated, its basics. Ensuring a patient in hospital has their own insulin or even making sure they have it on time with food is not complicated, its basics

Priority B:

Getting everyone on one sheet: Do you know how many organisations there are in Diabetes in this country? Let me go through a few: Diabetes UK, JDRF, ABCD, PCDS…factor in RCP, RCGP- and you see the problem we have. Beyond all of them, there are many many patients, countless professionals who aren't part of those organisations…all individually trying to do the right thing, separately? A divided voice.
I want to have more TAD events- for all "stakeholders" to recognise the importance of joining hands. All of those bodies want to improve care…and if you genuinely want it, patients are asking for help- join hands and lets do it together.
Step up to the plate- and remember as a pack, sometimes different organisations may need to take a lead on different issues. Its not about who does it - its about what the whole collective wants to achieve. On that note, specialists have to step out of the breach- primary care needs support- lets do that- and do that properly.
Start thinking- do Vanguards offer anything? Does the GPforwardview offer anything? Look at opportunyies- any opportunities to offer primary care the support they need. They- and our patients want better access- in 2016,we must be able to do that

Priority C:

Technology- lets do this properly- not have meetings eulogising projects which have no legs. Let technology flourish. (I already thank Roy Lilley for putting me in touch with some interesting folks!) This is 2016- Skype is NOT an innovation- and no, the North Koreans are not standing by to hack anyones blood sugar readings.
Lets stop putting bureaucratic barriers and get things going. If YOU have an innovation, bring it to me- I want to know about it.
And please, think of this- does your innovation make life easier for the patient? If it does, I am interested- if its about you selling your wares, please don't bother.

Finally, I won't make any bones about it- I am a quintessential maverick. I don't follow rules, and I especially dislike them when its built to obstruct patient care. I may not be as clever either as many- but I do have a burning desire to make a difference.

What I do need? Not advice about my style or how I operate (am sure NHS England have hired me knowing all about that plus lets be clear- bar my parents, no one can do that- so don't waste your breath) but about what YOU think will help improve care. The door is open- and to anyone with any interest, patient, carer, nurse, doctor, Commissioner- please let me know.
No- you do NOT need to be part of any organisation or hold a title to do that- everyones view is important to me- and to be honest, I have grown more cynical seeing the roles some "leaders" have played in the junior doctor fiasco. As they say, silence is permission, silence is consent, silence is acceptance.

So contact me- and for ease- my email is Whoever you are, no ones view is immaterial- you want to improve care? As Frasier used to say…."I am listening". Yes, there are challenges- but I am confident we can make some good changes. All I need? Some help from you all along the way.

Shall we?

Sunday, April 17, 2016

Mend the Morale

What exactly have we lost sight of in the NHS? Targets? Patients? Safety? Difficult to pinpoint it down but above all, we certainly have lost sight of one thing..the importance of looking after the staff. In an environment when you don't have extra money to attract staff, don't have a amazing work life balance to dangle as a a more complicated and complex healthcare atmosphere, you need one thing as a from the workforce in you...and most importantly, a positive morale. When you are asking a nurse, doctor or admin to go that extra mile with nothing but an arm around the shoulder, you need that zing factor as a leader.

Crack a whip? They walk away. Shout? They shrug their shoulders. What can you do as a leader in that scenario? Nothing really as without the staff, in healthcare, you are gets compromised, targets's inevitable. A person on the street when they get ill are not wanting to see the latest swashbuckling leader, they want to be seen by someone competent...someone who is there to help them...someone who may have stayed on more than their scheduled time. Can you put a price on that? I don't know but I do know shouting does not achieve that.

It's also time healthcare professionals stop being embarrassed by what they earn. It's a job, a well trained job and you should be rewarded for that. It gets slightly annoying when leaders on big salaries or who have spent considerable time reaping benefits of the system start pontificating about others. That brings forth derision, not discussion.
Let's face it..7 day services need improving- forget the science and data, a weekend isn't the same as a weekday. Anyone who works on a weekend knows that..there isn't enough staff for that. We absolutely needed a debate on that..we needed brave leaders to step forward and say we need this as a priority but don't have the money for we may need to stop something else. But we didn't..we tried all sorts of smoke and mirrors, lost the whole argument, and now are on the verge of losing those on whom we depend to run hospitals. Newsflash..a hospital without junior doctors or ward nurses isn't a hospital, it's someone's utopian fantasy of a world where patients just use Apps and get themselves better. Factor this in- do you know which one is the safest hospital? The one which has no patients. The error rate is about 0%

So to all leaders, please, get a voice and stop focussing on models, strategies, flow charts or graphs. It doesn't matter what you call it..without the staff helping to deliver it- above and beyond what you pay them- it won't work. The NHS is littered with such examples and yet we learn nothing, we try yet more models and organisations.
Whatever we have achieved locally, whatever notoriety we have achieved was never down to models or pathways, it was down to one thing-  working with the staff to ensure we didn't let the morale dip down where people stopped caring. Morale is the one thing that matters...get it right, the rest will follow. Today, in my new role, one thing I can promise is never to come out and tell the staff how bad they are..if I do want to improve diabetes care, then it's the staff one needs to deliver it..patients are the most important bit of the jigsaw but a fundamental cog are staff and we must, absolutely must look after them.

