Wednesday, September 28, 2016

Daz, Shaz & Kate

2010 I think it was. Or maybe 2011…either way, the memory has always lurked deep. Waking up to headlines of Portsmouth amputation rates. And it hurt. We had embarked on the Super Six diabetes model- trying something different…things like 3 different Trusts working together, specialists working inside GP surgeries. Its all the rage now, you know- but hey those days? Ah blasphemy…I still have saved some of the scorchingly negative emails from leaders of the diabetes world- how this model would spell the end of specialists- surprisingly little about patient benefit and all that.

Anyway, I digress- but hey- you know what- it hurt. A lot. The pointed remarks from other specialty colleagues as to why we should be the ones to do general medicine, no one else…the barbed comments about legless Pompey lads..ah the black humour of medicine, eh?

So we tried - and I am not going to bore you with all the details, the journey- but its the point where we are at which matters. Same newspaper- same people- but this time, with a far more positive headline- and today morning, I smiled. No, didn't smirk but smiled. It didn't hurt all those years ago regards who said what- I brush off non-constructive criticism pretty quickly (its a character flaw/trait which has served me well so far…) but what hurt was the fact that genuinely, we weren't doing local people much favour with what we were providing.

Enough will be written by someone and somewhere about what we achieved, what was set up but this blog isn't about that- but is more of a thank you to many of the unsung heroes who should take the kudos but never will-simply due to their quiet and polite nature. And there are many…whether it be local GP leads such as Paul Howden, Jim Hogan, Barbara Ruston, David Chilvers et al or commissioning managers such as Sarah Malcolm- there are indeed many who have helped along the way. No system, and I repeat, no system can improve without a cohort of folks working together -whatever be their title or grade. Have there been obstacles? Many- and I could spend much time on false promises, threats or even attempts at bargaining to get foot clinics in place- but tonight- I won't. Tonight is about the ones who did the good stuff- the folks who cut across divides and helped.

Folks -who have moved on- Mike Townsend, Graham Bowen - folks who have been part of the change, Diabetes UK in the form of Jill Steaton, local patient advocate (now theres a man with passion!) Raymond Hale…so many to name, so few words for a blog..but thank you to you all.Orthopaedic surgeons such as Billy Jowett, Irwin Lasrado-folks who have been fabulous- or vascular chaps such as Mark Pemberton, Simon Payne or Perbinder Grewal…who said surgeons and medics cant work together?

But a major kudos perhaps sits with the amazing twosome of Darryl Meeking, Consultant colleague & Sharon Steele., lead podiatrist. We like to call them "Daz & Shaz" but their grit and determination to see things to this point? Simply remarkable- turning the tide in such present environment is no mean task- and they indeed are individuals who will shy away from taking the credit…but on behalf of many many patients and staff- a big thank you to both.
Much more to do- and results need to get even better- but this is a journey which takes time, determination and a lot of patience. To anyone looking at foot data- have trust in your local team, back them, support them…and yes- give them time.

A final word to someone who left our department for greener pastures..Kate Marsden…one of our specialist nurse colleagues- who was instrumental in many changes to local foot care. Thank you for what you started, your energy, drive- we haven't forgotten what you did- and we all are grateful…and miss you too. Data is what it is- numbers are what they are…but to change something positively needs something and someone special

So…Daz, Shaz, Kate and many others- thank you. You all have been very special indeed x

Thursday, September 22, 2016

The beginning?

I did an "update" style blog about 1 month ago regards my national role…"Where We At"- and promised an update in about 3 months- but I might have underestimated a bit the pace at which some things have been moving! I know, I know…I am acutely aware of whats happening in the NHS…junior doctors, STP plans, disputes, 4 hour targets, Vanguards, anger…all of it- I work, you know? Haven't given up anything in mu day job- so acutely aware of all the issues- but its just been a delightful month as regards diabetes.
Yes, I know its a narrow view- but hey-its my passion to improve that sector of care- so bear with me, ok?

