Sunday, January 31, 2016


With a flourish, the National Diabetes Audit made its annual appearance- and being part of the core audit group, I already knew what was coming. Messages were hard, stark- and perhaps worryingly, it was actually worse than previous years. I will just concentrate on Type 1 diabetes- and it makes pretty sobering reading- about 39% folks getting their basic care processes;if you were under 40, this was down to about 24%, huge variability across CCGs....but to me, the most worrying bit, the sharp decline in reporting from GP surgeries- down from 70% to about 57%

So in short, not only have the numbers worsened, we actually know even less of whats going on and not surprisingly, folks have reacted in different ways. Fingers have been pointed at each other- Lazy patients not having ownership; Lazy GPs not bothering with care; poor communication from hospitals to GPs resulting in poor data transfer....irony? Its exactly the same debate as last year; or the year before that..or the year before that- you get my drift, the figures have worsened, the debate hasn't moved on.

I don't blame anyone- I don't have type 1 diabetes, I don't have the foggiest idea what it involves living with it day in and day out, I don't have hypos, I don't have to worry about my eyes- so I am the last person to sit here and judge another person on why they haven't had their care process done or not attended an appointment for that. I am acutely aware reading blogs, meeting carers, talking to patients that its isn't a life that resembles a walk in the park and from behind a desk or a PC, as a health care professional, its easier to say "why can't you have your feet checked" rather than the "what is stopping you- do you need help".

I don't blame primary care either. I am not a GP- so won't pretend to understand what they could do differently. I do know that years of cock-eyed leadership have given them more to do without any resources. I do understand that politician (of all colours) whipped  expectations of the public have put them under huge strain- and diabetes is only a fraction of what they do. It is not their fault they had a multitude of things to do without back up and support. And why submit data- when all that results in public vilifying? A media storm better to just avoid any data. Some say about enforcing it- by all means try- all that brings is gaming- apart from a further disillusioned workforce- apart from a further drive into making Type 1 diabetes a tick box exercise. That's pretty much the last thing we need- ask us in acute sectors and the impact of a 4 hour target.

I actually blame ourselves. Specialists- us- Type 1 experts- we must learn to put our hands up a bit. Over my career I have heard many a reason- "the PCT/CCG made me do it; I have to do other stuff; Have other priorities etc etc".
Well, in a system where patient voices are more of a token tick box, I am not quite sure who else is supposed to fight the corner of Type 1 diabetes patients- apart from the ones specifically trained to do so. When I say "every single Type 1 doesn't need to be seen in a hospital", let me- again- make this clear- that does not mean "not seen by a specialist". It is up to the specialist to see them anywhere- be bold enough to break the rules and understand that a diabetologist isn't the sole preserve of an acute or community provider- he or she stands for the well being of the system- and yes, that should, even must, be the responsibility of making sure patients get their basic checks done.

I can't account for others- but have decided to focus on simple basics in our locality over next few years. Ladies & gentlemen, the responsibility is ours, not anyone else. It is within our gift to work with our patients and make it better. We, as a community, need to decide what our identity is- across the system or confined to one silo- and doing jobs at the expense of our specialist training.

I don't need to see yet another data set; I don't want to have primary care forced to submit data...I know we have a baseline which isn't good. Lets stop dithering, develop a bit of steel and try and improve it. I am willing to bet that it would be much appreciated by both our patients and our primary care colleagues. Let's not wait another year to berate each other over another data set.

Friday, January 22, 2016


Are we getting somewhere with the junior doctor contract? Well...who knows. In a fascinating game of cat and mouse, mostly played out in the public eye via selective leaks to selected people, chinese whispers, Facebook forums etc...a macabre tale of politics continues to rumble on- leaving many, many junior doctors wondering what exactly waits for them around the corner.

I have said all along...the junior doctor contract has nothing to do with 7 day service and patient confirmed now by Julie Moore and Jeremy Hunt himself now. Even the disputed studies haven't said it had anything to do with junior doctors...for sure, the usual suspects jumped in to say it was...but we conflated 2, a genuine look at 7 day services and a contractual issue which simply meant to have more junior doctors on weekends, you either had to change the pay envelope or spread them out thinner on weekdays. Anyone who opined it was about working differently..well there's a difference between actually doing the job, running departments...and then being s keyboard warrior.

