Saturday, June 27, 2015

Nothing is sacred

Have you seen a movie called the Matrix? The original one that is? Pretty special..apart from the spectacular special effects in the movie, for the uninitiated,it depicted a dystopian future in which reality as perceived by most humans is actually a simulated reality called "the Matrix"...pretty good movie  and one in which, for once, Keanu Reeves managed to put more than 2 expressions together.

It's relevance to the NHS as it stands is simply stunning. Whichever way you turn, all data point to the money running dry, acute Trusts in quandary, revolts from provider organisations against central diktats. Then again, there is the unflinching believe (and perhaps rightly too) that the money is there- its just not in the right place. We talk about the Matrix- and never before has it been better encapsulated than in the debate about Public Health. However you want to couch it, type 2 diabetes is on the rise- at a pretty startling pace. Drugs aren't cheap, it costs 10% of the budget- so Simon Stevens quite rightly pushes forward the National Diabetes Prevention far so good...thats the swish world where Keanu can dodge bullets. And then simultaneously, a 200 million pound axe falls on public health..evidently because they didn't spent it. Welcome to the other side. Let me take a pause and say that again. There was 200 million pound underspend in PH IN 2014...did we just discover that type 2 diabetes is increasing in prevalence? Cue bemusement 

Then comes the basic question- we need more money in primary care- lets not deny that fact- given that majority of work is there...the usual debate always surrounds why it can't come out of acute Trusts. All acute Trusts will also agree on paper, social media about the need for working differently - that's the glossy side of the Matrix. On the other hand, do look a bit deeper into the provider revolt and the MRET negotiations (Marginal Rate Emergency Tariff) negotiations. Do I blame them? Not a jot-as they have building to maintain, staff to pay for. Thats your other side of the Matrix. 

So as Roy Lilley has said, its time to look at all the bodies funded by taxpayers. There should be no sacred cows anymore. Review all, see what they have achieved, see what they can deliver.Because when it boils down to it, do you want enough money to fund safe staffing on the wards..or is it about a quango which may or may not have outcomes?

So let's start looking- let's ask for a public debate- let's ask what NICE contributes, what NHS IQ does, what NHS Leadership Academy does, CQC- everything - no sacred cows. Let me be clear- this does NOT start with the assumption they don't contribute- it must be a open process where the money invested from taxpayers is worth its value or not. Let me give you an example from NICE. An august body- well respected...recently tried looking at Type 2 diabetes guidelines. 1st draft got ripped to shreds, second draft looks like simply adapting what the American Diabetes Association/European Association for the Study of Diabetes published in 2015. much taxpayers money wasted behind a prolonged exercise when all that was needed was ratification of a guideline the world now accepts?

So no more sacred cows please...put those cards on the table. Lets see what NHS IQ has delivered- and please look at patient outcomes- not simplistic bits like "it made us feel all better". Going on a holiday does that too- but unlikely that would be funded by taxpayers money, right? So lets see the investments, lets see what they have achieved- if its all about transparency..lets do so properly - and let there be a decision as to whether to continue with those bodies- or whether we use it to fund primary care properly.

Nothing is sacred. Question for all..I know how much taxpayers money is invested in our services. I also have outcomes to show- including patient satisfaction. Do you?

Wednesday, June 17, 2015

It's about quality

It's come to a pass. Finally, after much debate, negotiation, mulling and soul searching from many parties, the diabetes department of Portsmouth Hospitals NHS Trust has a new Clinical Director.

For those who don't know her, she is Lisa Skinner, one of our Diabetes Nurse Specialist colleagues and who has been the nurse lead for many a year. I am not aware of how many departments have one of their DSNs as their clinical lead or director, but whatever be the case, she is certainly among the few. The question is however, does it matter? Should it matter what her background is..that she is a this to be celebrated or is it just a reflection of the detachment from reality of the NHS many have? We talk a lot about valuing everyone within the team but then seem to shy away when it comes to leadership positions...we all believe DSNs are the linchpins of diabetes what does make us applaud a nurse being the lead when it should be just another person of the team stepping up to a leadership role? Has diabetes done the ultimate volte face when it comes to leadership? Is it possible that the long term condition which is all about people of different professions working together has, when it comes to the crunch, shied away from handing over the leadership roles to others beyond the medics?

