Sunday, May 1, 2016


What next is pretty much the question on everyone's lips. Many theories, many conjectures, many thoughts…but to be honest, when you are in uncharted territories, all bets are off. So all guesses, including mine, are all, at best, guesses- some tinged with reality, some in hope, some in despair- and some as ever with an agenda lurking in the background. Many blogs have appeared where patients feel left out of the discussion- as far as the government is concerned, they did have a discussion- it was in their manifesto- to have 7 day services. That discussion went quite well actually- it was called the General Elections.

So what will happen next? The strikes have happened- the seniors moved things around, cancelled stuff, stood by their juniors and to, what appears, the utter incredulity of some, no major safety issues cropped up. The scaremongering was anyway a bit silly- most seniors on the ground knew it would be ok- and to be fair, as did most NHS managers. All it needed was a bit of planning, cancellation of some activity, teaching etc- and there were enough personnel around to cover what was needed. I have no idea what happens next- more strikes, more the mix of that the Euro referendum - all of that makes this all pretty unpredictable- who knows- maybe both sides may have an epiphany and decide to go have a beer…though to be honest, the chance of that happening and Lance Armstrong coming back to competitive cycling appears to be at par-at the moment.

But heck, everyone's having a go at conjecturing- so why not me! Trusts are not stupid- they know, beyond everything, they do need their staff to run things safely. Given a choice- most executives will choose patient safety above fiscal discipline (aka being tight with money)- the reason? They rarely do their job to balance books- they do want to make a difference. Want an example? Pretty simple- the reason the NHS is still running reasonably well in spite of all pressures is because its happened at the expense of the money side…the billion dollar question is how long that is sustainable.
Anyway. so Trusts won't be stupid- and they will find loopholes in the contract to ensure their juniors find it reasonably acceptable. Roy Lilley's suggestion of "local negotiations" will happen- but not publicly- and variations will emerge- but by using the new contract.
That will result in gaps- which will need filling. The locum caps will be breached- has to be - in fact there exists a clause of breaching it for patient safety- and it will continue to happen at pace. If Trust X decides to hold to the cap, a neighbouring one will breach it…all about who wants patient safety above the issue of money. Tricksy eh?

What will that do for 7 day service? Nothing to pretty much nothing- why? Because the whole 7/7 had nothing to do with juniors but heck, who cares about technicalities. All that aggro, fights will result in little for patient safety, the finances will continue to take a hammering - so we are stuck where we are. And then comes the most important bit…to keep the NHS going, what you do need is a lot of "extra"…"extra" bits that are not paid for, bits that come from vocation- and angry disgruntled people don't give you that. Thats not special for a  medic, but is the same for the chap seeing you drinks at a bar too…he will stay on a bit extra because his boss made an extra effort to make him feel valued

So how would that happen? Well- it will require the medical leaders to do so…the question is whether they have the trust to do so? Would the juniors trust those who have either stayed quiet or openly forced the contract? Would those seen as, rightly or wrongly, furthering their career be trusted to put an arm around their shoulders…or will it need a new generation of leaders to do that? Tricksy indeed. How would Dalton fare when he stands up to speak to juniors and regain their trust- who knows indeed?

So, in short, a forced contract, achievement of bits of government manifesto,more financial troubles, need for new leaders to rejuvenate the workforce…that's my prediction for next 6-12 months
Or I could be completely wrong- and it could all be sorted by that one single beer between Johann and Jeremy.  Or the next battle with consultants will erupt with further embitterment, angst…and all those attempts at "working together"? Take one further hit.

Imagine…all of this potentially avoided by an open honest discussion with the public…something along the lines of "We genuinely want to improve 7 day service- however, we don't have enough money for it- so lets discuss what needs to stop or reduce"

Now…THAT wasn't so tricksy..was it?

