Monday, March 16, 2015

Optimism...with caution

It's a world of fascinating dichotomy at the moment, isn't it? The colleges have asked for political parties to commit to the 8 billion the NHS needs to survive, no main stream have agreed to it..while on the back burner sits the issue of having to find 22 billion of efficiencies. Even if one finds that 8 billion with the appropriate political will, the eye watering efficiency number would make most finance directors reach for their bottle of Gaviscon. Then we have a presumed crisis of leadership as the right leaders potentially would find the money, only if they knew how to lead. Parallel to that we have the "shiny" brigade...striving to improve the emphasis on empathy, trying to spread the feeling of doing good, while at the same time, we have Kirkup suggesting silos, professionals turning a blind eye to poor care..dichotomy all around us.

One more bit in the mix is the fascinating situation of the makes me smile when people rail against those who do private someone explain to me what PbR has now become? See more patients,turn the wheel, for each activity, you generate money for your Trust..did you say we were all in this together? How many trusts do you know who have made a profit and then handed it to primary care or social, they rather invest that in developing maybe another wing or an IT project to improve "their" services, not necessarily the system. In between all that, an institution like Barts is now on its knees...leadership and shininess won't sadly help what actually is's the injection of cash. Who's feeling confident about that 22 billion efficiency savings now?

So as a clinician who has spent a significant time in management, looked at enough balance sheets, it's darned difficult to be overtly optimistic, believe that a solution is around the corner...but having said that, there always comes along a few things to lift the spirits a bit, give you a bit of hope that we aren't sliding inexorably towards a health system where availability of quality will be dependant on your wealth. It's tough though..the world of healthcare in the UK is already having encroachment of companies putting their products on the market, outside the NHS, creating a 2 tier system..those who really need it, can't afford there much to arrest the slide?

Thus it's with a degree of optimism, I have looked at the Vanguard projects..a new and interesting development. Am also fully aware that this already has had its cynics but with the challenges mentioned above, we need some major game changers...could this be one? The trick as ever is to implement the clever words, the glossy power points into reality..and then the toughest bit, to sustain. Can the vanguards do it? Time will tell but certainly it's something new, something different.
In American football term, it's as close to a Hail Mary pass as it gets...we need to decide as a community whether we engage with that constructively or simply sit back, criticise and just ask for more money. I am an optimist and I want to see how this works, how it can be sustained, how theses can work without breaking the local trust or imploding primary care. Whether right or wrong, it's different, it walks away a bit from silos and it's worth a try for sure. Best of luck to the ones who lead in's not easy to put your heads above the parapet..for that to be's now about implementing and sustaining..and maybe also know when it's going wrong and being big enough to stop. It's not about your local trust expansionism or even a GP cohort taking control of the system...but about whether the patients are served best..whatever garb it maybe in as.

The other bit has been the recent Diabetes UK Annual conference..maybe one of the best I have attended in recent times and I won't spend much time talking about it ( Read a great piece here) but what struck me was the change of mood...there seemed to be more of a mood of optimism, a more stronger willingness to improve care, a better mood to work together..I loved mingling with the patients amongst all the HCPs...but the best bit for me was the energy I saw within the up and coming trainees. I am enthused by their views, their desire....we, as a community, must let these guys flourish..they are not uncomfortable in mingling openly with patients, having a debate about care....I like that..I really do.

Meeting so many people I knew via Twitter (Anne, Roz,Mike etc) was fabulous..talking about what we have done over 4 years in Portsmouth was proud, trying to share the importance of SoMe to many was fantastic...but mo than anything, it was the desire to share, interact as well as say to many HCPs...please do go and engage with patients..beyond what you can learn. Share with them our frustrations too, the issue of the finances, what choices we have to my experience, people understand, people have time for being honest and in the main, appreciate the work we do within the tightening constraints

So, times a changing...we need realism..we need to understand the finances aren't stacking up and all we can do is to collectively raise the voices loud enough for the politicians to listen. Till then, we must and I stress, must, work collectively. We must look at efforts of new working with positivity but also be a friendly critic. Let's not shun the ones who are trying the Vanguards but let's try to be constructive..we are all trying to do this for the let's try..while at the same time, keep the open dialogue with the patients about challenges we face. If our politicians can't say due to whatever reason the problems the system faces, the. It becomes our role to do so. Yes, we have much to learn from patients but at the same time, it's a 2 way street and opening channels gives us the opportunity to share with all our issues too.

