Saturday, October 3, 2015

Inspired maverick

It's been actually a lovely few weeks. No I am not really has been..on many levels. Weeks which have been laced with meeting new people, learning about new the cursory question one gets when one meets someone after some time.."How's things?" The answer, truly has been "Not bad at all".

The request to meet Simon Stevens came out of the blue and admittedly, a pleasant surprise. There's only so many times you can believe your own hype so I suppose an invite from the head honcho is always welcome. Without going into too much detail, the personal meeting was informative , enlightening, not to mention actually quite educative- away from the bubble of 140 characters opinions on Twitter, it was nice to talk to the man who runs the NHS. Clear thinking was a feature apart from the calmness - sometimes you learn about leadership much more from personal meets than any leadership course can teach you. Stevens has his share his detractors- would anyone in that role but he had encouraging words for someone much down the food chain- I liked made me think again where I could help as regards type 1 diabetes in this country.

Interspersed in those weeks was an obligatory trip to meet some CCGs, yet another tour for the Super Six diabetes model- and once again, met with many a people who had the will, but not necessarily the finance needed upfront to get things moving. A transformation fund - if monitored well- could indeed unlock many a door..austerity has brought forward a fleet of new thinkers...the system needs to support those, not deflate their energy when the NHS needs them most. What was nice was to see the belief that diabetes care needed to change, and change needed based on needs of patients, not as a money saving exercise.

A trip to Ireland brought many joys not to mention to observe some amazing work being done by Neil, Lesley and Athinyaa- what struck was not only the talk- but the actual ability to walk. I will be honest- in my travels and different roles, I meet many, many folks who are brilliant at doing the talk- but pretty ordinary when it comes to delivering- certainly not these guys. It was wonderful to watch over dinner the sparkle in the eyes- as the discussion was about how to do it, less of what wouldnt make it work. If you really want to see something special in development- based on sheer energy and infectious enthusiasm of a team- take a trip to Londonderry- many many diabetes centres could have much to learn from them.

In between clinics etc also came a trip to Hertfordshire- at the request of a friend- to talk about diabetes and the role of inspectionthe fear factor as regards CQC was palpable- and thats the feedback the CQC needs to take on board. It has the potential to be a critical friend- a power for real good- as well as being something leaders within organisations can use to improve care. A force not to be feared- but for that to happen, all parties need to change a bit. What however struck me was the 2 patients who spoke to an audience of more than 200 HCPs. The message was loud, it was clear.please stop judging us, please work together. In 2015, that cannot be that big an ask. A loud message to me what needs to change across the country!

A lovely few weeks- much seen, learnt- and much positivity around too- in spite of the virtual meltdown we face as regards finances. Austerity has clearly inspired some thinking differently- the question is whether its come about 4-5 years too late- we shall see. There is indeed a lot of chaos but within that, the question is whether it offers opportunity too. My passion is for type 1 diabetes care-a nd the energy seen over the last few weeks has indeed rubbed off a bit. To all the people who matter whether it be Simon Stevens or Samantha Jones or Martin McShane or Jonathan Valabhji, my message has been crystal clear. Sitting on my laurels is an easy option for me- but the energy and desire to do things is now. 

So thank you to many who have inspired- I hear plenty of medics shying away from leadership- I will publicly buck the trend and simply say..Here I am. I, along with many others such as Pratik, Emma, Natasha etc, want to improve type 1 diabetes care- and the time is right with all technology, patient power at a nice critical mass. 

Shake off the cobwebs- and ask away. Brave enough for some mavericks? 

Monday, September 28, 2015

Reach for the Stars

Aspiration. A word that galvanises many to think of what we could do. It is however a fine line though. Take my own football club..Liverpool. Past glories abound and every year, the hope builds that maybe, just maybe, this would be the year. Aspirations are high but time has been a good builder of temperance. Now we talk about rebuilds, we talk about getting into the top that to's pretty everything you play in.

The NHS is in an interesting bind of its own. the pride of many who work in it is palpable, any suggestions that you may not be doing to the utmost level ( check any negative CQC report and responses) and we all bristle at the very whisper of it. Inwards, I suspect we all know we aren't doing as much as we can and different reasons are given for it whether it be vested interests, inability to work together, culture...the biggest one which does come through is of course finances.