Muddled in all this has been a fundamental debate..the whole issue is 7 day services. Now that we have the issue cleared that this is NOT about elective services ( now there was a joke and a half) there is a need to have a serious discussion re 7 days. Let's park all the evidence for a minute and look at our own experiences. Is a Sunday as adequately staffed as a Tuesday? No, it isn't. Do we need it to be? Well, that's the debate when we have the financial issues we have at present. We are, officially, in the world of Monty Python where transformation funds also have a sustainability aspect, which you can only access on certain conditions, but need to be used to shore up failing trust bottom lines. We have a frothing debate about nurse staffing ratios when we don't have the finances or staff to get those ratios a tick box. We rail at the foreigners blighting our beloved NHS and then try our best to cripple other health economies by raiding those countries for their nurses.

We want better end of life care, we want better diabetes care, we want technology, we want better dementia care, we want improved community care, we want better access....we also want a 7 day service across hospitals. So which one is it that we want? All of those? Some of those? Is there any evidence that any of those are better than the others or is it driven by evangelism of a few, driven by who shouts loudest, driven by whose agenda is best suited to political needs? 

The message is muddled. The message is confusing...all the while we tear ourselves apart by opining, thinking, jousting...fantastic fodder for the press no doubt..while patients and health care professionals sit in between watching the saga unfold. We want a hospital to be safe staffed and resourced the same on a Sunday as on a Tuesday..well that's a fantastic and much laudable idea and as a health care professional, I will stand right by it. But only if you are willing to tell me what you want to stop doing. Did someone say change working habits? Don't make me giggle...I have tried/trying anything you hear about at conferences and meetings..emails/phones/Skype/hugging GPs/kissing babies....marginal benefits, amigos, marginal benefits at best till we,as a system can have a clear message about what's actually needed. And you think changing contracts will give you better staffing? Well, folks can't even implement what's in the PRESENT contract which has NO barrier to change weekend working for seniors. Did you say opt-out? Ah yes, but that's fir elective which has now been confirmed as not needed. Go figure.

So back to the junior doctor contract..a completely unnecessary protracted battle which has made even less sense as days have gone by- apart from the simple save money, we wanted the same doctors to stretch themselves for the same money, Heres a tip: you can't force vocation on anyone. Romanticising the notion of being a healthcare professional is beautiful and looks nice on a piece of get that bit extra, you need hands around the shoulders, a smile, some thank yous, a whole lot of genuine appreciation...not "do this for dare you don't"

So to the many MANY leaders of this county, please...stop muddled messages. Stop coming to meetings and talking about challenging if you can't do so yourselves. Be brave, be bold and ask what exactly it is that the NHS needs as a it more nurses on wards and if so, is it at the expense of community nurses? Is it 7 day service it needs and if so, is it at the expense of end of life care..or is it by reducing dementia carers? Or is it stroke medicine.

Decisions...decisions..the problem? None of them are palatable. But then again, it may just be a whole lot better than a message which is muddled. Better get thinking quick...because that efficiency fund or transformation fund ain't coming time and time again. Either way, the muddle doesn't give the poor Trusts a chance to plan their strategies etc if no one quite knows what the message is.

Sunday, January 17, 2016

Talk T1

It really was a back of a fag packet idea. Honest. Just thought it maybe a good idea to get some folks together, folks who wanted to improve Type 1 diabetes care- and roll the dice. Much of my life has been about that- trying things..some work, some don't. So why not? Had a chat with Pratik and Emma..some co conspirators with whom many a plan had been hatched. Some of the most creative times I have had in my life was when I developed the Young Diabetologists Forum- and those 2 were always the first on my list when I had started to form a team...and what great times we had indeed!!

So here was another opportunity- and slowly the idea developed further..a list formed, names cropped up. Fast forward a few months- and a crispy evening in was fantastic to see the folks who made it all the way from around the country. Bar a few who couldn't due to other commitments, it pretty much had the who's who of Type 1 diabetes specialists- along with a fair few national leading lights. Setting the programme was pretty simple..Type 1 diabetes care isn't delivering what it could for why not try, in the world of vanguards etc to try and develop something with the patient in mind?

Lets face it..if we redesigned Type 1 diabetes care from scratch, we wouldn't do it as we have now. The system isn't fitted around the patient, flexibility isn't a key feature..instead the patient has to fit around the financial envelopes, priorities of individual organisations- rather than the NHS working as a whole to fit around the patient. It may sound incredibly glib- but the fact of the matter is that if I develop Type 1 diabetes, I can pretty much access the best possible care and technology due to my knowledge of the system, personal relations etc- while Jo Public has to depend on post code lottery.