It's always one of those conundrums as to where and what quality represents. People are torn between the past and the you right the wrongs of the past by giving quotas or is that wrong as it doesn't recognise leadership irrespective of their job, sex or colour? 2 wrongs never made a right and India stands as an example of where quota systems can go wrong. We talk about diversity in leadership,we have Twitter groups to discuss issues, we have passionate individuals battling the cause..and then again in 2015, you have the HSJ report and you wonder whether the hashtag "Windrush" is more a Freudian slip to indicate more hot air or a genuine effort. Hashtag campaigns can only do so far..and no more.

So back to us,as a department. Many a times I have been asked about the cause or reason for our success in recent years...I could probably sum it up in 1 Sometimes it may sound a bit glib, sometimes a bit obvious but that's what has made us tick. A healthy dose of mutual respect, understanding of each other's roles and being comfortable about your own values ..mix that together and you have what you need

So to new beginnings, new vision and new management. On behalf of all, the best of wishes to a new role for Lisa...she has our support, our confidence and a belief that in her we have asked the right person to take the mantle. It doesn't matter a dime what her professional role is, what matters is whether she has the skills to take it forward.
And by the way, last 3 clinical directors of the diabetes department ? A white man, an Asian man and now a white woman. Or just people who have the backing of their team to lead and deliver hard patient based outcomes. The sex, the colour, the role never mattered..neither did ever the idea of ticking a box to satisfy the hashtag of diversity.

Spread good practice. Talk less..and do more. Appoint who's right for the job, appoint those who represent the workforce....get on with it, will you NHS?

Tuesday, June 9, 2015

Beautiful Boston

Must admit to having fallen in love with the beautiful city of Boston...something special about this place indeed- and coming here for the American Diabetes annual conference has been simply a joy.
In my opinion, perhaps one of the best meetings I have attended in recent times..though perhaps that was also the reflection of the personal calmness in life I find myself in- as well as the superb company I shared over the last few days.

Learnt quite a fair bit..honing into areas of interest..only one query..what could I possibly take away back to where I work? What practices could I adapt? What new information was there that I needed to learn about, change my own work accordingly? And on all those fronts, I go back armed with much. Whether it be evidence of safety of new drugs, whether it be learning about use of adjunct therapies in type 1 diabetes, picking tips regards social media and patient engagement...the mission surely has been accomplished! Posters gave some good ideas, reinforced some views but a strong message was about patient engagement. The barriers are coming down, albeit slowly..but it is.

Beyond the science, it was some amazing company of friends I spent time with...specialist colleagues, Gp colleagues, nurse colleagues, pharmacists...all bonded for a few days. As ever, some of the old reluctant guard were there but every year, I see their numbers dwindle and more engaged, passionate people who think beyond silos..and I have hope that a collective mass is forming who will lead and improve diabetes care in the NHS. Times are certainly changing. Changing for the good.

Was also a highlight meeting folks who you know on Twitter..a brief conversation with "grumpy pumper" was fun, meeting Kelly Rawlings was simply a joy, listening to Amy Tenderich passionately driving patient engagement and exhorting HCPs to join in..was all part of a fantastic experience. A lunch chat with Pratik Chaudhury as ever an enlightening one..the knowledge he possesses simply scary but listening was fun..the passion to improve care was palpable. Ribbing Stephen Lawrence about his multiple collection of suits, watching the Champions league final in an Irish pub with an amazing crew of Scotsmen, spending late night in a pub singing Irish songs....what can I say..I am proud and humbled to have such super friends.

Personally, have been at a bit of crossroads...its that what next you stick to diabetes and drive change or branch out and do other bits? This ADA probably helped to make my mind up. So a thank you to Phil, Marc, Gerry, David, Chris, Stephen, Pratik, Wasim, Vinod and many others I haven't mentioned, a personal thank you too..without knowing, you helped a lot.