This is where a dichotomy seems to have emerged with organisations within the NHS. Let's take NICE for example- a respectable body who looks at the evidence and makes recommendations. The problem is the aspiration doesn't quite match the resources or even the ability to deliver. Any think tank or health economists will tell you we are in a financial crunch and struggling to deliver what we how would it be possible to deliver more? Therein lies a fundamental question.
Take for example the recent NICE Type 1 guidelines. One which would be a dream for anyone with type 1 diabetes...but to deliver it, something needs to stop or there needs to be some investments. I absolutely take the point that working to evidence base etc would help stop complications- but in the world of diabetes, that's about 10 years where's the resource to invest to save?
When you ask NICE, their response is "It's not our job to give you the how". That makes it tricky because at the moment, no one quite does either. The problem is that NICE guideline manages to raise the expectation that those guidelines will be delivered- and when that doesn't happen..cue anger, angst..take it out against the HCPs who are the face of the NHS to many...drop in morale...the cycle continues. None of the policymakers, twitter champions etc actually face the patients...its the staff who are the face of the NHS.
CQC is another example. It sets the standards, then judges you based on that. However,when you ask them how with the financial crunch..their answer is pretty similar to NICE. "Not ours to give the how". It's an interesting position to take especially when all these bodies are funded by the NHS itself and not quite external per se.

So what would help the debate? Anything involving the public gets divided along political lines which as relevant as it maybe, hardly furthers the debate. Professionals raising their voice are sometimes branded as being of vested interest- so efforts continue at pace to try and get the public and professionals together. However think of much would it add to the table if organisations such as Monitor, CQC, NICE all did their roles but with a caveat that these are aspirations which needs a financial review to deliver? It would certainly strengthen the focus as well as be fundamentally strong voices? All bodies with their respective roles but working together for a sustainable NHS. Too tricky?

I want Liverpool to win the Champions League...I want them to be Barcelona. But I also know that to do that, we need injection of finances to get the best players etc. and if that doesn't happen, I will learn to be satisfied with a trophy here and there and perhaps a top 4 finish. The question is where do our aspirations for the NHS sit and do we all have a responsibility to reach for the stars? If we do, then it's about time, all national bodies had a think..because if it comes down to the wire, they may not have much to inspect or create guidelines for. Or the crunch of money will shut them down too.

The choice isn't that tricky. If we believe in the NHS a and improving patient care- which is indeed the basic role of all those organisations too- then it's time to reach for the stars..together.

Saturday, September 19, 2015

Say it loudly..part 2

Lets do some maths, shall we? We know the NHS needs about 30 billion £ by 2020- not my figures- but as per health economists, think tanks etc. To help, Mr Hunt promised 8 billion of that and in fairness, thats what Mr Stevens asked for in the 5 year forward View. So he got what he wanted- the idea being that the rest 22 billion would come via efficiency savings, working differently etc etc

You with me so far? Ok. Good.. so that brought forth the Vanguards- a bit of extra cash to help them develop- never mind it came from Public Health (a 200 million spreadsheet shift)- all for the greater good- and if the Vanguards fly, maybe those efficiency savings would come. No problems there- big picture and all that. So we on track for what we need. All good. Innovation needs headroom - as the think tanks always talk about the much needed transformation fund

Problem..ah well.. a few here and there. For starters, 7 day working wasn't quite in the 5 year forward view calculations and its inherent bill...especially when folks started talking about elective work on weekends, that calculation started looking seriously awry. Thankfully better sense has prevailed and we are talking about non-elective care which actually is about patient safety. Still, a bit of a calculation upsetting curveball indeed

Then came the issue of efficiency- asking the NHS to achieve what it has never done- a level of efficiency never before seen. Even the most optimists don't see that happening- and with all thats possible, reckon, we would, at best, achieve about 10-15 billion of that needed 22 billion - hey-whats 5 billion here and there between friends? That would leave the NHS  gap of 7-10 billion, come 2020- early signs are there..have a look- the NHS is likely to declare- how much- around a deficit of 2 billion come end of financial year. Election time come..I predict a bit more injection depending on whether we have an opposition or whether NHS is polling as a major issue...and we will limp on a bit more.