So we tried. And I tell you what, I must admit to being pleasantly surprised. We had Sam Jones giving us an idea about Vanguards- and I wanted her there to share with folks that they do not need any permission to develop something fresh- they just had to think beyond the confines of traditional hierarchies and silos. Jonathan Valabhji, National Clinical Director Diabetes, highlighted the work he has been involved in- as well as the upcoming CCG scorecards on diabetes, the priorities sounded, inpatient, variations, foot care; Martin McShane pushed us to design care around the patient; May Ng showed us what paediatric care had done- and her frustration with transition; Pratik breathed fire about specialists themselves failing patients without appropriate training; Emma exhorted us to do better, gave a patient and HCP perspective of what we forget in our day to day lives...its not easy to live the life of a patient...while Chris Askew firmly placed Diabetes UKs support to initiatives to help care, offering help where required, outlining their plans for the future.
The evening ended...but the conversations continued over dinner and kept its focus on what needed to improve..a late finish was inevitable with a bar and some usual suspects..just felt like the old days- developing and working on something exciting!

The following day, we had the patient perspectives..Kevin sharing his views as a Diabetes Dad; Laura  outlining her journey, the role of peer support, Jens sharing the frustration at lack of transparency in the system, the inability to know who was trained to do Type 1 diabetes while Mike face us his thoughts on his involvement with the NICE Type 1 guidelines- why he thought it wasn't just utopia- why it was something to aspire to! Simon Heller and Fiona Campbell brought their experience as a adult and paediatrics specialist respectively- and called upon us all to do the right was simply inspirational stuff indeed.
The delegates further split into 4 groups, was given a case with a financial envelope- kindly designed by our local Commissioners to work on- they called up on the patients- and then each group had to present to a panel of Commissioners,Lynn and Jim along with a patient representative, Roz, their model of care

I won't go into details of the models proposed as will write them up separately but what was great to see was the different ideas coming through. There was no primary care bashing, little ask for more money- but a huge drive to work differently- work across the system, use technology, upskill others. No one had the magic answer- but between themselves, I think, if we pick the right ingredients, we might, just, have something there. More importantly, it felt they all had been given that permission to do whats right- away from the trappings of individual organisation wants.

The day and a half passed in a blur and before we knew, it had ended. The purpose was to get some clever people together, work with the patients and try to change the paradigm of care...all the while having a bit of fun. I hope each of the attendees found something to take away-which they would pursue further locally- this was something co-designed by patients and was already better than something designed by carers alone!

As the word cloud from tweets would suggest...the ethos..was spot on.

So thank you to all of you who have all been absolute legends- giving up your own weekend to answer a call for help. I appreciate that- and with great humility, I must add..I am very touched indeed. I hope we can take it further- and for the sake of patient care, hopefully, in the idyllic surroundings of Southampton, on a cold crispy morning in January 2016...history will tell us someday that we actually did something pretty special.

Amen to that.

(For a storify-ed version of the event- check this: …)

For a patient perspective: check this from Roz Davies!!

Sunday, January 10, 2016

FAQ "Junior Doctors Strike"

So it has come to pass. A doctors strike. I will be very honest- I don't like it, I don't want it and I sincerely hope the future ones won't go ahead. But we are where we are- and plenty of rainforests have been burnt down already trying to justify or refute the reasons for the dispute- so let's not go there.

One has seen on twitter and elsewhere a lot of conjectures as to what will happen on strike day- some genuine, some political, some trying to show themselves as neutral- a whole lot of reasons- so thought would make an attempt at doing a FAQ (Frequently asked Questions -in case you didn't know) as to what will happen on Tuesday as regards patients.

To start with a clear statement...there is NO precedence of this. So all theories, scare stories are only conjectures at best- as are the opinions below. They are based on experience to a degree and an assumption that seniors will do their bit to help their junior doctor colleagues.

Theory 1: Patient care will be compromised:

It shouldn't as - going by the planning of where I work- and as per contract regulations too- Consultants are indeed going to be more on the wards than a "normal" day. Will they be filling each shift as per a normal day? No -they will do enough as well as have the experience to keep patients safe- and ensure no harm comes to them. The juniors doing their emergency shifts will still be there- as well as nurses. med techs etc.
If we believe that much that without junior docs,care will be compromised, maybe we should put more attention to their concerns- as getting them disgruntled or indeed if they leave would compromise patient safety by that argument? If they are THAT special, maybe that's where the thinking needs to be centred on?