So what have we had? Well, lets start with the website, shall we? A curated information portal for anyone with Type 1 diabetes- a wonderful, amazing piece of work driven by some super folks- the brainchild of Sophie and Mike- helped by Pratik & Laura- along with support from so many- what a spectacular piece of work it has been. Much to be admired, much to learn from- folks- I am so happy that we kickstarted this. As part of this, meeting the folks who have helped with, what amazing stuff indeed.

And the comic book- dear Lordy- cant wait for its launch- it is SPECTACULAR- if I may say so. The 4 folks who have helped create it- more to be revealed later- but I genuinely hope it does become a source of funned inspiration for many- just so glad its complete.
Then we are on the verge of declaring the date for the next edition of TAD - remember the last one? Oh the Type 1 diabetes pathway is also ready- just a final tweaks- and many many thanks to all those who have helped so far (you super folks of the London network, Diabetes UK, ABCD and all those who came to #talkT1)…I hope you can see why I am just so delighted? And I know some think these are gimmicky and don't contribute much- well, I disagree- ladies and gentlemen, every little bit of support we can create? All of it helps.
Nestled in there has been the launch of an online education programme for Type 1 diabetes (BERTIE)- led by the Bournemouth team. Evidence based? Not yet. But hey, when folks are not going to any of the evidence backed programmes, then maybe its time to upgrade ourselves to the 21st century- and try something different- yup? Time and evidence will tell where it sits- but I like it- I like the effort- and would encourage all to back it with optimism- albeit with a cautious one.

And finally to the big one. And it does come down to it- yes, money. NHS England have just declared their plans and funding etc for next few years- and there are 5 areas which have additional funding- and its such a delight to see diabetes amongst them.
Kudos to Jonathan Valabhji- the quiet man always speaks the loudest- and for me, working with him has been nothing but an absolute pleasure- we are chalk and cheese as someone said- I would rather go for Butch Cassidy and the Sundance Kid…far more catchy-I reckon!

Beyond the National Diabetes Prevention programme- 4 key areas will be ones to tackle and prioritise- improved uptake of structured education; improving inpatient diabetes (that pesky insulin errors!); improving foot care and finally, tackling variation. 40 million pounds to do it. Enough? We shall see. More than what has been norm or most other areas? Yes. And frankly- now its up to diabetes leaders to earn their corn. You wanted ammo- here you are. Go engage with your CCG, Vanguard, STP and come up with plans to improve those areas of priority . We would want insulin errors to be a relic of the past, we want amputation rates to be the lowest- go and do it.

In the midst of all the cacophony, diabetes has a chance. And its now. Don't lose the chance. If you are someone who lives with it, are a carer, works with folks who have it, passionate about it..come together and lets get this done. There are many more strands of good news potentially in the pipeline  ( a possible e-diabetes passport; CGM; expansion of NightScout as a few teasers!) but for now, its time to get up and get things better.

Let this be the beginning of something special.The chance is there- lets not let it slip.

Sunday, September 11, 2016

Honest debate

Its nigh impossible to have an honest debate about the NHS, isn't it? Forget the politics, the funding for a moment- its rarely possible to do so within NHS circles. Now lets lay some cards on the table before anyone unfurls their indignant banners and views. I have been asking for an honest debate about NHS over many many moons- go check my blogs over last few years. Heck I have even been involved in asking for an honest cross-party commission to look at NHS funding when many leaders were singing Hakuna Matata or running around a fire chanting Kumbaya whilst waiting for the holy grail of leadership to land. For information, I also stood outside Richmond house supporting our generation Next while many ducked, weaved, touted out sanctimonious lines about "patient care". Just in case you missed any of my views- these folks called junior doctors- they care- and they care a heck of a lot- so lets stop knocking them.

