Saturday, August 23, 2014

Pied Pipers

Fancy a trip in a time machine? Why indeed not? If you ask around, then most agree the past was better, something about the present never seems right, the oft quoted phrase.."In my days"...so hop on..and let's zoom back to 2004.

The venue: Royal College of General Practitioners. Occasion? Discussion of diabetes care. In the audience- the who's who of diabetes care, discussing how to improve diabetes care. And times were good...there was money in the system and there was,evidently, big need to improve diabetes care. There was a recurrent theme- it was time to break the stranglehold on diabetes care of the hospitals, the Consultants. I was there, a junior Registrar- listening and trying to understand the politics of it all. And then it happened. A GP stood up, announced his title (quite impressive, more so perhaps he claimed or perhaps did have the ear to the "policy-makers") and said this.."I cannot see the point of having diabetes centres- all that resource should be in primary care". Lots of debate ensued but interestingly a lot of GPs in the room stayed silent....was silence a sign of acceptance? The revolution had begun.

Let's zoom forward...its 2009...one of my first public meeting with GPs in our local CCG...we intended to float a new way of working..Partha Kar was the new kid on the block- and it was part of an overall area wide strategy session. Loads of GPs in the room, lots and lots of important and grass-roots in there. I sat in the background- waiting for my session- and then my name was called out. I stood up- and recall having to walk the length of the room..and all I could hear was a murmur. Not many had met me then...and as I walked, you could hear the comments with little effort to hide them..."Another new plan eh?"; "Must be about protecting Consultant patch"," Who is this boy?"..a slight gritting of teeth as you walk up- the mantra in my head buzzing firmly..."Work with them, I must make them believe"...Got to the stage- and the GP leader turned around to the audience and said " Partha will now explain the point of having a diabetologist" with a smile, nay, a smirk. Disdain? Perhaps. Disrespect? Perhaps. Ignorance? Read on and I will let you decide.
My answer back was simple.." How's your skill at working with pregnant diabetes patients?" Pause..nothing much back.."Or for that matter Insulin pumps?". A moment of silence followed by.."Well, I will give you THAT". A murmur rose again in the room. We continued, we sparred, we debated and the birth of our model happened..but the majority stayed silent.

2010...an evening meeting with a group of GPs...explaining our model..and a lady introduced herself..again, another grandiose title, another leader..who opined that the new Health Act was finally the "time for GPs". The years of underfunding was now past...the time to strip hospitals bare was here now..to fund GPs. I smiled and wished her the best. The other 7 people in the room...stayed silent..looked uncomfortable...one mentioned something about the importance of a local hospital...but then concentrated on her drink. 

4 years later, its now pandemonium city. Leaders have tried their best to create pathways, create tramlines which restrict the type of patients who can go to hospital...they now need to go somewhere- so the GP surgery it is. The expected holy grail of money follows the patient remained an El Dorado..and suddenly the patients were there, the money wasn't. Diabetes was a prime example, perhaps even a forbearer...extrapolate that to all specialities and why is anyone surprised that GPs can't cope? Pathway to refer back also closes with clinics being disbanded, so where indeed does the patient or the GP go? 

5 years taught me a lot in management...what it also taught me how the silent majority are not part of decisions made. The fault lies with both- self styled leaders who dictate for others as well as the majority who chose to stay silent..perhaps even keeping the faith that resources would follow. Diabetes care has suffered as a result..there isn't even resources or time to do simple 9 care processes (just wait till the recent National Diabetes Audit comes out- makes for woeful reading)..let alone anything else. In the main, diabetes care is delivered by practice nurses- and by god, they are struggling. Struggling to even do basic stuff, let alone do professional development, keep pace with the changing times, new developments, evidence based medicine....

So to all leaders who ask for "more GPs"...that will solve little. There is need for increased resource in primary care, time for education- and perhaps even think of specialists in primary care. More importantly, it certainly is time to stop leading GPs off the cliff by agreeing to yet another pathway which is designed with only one intention..less patients for hospital. That has little or nothing to do with patient care but translates to more work for primary care with little added resource...if you don't understand that simple economics, then drop that title, stop attending the meetings and go help your colleagues in their day job. The rest? Stop being silent..otherwise that cliff edge now isn't too far away.

