Sunday, September 17, 2017

Libre…What next?

Are we all a bit more calm now? Post the news breaking of Libre being available on NHS Tariff, the reactions have been pretty much on expected lines. Feverish excitement, wild speculations , a tiny minority expressing their concerns, views, forums abuzz with questions…its all happened. My inbox exploded- as did my Twitter feed- with views ranging from a former MP suggesting I be knighted to some suggesting I had little idea of what I was doing. To me, however, a measure of whether policy decision X or Y is good or bad is measured by the side on which the majority of reaction falls. This isn't a job to make everyone happy- its to do what would benefit the majority- beyond the white hot realms of social media. You listen to the views on social media- but you never accept that as gospel- after all, Twitter is where, depending on the social bubble extent, Brexit never happened, Hillary Clinton is POTUS and Corbyn is the PM of this country. However, its a good barometer too about public mood- and thankfully, doing a full time job, interacting with patients, seeing the pros and cons does come in handy. So- its no small sense of achievement to see the news- broadly greeted with optimism- though quite rightly, from sensible heads- with a degree of cautious optimism.

So whats next? I would encourage you to read below- as the majority- if not all- of the folks speculating etc haven't been involved with discussions or negotiations- so for want of a better word, here you go- from the horses mouth
The next stage of this process is to convince all local economies to put this in formulary. The justifiable concern is that it opens post code lottery-just as has happened with Pumps and CGM etc. To help avoid that, the Type 1 diabetes network are working to create a business case template that areas-if they are struggling- can use. The network is spearheaded by the Consultant Diabetes organisation, ABCD- with contributions from doyens of BOTH paediatrics and adult world- ergo Fiona Campbell and Stephanie Amiel; diabetes charities, leads of the Insulin Pump network, representation from all 4 countries, as well as respected experts, former NHS England National clinical directors- so a pretty good bunch of folks who can help steer this. I would also encourage anyone successful to get this on local formulary- to share with others. Its called cascading good practice- the N in the NHS is supposed to stand for National. Who knows- this could actually be a template of working we all learn from and tackle post code lottery in other areas of diabetes care!

The next phase of concern is that it will "eat into the CGM budget". So let me explain something to all and sundry. There is NOTHING called a CGM budget- there is in fact nothing called a Type 1 diabetes budget. There is a "Diabetes" budget.Which, on this instance, is a good thing. Here is something as regards how much we spend on diabetes drugs in the overall budget. Of every £9 we spend in the whole NHS, about £1 is spent solely for diabetes care. Thats a huge budget spend- is there opportunity to ensure that this is used appropriately? Yes- absolutely. Simply take your time and see the amount of expensive drugs we use in elderly people or folks who don't need them as per indications or indeed look at how over-treatment in elderly frail Type 2 diabetes causes more admissions. Stop those-save the money on the drugs and indeed the admission costs- use the money elsewhere- such as on this occasion, appropriate use of blood glucose monitoring. It is not rocket science, it is about being savvy, being focussed on what the whole diabetes population needs and use of appropriate medication. Needless to say? The majority of spend is NOT on strips- BUT on medications in Type 2 diabetes. They all have their place- just not for everyone- we need to be better at understanding population based care- and use of technology where appropriate.

Abbott also have a responsibility and we are working with them to ensure data collection is done on a national basis so we can see the impact of its use- which must be published too. We are also working with them to ensure the onus for educating patients and professionals simply doesn't fall back on the NHS. For the areas who may not necessarily have those programmes to hand, Abbott must have a commitment to help that process. I am aware they are working on it- and we are working closely on this too. Watch this space!
We are also working with patient charities- together- Diabetes UK, JDRF and INPUT- to ensure we manage expectations properly- and all appreciate that "going on tariff" is only step 1- albeit a big step. Be patient, avoid speculations- and if you want an official update, listen to what the charities put out- not forums or individuals who have little involvement in overall process.

Would you like to know the aim of our ambition? It involves CGM availability- uniformly across the NHS- and I can assure you conversations are ongoing with relevant companies such as Dexcom, Roche, Medtronic et al to tackle this chestnut too. Feel free to contact them and ask too.
It involves ensuring we have enough HCPs too- who know what they are doing-it involves financial assessments etc.
I am also keen to have a unified IT system which cuts across all systems- and ensures a diabetes patient has access to all thats needed as regards notes, data, results etc. I will make no bones about it- I admire the SCI-DC system the Scots have- the query there is whether a disease specific platform is the right way ahead-or not. I would like to have a out of hours hotline/Whatsapp system that is available to any ED in the country to ensure pump patients etc are safe….so many things, huh?