Times a changing..approach it with a degree of optimism, shall we? Cos without that, what else do we have left?

Tuesday, March 10, 2015

NHS Change Day...the good, bad and...

Be have started reading the blog with a degree of intrigue or trepidation- depending on whether you believe in the principle of NHS Change Day..or not- right? It's not unknown that I am a cynic to a degree though my past blogs have tried taking the route of friendly criticism rather than disdain. So let me ask you to be a bit disappointed- this blog isn't to rabble rouse but an opinion from someone who has been a Consultant for 7 years, someone who works both in acute and  community providers, someone who has traveled the breadth of the country talking about "working differently" a bit of experience of change.

Th debate has raged...why this tag, this label in a climate when Kirkup and Francis exposes the NHS warts and all, why this initiative when whistle-blowers are yet to be given their just due..why even pledge to do things when we should be doing some of those pledges as part of our usual work? It's been fascinating to see both sides of the spectrum as the proponents have said this is exactly what the NHS needs- something to help it heal.

So how has it been over the last 12 months? Let me give you a personal perspective, my experiences, my dealings with NHS Change Day...

The Good:  There has actually been a lot of good. It would be wrong to doubt the commitment of those who have volunteered their time to do this, it inherently comes from a desire to improve things- and that, in my view, should not be sneered at. 
I appreciate I have been provocative but among all the people involved, I know a few, don't know quite a few too- but there burns, unquestionably a desire to improve things. It comes through in blogs, their willingness to engage on twitter and a fierce willingness to stand for the value of the NHS. So yes, there has been good- there has been a collective of the willing to "make it happen".As eloquently as ever, Damian makes his point- and indeed is a good one, a balanced one. It gives you, perhaps an insight into what NHS Change Day should be- a force for good, maybe not to the taste of all- but most certainly an ally for all of us who want to improve care- albeit in our own way

The Bad: However, as ever, every initiative will have its drawbacks- and the biggest one - which has been picked up, time and again, has been the "with us or against us" view- shown up on twitter or otherwise. 
It is getting better but efforts to engage or question has met with varying degrees of defensiveness or surliness. Recently when I asked "convince me" one of the answers was "why do you think we need to convince you?"...well, for starters, I am a Consultant in the NHS who is trying darned hard to improve diabetes care- so do, please try. 
It made me smile but that is exactly what has switched off a lot of folks too. You want to be inclusive, do it properly- not by surly thoughts in 140 characters.  Finally, for this category- a huge play has been made of volunteering- the NHS is surviving on good will and volunteering-it has been ever thus- and will ever be.Someone on twitter said.."we all find time, so should you"...a retort to that would be simply juvenile

The Ugly:  Actually there is no "Ugly"- when you have a group of people trying to improve good- there can't be anything "ugly" about it. But there is one thing- its' called the "Hijack". Last year, in my blog, I had mentioned the importance of the original founders holding on to this concept- right now, it's now an NHS IQ project- or at least that's the perception. That makes it all shiny, official, pretty but also laced with words and jargon most people can't understand or switch off to. Some of the biggest workforce in this country or at least the spearheads are Consultants and GPs. How many do you see actively engaged in this? Is it because they don't care, don't have time or simply have had enough of NHS speak jargon which means little-as per their past experience with NHS IQ and the ilk?  Is NHS Change Day now simply a project run by official body which has hijacked anothers concept? Is it alienating people or drawing more to it? That's the question that the organisers need to think about or consider. Do the "hubbies" believe this is their project anymore- or as one of them asked me  not too long ago- "should I stay with it anymore-as it feels like being taken over"?

In the world of twitter, NHS Change Day is a big thing- in the real world, it perhaps isn't. I have done a snapshot of 50 staff recently- inclusive of medical students, Consultants, nurses (senior and junior), number of folks who had even heard of it? 3. Twitter is NOT  a reflection of the broader world- if it were, the HSCA would have been repealed, the Liverpool Care Pathway would have stayed, the NHA party would have been in Downing Street and oh yes, Madonna would have retired. Mutual backslapping or tweet chats may convince yourselves, not the broader world you need to convince

So, pause, think and see how you can take things forward. Try this simple example. Where you work- can you, hand on heart, stand up and raise patient safety concerns without concern of reprisal? Are all the modalities of safety for patients covered? If not, charity begins at home. Hold fire on changing the whole NHS. Just change 1 thing where you work- let that be openness regards patient safety. 