Finally, Lisa and Gary..thank you- you have been absolutely amazing. To the American Diabetes Association, much kudos for organising this event- it's been excellent. are just wow...thank you for having me. Tomorrow I shall be back in the UK...recharged and armed with much info and knowledge and a much clearer direction of travel. It's simply been a blast. 

Wednesday, June 3, 2015

End product

A wry smile. Pushing the chair back in my office, I took a moment to look at the figures- and then look again- with a wry smile. You know those moments in time when you look at something- and you want to ensure it's correct...this was one of those. In fact, I had to go and get my colleagues to sit down and look at it with fresh eyes...just to make sure I hadn't missed anything.

What was it..well this was the 5 year data on our model of care...5 years is a long time but has flashed by..a model which by a distance is the biggest area covered in the UK as regards diabetes models of care go. One pathway- cutting across 83 GP surgeries, 3 Trusts with their own individual politics- and a diabetes population of more than 40000 patients. When you venture on a journey for which you go through a lot of personal pain, you know you stake your reputation on the line- and at the end, the end product boils down to only one thing- outcomes. Yes, patient or user satisfaction is important but in an environment where money is tight, outcomes which benefit a larger populace may sometimes not end up making everyone happy.

The principle was simple- the specialists were coming out to play- be a friend of primary care- pretty old school. No forms, no complicated referral system- you get stuck- you ask- email/phone/face to face- simple and effective. Easier said than done. Vanguards? 5 Year forward view?- we didn't stop locally or wait for the Messiah to show us the way- armed by a fierce determination, an absolutely amazing team - we embarked on a journey. Did we know it was all ok? No but we said we would try- we would try to make a difference.

I won't bore you with details but the vitriol I personally faced, the sneers, the barbed comments..I have never forgotten. Most of them are still around- I haven't forgotten- but I didn't say anything as we staked everything on the end products. This is diabetes- it is and never should be about how good you have been at HbA1c reduction- its about end organ damage prevention, its about admissions, safety. So I waited. Kept an eye on data- and waited. Initial trends were good..though detractors never gave up the chance to pick on data dating back from 2010 or 2012 to say .."doesn't work, won't work". I haven't forgotten, ladies and gentlemen

So today was a special day..all the data from census office, national diabetes audit, public health, local business intelligence, QoF data...were finally in 1 place.

  • Diabetes prevalence has continued to increase at pace- partly due to the public health turmoil we have, partly due to better detection but across 3 CCGs, diabetes prevalence has gone from 5.7% in 2010/2011 to 6.9% in 2015
  • Hospital admissions have surged at a frightening pace- from a total of about 12000 to 17000
  • On the face of that, the outcomes have shown over 5 years:
  • Drop in DKA by 29%; Drop in Hypos by 42%
  • Drop in MI and CVA in patients with diabetes by 22%
  • Drop in diabetes amputations by 39%

Today, we stand vindicated, happy...the detailed article is to follow- but the journey we took those years ago- on a leap of faith has today borne fruit. I will just say one thing- without some amazing local CCG folks and most importantly a super bunch of primary care colleagues, this simply would not have happened- so thank you- muchly.

Much more to come- but those who want to see whether "integration" works - there you go. If you have a better way of doing it, then stop criticising others, make your model and produce outcomes. At the end of the day, its about what end product you show.

I will finish with this. Those who sneered or passed comments, I haven't forgotten. The biggest answer to that is when your own CCG comes and asks us for ideas- because YOU haven't- because you have opted to stay in your palace and benefit a few, not many.
I am no leader- I have never been on any leadership course, never won any leadership award, neither been ever been on any "leadership list". But locally, I have never needed any to those who wonder how to change things...find out willing friends in CCGs or primary care- they are there in abundance..and go do it. 

To the rest of our powerpoint leaders...Partha Kar is not known for false humility- so without any false pretence, go and match what we have done locally with our primary care colleagues. Show some end product- which in the healthcare system, lest you need reminding, are outcomes, not tweets.