In short? My ambition to improve Type 1 care has no limits- but I am also fully aware that not all can or will be achieved. However, that shouldn't limit the efforts either. To all those who are worried re Libre, my appeal is this. You are one community. Be happy for those who may have access to Libre beyond the ability to pay. and work with us to ensure we also can ensure the other bits-as outlined above- can happen.
Finally, a big thank you to so many who have left messages of thanks- and more pertinently, have asked me not to be discouraged by the negativity of a few.That is unlikely to happen- I know my goals, I bank on the support of the majority and the day the overwhelming feedback is that I am getting it wrong, I will step down

I repeat-again. Together? Stronger.
Divided? We Fall.

Wednesday, September 13, 2017


Freestyle Libre. It captured the imagination of the public and professional as soon as it arrived. I suppose you could see why. I use the word "suppose" as for someone who isn't living with diabetes, it is slightly odd to say otherwise in my view. It opened up the prospect of "checking your glucose levels without having to prick your finger". Pretty revolutionary as a concept, no question. You put a disc like thing on you, it lasts for 2 weeks and just scan yourself-whenever you want and voila, you can see your glucose levels. I mean, what the heck, right? This was Star Trek level stuff and when it landed, the expressions of incredulity were understandably high.

However, post that, started, quite rightly, the questions. It looks fancy, sure, but does it do the job? Does it check glucose levels well? Does it stand the test of time? As someone who works in the field of diabetes, I always try to learn from evidence in the public domain, talk to colleagues using it as well as and perhaps more importantly the feedback of patients. It started with a degree of mixture of views from the "oh my Lord, where was this thing all my life" to the "Meh, doesn't really match with my needs in life". As time progressed, other issues emerged, such as evidence base or lack of it, problems with adhesive used, data fatigue for name a few.

As time progressed, reports started coming in about its improvement, it's use as well as local knowledge about patients needing it, benefitting from it, and my own understanding grew. What also grew was the clamour of why the NHS was standing by and encouraging a 2 tier system. Available to buy on the market, it became available to some, but not to many. Frustrations grew as those who really needed it couldn't afford it and some departments ended up begging their local CCGs for case by case scenario as well as use of charity funds etc. A non sustainable situation emerged as its efficacy-as per clinicians- grew, and the clamour for it being available grew with it.

It's been a fascinating experience working on this from within NHS England and liaising with Department of Health, NICE, diabetes charities such as JDRF, Diabetes UK and INPUT- as well as numerous individual patients and clinicians. Many issues emerged- such as the importance of training both clinicians and patients. What good is a device - however slick it is- if you don't know what to do with it? I have found views from academics fascinating- driven by numbers and asking for more trials - where do you go with that when a sizeable number of patients ask for it,should be having it and daily input from clinics suggest this could be a way ahead for the thousands who don't check their blood sugars at all? Or those who are fed up of testing? Or the kids who can be checked for night time lows without having to wake them up? Is it my role or those who don't have diabetes to make a judgement and make them wait? Or is it our role to listen yet ensure we have enough checks to facilitate the process of improved care? It's a tough one as as I also pick up the frustration on both sides- one clamouring for more data, one for quicker adoption. The whole sphere of medicine is forever engaged in this tough battle- with accusations of the NHS being archaic, old. An NHS which is afraid to use WhatsApp due to security yet send letters by post, uses fax machines....fascinating.

So what about this bit of kit? You want to have a bit of rough context? A bit of finances to whet your appetite? Each DKA admission costs approx £2000. You could approximately treat 20-25 patients with type 1 diabetes in a month and need to prevent 1 of them getting admitted - that month- give or take. One. That's all that's needed to "recoup" the cost.
Throw in the lesser strips needed, the benefit of added education, the impact behind sheer numbers such as A1c, relevance in hypos, engagement ...well...we may just have a case for it. This is a simply more innovative way of measuring your glucose levels- nothing else. In a world where Expo17 was mostly about adoption of technology and innovation, it's up to you as a payor how you see this in relation to existing blood sugar monitoring systems.