The day you can do that, you can call that day NHS Change Day. Till the day we can prevent the James Titcombe's from losing their loved ones, a clever tag will remain only that. So feedback from a Consultant? A good project which has legs but needs to be more inclusive, a bit less jargon-fuelled and perhaps even less centrally driven by a national body- try that and you may, just, win some of the doubters over.Doing good doesn't have to be done in any one particular way but it wouldn't be a bad idea for all those forces to at least have a loose alliance - the endgame seems to be the same- would make sense to do it together. 

Friday, March 6, 2015

The reality of leadership

Leadership is always a tricky one. Debate about what it actually means always is interesting as it brings out a range of views- starting from "its all about values" to "its a natural skill not all have". Then you get into the areas of discussion such as "we are all leaders in our own ways" and suddenly it becomes a cosmic discussion while at the same time, review after review tells you the NHS lacks leadership, especially of the clinical type.
Sometimes we confuse the term leadership with charisma and thereby it becomes even more a leader about whether they have delivered outcomes or is it just the inspire factor? Is Obama a leader or just a charismatic speaker? Views differ...and we never quite get anywhere.

For the cricket  affectionado, think of Stephen of the acclaimed leaders in the world of cricket. To some, he was lucky to be in charge of some of the greatest players in 1 team..whats so tough about leading that sort of team to victory? To others, he brought together a disparate group of brilliant individuals and forged a team, one of the greatest ever. To others, he simply bullied other teams, used every tactic in the simply achieve one goal...a win. To many more, he was n incredibly kind hearted man who did some amazing work for children with leprosy in Calcutta...little kids for whom he was just Steve-da, an affectionate term for brother in local lingo.A leader? A bully? A philanthropist? A legend? All about perspective, isn't it?

So what about the NHS? Firstly, what makes a great leader? Someone who has forged a great team spirit but not delivered patient based outcomes? Someone who has happy staff, happy patients but not much in way of delivery? Someone who has developed amazing services for patients but not bothered much about keeping others happy? Some would say we need all of that...but history has taught us time and again that not to be true, not to be rarely possible. I see many leaders quote Gandhi at the drop of a hat. History will tell you he was perhaps the biggest rebel for many Indians but one of the biggest troublemakers for British Raj. One man's freedom fighter is always another mans terrorist. Leader for some, troublemaker for another. All about your perspective....the debate continues.

The question is always why so many clinicians stay away from leadership roles. Well...what would attract someone to it? In general, for right or wrong, there's a few factors, either in isolation or combined which draws an NHS Consultant towards these roles. They are...Glory, Power, Altruism, money. I appreciate we would all like to believe that altruism should drive us all but it ignores the reality of life. Money isn't much of a driver for many firstly because the financial reward is pretty average for leadership roles to start with- not to mention it's not really a huge issue for folks who are in the top 4% of the country as regards salaries go. As ever, there are exceptions, but financial reward is hardly a draw.

What about power and glory? A huge draw for many and whether we like it or not, the NHS is awash with folks like that. Let me be crystal clear..that doesn't diminish what they can offer, their passion is worth emulating and there are examples of great care driven by individuals such as that- but for them, glory, either self or the department has been a major driver. I will be honest, time may have tempered my desire but I started my leadership journey because I wanted to put Portsmouth on the map of diabetes care, make it one of the best.
Time teaches you the biggest currency isn't the title you hold, but the influence you carry but hands up, that has been my personal driver. Which brings us to altruism- there will always be people for whom that carries a significant part...the problem with that is the sustainability and also the ability to balance your personal life. The NHS is astounding in its ability to ask those who do a bit do a bit more more time for the patients. Every one of us has a limit..everyone of us has a life..altruism only goes so one point, the rubber band stretches, it snaps..and in 1 fell swoop, you lose the power of altruism as well as that individual.

The problem as always is of the NHS a being awash with leaders without track records..good speakers, good motivators but a bit thin on the ground as regards delivery. We spend too much time describing a shiny world, spreading the goodness of optimism but it needs balance. It needs realism, stories of leaders failing, stories of how the first hurdle was the toughest one, how adversity is a part of life in the NHS and how lack of resources are impeding progress. Did I hear someone say "Resilience"? More different words crop up but we need to be more realistic about what we are asking our optimism filled, leadership cadets to do. Otherwise in the real world, disenchantment sets in quick and you lose even the ones who have been inspired by your slides on a pretty PowerPoint.