And Portsmouth team- across Portsmouth Hospitals NHS Trust, Southern health Foundation Trust and Solent Trust- plus all primary care across 83 surgeries- do take a much deserved bow. You have been simply..awesome x

Tuesday, May 19, 2015


Those who know me can vouch for one thing. I don't do pessimism...very rarely....mischievous? yes..wind up people?...always with a smile...but pessimism? Nope...its all about the art of what can be done. I am not even going to try and do mock modesty but backed by supportive CCGs, primary care colleagues and just a ridiculously good team, we have achieved changes in diabetes care- which others have looked at with admiration or jealousy..depending on the personality. And we have carried on regardless...

But you know spite of the obvious blazing confidence, in the heart of hearts, you know whats coming over the hill is making that all-confident smile get tinged with a bit of wryness, a bit of grimace is probably starting to set in. And it's not the politicians or the media who I am sceptical of..they are doing, what their ideology drives them to...that's life, thats the harshness of what we live with. Have said before, a change in political colour would have made no difference to where we stand its not about petty politics, its not about ideology- though some may choose to differ..the fact remains that no one and i mean no one had the foggiest idea or bravery to set out a discussion with the public that maybe, just maybe we can't deliver everything anymore. Just start the discussion that the NHS has had a great ride, its been amazing but its now time to be realistic and its no longer everything for everybody. At nearly 67 years, the time to dial things down may indeed be here.

My annoyance and pessimism is centred on those leaders within different quangos who post elections have continued to say it will be fine if we work differently. Don't ..just stop saying that. ..stop using words like "transformational change" without saying we need to change contracts; don't use terms such "boat-rocking" without saying that "we need cheaper alternatives". Be open...stop using studies to counteract views of each other...of course be positive but with a dose of realism too.

People talk about efficiency drive...what does that mean..would you give up a backroom staff of your organisation? Patient centric...well...have you actually involved the patient? Have you been honest to say that somethings can't be delivered? Come on ladies and gentlemen, good to pick up awards, attend glossy award ceremonies (I have attended a few) but at least come back to your staff and be honest. Don't sit in the echo chamber of Twitter and say "we simply need to work differently".

The dishonesty about it all is now starting to grate a fair bit- especially on twitter. There are few folks in the NHS who genuinely believe this will survive as things are. 7 day GP working is coming- whether with support for Physicians associates or not. 7 day hospital service is coming- rightly too...but let's be honest to say what will now stop. We must otherwise we are colluding and misleading patients who believe we can still provide all.

I wil finish with giving an example of diabetes. Overall, the quality of care in this country is average- due to a combination of factors..can we improve it? Possibly not everything but we may have to prioritise and decide what to aim for. I strongly suggest in your own areas you all start thinking of what needs to stop. There will be some who will want to provide "that's what we do". Just one thing...when you burn out, even the few who would have benefitted from you, don't any more.

Time to think, time to challenge clever word play, time to be honest. Time to think whats high priority and focus resources on that, maybe not everything

Sunday, May 10, 2015

Heal & grace

So it's done. The elections are over- and last week, I had asked for all of our leaders, in the main, the clinical ones to be honest. However what I have seen since the elections results maybe needs one more important bit- the need to heal. For many, at least on social media, the results haven't been as expected- the clashes with those who disagree, or those who have made suggestions for future have been angry, sarcastic, sometimes even vitriolic. The winners have been sometimes a bit gloatful, the losers bruised and unhappy- perhaps some even consigned to the NHS fate.

It needs some space to heal- all professionals need space to heal or a place to be graceful. Over the last 5 years, for reasons which suited many, rightly or wrongly, many have tended to put the reason for the slide of the NHS on the Health care and Social Act. Too many times, it, perhaps has been a convenient and sometimes valid reason to blame for poor patient care. The many neutrals will know the reason are manyfold- issues which we have closed our eyes to, issues we have shied away from, issues which have been in play for years, not just the last few. But now that we know where things stand over next 5 years, its perhaps time to take a step back and see what we can do for patient care. There are many who have succeeded over the last 5 years as well- and there have always been many who have failed even in times of plenty...that goes back to the leadership issues which Umesh Prabhu and Vijayanath refer to- are we honest enough, are we strong enough, can we work and deliver patient care whatever challenges be?

No one is shying away from the money issue and neither was there going to be magic money appearing if your chosen party is not in power. Through my blog, I would like to appeal to many to absolutely keep the faith in the ideology you believe in but please take time to heal, take time to see what needs to change- and above all, go to work in the NHS tomorrow and see what can be done to improve things.