So we are here and the obvious questions are : what's next? Is it for anyone with diabetes? No. But given the right education with the right support, it indeed is for some. The device is not a toy- it is to be seen as a tool to help folks self manage- just as blood sugar monitoring is for those on intensive insulin- and without hesitation, that principle of "do you have the right education" applies to BOTH the patient and the healthcare professional. It is thus satisfying to see this "land" and have a place in type 1 diabetes management in the UK- it's about time we modernised ourselves a bit. It is now available on tariff- which I also appreciate does involve local negotiations. 
And ladies and gentlemen, this is exactly where specialists need to stand up and be the advocate for their patients. Use your relations, make your business case, learn from each other, if needed- do ask for help- but please, do make the case. If you can make the case for a GLP-1 analogue or a new swish insulin, you can make it for this too. That is YOUR role. My role was to work with all concerned and ensure it got to tariff- the next step is all yours. And if you don't believe this is for your patients? Then explain why to the patients when they come along- why they are being sucked into a post code lottery because of your personal beliefs.

Finally, the question has been why only Libre for Abbott. The answer to the question is simple- because it is the first of its type - at a financial competitive margin. Does this open up the door for others? Possibly but it needs engagement, it needs working with policy makers, not doing silly things like denigrating your competition. I would like to see ALL relevant technology available to patients- but there needs to be balance, there needs to be evidence that professionals know how to use them, there needs to be financial considerations, there needs to be dialogue. Working with industry is a 2 way street. This could be the start of something exciting- the environment seems ripe for digital innovation- this is only but a part of it.

I would like to finish this by thanking Diabetes UK, JDRF and INPUT for their consistent support and help while putting up my flashes of temper & impertinence ( no puns), the team of Lord O'Shaughnessy in the Department of Health, NICE team who helped with the Innovation briefing and the finance team within NHS England as well as clinicians like Pratik Chaudhury, Emma Wilmot, Marc Atkins,Iain Cranston, Gerry Rayman, Mark Evans,David Russell-Jones, Stephanie Amiel, et al who have been fabulously supportive as well as has had kind words of advice when needed. It's been a tortuous journey but we are here. 
But most of all? Thank you to the numerous patients, either those on social media or those I meet who continue to be a source of strength- supportive, encouraging, helping- especially during those late nights when the knocks taken hurt just a little bit more.

The journey however isn't complete. This is perhaps only the end of the first quarter. The second will need to show adoption of this technology uniformly while the following ones will look at other relevant technology such as CGMS devices, sensor augmented pumps, further non invasive glucose monitoring, OpenAPS technology et al.

Can we do it? I have faith in you all we can. This has been a perfect example of what can be done if all relevant bodies join forces for need of patients. 
Together, ladies & gentlemen, we are much stronger.

Saturday, September 9, 2017

More please?

You know it that time of the year- its pretty much become like a well scratched vinyl. And on cue it appeared- the ask for more money- as the "worst" winter is about to hit. More money for the acute Trusts, more beds needed to somehow scramble past yet another winter. I must admit to finding it all very fascinating - not to mention even more so now- as our local hospital -like most others- try to fill in gaps-helping out acute medicine- as a shortage continues to recruit folks to do that role.

Over the years, I have always taken more than a passing interest in this- and my recent experience has  piqued my interest even further. Our desperation to get more senior staff to see patients has now ended in square pegs into round holes- somewhere, somehow exists the belief that "any" senior seeing the patient is better than one of those pesky, unsafe, untrained folks called "junior doctors". So we all pile in- the drumbeat for generalism beats louder- sadly showing signs of losing focus at which point a generalist seeing a patient is actually more dangerous than the patient seeing a specialist at the right time. Lets give you an example- I would say I am reasonably ok as a generalist- is it safe for me to review a patient who has issues which have made the cardiologist admit the patient to a cardiology bed? Do I do anything apart from saying " Carry on?" Should I? Could I? Somewhere it clocks as a senior review- when what that patient needs is the right senior seeing them to progress their care.There is a balance- cross that- and a generalist has their limits- you move into areas of uncertainty prompting further investigations, more delay, more angst…Beyond that, all you are doing- well…you may as well as call me a "Senior Registrar".

So is more beds the answer? And if it is, why would that change now? What exactly is changing that would make the need for beds less next year? For this blog,I have a couple of things (beyond the usual of social care) -improving which, in my mind- would go a long way to solving -at least a few things.