Saturday, April 23, 2016

Three at a time

So here we are- a national role in diabetes. 7 years as Clinical Director, work with CCG as secondary care advisor, work with Kings Fund, CQC..a model of care- which for all its faults- is at least seen as a template to work on….the opportunity and the ask was perhaps at the right time. Working alongside the present National Clinical Director of Diabetes, Jonathan Valabhji…the opportunity is there to make some changes. The billion dollar question as ever is will I be able to? How restrictive will the trappings of central NHS be? How much freedom will I be allowed? The thing however is that self doubt is not really in my genetic make up- so after a fleeting few seconds, to me the job became pretty simple- you make of it what you want to, right?

Thank you to many patients, carers, colleagues for the kind words received, the hopes placed and the suggestions but I don't intend to change the whole world of diabetes overnight. A great tip for me when I set out on my management journey back in 2009 was always to focus on 2-3 things for starters. Get those right- then move on to the next phase. Try too much, you struggle to achieve much…so have mulled over many things, lots of conversations with my to-be partner in crime, Jonathan- and I think I am honing into 3 things…I suspect if we can get those things right, we will have progress.

Priority A: 

Improve Type 1 diabetes care: With my background, this was pretty much a given. I have always maintained that in the term "diabetes", we have meshed everything and done a huge disservice to all types- Type 1; Type 2, genetic ones- they are distinctly different with distinctly different needs and skill mix- if powerbroker/Commissioners don't know that or fail to recognise that, we will never ever improve quality of care for anyone.
Part of that will involve increasing profile, raising awareness, getting all to agree to appropriate pathways (and that has indeed been part of the reason for setting up the #talkT1and #TAD talks. Lets get the basics right.
Giving basic foot checks t folks with T1D isn't complicated, its basics. Ensuring a patient in hospital has their own insulin or even making sure they have it on time with food is not complicated, its basics

Priority B:

Getting everyone on one sheet: Do you know how many organisations there are in Diabetes in this country? Let me go through a few: Diabetes UK, JDRF, ABCD, PCDS…factor in RCP, RCGP- and you see the problem we have. Beyond all of them, there are many many patients, countless professionals who aren't part of those organisations…all individually trying to do the right thing, separately? A divided voice.
I want to have more TAD events- for all "stakeholders" to recognise the importance of joining hands. All of those bodies want to improve care…and if you genuinely want it, patients are asking for help- join hands and lets do it together.
Step up to the plate- and remember as a pack, sometimes different organisations may need to take a lead on different issues. Its not about who does it - its about what the whole collective wants to achieve. On that note, specialists have to step out of the breach- primary care needs support- lets do that- and do that properly.
Start thinking- do Vanguards offer anything? Does the GPforwardview offer anything? Look at opportunyies- any opportunities to offer primary care the support they need. They- and our patients want better access- in 2016,we must be able to do that

Priority C:

Technology- lets do this properly- not have meetings eulogising projects which have no legs. Let technology flourish. (I already thank Roy Lilley for putting me in touch with some interesting folks!) This is 2016- Skype is NOT an innovation- and no, the North Koreans are not standing by to hack anyones blood sugar readings.
Lets stop putting bureaucratic barriers and get things going. If YOU have an innovation, bring it to me- I want to know about it.
And please, think of this- does your innovation make life easier for the patient? If it does, I am interested- if its about you selling your wares, please don't bother.

Finally, I won't make any bones about it- I am a quintessential maverick. I don't follow rules, and I especially dislike them when its built to obstruct patient care. I may not be as clever either as many- but I do have a burning desire to make a difference.

What I do need? Not advice about my style or how I operate (am sure NHS England have hired me knowing all about that plus lets be clear- bar my parents, no one can do that- so don't waste your breath) but about what YOU think will help improve care. The door is open- and to anyone with any interest, patient, carer, nurse, doctor, Commissioner- please let me know.
No- you do NOT need to be part of any organisation or hold a title to do that- everyones view is important to me- and to be honest, I have grown more cynical seeing the roles some "leaders" have played in the junior doctor fiasco. As they say, silence is permission, silence is consent, silence is acceptance.

So contact me- and for ease- my email is Whoever you are, no ones view is immaterial- you want to improve care? As Frasier used to say…."I am listening". Yes, there are challenges- but I am confident we can make some good changes. All I need? Some help from you all along the way.

Shall we?