Depressing? Not really- as the optimist also knows that it is possible to get good efficiency savings but the realist knows we are a fair bit away from it.
Why? Well- for starters, lets talk efficiency. In an industry dependant on soft touch approach, good get efficiency, you need the goodwill of the workforce. Due to some mysterious reason, powers that be are trying their best to break that down. Which is exactly why as a Consultant, I look at this whole junior doctor thing with dismay. Forget the efficiency bit..we are struggling to get doctors to continue their careers and we are trying our best to make it worse. Odd...I always take pride as to what we do as a team- and what our juniors contribute..bottom line? Morale. Piss on it..and you can surely piss away your efficiency. Innovation? Technology...try and find someone more committed to it..and I can tell you without the presence of the person or the good will, those machines or technology are as good as cold machines. Newsflash- we haven't arrived at a dystopian future where machines do it all (and then take the world over either)

So, whoever you are, think about the generation next and the impact on patients. Our evangelist safety leaders are a bit quiet on this- perhaps out of embarrassment and realisation that championing patient safety without the resource or indeed, without a motivated workforce runs the risk of making things worse. As a Consultant, I am very clear that imposition of contracts is wrong and must be challenged. Whoever you are, whatever your title...have a think about why, for the NHS and patients, you do need to stand y our generation next. Say it loudly.

Next week, some suggestions as to where we could get some of the efficiency savings Mr Stevens alludes to...but till then...think of those glossy powerpoint you have made or seen umpteen times...think what they say about morale.

Then say it loudly.

Saturday, September 12, 2015

Whisper it softly...part 1

Take a moment. There..can you hear it? No? Try again...yes...there it is..the slowly dwindling voices. Voices of the few who have fervently championed the cause of "working differently"..championed the cause of doing so with scant regards to the "ask for resources". Eager to capture the eye, they wanted to make the case that finance wasn't the voices dwindle. The hard facts of balance sheets strike hard...the ethos of working differently sits in pockets...down to sheer charisma of a few individuals..not across the system the NHS desperately needs.

But why is it so? Is it about the money itself or could different working close the gap? Here are some of the fundamental chicken and eggs facing us today:

Staff costs: whichever way you cut it, staff cost is an issue and a pressure. Solutions could be to reduce the costs itself by cutting staff or reducing salaries. Cutting staff involves asking the existing ones to work differently ( ah yes), sometimes going beyond the call of duty..banking on vocation. Problem? By dropping the salaries or changing the dynamics of work life balance, the staff doesn't play it all comes to a head. What about hiring cheaper options? Divisive, inflammatory arguments rage about efficacy...debates rage about roles of others ..bang goes the thought of a team working together to deliver efficiency. Or even working differently. Oh and there's plenty on morale and its impact on safety, clinical delivery etc etc

Goalposts: it was a Herculean task to get the workforce to deliver what they were previously there are add-ons. 7 day aspiration of excellence- but go back to point 1 and the pressure cooker builds even more. Think of being asked to serve 5 people omelettes but with 4 eggs..somehow we were whisking them all together and cutting the omelette up to make it look like 5 suddenly 2 more folks have turned up. That's a challenge,No? The desperate hope that someone isn't that hungry...ah those tricky breakfast parties!

Patient power: The world is now a different place. Blogs, articles, social media, patient leaders, patient representatives ensure patients have a voice..and with that comes shifting of expectations. The dialogue of want and need gets patient leaders speak for many or for a few? The debate continues but one thing is for for sure...a realisation starts to dawn that not everything is deliverable. It creates frustration, angst...cue clashes with clinicians. Cue morale issues, cue burn out.

Evangelism: Beyond patient power, there is evangelism. Guided by personal experiences, they have championed, quite rightly, the issues of poor care. But has it been too niched? Has it resulted in funds moving around from where the system needs? Nurse staffing on wards have been emotive...any Trust around the country will tell you the costs it brings. Is it important to recognise something else needs to stop? If it was that simple, we would have it everywhere...we don't due to combination of lack of staff and realisation that to do so, it will deprive someone else of something. Charities shout "outrageous" and tackle their own niched areas...the reactionary responses from policy makers help a few but does ti take money away from many? Cost isn't an issue when patients are concerned...a fair point...but then ask the source of the money that the question to be asked?