The million dollar question is whether all the leadership bodies can walk away from a mutual session of backslapping after an annual session or Twitter chat..feel that's enough to justify their existence or whether a new ring of leaders will come through armed with the knowledge of what both success and failure looks like. The NHS needs clinical leaders...and it's running out of volunteers pretty fast.  An edge could be a cutting edge of the new could also lead to the face of a cliff. Leadership is rewarding, can be fun..but it's tough and spiked with failures too

Temper the optimism with realism...and then the future looks a bit..better.

Next week: NHS Change Day...progress or another year of banality? A personal view..

Sunday, March 1, 2015

Clash of the levers

By now, you must have read it. Sir Bruce Keogh's frustration at the lack of progress at 7 day services is palpable  His views are not new and rarely if ever will you meet a clinician who has not agreed with the principle- and many a forest has been razed at trying to extol the importance of it while also laying out reasons why it cannot happen. NHS IQ have been trying to squeeze out the kernels of examples - trying to exhort others to follow suit..the reality has however been laid out starkly by Sir Bruce himself- progress has been slow if not painfully slow.

The man himself, predictably has copped some flak on social media. I have a simple rule in life- I try to stay away from judgements of folks if I haven't met them- the baseline is simple, all other views are prejudiced or biased. I also do have a degree of respect who do take up senior leadership positions- simply because of the extent of the challenge in front of the NHS- to expose yourself to criticism and be bold enough to raise your head above the parapet takes a significant amount of courage- its much easier to be a keyboard warrior. And I must say I have always liked Sir Bruce- Why? Because all those years ago, when the "great and good" of the diabetes world gave me a lot of flak, played politics, made snide comments when we were trying to change our way of working..I met him in a meeting and he took some time to listen. At the end, he said simply.."Do it- its the right thing to do". A flake of support meant a lot- so after all these years I haven't forgotten either.

The stalling of the 7 day service isn't surprising - especially when you are now mostly banking on good will for folks to extend their work to 7 days. Money is out of the question- so that leaves us with good will. The erosion perhaps started when you moved from a block contract for Consultants (I pay you a certain salary- and you do what patients need) to the session based one (we will pay you/monitor you per sessions done). Everything started to become like. Patients became "clients", Trusts ran "Customer support sessions" while lots of the old school professionals looked with a sense of doom.

Today we have an odd situation. The call is to stop the "unsocial hour payment"- at the same time, you need to bank on goodwill to ask folks to work more. Which way to turn? The levers clash against each other. can you give time off in lieu? Of course- but then who covers the work when the person concerned is away...the levers clash again. Performance monitoring? A middle manager is keen to know how many patients were seen in X clinics but becomes uncomfortable when asked whether the extra patients added to the list or the adhoc patients seen somewhere else would be rewarded. We performance manage negativity, unevenly- the faith is gone, the trust is not there- so when you ask for a goodwill gesture, the levers clash again.

The chess pieces are well and truly set- those who believe the new contract will solve it..dream on. It would perhaps make it financially a bit easier- how do you define emergency- stay tuned for disputes up and down the country as regards definition of that- the legality etc etc- this will get messy. You want to force the era of MSPs- you sure you want to push your Consultants to walk away with the business of PbR and join the GP groups? Heaven forbid.

Our story of rolling to 7 day services has had all of that- a team which believed it needed to do so, a CCG who backed that, a game of chess with management, use of existing financial levers such as Best Practice Tariff- and a sharing of work load amongst all the nurses and doctors. However, the freedom to make career moves must be given the leeway that a family needs, if doing weekends is tough for a single parent, then that deserves the respect it needs- not finger pointing or blaming. We live our own lives, in our own bubble...why judge others based on that?

However, as ever, the chickens are now coming home to roost. You wanted healthcare to be a business, patients to be customers, each activity to be a transaction...the shopkeepers are now saying that they they will decide when to keep the shop open.
The 7 day service needs investment- not just for doctors but a multitude of groups- we will "work differently" or " lets work together" are all fine powerpoint bullet points- neither does it pay the bill nor make up time for the hours lost with the family. Always think what you wish for...never relegate a healthcare professional to a tick on a when the time comes to ask for a favour. ask for a good will gesture, the levers clash. Gratingly so.