To begin with? Process. Look at all the hashtag campaigns running- whether it be #Red2Green or #EndPJparalysis the fundamental is about process- the process to get patients moving quicker. You can't quite quicken up the pace of antibiotics- but you can certainly quicken up the post -recovery period. We, in the NHS, run process in some of the most archaic and frustrating ways possible- all aimed at short term gains- without any note of the future. If you want to invest money? Worth their weight in gold- are operational managers who know how to hold their nerve.

Secondly? Over investigations. You think juniors do that? Wrong. So do seniors who haven't had exposure to high end specialist stuff or indeed much stuff beyond their specialism for years. It is a fruitless exercise- it doesn't matter the tag says "Consultant"- they are as much laced with self doubt as anyone else when seeing someone they haven't seen for ages. Defensive medicine rages all around us- and in a litigious culture, cue "image" anything that moves. Ask any radiologist- how unnecessary requests clog up their time while those who need it- wait. A Consultant is only as good as what they are keeping themselves up dated with, what their existing jobs are- we forget that, we put others at risk. A senior review isn't the mandate, the appropriate senior review is perhaps more apt. Right people, right seniors. Push everything else into a herd, you slow down the process.

Finally, throwing money into acute hospitals will solve- nothing- unless you believe a sticking plaster on a  compound fracture is a good thing. Money is awash in the acute system for those who want it-especially as a senior. So many gaps in acute medicine - you can pick up shifts at any point of time- I get emails on a regular basis asking. Its called locum rates- internal or external- or Waiting list initiatives in old parlance. It helps no one- bar the senior making some more money- that is the brutal truth. Why open more beds- when you don't have the staff- and stretch existing staff to do more? You want to give more money- then lobby for more money into the system- into better community services, better primary care, NOT more beds. We cant man the ones we have at the moment- while better primary care support is what will help.

The freudian irony of NHS Providers leading this call hasn't escaped me either. They now lament the lack of staff- an organisation which was one of the few to ask of imposition of the junior doctors contract. "Look after your staff" should be more than powerpoint sound bites- the actions must match that. Many, including me, had said that this would come back to bite- and it is now. There now is a lot of money to be made if you want to do "front door senior work"…I would respectfully suggest that money be put to better use, not acute Trusts - especially in a system where we are now all supposed to be "one", not "separate". And if you do want to use money in an acute trust, get the process right, get the right people seeing patients- then- we may just make some headway.

Saturday, September 2, 2017

Care & Quality

Where do you start? What do you do when a Care & Quality Commission report lands reporting on your trust which is difficult reading? Its perhaps slightly weird having done a blog on this before- back in June 2016. The report would suggest a further regression- and there are always many emotions that emerge out of that.

I think the NHS has now been through enough of the fallacy that is of its view of the CQC. Reports became something to be shared widely and celebrated if it was a good one and ignored with disdain if it was negative. It is but a natural phenomena to look at bad data or results and conveniently label it as a cock up or a conspiracy. I know it- I have done it many times before in my career- I recall the days of poor amputation data- surely couldn't be us, could it? 

And as much as some would perhaps want it, this blog isn't a forum to go through the whys and hows of where we are. Its about what happens next. The report is what it is- and as an organisation, its time to say there are many instances where we have fallen short. The Trust has a new CEO and MD in place- and I will be honest- so far, their presence, visibility and most importantly, the frankness of accepting the report as it is- has been welcome- if not endearing. Sometimes you just have to- and rebuild again. History nowadays seem to have a very interesting way of viewing leaders- we appear to remember them more by their foibles and failings rather than their successes. Maybe take an example of British prime ministers over the years- would history have judged Churchill as kindly as they have in an era of 24 hour news, social media etc? I very much doubt so. Our NHS leaders are no different I suspect- its easy to look back at predecessors amongst Portsmouth Execs and point fingers at them- quickly forgetting the achievements too. I worked in pretty dire wards back in 2002- today we have sparkly new building- much more open, much more clean….individual leaders are rarely to blame- its more about who they take along with them in my experience.

So- to the now and future. What has been noticeable has been an attempt to redraw the lines and start again at the top tiers. A fresh start without denigrating the past- which to me, is good. And I will tell you this- I have been part of this Trust for nearly 15 years now- as a junior doctor, research fellow and now a Consultant- and it buzzes with people who are keen to help, keen to make a difference- the key as ever will sit in listening- and time will tell. The initial indications? Very positive - so lets see where it takes us. In my book, leaders should be judged by outcomes- and thats where the bottom line lies. Have you improved care for patients under your stewardship? If the answer is yes, you have succeeded- and the barometer for that, in the present system, whether we like it or not, is indeed the CQC. Use that as your appraisal, use that as your indicator- the aim is simple- make the next CQC report better.