Theory 2: Patient "flow" will be compromised:

Not any more than the weekends to be honest. Aha- I hear the detractors say- calm down, the "flow" is compromised due to many a service not being 7 days. There is this thing called social service- ironically they will be there on the strike day as well as all GP surgeries open- so the sheer load through the front door could be lower- as well as easier movement as regards discharges-as compared to a Sunday. You want to improve 7 day care? Try investing into social care.

Theory 3: Electives will be compromised:

Yes- to an extent- and lets be clear- any patient having their hip op or clinic cancelled- is not nice. The system may call it an "elective"- for the person concerned, it is anything but- its the one thing they may have been waiting for a significant time. And i have no issues with that angst- but heres my view- if YOU feel that strongly about electives being cancelled, it maybe worth raising that angst to that occurrence happening on a daily basis due to surgical beds swallowed up by medical outliers or a 4 hour target- which penalises an acute trust selectively- while we whip ourselves into a froth talking about system changes.

Theory 4: Consultants will have to cancel something for patients to do this:

Not quite. All Consultants have non-patient facing activity built into their job plans- an advantage over their GP colleagues. What are they-do you say? Well, things like- teaching, personal professional development, audits of their services etc...the time allocated maybe variable and debates can happen whether they deserve it anymore than others...the point is they have it- and for a day, cancelling those non-patient activity to help on wards/be extra hands for surgical lists depends on the assumption that seniors will pull out the stops to help their junior docs. Time allocated for such work in job plans? Anything from 2-10 hours / week.
If we are worried that a patient death/harm will undermine the junior doctors cause in eyes of the public, then its up to US as seniors to ensure it doesn't happen- as simple as that.

So, to patients, rest assured- at least where we are, as seniors, we will- and have- made plans to ensure patients are safe. Beyond the arguments of whether the junior docs are right or wrong, lets say this- this is NOT just a bunch of socialists up in arms. Calling me a socialist would make pretty much all my friends fall apart in laughter- apart from my college political rivals have major acid burn. Heck, I am not even a member of the BMA- beyond the support, I,as a senior, have a responsibility to ensure patients are safe on Tuesday- and many many others, I am sure, will do the same.

Post Tuesday- let's all hope that we have no such further days- but for THAT day, lets all try to forget our differences and assure patients that we will be there as seniors working with the many many others who form an MDT to help keep them safe.

Sunday, January 3, 2016

Road to somewhere

If you are an HCP, you already know this.

If you belong to the cynical brigade, a Han Solo-esque smirk escapes your face every single time an episode of poor care or failing of targets are highlighted. The battle weary shrug their shoulders and the expression of "told you so" flits across their countenance.

If you belong to the positivity brigade, then deep down, you know what's happening. In pockets, the sheer passion and zeal of a few try and break the trend- the rest slowly struggle on..slipping just a little bit more.
And its difficult to do that extra bit day in, day out to keep the level of quality where it needs to be. Because beyond all the evangelism, all the NHS workers have their lives, their families, their own selves..burn outs help no one at the end of the day.

If you are a patient, the signs are that people are starting to take notice, starting to worry. There is a growing realisation that the crown jewel, the religion as its called maybe in a spot of bother. There is a worry about the care they will receive, can it be on time;can it be good enough...can things improve from where they are?

As a professional within the NHS, here are a few thoughts for the public and fellow professionals- you may agree or disagree- and indeed its a personal opinion at best

1. Unscheduled care or emergency care:

In my opinion,the 4 hour target is not solvable any more. Without social care, all that is being tried, however well meaning, is now within marginal gain areas at best.

Primary care is flat out, patients arriving are sicker, riskier discharges are happening, an over reliance on senior docs have disempowered junior docs...its now all about the "Now"- without any eye on the future or any lessons from the past. Quicker, harder, faster is the mantra- patients are now commodities to be churned through the system.

I am afraid this one's a busted flush without social care- and dare I say, increased social responsibility of the public towards alcohol etc. Hospital managers are being driven harder- and if I could do anything, then it would probably be an arm around the shoulders to say..."You have tried everything you can- its not your fault". With a mystifying ignorance towards public health issues, this issue is going to get bigger, not smaller.

2. Scheduled care:

This probably has a lot of potential IF we genuinely develop the zeal to work together. I have my doubts- though at a national level, the attitude on this front as regards working together- is there.
Has it cascaded down to local levels? I am yet to be convinced but if, and its a big if, folks can indeed accept that some Trusts will have to take a financial hit etc, then maybe,just maybe, patients may have the chance of a joined up system.
The ingredients are certainly there- both GPs and specialists are more keen to work needs unlocking and strangely, in some cases, permission.