Beyond that, just so we are clear- as I have said before, lets get some credentials laid down. Not to clarify how "awesome" I am but it appears I need to do this time and again- as "what do you know? /You look young/Wheres your experience" is such a prejudiced and regular opinion that it genuinely is starting to get on my wick now.
So- here we go- worked in acute Trust as clinician & manager; worked in community Trust as clinician & manager, part of a Think Tank; involved with CQC; work as a secondary care advisor on  a CCG; spend truckloads of time with GPs- in their surgeries and oh yes, also work with NHS England. So don't give me that nonsense that I don't know enough- am sure theres much to learn but enough knowledge about internal politics, tariff and silos too

So let me make it crystal clear- I want to improve diabetes care & outcomes- and yes, some of it will need funding- no question about that. I have publicly said this before- we fought tooth and nail locally to get 7 day acute diabetes service, it needed staff & finances (a quick thank you to Julie Dawes on that!)- no magical "working together" did it- nor was my leadership skills so awesome that I made it happen with some cool alien powers. However, beyond that, lets be a bit more honest and ask some questions in that case.

Lets start with acute Trusts. PbR does NOT work for long term conditions- everyone knows that and accepts it- the journey of someone with an LTC cant be reduced to widgets- plus it is now a perverse source of stopping integration/working together -or whatever the term is this week. So how many exactly are up for working to a Year of Care Tariff on diabetes? Care to give up any extra money (which PbR brings re diabetes) to primary care? To invest in technology?Or is it only about how to keep acutes going as they are?
Its a tough question- but if you want to have an honest debate, lets start it. What about Best Practice Tariffs- lets say for diabetes? Does every single penny go to the Paediatric teams? No-it doesnt- so where is it? Does it go to the adult teams to help them? Why not- aren't you part of one acute Trust? Why is an adult team scrambling for a psychologist, patients getting admitted due to lack of metal health support when the tariff can justify all of that- why the locked in silo to a paeds team? Want honest debates? Lets start it now.

How about primary care? Theres X million in QoF solely for diabetes. Ok- tell me what you could do differently with that money.(No- I am NOT planning on "taking it away"- don't be silly- I am not the Lord) QoF in diabetes is now more about process than quality- most GPs know that and find it frustrating- so if we wanted to use that money differently, what would you ditch from present QoF, what would you keep to improve care? An honest debate? Lets start it now. You want more investment- well- tell me what that translates to- whats the plan? Which primary care group has a plan for diabetes care?Bring it along- lest chat. I don't have all the answers but am sure as heck ready to listen

So you know what? I am with you about "saving the NHS". But lets do it as a system- shall we? From a diabetes perspective, I will try my darned hardest to improve care (whether I stay in this job or not)- but give me a system plan- not what just 1 care need or just acutes need.
As one of my patients always likes saying…"I don;t really care who works where- as long as I am seen by someone who knows what they are doing- and on time". 

An honest debate? Lets start it now.Email me, talk to me, phone me..heck even use Twitter if you want- but lets  have that debate,shall we?

Tuesday, September 6, 2016


Enough. Just enough. This has now gone far too long- yup- its the whole junior doctopr fracas- and we are now at yet another crossroad - of perhaps an I am going to use this blog to implore- NOT my junior doctor colleagues but to many others within the NHS to get a bit more involved to help resolve this.

Lets get something pretty straight. A 5 day strike with less than 2 weeks notice wasnt the brightest idea- and forget about the points to be made to the government- this was more about testing the seniors as regards what they can do to keep patients safe. Those 5 days would have been tough- would it have been unsafe- well, its all areas of conjecture- there is no precedence for it- and in Star trek speak- its indeed a bit like "Going where no doctor has gone before". Anyway, we can criticise the BMA for all we want but lets also laud them for making the right decision on this instance. It's a moment in time, an opportunity- or one more opportunity to resolve this ugly acrimonious fracas.