Next week: "The Leadership gravy train"

Friday, August 15, 2014

Eeny Meeny Miny Mo

I loved him in Good morning Vietnam...there was always something about the clown with a tinge of sadness in him..and it wasn't just comedy. If you wanted to know about his acting chops...watch one of the classic Chris Nolan movie..Insomnia..head to head with Al Pacino and Hillary Swank..simply an artist. So had to wince a bit when the news flashed about Robin Williams..another celebrity taken away due to mental health issues...and the issue got the focus it has always deserved, some good and measured; some downright awful and morbid..but it got the attention. More closer to home, Shaun Lintern who is not afraid of rocking the boat (Shaun, that Superman logo isn't you...try a Bat symbol...much more of a rabble rouser) published his investigative findings on mental health issue and it's provisions...and makes for grim reading.If you haven't read it, suggest you do..crisis? Nope it's close to apocalypse now. As a physician, I know so from ward rounds..Shaun's work just confirmed it.

The million dollar question however is what now? As I mentioned to a few colleagues, pick ANY service and you will see holes, some more than other, but holes none the less. And to every single person I have asked one question..but the answers have been ethereal, abstract, wrapped in buzz words, catch phrases...none, I repeat, none of which actually solves the problem.
So here is the question...we know mental health needs funding...in our cash strapped environ...where will you get it from? In the spirit of multiple choice questions, try this...

Option A: Raise taxes (Pros: will throw more money at system, according to some ONLY way out; Cons: Look at the wastage within the NHS ?..sure more money will solve it?)

Option B: Abolish competition, make it a monopoly (Pros: transaction cost saved,procurement issues lessened etc etc; Cons: lack of it may raise issues regards where the drive exists to improve..any attempts based on data is anyway neutralised by most poo-pooing them on basis that its either a cock up or a conspiracy)

Option C:  Prioritise services; accept that to provide high quality services, you may need to prioritise some above others (Pros: Gives opportunity to develop those services properly, not pay lip service Cons: who chooses the second tier services and based on what?)

Option D:  Do nothing and stick to camps based on ideology and have a shouting match.

Option A may happen..but where do you stop? Keep on raising it with demand and need growing exponentially? Option B: Perhaps gives you a release as a one off saving ..still not convinced how that drives quality..but then what? We do the cycle again?
I put in Option C simply because we already have that steadily, if not by stealth. Lots of areas have procedures not funded by the NHS or needing permission."Free at the point of delivery"? Or "Free at the point of delivery chosen?"

Here's a question...what's more important ..mental health services or diabetes?Cancer treatment or well funded primary care? Midwives or treatment of Psoriasis? Tough, isn't it? But the answer is simple...based on who you are asking. If you have debilitating rheumatoid arthritis, for you, that's the service of prime importance...it may not be maternity services.For the mum struggling with a 2 year old who has type 1 diabetes, it will, of course, be a fantastic type 1 paediatric service, it may not be a COPD outreach service or a dementia service. And then there are the charities..quite rightly driven by the prism of their own views.

So we come to an inevitable cross roads..and frankly I do not envy any policy maker, any politician who has to make those calls...it's always easy to criticise than to do...and will forever be. But time may it be too far away before society is called upon to play this game of MCQs..as tough as it will be. What started as a fantastic development of socialised medicine now comes to a crucial juncture.
The fundamental question is..will we make the decision based on sound facts, reason or are we going to be driven by emotions? Are we going to be able to make a tough decision which will not make all happy..or are we going to roll the dice and see what comes up?

Time stands for no one...and this question will keep coming back..again and again. So have a think..when you are asked the question..Choose wisely. Better that than a game of eeny meeny miny mo..right?

Next week: "GPs, vacuous leadership and inevitability of strife"

Thursday, August 7, 2014

You never forget

It's an emotive topic...the topic of colour...prejudice based on the colour of your skin and I recall listening to the experiences of my parents in the UK back in the 70s...people refusing to sit next to them on buses, bosses in the NHS being open that Indians shouldn't be in "high positions"...and then I look back at my journey and it's a darned difficult topic to discuss or talk about.Reports such as "Snowy white peaks of the NHS" are a reality check, a discomforting feature for many..an uncomfortable truth which grates with many, but a reality nonetheless.