Lack of headroom: Many clinicians will also agree that there is wastage in the system. To clear that, to get a fresh start, you need headroom. But there is none. Examples? To help deliver better flow in hospitals, you need better community support. Where do CCGs said get money for that when you are spending it on existing services, some non evidence based, fancy projects..but those that still continue? In the world of type 2 diabetes, to save money, you need to invest in prevention and structured education...where is the money for that when you are spending it on the tariff needed to pay for end organ complications such as heart attacks?  

So there we are...what was softly spoken hushed whispers are now starting to gain voice. Think tanks, health economists, politicians of all hues, managers...heck even the public as per recent polls are starting to query the feasibility and more importantly resources. It's also very easy to dismiss such blogs as the one I am penning as one of the "doom mongers". Au contraire, you will struggle to find a team which works more "differently"...and I am telling you this..the aspirations are not under challenge, the resource to achieve that however surely is. We did what we did..with resources.

So where do we go from here? The screws are tightening and there is an impending sense of everything building inexorably....hospitals are jammed in summer and autumn...frayed staff are everywhere to see. No amount of spin and cheery messages can drown them out anymore.

Next week....I will try to cobble some suggestions as to what could work...targeting exactly the points the interim, have a think yourself and suggest some..I am all ears.

Saturday, September 5, 2015

Invest wisely

Its all very weird. Debate about 7 day NHS has started to walk into Pythonesque territory now. To start with, a 7 day NHS is absolutely what is needed...but somehow we need to get past the belief that the NHS exists only within a hospital. Talk about Safe staffing, talk about 7 day working..the debate is mostly centred around hospitals...which is a bit odd- given that the bulk of NHS is based in the community!
Look at it...Health economists are saying it; Think tanks are saying it...let's forget for a moment what the BMA is saying..(as that provokes various debates about vested interests)...but the message is loud and an era of cash strapped environment, the more cost effective way of doing things is to invest in the community.

Everyone, or at least most importantly, Mr Hunt, seems to have at least agreed that implementing a 7 day service will need significant amount of investment- but as a diabetes specialist, I am baffled. To begin with, I was told there was no money...fair we walked down the road of discussing tough choices, thinking of I am being told, there is money but for ...what is it...elective work? Do you want me to do type 1 clinics on a Saturday? No problem..but unless you uplift my salary or give me another colleague etc, someone else will have to do the weekend rounds I already do. I have yet to have had any patient ask me for that- as they have adhoc slots, emails and phones to use regards their care anyway.

But let's not rehash all the old debates about other stuff appears that we have lost all sense of understanding as to what is actually emergency work. Evidently, me doing clinic on a Saturday will stop a diabetes specialist, let me say this, if you have money to burn..rather than increasing my salary further, how about you use that money to fund education for patients with diabetes, set up a help line, fund education of practice nurses...heck..even do something to prevent type 2 I can assure you THAT would certainly help save admissions, future cardiovascular know..the sort that we all are doing this job for.

Let's be crystal clear- we are struggling for money- and for trusts strapped for cash, more money to do more elective work in present times will be like manna - will it help patients- the health economists say No. Should we use any available money in community care? Mental Health? Think tanks say Yes. Can't really accuse them of vested interests. Let's be serious- there is no extra money- its shifting lines on balance sheets...recently Public Health lost money, remind me how much did the Vanguards get to kickstart the brave new world? To get the money needed for 7/7 working, something else will have to give...will it be mental health? Community services? GP funding? Who knows

However,if this is all about making sure election promises are kept, little else, then please- do carry on. I will happily do some extra clinics on weekends- will it help anyone bar a bit of convenience for a few? No- it won't. We have made a savings of 1.8 million £ over 4 years based on outcomes saved in diabetes patients- NOT by doing more clinics but by providing support for primary care- but heck, are we doing evidence based anything anymore?

We must, absolutely must, think beyond our own silos- and consider we work for the NHS-as a whole- take a step back and see where the money is best used. In a climate of no restrictions, we can and must aspire for everything...otherwise we put resources where it makes the biggest difference for the population. It can't be that difficult..can it?