So this blog is to all NHS leaders or even media with influence in "higher circles" ( yes thats you HSJ)- yes- those ones who make their way on to lists, attend the glitzy award ceremonies, tweet, write blogs, run organisations...drop the cuddly chat, drop the theorising about compassion, empathy- and get a bit more involved. You are important enough, know enough people- well, go and say to NHS Employers and DH- please, do go back to the table with the BMA. Did you say "why? Well- at the very least, to give peace a chance, ask the BMA what they want, have an adult conversation behind closed doors, try again- do whatevers needed to stop a 5 day strike in October.

Be a bit less biased- drop that chip on your shoulder about doctors or your hate towards a union- and be a leader. Powerpoints, degrees do not make a leader- if you GENUINELY believe in patient safety, forget the circular debates about who has the better argument- just try to help resolve this- altogether ask both parties to get to a table- yes- again- yes, one more time- for sake of patients.
The GMC, rightly were worried about patient safety- well I do ask them too- they were accused of bias by many juniors- well, show to them that your worry extends to asking NHS Employers to resolve this. Health Education England were rightly worried about training being compromised- well, extend that to DH and ask them to ensure our generation nexts future is not compromised

Am I a  leader? Don't know- haven't made any lists - but I work in circles where I can ask the powers that be to engage with the juniors. So I will try. I will ask.
If YOU  are someone who can influence that- then do it too. Please. An FMLM fellow? A Keogh fellow? A Chief Executive? A Medical director? You know enough people- do the necessary. Stop being political and trying to protect your job- a 5 day strike is a month away- do what you need to do for patient safety.

I will be honest- I have never done a leadership course - so I don't know what they teach on those courses...but let me finish with a quote regards leadership..

Remember that. And go do the needful.

Saturday, August 27, 2016


It rarely fails to fascinate me. And in my opinion- is a key issue to a whole lot of disputes which ranges within the NHS. Its probably applicable to life too- but lets keep this to within the NHS.
Do you know what I am talking about? Ok- its the sheer inability to treat adults as…well..adults. Have a look at the junior doctor issue- my views is well known- it hardly matters whether I work for NHS England or the Ming Dynasty (No- there is NO parallel there- don't be naughty)- my view is what it is- its been handled appallingly. And it stems from the inability to treat a group of qualified professionals as..adults.

Lets check this theory out. Lets take the example of a junior doctor I supervise- she is 32 year old, she has a mortgage, she is married- along with the fact that she is a fantastic professional. Society has trusted her enough to have a mortgage, have a family, treat her as an adult when she goes on holidays, watches a movie- yet we, somehow, have been incapable of doing that. When this group of folks started off by trying to say in a decent manner- guys, this won't work, its tough as it is, we have gaps, we are struggling, we have training issues…the response from a significant part was what? Well- it was a bit of 'There, There"..a bit of "Well in my days"…a bit of " its a holistic profession"..and a whole lot of "well you are all kids so what do you know"…let me tell you what happens when you treat adults like that…its annoying, its disrespectful, its patronising and it creates friction. Funny that we have such an angry bunch of people around, isn't it?

Let me give you another recent example- a trainee comes to see me- has had an incident flagged about her- there has been a meeting where some folks around a table have decided what rating the fault was. She, has had no opportunity to answer the question raised, she has had no right of reply but hey, there's report to her educational supervisor. On which godforsaken planet is that even remotely right? Its awful, a lack of respect but stems from treating, once again, groups of adults as…well..not quite adults. Times are different, ladies and gentlemen, the take it and lump it era is quite rightly over.

Then came the issue of 7 day services and the risks being evident from leaked reports- and the response was simply astonishing fro many quarters. A lot of tut-tutting, a bit of "Meh, its just a risk register"…folks -UNDERSTAND the angst here..its being proven right after being fobbed off..respect that- again, adults talking to adults. Maybe the misnomer,as pointed out by many, sits in the term, "junior" doctor. A risk register existing is no good for patients unless there are mitigating processes put in place to put a red into green over course of time. If thats our attitude to any patient safety issues (hey, we have it n the risk register) then lets not bother with this lark of improving patient care. Its not the register that matters- its the effort to make sure the register has no cause to exist that matters.