And I will tell you why it's difficult for me to discuss this. One one hand, here I am, rabble rouser-in chief, made my reputation for good or worse in the world of diabetes, stepping down from a 5 year tenure as Clinical Director when most people begin...would I have been able to do this if there was a severe colour bias? On the other hand, is it not because I have some friends I work with, who have been comfortable with me being the lead albeit the youngest of us all,a group for whom colour has meant little?

I say so as throughout my career, there has always been instances...you never forget...my dad always used to say, and still does say to me..."don't aggravate people, it's not your country after all, colour bias will come through in the  end".. And I have for ever tried to rail against that...I was born here, I contribute to taxes, do everything any British citizen would need to do..this is my place too, right? But you never forget..you never forget a senior Consultant telling you while you are looking for a substantive registrar post that it was better to apply in the Midlands as that where "your type stood more chance". He/She of high fame..great endocrinologist, great doctor...slip of tongue, didn't mean what was said? Who knows...but you never forget,right?

For those who have never faced any race bias, being questioned on the basis of your colour, you will never understand the impact of it..you just won't.  Every single word uttered grates, makes your teeth grit, and depending on your personality, either creates a fire to consume all or a state of resigned depression and acceptance that colour is a bar and there isn't much point in railing against it.You never forget...I recall a conversation with a nurse specialist and a research registrar while at Diabetes UK, many years ago..during my tenure as a trainee..we were talking about job opportunities...2 educated women, high flying and in the course of time have become well established too...their collective view..why didn't I "bugger" off from where I came? Was it a joke? Was it tongue in cheek? Who knows...all I do know it stuck..you never forget,do you?

Patients are no dissimilar either...you think racism is associated with poor socioeconomic conditions and lack of education? Au contraire amigos, some of the most educated have said things in clinics, in ED,on the wards which have elicited mostly a witty response back...("You are a Chink,aren't you?" "No, actually I am Indian..the high cheekbones are just features of my dashing good looks"...keep it deadpan, Partha, keep it deadpan)...but they stick..you never forget. Beyond the veneer of polish and education, the nastiness of racism bubbles away.Society has made it more difficult to be explicit and open about your inner feelings but it bubbles away, ever present..it exists in a different garb..what did that report on the snowy white peaks say again?

To be honest however, for me, that has always acted as fuel. Fuel to prove that I belong, as much as anyone else. On the contrary, it makes me wryly smile to see any achievements which perhaps inwardly makes the covert racists wince. I see educated Consultants, holding positions of power and authority making fun of accents, the way people dress, the food they eat- and now ensure they dare not repeat it again- at least not in front of me. Don't demonise UKIP when the so-called educated ones harbour similar feeling albeit beneath the facade of  charm.
You never forget the barbs...you never forget who threw them..and you never forget as well that a few rotten apples don't make the barrel bad. The reality however,still is that you have to work that bit harder, that bit more differently to make a mark..everyday in the NHS. Some deal with it by battening down the hatches, some stop caring and some relish the challenge of the odds. Either way,as with anything, documents will do only so much, bold statements from Simon Stevens will only go that far...we shall see with time whether the NHS or for that matter society has it in them to narrow the divide.

Till then, you never forget.

Wednesday, July 30, 2014

Gosport Gathering

It was a nice pleasant evening, perhaps a tad muggy as I walked into the seminar room at Gosport War Memorial. A patient engagement event laid out to discuss openly with the people in the community about their diabetes care and it was nice to see people spare their time to come out and simply..chat.

The fabulous community nurses - Jane and Julia were there outlining the educational role they have for primary care before some open Q&A from the audience and it was nice to see a lot of interaction from the attendees. And there were a few..frustrations about lack of communication between different sectors of the NHS, frustration regards access, queries about local amputation rates,the essential healthcare checks, the need for healthy food, the practical difficulties regards exercise...but amongst them, there were also those who were simply happy with their care.

An evening which I must say I really enjoyed as I genuinely believe that patient engagement continues to be nothing but a mirage, a tokenism most adhere to. Case in point? You can simply close your eyes and say what the main frustrations with diabetes care is...yet, we spend hours in meetings, drawing up pretty pictures, heck..even perhaps adding a name tag to something...while the patient issues? Exactly the same as it was a few years ago.We discussed finances, briefly ventured into politics, exhorted patients to be constructive critics, not join the media maelstrom...and was nice to see most still have faith in the care they receive. This was an audience primarily with people who have type 2 diabetes and this was an opportunity to show that healthcare professionals too are only but human. An intense desire to improve things but still as susceptible to coruscating criticism as anyone else. 