Friday, February 20, 2015


It's actually Helgi's fault. Yep, pure and simple- a chap otherwise known as @traumagasdoc on twitter. He got me started when we discussed whether things got better in Medicine- and to be honest,reminiscing...would I do it again..yep, without a doubt- and Helgi as ever, eloquently put his thoughts down

So here's my tuppence worth. I was a House officer, then a Senior House Officer for nearly 3 years then became a Specialist Registrar for 5 years- with 2 years added on doing research- and you know what? It's been quite a ride. I am not going to get sucked into those puerile debates about "in my days"- I interact with juniors enough to know that the fire of dedication, the urge to work hard and do good is exactly in the same proportion as we had in "our days". It's not their fault if hours have changed,training have shortened- within those limitations, all junior docs are as hard working as ever or at least the proportion in't any different. Do they moan more? Well- its more public now- why? Because we have social media- on twitter, in 140 characters, you can offload your angst, grief, frustration - which to many may seem like moaning. To the bystanders, I was no different. We used to do it in a pub, among friends, complain about the system- the opportunity for it being public simply wasn't there. If there was, would it be any different from now? Probably not.

So many folks I worked with- whether it be Azman when I was a clinical observer, John when I was a House Officer, Aparna,Kate,Ros, Matt,Paul,Jeremy,James when I was an SHO...they were all good fun- hard working, dedicated folks who have now become GPs, Consultants- and are the same folks I knew that many years back. Life was tough, pay was..heck..that certainly wasn't great - (anyone remember those Additional Duty Hours??) but I suspect we all knew where we were heading to. Being a Registrar was tough- and none more so than being the Medical Registrar on call. Consultant coverage was a rare beast, you were pretty much the last vanguard- whether it be the wards or on calls- it was tough, referrals were rubbish, but you worked, you had fun, sometimes lost your cool- but in general, worked your time. The pay was better- while the world kept changing. We probably weren't as politically aware as the present generation started to hear vague terms such as PCTs- what was noticeable was the contract changing,

And life was fun- there was a sort of a trench mentality I suppose due to the hours etc- but most of all, the concept of a team was ingrained. There was friendly banter between specialists but heck those were the days before everyone cherry picked their thing. Cardiology had just started their campaign to prove how special they were- and as thrombolysis improved, we watched with bated breath as Medicine evolved.

Then I became a Consultant- and what can I say? It gets better since your junior days. You hear that pay could be better- I don't know- I feel its actually pretty good. If in doubt, use this tool..go on, check it yourself- maybe get some perspective when compared to the UK. If you fancy a small flutter of your socialist heart, see where you stand with respect to the world. Interesting, isn't it? Working hours are good- am on a 11.5 PA contract for my trust- thats 46 hours- ok so I work more than that- but heck, clocking in and clocking out isnt why I took this profession up.

I can't speak for others. I am not a GP, I am not a Acute physician, I am a Diabetologist- because that's what I chose to be. The pension is good- and in fact most finance advisers would, still, advise you to stick in spite of all changes made. The weekends are few and far between. I go to work, have amazing colleagues in the department- of course there are ups and downs- that's life. The NHS is under pressure- I would expect to be put under pressure too but if I take a step back, sorry- I can't pretend life is bad or even life is ok. Life is actually quite nice...I do the job I love, the job I wanted and while doing that, I try to smile and give the patients the expertise I have been taught. I know others will disagree and tell you how rubbish life can be- but having worked in other health systems? No- its not bad at all.

So guys and gals, its actually ok. Yes, there's a lot of negativity and no I am not saying being a Consultant is about skipping over a rainbow chilling on top of a unicorn either. All I am saying is that I appreciate you all put in a lot of hard work and effort. Stick to it- and if it means anything, Medicine does get better. There are ups and downs, there are frustrations but in the main? It ain't bad. Don't leave as for starters we all need you and more importantly? You would have missed out on the best time which you have worked so hard for.


Sunday, February 15, 2015

Radically different

It's easy to say when you don't have any consequences to bear. Easy to ask someone to "rock the boat", easy to ask people to "change". Let me be very clear at the very outset. To the many who have joined different campaigns, there is no doubting your willingness and intention to change. Yes, as I have said before, an ever increasing question is what it has ACTUALLY delivered as well as whether some of it is nothing more than tokenism. I have said before and I will say so shows nothing but the stress of the system, the situation we are in that we have to pledge to smile at someone, be kind, answer a telephone or be polite. It's not necessarily something we should be proud of but if anything a bit worried that in a healthcare system, we need a pledge to keep patients safe. However if that works as something to reinforce the basics, so be it.