Should you support the Vanguards? Your choice- but if you have a better idea, go for it too. There is a growing appetite amongst specialists and primary care will do well to grab it. Politics as ever will play its part- big questions beyond the doctors is whether we genuinely believe nurses, pharmacists have the potential to input or are held back by vested interests. In short? Good potential with lots of possibilities of fizzling out.

3. Money:

"More in! Robbing Peter to pay Paul! Smokes and Mirrors!" Well, there are different views to it but I will simply say this- read what John Appleby has to say- its pretty straightforward. The finances aren't enough to cope with the demand.

At the risk of sounding like a broken record, it needs an independent review- away from the political football. Either we discuss openly what we stop or we increase funding (by whatever means) to deal with whats needed. I suspect however, with the poll ratings where they are, the Tories will be quite comfortable with the status quo of throwing sticking plasters from time to time.

Stevens got his money- but crucially without the support he needed in public health or social care. And THAT is exactly where this will implode.

4. Type 1 diabetes care:
Finally, to this. I don't know what is likely to happen and I wish all the best to whoever becomes the National clinical Director of diabetes. Personally, I will try and my offer to help anyone- whether it be policymakers, CQC or anyone who is interested.

I am excited to be working on a few projects which I hope will help- whether it be a meeting of specialists around the country to try and draw up a model of care- working with patients; whether it be trying to develop a comic book for type 1 diabetes patients or working with GOSH for a day of TED style talks from patients with type 1 diabetes. They are being done on my own steam- simply because I enjoy using my energy in those type of projects- most importantly? Its fun.

The aim is simply to raise the profile, use Twitter for this, impress to as many as possible that its a serious issue to all and hopefully if that helps even 1 patient have 1 less error or acts as a small impetus to have better care work in 2016 is complete. To type 1 patients, all I can say? I will keep trying.

So is there any hope in the future? To an extent, yes but this will be a tough year for many doctors whose future is indeed on the line.Whether it be bad advice to a well meaning person or a well designed strategy by ideologues who want less of the public sector, either way, this year will be tough.
I can only assure our local Type 1patients that we,as a department, will continue to try our best while nationally, hopefully bring together some dynamic minds to raise the profile higher

Have a great 2016...hopefully its a road to somewhere.

Sunday, December 27, 2015

An interesting year

Another year. Gone. Just like that. Whoosh. Whistled past while we all wrestled with life. And it's pretty obligatory to have a look back. Look back as time fizzed by and hair greyed just a tad.

And I will be honest...personally, it's actually been a satisfying big things per se but the aim was to keep 2015 as one of the job one is supposed to do and try to do it as best as possible. NHS work was good - job satisfaction was high and as ever it boiled down to the colleagues or should I say, friends I work with. I work about 8 weekends a year, I work with an amazing team, have good relations with local primary care and Commissioners...sometimes it's not a bad idea to stand back and take stock. Sometimes its easy to forget the bigger picture.
Taking stock suggests it's not a bad place to be in- about 7.5 years after being a Consultant. Tips for anyone interested as regards a good working condition? Find a good team to work in...and invest a heck of a lot of time in building relations. Keep it casual, keep it simple, don't forget your sense of humour...and cardinally? Learn to laugh at yourself..believing your own hype is always a slippery road.

Nationally or in general the NHS got itself in the throes of an odd mix.
On one hand, if you looked hard enough, there were some good ideas out there. I am a believer in the principle of Vanguards - I like the concept, I like the direction as regards system leadership, need to measure outcomes of systems...and that is exactly how healthcare should be delivered and measured.
It's a sad indictment of the times that all of this is somehow hamstrung by the tentacles of politics. Money talks as ever..and whichever way you turn, the sums don't add up. We talk about a transformation fund, we talk about innovation...whilst also talking about financial balance. John Appleby is not someone to turn your nose up at....if he says we are in trouble, we actually are.
Money did come as per the ask of Simon Stevens but without public health and social care support, all it has the potential to be is an expensive sticking plaster at best. Politics doesn't allow thoughts for the future, it only lives in the present, learning nothing from the past.