And it also made me realise how difficult it is to have an actual debate about finances, the inability to make ends meet- some due to intransigence of some to change their way of working, some due to inability amongst separate organisations to work together as the bottom line at the end of March is still King...and the constant appeal that more finances will sort the mess out. It may to a certain extent, it certainly won't go the whole hog.

But amidst that, are the patients, still wondering how to exactly be seen by someone who knows what they are doing, someone who can simply see them on time. Social media and use of internet..simply the bastion of the young? Don't fool yourselves based on some half baked stats...the elderly gentleman in the front row had a twinkle in his eyes when he asked why in this era of skype and emails, communication wasn't better. Why indeed? Why is it that Newham can do it but Gosport can't? Both still have the same umbrella logo..NHS...so why isn't it a governance issue somewhere and is somewhere else? 

So thank you to Liz, Dan, Gethin et al for laying out this event- and gladly look forward to helping out with more of such events. Makes much more sense to hear directly from the patients rather than send a 27 question loaded form to fill out. Ask and you shall hear what you need to hear...the question is whether you genuinely believe you can make the changes. As a diabetes department, we would be the first to acknowledge that everything isn't sorted but would also say that we are keen to improve things as we take advice from patients on board- our transitional service, 7 day working bear proof of that.

Patience and time...give the healthcare professionals that...mix that with the dollop of passion they bring and sprinkle on some charm...I promise you...a heady brew can't be that far away.

Friday, July 18, 2014

The Servant God

How many times have you heard that one? The old stereotype built in by years of media, bluster and self-aggrandisation...the all-powerful doctor who knew it all, blew everyone away with their knowledge, their skills, their arrogance...whisper it softly perhaps even God like in their ability and demeanour...healers weren't they? They told the patients what to do...and they did. They told the nurses what to do...and it happened. A paternalistic model doesn't develop overnight, does it?

But then times changed...the world changed...patients, quite rightly, found their voice, became more inquisitive about their care, tried to know more about why their care may have faltered.and then found their Gods, self-styled or otherwise, wanting. And as sure as what happens when you see your hero or deity slip, obeisance changed to disappointment, disappointment then moved to anger. How dare they? How dare they fail their duties? The disappointment in seeing these God like creatures be fallible, be prone to the same errors as others, with the same foibles hurt...the angst was palpable. But slowly but surely the tide has started to change...even the media has started to move on. Yes, most of the Consultants are still ridiculously charming, handsome, sweeping folks off their feet, but the George Clooneys and Patrick Dempseys were also fallible, with emotions, making mistakes.perception is key, isn't it? How big a role the media plays in the depiction of anything...all you need to look is at the public perception of success of CPRs and the disproportionate attachment to reality.

The bigger question is who wanted the God like status...perhaps it was society in those ages, perhaps it was the desire of some, perhaps it was the wish of many..who knows. What I do know is that in  a modern era, that's not a title most young guns who have become Consultants want...(though recently a vascular trainee did do his best to change my romantic view on that) and to be honest, unless we shed such ridiculous artificial notions, you can forget about any level of patient or staff engagement.

Lets make it crystal clear what doctors areHuman beings, trained to do a specific job, at the cost of the taxpayer. Human beings with exactly the same amount of foibles as anyone elsePossessing the same level of angst, empathy, indifference, passion, tiredness as anyone else. Lets not elevate them to the level of Gods as I can guarantee you it will, as it already has, end in disappointment.  

By the same token, don't say they are servants either. That implies lesser rights than others, a person at the whim of others, a person who must serve their masters, come day, night or otherwise. Let me repeat again...they are human beings with same needs, same desire to sit down with their families at end of day, same need to enjoy the latest Marvel movie and talk silly with their kids, same interest to go out with their friends and enjoy a drink or two.  I know there are many who like to label themselves as servants, public servants, servant leaderswrong terminology, wrong perception- and by your evangelism, you tar the majority who are struggling to battle the everyday pressures while balancing their own lives. Use that tag...you can kiss engagement goodbye too. They/We are paid by the tax payers...do please hold us to account but don't give us tags that create an illusion.   