Monday, August 31, 2015

Not quite NICE enough

It's an interesting you set the principles first before attempting to achieve it? Now normally that seems to be the perfect approach- how do you know where to go if you haven't set your destination first? That clearly makes sense in a normal world but unless we have all been living under a rock, you may have noticed the NHS isn't quite in normal back to the it the principle that needs to be set first- or more a question as to what is affordable/needs investment/needs working differently...take your pick depending on your inherent belief

The problem also is that as soon as you raise a question...its because you are against it. Well, not quite- sometimes questions are asked to raise the validity of what can be achieved, not necessarily questioning the principle. Let me give you an example- recently, lots of media attention was drawn towards how lack of senior cover was compromising patient safety on weekends- beyond even the debate about the accuracy, when I raised the question whether what is being asked is achievable, many a patient safety advocate felt I was against it. Well, not quite - just want to know how those extra bits are going to be funded. Leaders of all hues have a responsibility- to aspire to quality care- but also to be realistic and more importantly stop raising false hopes- as for those who have pinned their hopes based on promises made...not achieving it causes angst, hurt and frustration.

Let me give you another example- whats new in town? Ah yes, the latest NICE type 1 diabetes guidelines. Now before the world and its dog descends on me after reading this- let me make2 things crystal clear. Firstly, I am one of the biggest supporters for high quality care for type 1 diabetes patients and secondly, the committee who have come up with the guideline are comprised of folks I genuinely respect. It's led by Stephanie Ariel, one of the few folks in the whole world to whom I would bow anyway based on her prowess- not to mention some others on the list. For a change, its a committee comprised of folks who garner respect- which is light years away from what the type 2 guidelines committee are- making a pigs ear of a guideline, wasting valuable tax payers money...but that's a different story altogether.

So back to the NICE guidelines- whats good about it? Well, pretty much most things- as something to aim to- simply fantastic- it has most things which all Type 1 diabetes patients should be able to have. There are new bits added to the 2004 guidelines and on face value, its not too far away from utopian type 1 diabetes care. Just one snag- it doesn't appear to be grounded in reality..or to put it politely, it seems like the principles are set- but without any wherewithal as to how to achieve it.
I know some will say its all about working differently, efficiently, using consultants differently...and without putting too much fine a point on are speaking to the converted. Efficiency is what our care model is about- many an area spend many an hours trying to emulate what we do- so yes, I know. The problem...its just not stacking up anymore.

One small example- CGMS or Continuous Glucose monitoring system- approximately 4K. Flip it- thats about 40 outpatient appointments. OR care of 3 pregnant women. OR review of many a foot ulcer. Did we say priorities? Heres another one- blood glucose monitoring- it says 4 times/ day - if not 10/day. This in the face of an NHS where some type 1 patients have their strips rationed due to cost. Access to walk in clinics and phone what tariff- built into job plans? Or not? So many questions, eh?
Do I think patients need what is said in the guidelines? Absolutely- do I, as a provider and a CCG board member think its achievable? No- it isn't- unless we have one of the 3 options:
a) An investment to create headroom- to allow new models to flourish, technology to ramp up- and thus give the savings in long term-as advocated by the think tanks
b) A debate about prioritisation- lets not broaden it too much- we could just start with diabetes as a whole
c) Increase investment overall in the NHS

I know its boring- I know its the same record...but on behalf of many a patient with type 1 diabetes, all I can say is that don't raise false hopes, unless there is a plan to implement. Otherwise discussions will be about patients, rightly expecting to have CGMS based on NICE guidelines...grinding to a halt with providers having to make business cases in a choked financial climate. Cue frustration and misunderstanding that the professional hasn't tried hard enough...the truth could be they did- and got turned down as something else took priority in the bigger NHS schemes. Here's something to ponder about. The last type 1 NICE guidelines from 2004...we achieved little of what was there- in times when finances were better- what gives us hope that 2015 will be different?

However, I will finish on a positive note. The NICE guidelines is achievable- to do that, it needs some big bold steps, steps that will upset some, steps that will not be palatable for many, steps that will need some serious leadership.The billion dollar question? If the present lot haven't been able to deliver over the last 10 years, in times of need, what faith do I have that a NICE guideline will impact much?
To end- my final view of the NICE Type 1 guidelines? Good but not bold enough. Positive but not revolutionary enough. In a delicious twist of irony...a bit more boldness could have opened up the way to achieve much in there. Have a think what that could be..won't you?