So it continues- the NHS and its inherent way of being paternalistic- for ages, it has done so with patients- the "its ok, I know more than you", the "There, There"- and that has now seeped into bringing that attitude to our own generation next. What chances do patients have of moving past lip service to "patient engagement", "patient centred care" or whatever the latest buzzword bingo is -if we cant even treat our own colleagues with a degree of respect adults deserve. Its not all about politics- when such a group of hard working folks, raise an issue- listening to their concerns isn't that tough.

So I don't know how we move on- but I would like to appeal to many within the NHS- whatever be your position or grade- to respect adults for what they are. You don't need to be fit a certain "prototype" to be seen to be experienced and knowledgable. Experience is of course important- but lets not ignore the youth either. Treat them as adults- they could turn out to be amazing allies to ensure risk registers don't have a reason to exist.

As the saying goes…"Give Respect…then you will get some back"

Sunday, August 21, 2016

Where We At

So I have started my new role. At least I think I have. I mean, I have a badge which gives me access to Skipton House, so I must have. Either way, its been about 3 months or so in this new role as Associate National Clinical Director in Diabetes with NHS England. Did I hear a boo and a hiss? Ah well, anyway, it's a role and as promised to many of those who live with diabetes, here goes as regards an update as to where we are! After all, its all about transparency,isn't it?

So lets start! Recall me making the three priorities? So where we at? 
As a follow on from some of the work started on a Type 1 diabetes pathway, paths merged with some fabulous work being done by the London network- and to cut a long story short, we are very close to having a national Type 1 diabetes pathway- which hopefully will guide CCGs and STPs to develop these accordingly. Before my primary care colleagues jump up, no, this does NOT involve you doing more work- so rest assured- and hold fire till you see it. It hopefully will have the blessings of all relevant diabetes organisations soon- specialist/patients etc- and we should be able to progress things soon!

Next up in the pipeline are plans to develop online educational modules for diabetes patients (Bournemouth are already doing a fabulous job at one for Type 1 diabetes - and I don't like reinventing the wheel- may as well back something of excellence!) To emphasise, these will be in conjunction with existing structured education platforms so hopefully will help to support education. Other exciting developments are possible online platforms for blood sugar downloads etc- and yes, as part of all this, am meeting all and sundry to see whats out there- and try to narrow it down to the best available.Other exciting areas are a national Type 1 diabetes platform- that anyone can be referred to- patient or carer- a sort of one stop shop of all curated information available.

As regards technology, a lot of discussions with Abbott and debates regards Libre availability. We- after plenty of coffee and discussions- hopefully do have a plan and I can only assure all that we are working very closely with the company. I must stress that there is a process involved and if we are to invest public money into it, evidence is key - which takes time to gather and accumulate. We shouldn't be too far off it (the recent data published at the American Diabetes Association meeting and the work done by the Scottish group are certainly helpful)- but again, do bear with us on this one- its not something that has been rejected or put on the back burner! I personally would like this to happen- as I do see its benefit- but patience and time please.

As regards inpatient diabetes, again, plans are afoot- which involves role of CQC, a possible adaptation of self administration of insulin becoming a necessity, definition of inpatient diabetes teams or indeed its presence in the diabetes aide-de-memoire for STPs to follow. The aim is not to have inpatient diabetes teams as an "option" but as a fundamental part of acute Trusts- given that 15-20% patients admitted at one point have diabetes and the errors are far too many!

What else? Much actually…the "impossible tour"? Oh yes, letter being drafted to go to all teams- and if they want, will be visiting for sure! There's a meeting with the Night Scout team coming up, there's keeping an eye on data from Cheshire, there's discussion on information for pregnant mothers, education run by patients for professionals ("Flipped Education"!) and of course, the issue of extending the Best Practice Tariff…did I ever say its actually been quite good fun?