Patient safety continued to be a focus..and one of the highlights of the year was meeting James Titcombe. You can disagree with his views but you certainly can't fault him for his drive to ensure no one else goes through what he has. Jeremy Hunt tried positioning himself as someone devoted to patient safety- and then proceeded to hand the initiative to his detractors by withholding safe staffing guidelines for nurses. If that was a faux pax, he then managed to embroil himself in a quagmire by not only embarking on an ill advised battle with junior doctors but also converting them into a lightening rod for all factions within the NHS to unite. One of the smoothest operators in politics somehow, against all odds, walked himself into a cul de sac.

Finally, there was something different in 2015..and if there was an award for the showstoppers of 2015, it had to go to the junior doctors. Whether it be their sterling work forcing a government to back track or the Christmas number 1, the rebel alliance have found their Luke Skywalker to rally behind. The NHS - a factional beast on so many levels..GPs, specialists, Nurses, pharmacists...finally..managed to look a bit more than the usual rag-tag bunch. Managed to learn the importance of unity. That should act as a message for ALL political parties...a united staff is a powerful beast..and the public is now pretty aware the NHS is in a spot of bother. Closest thing to a religion as someone said...the Tories would do well to keep an eye on this ticking time bomb on their hands. So..much kudos to the junior doctors for teaching many an old dog some new tricks.

2016 is nearly here...and I will finish with something which has been a personal belief. I rarely join "campaigns" but this year I did join NHS Survival. Why? Because, beyond the political slants, beliefs or whatever, the NHS does need a review of its funding...the sticking plasters applied depending on what political pressure the ruling party is under, doesn't serve anyone. Some have said other such reviews such as Wanless haven't worked, so why another commission? One fundamental difference..a pre agreed cross party agreement to abide by the findings. 

A commission comprising of patients, safety advocates, the main political parties, think tanks....wishful thinking? We shall thing is for one else have much of a solution. The mood- bar a few quarters of shiny chirpiness on social media- is actually hostile...and we run the risk of actually not letting Vanguards place to breathe and flourish. The key for that does indeed lie with the government...whether to spend 2016 (and post that even closer to the next election cycle) in fractious battles with the staff...or take the gauntlet properly.

Here's hoping. Wish you all a fabulous 2016.

Wednesday, December 9, 2015


You have to be careful nowadays- the main 2 corners of NHS emotions either centres around doom and gloom  deep from the bowels of Mordor...or happy, shiny positive change things- where unicorns gently glide over sparkly rainbows- and you have to be careful not to be sucked into either of those- as the reality of the NHS continues to be somewhere in between. Mostly average to good care- spattered with examples of excellence and blighted by occasions of poor care- what we learn from either of those-again-is variable at best- but that pretty much in a nutshell is where we are.

 However, all said and done, what I am seeing now is a situation I at least have not witnessed. There are many merits to the discussion about family structures and what support children offer (or don't) to their parents- and perhaps much of that has been masked by the social support provided by the State..but we are now in different times. Hospitals are now having greater number of patients inside hospitals waiting for "something". Bed blockers is a reprehensible term- one to be condemned to the history books- and the dissolution of social care is now having a domino effect on many a services. 

Think of this beds are choked...greater number of patients are stuck due to no fault of theirs- the 4 hour target creaks and understandably hospital managers are under the kosh to try and resolve this. The irony? No amount of doctor time would help in helping these people go home- all it does is either make the doctor a bit richer or cancel elective work- causing further knock on effects- whether it be simply put financial revenue for the Trust or simply poor care to those for whom THAT elective clinic has been one they have waited for- or is of utmost importance.

Social care is now in crisis- and there needs to be a realization that the NHS needs to focus its attention to have a concentrated effort in raising a collective voice asking "what next"? I do ward rounds on weekends- and bed after bed I walk past- with frustration- unable to contribute much as a clinician...and that number is increasing every single time I go back on the wards. To the powers that be, please do raise the query- either that or we challenge the structure of a society which has devolved the responsibility of their parents to the State. 
I have sympathy for hospitals who are beaten up over a 4 hour target when a significant reason for that isn't due to lack of medical/nursing engagement or simply "process". What does happen as a consequence is those who are in hospitals due to genuine medical reasons are then discharged quicker, a bit more risk taken, a bit more closer to the edge...opening up further gateways to error- ask any GP and they will tell you about the patients being sent home- the risks being taken nowadays

The system is choked- and now the knock on effect is falling on edification  elective work, challenging safety and going to the basic core of keeping patients safe. More doctors and nurses isn't the answer- use that money (if you have it) to buy social care- THAT will keep patients safe- that will help patients- and that,just, may help the 4 hour targets.