Sunday, August 23, 2015

I don't know

I don't know..I honestly don't know the answer to many a things- and those who are sure they do..are simply either putting on a  face of sheer bravado or..I don't know what they know or believe..but its either not grounded in reality of life and politics..or they are aware of something I am not privy to. I won't say today I have seen enough, won't bore you with all my "achievements" in life, all my exploits..the honest truth? I don't know.
Do you know what I am talking about? Its the NHS and the direction of travel. There is a lot of things I don't know or believe views are too polarised in- all of which stops and continues to obstruct any meaningful discussion

For starters, there is a question whether the NHS needs more money...again..I don't know for sure whats the answer is- I really don't. I look at diabetes care- and I don't even know how much money is where, who is spending it, how the counter productive tariffs are supposed to how can I honestly ask, hand on heart, the public to give more? I look at the lack of finances needed for say, structured education..I also see the sheer wastage that inappropriate treatment of the elderly brings, the vested interest to which many acute Trust works, the Best Practice Tariffs which disappears into bottom lines...and I don't know whether there is enough money. Or not. I don't know but I would someone independent to tell me.

I don't know whether privatisation is the all encompassing evil beast some say it is. Is it because I do private work in my own time? No, its because I also am aware of many a state arenas providing poor care. No- did you say? Maybe so- but again, I don't know - I want someone more clever to make that call..someone independent,someone across political lines- I really don't mind who I work for, where I work for- as long as it serves patients and provides high quality care- thats my position. Blasphemous- did you say- maybe so in the tight chambers of twitter- not so much in the entire world maybe. Again, I maybe wrong, but I don't know- I honestly don't know.

Many dislike the market, would like the return of monopoly. Is that the right thing? I don't know. We have organisations like the CQC because we couldn't do the job what we were supposed to do. Would a monopoly help that? I don't know- I don't have the experience- but I would like someone independent to tell me.
Finally, to the name that seems to make all professionals bristle. Hunt. Do I know whether he is out to destroy the NHS? No- do I think so? I don't know but playing the man, having an angst against one man is no solution when we need to debate the policy as a whole. The point, in my opinion, has been made about what was said regards weekend working- it was aimed at the BMA and misfired..but it is time for us to ask the above questions- and if the answer is only from polarised views, then its time to ask for someone independent. Don't forget many also see the same man as someone who has set a clear agenda for patient may have a view that it is a politicians smoke screen- me? I don't know

I am tired of polarised views- and that includes those against political views. There is a certain quality about being in the tent in my view. There are many who hate the Tories, hate the fact they are the ruling party- but whether you like it or not, thats who are in the government- for another 4 years- if not longer. If we care for the NHS, then it makes sense to have that dialogue with those that are in the seats of power- a desire to improve /save the NHS should over ride all else. perhaps for some, thats too far a bridge but thats the scenario we have now- but I am more willing to try.  I apologise to all who may find my views offensive, wrong, out of order...but I have spent much time doing many things- and I must put my hand up..I don't know anymore. And I want someone independent to tell me.

Finally, I am a Consultant, reasonably entrepreneurial, street-smart and whether the NHS survives or not, there will always be a way for me. I do however believe in health being a fundamental right of any human beings- and so I would like fight..but engage with those who want to discuss it. I don't want to fight- I want to help..I want to try- and to those who want to, I extend my hand. If you want to take the offered hand, then join in.
You know what I am talking  about- its the group I am a part of and very proud of. It has a gathering of a group of individuals with different views and beliefs (and not all of the above views are shared by all either)- but all with a willingness to engage. We will stutter, we will stumble,we are not politically savvy...but we will acknowledge a mistake when we make it. And we will try. Any successful team always brought together a group of individuals with different beliefs...but the key lay in the ultimate goal...the ethos of NHS Survival is no different

In my life, I have never waited for anyone- forged my own way- so if you want to help, then can be of any political leaning, any belief- but if you think an independent opinion is the way  ahead, then do so. If you feel it isn't your forum, I wish you all the best in whatever forum you try and develop the NHS further.

Will it work? I don't know. But it most certainly is worth a try..and if not anything else, would have made some good friends for life. To those who are my friends, those who know me, know about what I stand if you can..if you believe in me. If you can't, thank you for considering.