Time has also taught me that most of these individuals who I hear about seem genuinely interested, passionately care and want to make a difference. I respect that and appreciate your desire to help, humbled by your dedication too. The problem is the NHS  needs not just those basics to happen but something much more fundamental. It needs changes in way we work, changes in how we deliver care in the modern century but a tripod of old school thinking, perverse tariffs and misplaced allegiance all combine to dissuade many a would-be a rebel or radical.

Let's take the case of the whistleblowers. If we believe what happened to them as documented, then what exactly has happened to those who were involved in shutting them up, destroyed their careers? The doesn't seem to have been anyone named, prosecuted or what's the message then? If we are saying the biggest radical of them was pinned to the cross for others to learn from and be dissuaded from raising the voice, where exactly does the slogan of "be a radical" fit in? Or is that we don't believe the whistleblowers and it was all just a personal vendetta we all just disagree with?

There's an oft used quote- rock the boat but don't sink it...I struggle to understand what that means. Go so far but no further? Be a radical but with limits? Ask the diabetes world, you will not come across a bigger rebel, radical, maverick than me, ask any organisation linked with diabetes- be it Diabetes UK, ABCD, YDEF...coin whatever term you want...and I bear the scars. The only thing that has helped me survive has been my colleagues, my family and the security zone of going back into that clinic, interacting with my patients and enjoying the day job. It's tough, it's hard, it's sometimes depressing and sometimes it doesn't feel worth it.Its easier to get your head down, do the day job- and go home. The salary stays pretty much the same, so why bother?

The million dollar question is..after seeing everything and reading the Francis report, ask yourself the question...would you whistle blow? If you are in in organisation like Wigan, as per what Umesh Prabhu says, you raise an issue, be a radical and you will be listened to. But let's face it...isn't that a rarity? I personally have been fortunate enough to work with different Executives locally and I have always had a willing ear, someone who has listened to needs of patients and helped....but does the story of the whistleblowers fill you with hope or dread? 

I will tell you what will make you think twice. It's called life. It's called everyone around you. It's called your career. On the ground, unless you can change THAT,unless you radicalise that, all sorts of movements will always be objects of derision a for some. There will only be a handful few who would put their whole life at risk for sake of the patient...the change needs to be much higher up...the change needs to be in the openness of the system. If you work in a quango (for want of a better word), then exhortations to join the radicals will always be looked upon with one question....what's the consequence of leading people to change when that individuals suffering or consequences don't affect you? How many of the self professed radicals have come out and stood publicly with the whistleblowers? We all or at least Roy Lilley certainly does question the appropriateness of use of public money when CQC and Monitor is questioned. Quite rightly too. As should I be for the amount of taxpayers money spent in training me and now paying me.

So shall we also question the use of public money for all the various networks, organisations which seem to have sprouted over the last 4 -5 years? When money is tight and believe you me it is when I am battling for a few thousands to justify improved what point do we question what these quangoes have achieved? Not in a derisory way but a genuine open that even possible or as soon as you do that, you are a troublemaker, not a rebel? To paraphrase, one mans rebel is another mans troublemaker...all about your point of view, isn't it?

I am not a sceptic, if I was, all that has been achieved locally wouldn't have happened. I am a born optimist while time has taught me to be pragmatic. I will be the first person to ask a junior doctor to think radically but I would also be honest about the consequences, also be the first to be there for them if the evangelism of radicalism burns them. Those who advise must tred with caution, must appreciate the impact on lives, must appreciate why there is derision from some, as ever, is cheap.

Leadership is a fine art...the rats all thought the Pied Piper was a leader too. You want to change the NHS, you want radicals to take the fore? Show them that being a whistleblower doesn't need to end bad, show them the eventual outcome is good, stand by them and challenge the establishment. Or stand up and show us your own track record of being a rebel. A clever worded PR campaign can fool some, not all. I appreciate the value of PR, I am someone who has been to that school of arts...I also know credibility is built on results, not on empty words.

Prove me wrong.

Thursday, February 12, 2015

The perennial question....