I have said this before and I will say it again. I work in a fantastic Trust- and I could close my eyes and reel off umpteen names -doctor, nurse, physiology, pharmacist, manager etc- who are some of the best staff I have ever worked with. The trick as ever is to harness that. Individually? Always here to do ones job-mixing up generalism & specialism, try best to ensure staff stay motivated within my own sphere- and advice always at hand if deemed to be relevant or worth listening to with wider system experience accrued over time.

In Mark Cubbon, we have someone new-a new man at the helm- attempting to bring back the glory days. I hear he supports Liverpool football club too- somewhere there's a freudian analogy there indeed. 
It would be thus impolite not to finish with a quote from Klopp himself… "I have only one understanding of development and making success -and thats by going step by step". 
Wise words indeed.

Sunday, August 20, 2017

It's NOT ok

"If you are anonymous, you don't exist to me…"…that line stuck in my head a fair bit after my meet with Helen - the RCGP Chair. Amongst many topics, we had touched upon social media, bullying…and I liked her style of dealing with it. I have seen some of the vitriol she and Jane Dacre, not to mention Bruce Keogh have sometimes copped- and they have rode that wave admirably. I have been comparatively lucky- though a few messages from evangelists within the low carb lobby have stuck in my mind.

"What does a Paki know about low carbs- go and feed your kids those shite"- ah yes…lovely indeed. Apart from the factual correction, I am a proud Indian to begin with, there probably is some fact in it- heck, without rice, curry, roti…what is the point of being an Indian to be honest.... But why that extends to abuse or to my kids- I am yet to understand. Anonymous account- yet another brave soul.
So far in life- and I am an unashamed fan of Twitter, warts and all- I have ignored all that- and Helens' words stuck in my head. That sort of attitude hurts the whole community who support low carbs- not me individually. Is it ok to brush it off? Ok to see a racist slur pass by? I see a lot of NHS chat about how they are correcting racism- you do sometimes have to smile wryly at that. Let me know when one - actually any one of the top NHS bodies have a non-white in place- heck even a few Chief Execs would be a start…but anyway, I digress.

What has made me think has been seeing some of the responses to Nish Maneks blog on Pulse. Applaud her for knowing what she would face up to- and yet publishing her views- and on cue, it happened. Its a democracy and differing views are welcome- why that has to descend to snide comments about individual- I am yet to understand- especially when you haven't even met the person. To a point, I still can get it- the work pressure, a bad day, the easy accessibility of a keyboard does sometimes allow that to happen- but what mystifies me is many of these brave souls not having a name. To me, thats no different to any troll who happens to have a pop, any faceless racist or nameless sexist boor.

So its probably time to say, its enough. Its not cool or ok to be personal- and as a collective, we must take a stand against such behaviour. Opinions are ok-as it should be- it can be strong, it can even be harsh- but not rudeness, not personal attacks- and if health care professionals are ignoring GMC guidance and taking potshots hiding behind pseudonyms, then lets call them out. Enough is enough- and to take Helens sentence forward? "If you are anonymous, then you shouldn't exist to anyone". If you do want to, then accept that society has some rules, some decorum and you should not, sorry can not say or do things which you would not be able to say face to face or publicly. You may say -is that an over reaction? I would say No. Look at where we have taken the world to- by allowing the slow creep of "free speech" being demonised to eulogising Hitler and General Lee.

We -as health care professionals may not be able to change the world- but at least, for once, hopefully, we should be able to stand together and say "Its not ok". Small things escalate to things far beyond our comprehension.
I do not think I have heard a more poignant quote than that from the late Heather Heyer. It applies to all spheres of life- including the one we inhabit as health care professionals. RIP Heather x

Sunday, August 6, 2017


“The genius at the top doesn't make the team look good. A good team makes the person at the top look like a genius”….Simon Sinek

August 15 2008. Will always stay as a red letter day in my life. It was the pinnacle of what I had set out to achieve all those years back....a Consultant post in the NHS. In my chosen specialty. In a place I wanted to work. With a team I had wanted to join through my training years. The date itself had a degree of Freudian poignancy. After all, August 15th was Independence Day for India- from the British Raj. I still recall the first day, walking into the department with a smile on my face.