Sunday, April 17, 2016

Mend the Morale

What exactly have we lost sight of in the NHS? Targets? Patients? Safety? Difficult to pinpoint it down but above all, we certainly have lost sight of one thing..the importance of looking after the staff. In an environment when you don't have extra money to attract staff, don't have a amazing work life balance to dangle as a a more complicated and complex healthcare atmosphere, you need one thing as a from the workforce in you...and most importantly, a positive morale. When you are asking a nurse, doctor or admin to go that extra mile with nothing but an arm around the shoulder, you need that zing factor as a leader.

Crack a whip? They walk away. Shout? They shrug their shoulders. What can you do as a leader in that scenario? Nothing really as without the staff, in healthcare, you are gets compromised, targets's inevitable. A person on the street when they get ill are not wanting to see the latest swashbuckling leader, they want to be seen by someone competent...someone who is there to help them...someone who may have stayed on more than their scheduled time. Can you put a price on that? I don't know but I do know shouting does not achieve that.

It's also time healthcare professionals stop being embarrassed by what they earn. It's a job, a well trained job and you should be rewarded for that. It gets slightly annoying when leaders on big salaries or who have spent considerable time reaping benefits of the system start pontificating about others. That brings forth derision, not discussion.
Let's face it..7 day services need improving- forget the science and data, a weekend isn't the same as a weekday. Anyone who works on a weekend knows that..there isn't enough staff for that. We absolutely needed a debate on that..we needed brave leaders to step forward and say we need this as a priority but don't have the money for we may need to stop something else. But we didn't..we tried all sorts of smoke and mirrors, lost the whole argument, and now are on the verge of losing those on whom we depend to run hospitals. Newsflash..a hospital without junior doctors or ward nurses isn't a hospital, it's someone's utopian fantasy of a world where patients just use Apps and get themselves better. Factor this in- do you know which one is the safest hospital? The one which has no patients. The error rate is about 0%

So to all leaders, please, get a voice and stop focussing on models, strategies, flow charts or graphs. It doesn't matter what you call it..without the staff helping to deliver it- above and beyond what you pay them- it won't work. The NHS is littered with such examples and yet we learn nothing, we try yet more models and organisations.
Whatever we have achieved locally, whatever notoriety we have achieved was never down to models or pathways, it was down to one thing-  working with the staff to ensure we didn't let the morale dip down where people stopped caring. Morale is the one thing that matters...get it right, the rest will follow. Today, in my new role, one thing I can promise is never to come out and tell the staff how bad they are..if I do want to improve diabetes care, then it's the staff one needs to deliver it..patients are the most important bit of the jigsaw but a fundamental cog are staff and we must, absolutely must look after them.

So a final appeal to all parties engaged in their present death stare match regards junior doctors...BMA and NHS Employers...please...resolve it. Go have a hug, get some beers, forget about establishing who was wrong so far...forget that, but go and sort it. I don't care how you do it or who needs to be the "bigger person" but please do get going. Apart from confused patients and public, there are a lot of demoralised, angry, upset and confused bright young minds caught in the middle of this- and as seniors within the system, we owe it to them to forget ego and hubris.
The NHS needs these sparkling group of people firing on all cylinders, working with a smile, giving that bit extra...and we seniors have got a role support them, guide them, have an arm around the shoulders, say a few more thank yous and try our best with whatever leverage we have to convince the power brokers to end this fight to the finish.

Naive? Idealistic? Maybe but I do this job to improve care and there is no hope in hell of improving that without a motivated crew of junior doctors next to me. As I have said before, I am not a member of the BMA, you call me left wing, my college political adversaries will choke on their cornflakes, I don't have a dog in this fight...except that I have a fierce allergy against junior doctors being taken advantage of- and they already have enough of that from many within the NHS a already.

On Friday, I went to offer the junior doctors doing a sit-in some morale support and I have some news...I didn't see some loony left wingers. I saw 2 bright young people, worried and anxious...keen to end this dispute. I want the, smiling, I want them back doing what they do best, looking after patients..ready to give that extra bit when needed. And we, the rest of the NHS owe them that.
Mend the morale folks...this is no way to help patients get better. 