So a final appeal to all parties engaged in their present death stare match regards junior doctors...BMA and NHS Employers...please...resolve it. Go have a hug, get some beers, forget about establishing who was wrong so far...forget that, but go and sort it. I don't care how you do it or who needs to be the "bigger person" but please do get going. Apart from confused patients and public, there are a lot of demoralised, angry, upset and confused bright young minds caught in the middle of this- and as seniors within the system, we owe it to them to forget ego and hubris.
The NHS needs these sparkling group of people firing on all cylinders, working with a smile, giving that bit extra...and we seniors have got a role support them, guide them, have an arm around the shoulders, say a few more thank yous and try our best with whatever leverage we have to convince the power brokers to end this fight to the finish.

Naive? Idealistic? Maybe but I do this job to improve care and there is no hope in hell of improving that without a motivated crew of junior doctors next to me. As I have said before, I am not a member of the BMA, you call me left wing, my college political adversaries will choke on their cornflakes, I don't have a dog in this fight...except that I have a fierce allergy against junior doctors being taken advantage of- and they already have enough of that from many within the NHS a already.

On Friday, I went to offer the junior doctors doing a sit-in some morale support and I have some news...I didn't see some loony left wingers. I saw 2 bright young people, worried and anxious...keen to end this dispute. I want the, smiling, I want them back doing what they do best, looking after patients..ready to give that extra bit when needed. And we, the rest of the NHS owe them that.
Mend the morale folks...this is no way to help patients get better. 

Monday, April 11, 2016

"Divided We Fall"

I cannot even begin to tell you how excited I am. Just around the corner is the impending release of a blockbuster movie called "Civil War". Now- its pretty common knowledge how much I enjoy comic books. Having grown up on them, its a fabulous world I live in watching those characters come to life. I also know its a source of mockery for some- comic books are for kids, right? Well- the world would differ- but in your eyes, if that makes me a kid, heck- that's a compliment and a half.

And comic books- they teach you much much more about life and its issues than some conference, course or power points will ever do. Want to know about discrimination  read the X Men; want to know about strong women - check out Wonder Woman; want to know about race issues- check out Luke Cage; want to know about teenage angst- Spider-man existed only for that...the list is endless.Most noticeably, the Avengers should teach us all about the importance of a team- how many strong characters needed to work together to make things happen. The ethos of Captain America- strong, idealist, leader or of Iron Man- cocky, confident, charming...we live with those characters every day in our lives.

Which brings me to the movie called Civil War. It was a seminal event in the world of comics- chasm between the superhero community- heroes against each other- everyone supposedly right in their views- toe to toe- no one backing down as they both- "fought for the people". Starting to sound familiar?
The tagline of the movie goes "Divided We Fall"- and its as apt as it gets. Social media has erupted with disputes- everyone keen to claim the side of the patient- everyone right. My view about junior doctors- and my support stands as ever- there is no flinching away from looking after the next generation but it appears we are now in Civil War territory- among ourselves.

In between all of these, there are many many who have simply taken advantage of an opportunity- whether it be some with chips on their shoulders about doctors, whether it be some who simply want to change the government, whether it be some who see it as an opportunity to eulogize about their private work...mix it in with many who have chosen to bring the "In my Days" argument into play- and many many junior doctors now simply feel trapped. Trapped in a toxic cocktail where no one is sure anymore how a "winner" emerges.
I know exactly what I would like- a simultaneous withdrawal of imposition and all out strike- and talks to thrash it out. The rest of us would applaud and breathe a sigh of relief- this isn't good for the present or the future- and it is undoubtedly frustrating to see an impending car crash to which we are all spectators at best.
I have no other suggestion to make to both parties- except that maybe all of you need to go and watch the movie together and understand the importance of what comic books teach us.

To end, do you know how the battle in Civil War ended in the book? The public in the end, stood up- and said enough- that finally made the warring parties realize that even though they ALL felt they were fighting for the public. in the end, they scared the public enough for them to stand up.
You sure comic books don't have anything to teach us? To reiterate the tagline, ladies and gentlemen...Divided We Fall".
Please..resolve this madness.I beg of you all.