Fast track to the cusp of my 9 year anniversary...and that smile has stayed. I don't think I could have predicted even in my wildest dreams being where I am at this stage of my career. And what a swashbuckling roller-coaster of a ride it has been indeed. I have loved being part of the Portsmouth diabetes team, being part of Portsmouth hospitals- and frankly, I couldn't have hoped for a better job. Many highs along the way- well documented across social media or general print- but nothing, and I mean nothing, would have been possible without the legends I work with. Mike, Iain and Darryl were my Consultants once upon a time and there never has been a day in the 9 years where I have felt I wasn't among friends. I have always been my own man- but if there is anyone whose counsel I would listen to...then there they are. Over the course of time, the team has expanded to 5 with the additional of Eveleigh- and the dynamics of camaraderie has continued. So folks,  thank you for...well...pretty much anything.

There as ever is the counterbalance. People only see the successes...not the many many failures or hard days behind them- and there have been many. Low points have littered the nine years...and to anyone who works within the NHS, my tip? Surround yourself with support who will be there when you need them. My favourite example? A particular few days at work a few years colleagues knew what I was going through- a bottle of Jack Daniels - honey flavoured too- and an arm around the shoulder meant much more than a glib few words. I recall going for a job, not getting it and being hurt by it all- the text I got from one of my colleagues? I keep it till this day - just to read it again on days when the darkness descends.

I suspect 9 years has also brought a sort of self realisation. What is my strength is also my Achilles heel- but I have now grown comfortable with it. There is no need for anyone to be perfect- and if anyone says they are, then they are frankly lying. Glib judgements are easy to pass, especially when you using a keyboard- scratch a bit deeper, everyone has dark shades- that's human nature for you. The trick I suppose is to have folks around you who complement you- rather than yourself trying to be "whole". My strength lies in my passion, drive, ambition- and that can easily tip over. I can be brash, my ego is the size of a planet, my confidence brims over into territories of arrogance...I know all that- and I am now comfortable with it. It is who I am- that has brought success as much as failure- and frankly, it's the failures I remember most. They make you appreciate your success more. I have no problem in failing- it just gives you something to learn for the next endeavour. Other foibles have been a very black and white distinction about trust. Loyalty and friendship are huge things for me. I like criticism but open, honest and to to my face. If it's behind my back, for me, that relationship is done. I don't have the capacity to forget- that is my failing- I accept- but again, that's who I am- for right or wrong.

Nine years. Time flies- doesn't it? And I look back, mostly with pride. Regrets? In my specialty field, perhaps not much but maybe a tinge that perhaps I could have done more for my own trust beyond my specialty area. Due to a multitude of reasons, along with the inherent nature of management trusting conservative approach rather than the maverick one, it's never quite happened. Meeting the new top tier of the Trust, Mark Cubbon and John Knighton has been enlightening and refreshing too- the future will tell us what direction all this takes. This is a place where I trained, did my research and built my reputation- based on which I do my national work- it is my mother institution whose reputation I deeply care about.

Finally, to those who take the time to read my blogs. There will be some who find it self- aggrandising and a waste of time. To them I say- don't read is now my view of the world, if you don't like me, I don't have any issue with that. Nobody in history has been omnipopular- so I have no illusions about me needing to do so. To some or anyone who reads it out of interest, a few things to finish...
The job that we do is a blessing, a gift which not many have. It's one life and there are are not many jobs which gives you the chance to help so many others. Try to enjoy the ride, don't be afraid to fail and most importantly, never believe your own hype. Retain the ability to laugh at yourself and always have those special friends around you...who can bring you down to earth in the twinkle of an eye. It keeps you grounded, it keeps you sane. We are in the middle of trying times, but keep the focus, keep trying and if you ever need some tips when you feel nothing seems to be moving in the right direction....always happy to help. I may not have the answer but I can certainly try to make you smile.

(This is blog number 250- and dedicated to the whole diabetes team at Portsmouth- but especially to my partners-in-crime: Thor; Hulk; Cap and Natasha. Thank you x ) 

Thursday, July 27, 2017

Sweet Sixteen?