The system, as I say, with any topic of discussion, is always like a pendulum.swinging from one extreme to another. Yesterdays God needs to be todays servant is the chant- the reality is that patient engagement or staff engagement, as always, is a 2 way street. Treat patients with respect, they engage.doctors are no different either. I am pretty sure I echo many when I say I am no God, neither am I anyones servant. Just a professional trying to do his job, with passion and desire to improve patient care. On the way, mistakes will be made and all one can promise is to learn from that and make things better.

Treat me as a God.absolute power in the end corrupts absolutelytreat me as a servantin the words of Charles De Gaulle..In order to be come the master, the politician poses as the servant.

I have no desire for that either. Have a great weekend x

Friday, July 11, 2014

Era of the nurses

All good things must come to an end,as the saying goes. And after 5 years, it's certainly time. 2010 July I was asked to become the Clinical director of the Diabetes department in Portsmouth Hospitals NHS Trust and no, it actually doesn't feel like "just yesterday". Time has moved at its own pace and 5 years later,you just feel its time for someone new..one thing I picked up in a leadership event was the ability to know when to move on..and the time is now.It just feels right.

For many years, the job has indeed come first,be at work by 630/7 am, working on the emails, spending evenings away negotiating with GPs, Commissioners, stakeholders, travelling, learning from others...it's been a long road. A long road but worthwhile every single bit of it and as I look back, it is with a great sense of pride at the legacy being left behind. A model of care which is viewed by many as a pioneer, many accolades, improving outcome measures, raising the profile of diabetes within and outside the Trust,..I have enjoyed every single bit of it. Of particular pride has been the fact that in spite of all the focus on clinical delivery, research and innovation has blossomed and feedback from trainees have suggested the department to be one where they feel they are looked after with ample educational opportunities.A department where morale appears good, low sickness and staff turnover rates suggests a happy work force while patient feedback has improved consistently as testified by low complaint rates..while hopefully we have paid more than just lip service to patient engagement via our Sweet Meet, our launching of a 7 day diabetes service, etc

People always ask me the catalyst behind our success...there are 2 strokes of luck which I don't know how to ask anyone else to replicate. Firstly, the ability to work with a dream team, with not colleagues, but friends, friends who are passionate and have delivered care with a smile..making work..fun! Secondly, an incredible alignment of the stars where we had a fortuitous combination of clinicians, Commissioners, Managers...all ready to make the changes needed, changes which attempts to redefine how diabetes is delivered within acute Trusts. There have been many to whom the success can be attributed to but Portsmouth hospitals CEO, local CCG commissioners, managers such as Sarah  Malcolm, Melissa Way, Lesley Munroe,Clinical managers such as Richard Jones, Simon Holmes ...I can only thank you for the support shown over the years.There has been treacle which people above have helped cut past...all of which have improved care enormously..so thank you.

So to the inevitable question...who next? For years, I have heard debates and discussions as to how nurses are the lynchpin of diabetes care...but always been a bit bemused by the lack of them or paucity of them shaping diabetes care. So, in a last bold "outside-the-box" move, as a department, we have suggested that Lisa Skinner, our existing nurse lead take over the role of the departmental lead. Hand in hand,I am also stepping down from diabetes lead roles in the community and asking Jane Egerton to take over lead role in Hampshire with Alison Tier in Portsmouth. Thus, a creation of a fantastic nurse triumvirate who can shape and run diabetes services across the community and acute services.We talk about nurse leaders...my suggestion is lets stop talking and do some walking in diabetes care.I firmly believe that these are exciting times for local patient care and with Lisa, Jane and Ali in charge, the local community care will be served amazingly.

In 5 years,I have tried, tried as much as possible and also fully appreciate the "Marmite" factor I bring to the table. The NHS is caught in a Hobson's choice...on one hand, changes need to happen quickly while the present structure of the NHS, management chains are not set up for innovation, quick,fast movements. To put grease on those wheels, relations have been bruised..but in my book, rightly or wrongly, relations can heal..what doesn't heal is the poor care we provide while we sit and mull and spend hours thinking how to ensure we don't hurt each other's feelings. In 5 years, our strength has been pace, the ability to make changes quickly, adapt to the times, be flexible and sadly, on occasions, it has needed more fire than charm. To all the NHS leaders who talk about change, medical engagement...look at the system where treacle frustrates and you will learn why engagement is so low down the scale..at a time when you need it more than ever before.