Finally, a mention to the team with whom I work- the background work being done by many is simply amazing-and especially Jonathan Valabhji who as NCD has been a fantastic guide- and believe it or not, in diabetes care, changes should be coming. There are many more ideas but for now, even landing those above will be a step forward.And of course there's TAD 2 (wasn't the 1st one fun?) and the Type 1 diabetes comic book.

3 months or so in- about 9 to go- No, its not a time limited job for 12 months but its a point where I assess my own role. If in 12 months, nothing much has changed, it maybe time for someone else to try. Till then, its actually not all doom and gloom…a tweet recently said "If you are not in revolt, you are in cahoots". Well, I respectfully disagree. I have a limited time doing the job I do- and I will work with anyone to try and improve diabetes care- whatever be the structure or political colour.There are many ways to help patients- I respect your fight- in return I ask that you respect mine too.

Over the course of time, as projects are launched, I will take time to pay tribute to some amazing professionals and patients who have been helping along the way. For now, you know who you are- and a genuine thank you. 
Much more to be done- but the support received so far? Simply magic- and thank you for that. To everyone else. I reiterate it again…if you have a good idea or a constructive suggestion, come and talk to me. I will always find time- promise!

Will update again in 3 months- but till then? Keep asking, keep suggesting and keep prodding…just do it with awareness for some one who also has a life, a family and a full time day job too! :-)

Sunday, August 14, 2016

Look up...

A fair bit of palpable angst dripped out of the voice. A young gentleman- early in his career- yet a bit unsure of where things were heading. As I sipped on a delectable cup of hospital coffee, you had to wonder what sort of role we as seniors continue to play in this whole saga of the NHS, the crunching environment of finances - and the responsibility towards patients we hold.

Politics always has fascinated me- and there is no denying Britain has offered a lesson in politics- which no one has been able to predict- the twists and turns being of a monumental proportion- and in the middle of it all, the healthcare system has gone through the squeeze. Junior doctors turned out to be a lightening rod for many, perhaps serving a bigger agenda for some- while most of the young doctors just want a good secure future, the ability to see patients and the support to do their job well. What DOES one say to these people? That the system is all shot- and we shouldn't bother? That we are willing to sacrifice them while we think of how changes can be made in a political landscape which has baffled many?

Whatever be ones belief or political leaning, a democracy without a healthy opposition is always a bad thing- whosoever is in power- and the billion dollar question sits with that young individual…what about me? And we must find some time to answer that somehow. I don't have all the answers but if one looks at Facebook forums, the answer doesn't sit there. Its angry, its burning, its driven with angst, its for a call to arms, its for the "greater good", its "actually all for the patients"…..what about the ones who struggle NOW? What about the ones who have uncertainty over their careers NOW?

I wish I had the answers- and I do not judge those who fight the way they choose- but we must also have some time who want to have some answers now…and thats what this blog is about. I wish all of those who have taken the cudgels up to save the NHS or raise issues but for the many others, a plea to also find time for all those juniors caught in the middle…juniors who want to know they have done the right thing by choosing this amazing profession, juniors who want to know that seniors are there for them- not just walking away with a shrug of the shoulders.

As a collective, we can and we should try- at least in my opinion. It costs little to buy a weekend team a round of coffee, find time to smile, say hello, talk about how #medicineisbrilliant and how, all said and done, its still such an amazing profession to be a part of. Not many get a chance to help others- and we should have our roles in there- making our generation next feel wanted- feel they are part of this entire family.

There are many ways to save the NHS- if thats what you want- whether that be by being part of a political alternative, or raising voices on the streets- or indeed working within the system to help others. Or just do the simple things every day- and make sure we have a bunch of good, motivated doctors to look after us when we need them. Many ways to help the NHS- and we would do well not to lose sight of them.

So, in the month of the Olympics, where inspirational story appears daily, as a senior, to all the junior doctors out there…take some time to look up too. I certainly will try to extend a helping hand when I can. Failing all..theres always time for a coffee and an arm around the shoulder.