You work for the NHS. Sure? You work for the patients. Sure? You work for whoever employs you. Is that better? A perennial bone of frustration for many who would like variability to lessen..the debate as ever is who do you actually owe your allegiance to? The public would say "us"..we pay taxes, we pay your salaries, surely you owe your allegiance to us. Or is it the NHS? We always balk at the suggestion of something like Tesco but we partly marvel at its consistency whether the store is in Stoke or Southampton while also wonder about the monotonous nature of all the stores. Is variety the spice of life?

In an ideal world, you would think we would all be employed by the NHS and thus work to a standard. Anyone who has been in the system will tell you that's pretty much a fantasy...we do a lot of things well in the NHS , consistency isn't one of them. If ever in doubt, beyond the tub thumping evangelists, ask junior doctors. An under used resource, they,at least to me, have always known the real truth..very few work in so many organisations, very few will vouch that the level of care was equivalent everywhere they worked. Why is that? Is that simply due to variability of staff? Is that simply because of lack of leadership? Partly yes, but partly because we live in a world of competing interests, a world of different targets to hit, different financial drivers...the issue is lack of honesty about that basic thing.

Let me give you a simple example. A patient with type 2 diabetes goes to their GP, has been on 3 medications for his diabetes, the marker for control still shows no signs of shifting. What could the GP or practice nurse do? Well, in a modern world, they could, in theory, pick up their phone and ask a local specialist, who they maybe friends with,about what the next step should be. The specialist theoretically could say Stop X, try Y and get back to me if that doesn't work. From a patient perspective, that sounds cool, doesn't it?Quick, fast, efficient. From a GPs point of view, again, quick and fast as well as a bit of education on the job..and knowledge what to do when the next case with similar problem comes through.

What does happen or has happened is they get referred via a letter, gets seen perhaps by the specialists after a variable amount of time (insert anything between 4-18 weeks) ,gets a letter back saying Stop X, try Y and patient will be seen again in 3-6 months. A letter follows after (again, insert anything between 1 week - 3 months) posted by Royal Mail or whoever (Governance, who's that?) the GP or practice nurse in between trying to do everything, tries desperately to see what he or she needs to do, if nothing, file away.

Payment by Tariff pays £239 as per this years tariff ( mind: an ever shrinking number since whenever) along with £99 for the follow up. CCG coughs up..then the financial screws tighten, it dawns on someone that that's too costly, so they suggest a community service.
The community clinic does pretty much the same thing (Stop X, try Y) but this time the cost is cheaper as its on a block contract, so send as many as you want...the activity builds, the screws turn, staff get exhausted and the cycle continues.

On the flip side, if we did go for the modern option of phone, chat etc, that would have stopped the local trust getting that money, which is their life blood to survive..that drops,income drops, staff start getting off laid...the cycle is set.Of course, we would/could have a phone tariff but as any finance person knows, it amounts to tiddlywinks compared to the real deal.

So, for a change, let's be honest. There is no point in asking people to be kind, change or anything else unless the drivers change. We all, at the end of the day, work for our organisations who pay our salaries and thus will do what naturally keeps our organisation ticking..whether it's a GP surgery or an acute trust or a community provider. An acute Trust gets spanked by 4 hour target while it should be a marker for the system..we all know the reasons why the 4 hour target is failing, yet Trusts are consumed by the desire to improve their 4 hour target...while it rarely becomes a beating tool for OOH, 111, community providers et al.

The question is whether the powers that be are adult enough to actually be honest about the whole picture as things stand. Grandstanding or campaigns will become objects of derision while the basics are not addressed. Rarely if ever, I have met a manager or a nurse or a doctor who isn't trying or keen on change but if you want to impact change, then the drivers need to change first. How many managers would go to their superiors and say we don't need the activity as it can be done much easier/would be better for patients/help education but the flip side is that the organisation would lose revenue? In fact, how many clinicians would?

Time to be honest, time to be transparent, time for all to understand what pressures the "other side" is under, what targets are being asked..whether the basic question is being asked. In public forums, plenty will say it's to patients, no one else, it's to the ethos of the NHS...when it comes to the nub, the majority will always swear it to the organisation.
Today, pause, think and answer this question...."who do you ACTUALLY owe your allegiance to?" The organisation who employs you, the NHS or the patients? In your heart of hearts, you and only you will know the answer to that.

(Next week: Why radical leadership and boat rocking advice is flawed)