April 2016...took the step of joining the NHS England diabetes team. Here we are in July 2017...sitting by a seaside in Corsica perhaps offers the best chance to look back and reflect. Many had encouraged, some had warned about the dark side, some had been openly hostile, some had said its a treacle which will frustrate. So how has it been? 

To start with, I am going to say the positives. There are some people the world of diabetes won't see much or even be aware of...folks like Mathew Fagg, Jeff Featherstone,Ben McGough and Nin Pandit etc but in my experience and view, the world of diabetes will always owe them much. The shiny public relations and blustery side is easy..I have always revelled in that space, but without these guys working their magic in their quiet, non-obtrusive way, little would happen. To me, respect is always earned- and it doesn't matter what your title says, whether it be the Chief Executive of the NHS, a trust or indeed the HCA helping you run your clinic- and these folks have certainly earned mine. It has been a learning experience and surrounded by such folks just reinforces my eternal don't have to be perfect as a simply have to have folks around you who will complement you, look after your deficiencies. 
Which brings me to my compadre, Jonathan Valabhji. We didn't know each other much but over the course of time, it is my privilege to call him my friend. We have laughed and joked together, planned together ...and in parts, learnt how to work with each other. It's been simply an amazing experience. The external facade of me can do no wrong...internally, I know that throughout my career, I have always worked with others without whom I wouldn't have delivered anything.

Other folks within NHS England...the few times I have met Simon Stevens, I have never failed to be impressed with his vision and thoughts..I haven't always agreed but that's life- what has been fascinating to see is the respect towards colleagues and unquestionable desire to make changes. Bruce Keogh has always been a favourite, and although within a sphere, he will never be seen with respect, to me, he has always been a support who I will miss when he goes- as will the wider NHS. I appreciate this may not fit some folks narrative, but that's mine- as simple as that. 
Finally, it would be amiss not to mention Simon Enright...sparkly twinkly eyes, the Lord of communications- there's always that cool banter where he knows I am someone whose ego needs pandering to...and I know he is doing it too...effortlessly. The man knows what he is doing...and I respect that...he has enough experience of handling loose cannons- and respect to him for doing that...perhaps the only one who has done so with me with such élan. 

So, what about the other side? Well, bureaucracy is always an issue as is the vast maze of NHS England. Beyond the top tier, there has always been a thin veil of "who the heck are you?" laced with a generous dollop of patronising when you come with new ideas. There's always been that bit where you have to go and prove yourself again...sort of a repeat of what the career has been throughout my life- and NHS E has been no different...perhaps it's just ingrained in the NHS DNA. 
Beyond that work wise, the layers confuse me as do the multiple chains of process- which to me, does halt progress to an extent. Perhaps I am too harsh...the last 15-16 months have seen a fair few things delivered and maybe I am just a man in a hurry. Beyond NHSE, in general, the reception has been positive- amongst the clinical community, you have the usual mixture of admiration, support, jealousy, disdain...there's always someone who believe they know better- such is life I suppose. There has been a degree of academic arrogance - I suspect bound to happen when you challenge existing bastions- but in my mind, when you have strong support from Steph Amiel, Melanie Davis or Andrew Hattersley about "approach", the wannabes can be ignored. This isn't exactly a popularity contest....Big Brother has never been a programme I have watched.

So where next? Folks asked for money - the transformation funds were delivered; folks asked for clear national strategy - the right care pathway with its 7 priorities was released; folks wanted digital interventions- it's in the starts the delivery for all, not just us at NHS England. Benchmarking is the next big thing- more on that in future blogs- but in my last sixteen months, I have had a mixture of all sorts of emotions...mostly it's been one of satisfaction. NHS England hasn't felt like the dark side, more like a body trying its best within the financial rules set - and keen on improving care. I would encourage others to consider joining in whatever role to help things improve- if my experience has anything to say, it's certainly a roller-coaster worth getting on to.

Finally, I personally hope that some of the requests folks living with diabetes have made, are being listened to- whether it be in directed use of funds or indeed in strategies outlined. And I would ask you to keep the advice coming- because that's what matters, not some clinicians individual view or an academics notion of evidence. What matters is what makes a difference to YOU and is one of the reasons why I keep myself open to ideas whether it be on social media platforms or elsewhere. I don't know how much longer I will do this role- balancing out a full time job, while doing all this over half a day a week is not the easiest juggling act to do. But till I do, always willing to try- point out mistakes with respect and I will keep trying.

That's about all I can promise. Let's see what the future brings