The election results have suited some, it hasn't suited some- thats how democracy has worked forever.  If you believe the NHS is in strife, think why that message never got across to the population. If you believe the NHS is in safe hands, great- then you have what you wanted- now show your patients what great healthcare can be like. For patients, what they need is access and expertise- till that is compromised, it probably is less of an issue- and it is up to oust see whether we can provide this or raise our collective voices to say when it's not.

So- to work tomorrow- us as HCPs either gloating or being angry helps no one- least of all our patients. If your chosen party won, be graceful enough- and work with those who are trying to heal- don't forget their passion to improve care is no less than yours. if you are hurt, then be broad enough to engage with those who may not agree with you but still, would like to improve care. Whatever be the case, don't sit back hoping it all falls down so that you can say "Told you so". That point is where you can't change it anymore either.

My appeal to all those on different sides of the divide (and the country is a divided one)- if you work in the NHS, take your time to heal, enjoy with grace- and once the process is over, join hands to give it your best shot. The numbers are stark- whether it be a 22 billion efficiency savings, 7 day working or increased GP access- remember- pretty much all parties were aligned on it- those challenges would have stayed irrespective of who won.

Give it a try, ladies and gentlemen- otherwise if it doesn't go to plan, do answer to the next generation  whether you tried or just spent time on social media tweeting your joy or angst.

Tuesday, May 5, 2015


So we are nearly there. Perhaps not too far away, the shrillness of the politicking, the electioneering, the preening, posturing will cease- or at the very least not be at the incessant levels it is at the moment. Come next week or thereafter, we will have a government in place- whatever be its colour or hue and the NHS will go back to being the one that needs support from the folks who are in it.

And the NHS, like never before, will need some serious dose of honesty. Not from the politicians- as they do what they always do- promise the moon, play to the audience, shroud wave when possible- NHS is only bt one of the issues in front of them, so no, I don't expect them to suddenly develop a dose of honesty and deliver something immediately. But the NHS needs it, needs a major dose of honesty- from its leaders. Whatever their tag, whatever their title, wherever you are, however many course you have been to...the time to couch bad news in jargon needs to stop.

I hear a lot about leadership, hear about values, the need for patient safety..I hear all of that- but to me, what makes a leader stand out is simple honesty. The ability to deliver the bad news up front- without any flowery tags. We are standing on the edge of a pretty sharp cliff- and any economist or finance director worth his salt will tell you how precarious it is. So why go to meetings and say things like we "need to work differently?' Why couch half baked studies and suggest we have found "other ways" of doing the same job- when the essence is looking for staff to deliver at lower cost? A recent study showed that twice daily ward rounds improved productivity and gave savings....hallelujah said the moneymen....let's do it. Buried in the study is the line that savings were actually based on bed reductions and staff cuts. Who needs honesty when you have a headline?

So on the eve of the elections, please DO go and vote- vote based on your belief, based on who you think would improve the country- but please don't expect whoever wins to "save" the NHS. There is no bigger disappointment than seeing your hero fail. Don't put whichever party on a pedestal and hoping they will "sort" it...nobody will- it's down to you and find something extra to deliver. Whatever cash will arrive, may arrive either too late or be consumed by the parochial age old squabbling as to who deserves it most. GPs? Why not Physician Assistants? Why not pharmacists? Cheaper about? Better quality? The debate will rage...the battles will continue, the posturing will carry on.

So, come next Monday, don't just sit back because your party lost and thus the NHS is domed, don't be happy that your party won and that it will be saved...try and think of something that will help your manager to effect some savings. If you are a leader, be open and honest about the budget cuts needed this year and work with your team. Those who have openly flaunted their political alliances, good on you and much respect too- BUT be a leader enough to go an challenge your own party if in power to deliver even a bit of what they have promised.

Honesty. Use that in your leadership role. People respect that- otherwise behind your back, once they step out of that meeting room? They all know your words about "challenges and working differently" are hollow lies. Give it a try next week. The NHS certainly needs it- past the intense bipartisan views of political affiliations.