 Finally, as a clinician I continue to do my work and revert to my original passion...type 1 diabetes care..all across from adolescence to adult life. Lots of things to do locally and nationally..lots of ideas in my head...the world does look exciting with the potential! There are bits which I would have loved to resolve such as psychology support but discussions are at a good stage so I am hopeful we should be able to close that Achilles heel soon.
To Lisa, I wish you all the best and as with my colleagues, unflinching support to you as we all know how patient focussed you are and what you will bring to the table. Advice? The role of a clinical director in my book, is two..One, ambassador for the department and Two, the patient advocate in a management circles. Never back down from what you believe patients would benefit from, never accept a compromise which you know will compromise care of patients with diabetes. Stick to that..the rest?Falls in place.

An exciting future awaits us.The era of the nurses beckon..Lisa, Jane, Ali....May the Force be with you. Amen.

Wednesday, July 2, 2014

Simply the best?

Its bloody confusing. If aliens descended and started reviewing twitter, newspapers, blogs, media reports...they probably would just shake their heads and leave- simply confused by the lack of consistency in any news story about the NHS. A recent example of that was the recent Commonwealth Fund report which compared different countries and came up with the analysis that the NHS was the best in the world, maybe even the universe. Cue folks going absolutely bananas...twitter was agog with adulation, back slapping, joyous outpouring...none of which is surprising given the absolute shellacking its been taking recently.

As ever with the NHS, any sensible debate around the findings or even using it to plan for the future has been pretty impossible. We again break into silos...in general three..."Team Happy".. proclaiming that its all fine and its the fault of the government that a perfect system is being broken apart- and it absolutely was the land of milk and honey 5 years ago; "Team Angry".. who vociferously proclaim that there are evil healthcare professionals out there, uncaring, money driven, dark,dastardly souls , killing folks and must be stopped ...and finally "Team Sensible" the more rational or sane ones whose voices tend to get drowned a bit while idealogical battlegrounds are marked out, posturing is done, credit is claimed for the NHS being amazing..while a rational debate to actually debate where we go from here in a few years time...no sir..that's a tricky option, isn't it? 

The Tories say we must name and shame GPs in an environment where we can't recruit them for love or money, present GPs are fed up with everything thrown at them...then countered by Labour saying they will organise for patients to be seen within 48 hours.Even the RCGP joins in saying more money to primary care will solve the puzzle...while any sensible person will tell you its not just about the money, its about the morale. Why would you pick a job, whatever be the money, if you face such incessant pressure and public flagellation- especially when some specialities offer a better work life balance, less abuse? Stuff their faces with gold...give over..those days are long gone.

So let's look at the Commonwealth Fund report...those who want to improve don't rest on their laurels..they don't just say - ah well, we are the best, so why bother improve any more ..they look at areas where they can improve. So where is the UK NOT good...look down the table..its in one category..we come 10th out of 11 countries...the section? "Keeping people healthy"...and in a nutshell thereby encapsulates the impending crisis of the NHS. We are amazing, fabulous, awesome etc etc in looking after people who are sick - and lets make no bones about it- but we are rubbish at stopping people GETTING sick. Cue increased pressure, cue need for more resources...and when that doesn't happen? The bubble..for want of a better expression...bursts. So if you are genuinely trying to learn from the report, where exactly are the initiatives to keep people healthy...do remind me who are the sponsors for the World Cup or even the Olympics again? The penny drops.

So to Team Happy, I say, rejoice but also be humble enough to see that there's only way from number 1..that's down. Rather than blame it on specific governments, maybe we need to address the issues which will make us slip from that enviable pedestal- as a profession we need to challenge ALL politicians. To Team Angry, yes mistakes do happen but by god, we are trying our best every day with cramped resources to learn and move forward. Don't denigrate this amazing institution- work with Team Happy or even better let the folks from Team Sensible have a say.

The NHS..Simply the Best? Possibly yes..will it stay there? Not if we as a profession fight siloed corners and idealogical battles...the capacity or its strength to cope will wholly depend on the agenda of prevention. If we can't tackle that..then we are dead in the water...whether that health system is a private sector led one or a public sector one. And THAT is the bottom line..cos the Common wealth Fund report said so.