Monday, April 11, 2016

"Divided We Fall"

I cannot even begin to tell you how excited I am. Just around the corner is the impending release of a blockbuster movie called "Civil War". Now- its pretty common knowledge how much I enjoy comic books. Having grown up on them, its a fabulous world I live in watching those characters come to life. I also know its a source of mockery for some- comic books are for kids, right? Well- the world would differ- but in your eyes, if that makes me a kid, heck- that's a compliment and a half.

And comic books- they teach you much much more about life and its issues than some conference, course or power points will ever do. Want to know about discrimination  read the X Men; want to know about strong women - check out Wonder Woman; want to know about race issues- check out Luke Cage; want to know about teenage angst- Spider-man existed only for that...the list is endless.Most noticeably, the Avengers should teach us all about the importance of a team- how many strong characters needed to work together to make things happen. The ethos of Captain America- strong, idealist, leader or of Iron Man- cocky, confident, charming...we live with those characters every day in our lives.

Which brings me to the movie called Civil War. It was a seminal event in the world of comics- chasm between the superhero community- heroes against each other- everyone supposedly right in their views- toe to toe- no one backing down as they both- "fought for the people". Starting to sound familiar?
The tagline of the movie goes "Divided We Fall"- and its as apt as it gets. Social media has erupted with disputes- everyone keen to claim the side of the patient- everyone right. My view about junior doctors- and my support stands as ever- there is no flinching away from looking after the next generation but it appears we are now in Civil War territory- among ourselves.

In between all of these, there are many many who have simply taken advantage of an opportunity- whether it be some with chips on their shoulders about doctors, whether it be some who simply want to change the government, whether it be some who see it as an opportunity to eulogize about their private work...mix it in with many who have chosen to bring the "In my Days" argument into play- and many many junior doctors now simply feel trapped. Trapped in a toxic cocktail where no one is sure anymore how a "winner" emerges.
I know exactly what I would like- a simultaneous withdrawal of imposition and all out strike- and talks to thrash it out. The rest of us would applaud and breathe a sigh of relief- this isn't good for the present or the future- and it is undoubtedly frustrating to see an impending car crash to which we are all spectators at best.
I have no other suggestion to make to both parties- except that maybe all of you need to go and watch the movie together and understand the importance of what comic books teach us.

To end, do you know how the battle in Civil War ended in the book? The public in the end, stood up- and said enough- that finally made the warring parties realize that even though they ALL felt they were fighting for the public. in the end, they scared the public enough for them to stand up.
You sure comic books don't have anything to teach us? To reiterate the tagline, ladies and gentlemen...Divided We Fall".
Please..resolve this madness.I beg of you all.

Friday, April 1, 2016

Who's the fool?

Always. Personally I have ALWAYS followed a simple rule as regards my children. Daughter or son- no difference- but to be given same opportunities, same chances, same amount of love and support. It's never ever been a debate or a fleeting through in my mind. And seeing my daughter on the verge of turning 15, it always fills me with pride to see an independent, young lady growing up- without any doubt in her minds as to whether she will have the same amount of love from her parents in comparison to her brother. No- none whatsoever. Why? Well, apart from it being like the 21st century, I have seen how my parents brought me and my sister up- and throughout my own life, I have always been indebted to women for the roles they have played, the sacrifices they have made, the support they have provided for me to get to where I am. I have always been a fierce supporter of #HeforShe and with good reason too. The fight for equality isn't just for women to fight- its for all right minded men to stand by them and support that.

And I must say yesterday- on the verge of April Fools day, I must admit to being absolutely stunned by what was published as regards the updated junior doctor contract. I won't go into details but the language, the terminology was simply, astounding- simply like an April Fools joke.

I won't go into whats right or wrong about the contract as all logical debate had ceased many moons ago anyway- with a conflation of 7 day working with junior doctors contract- and I watched in astonishment as many leaders, who in person, seem perfectly reasonable, have stood by and allowed this to travel as far as it has. Lets be clear- after all this angst, not a jot will improve as regards weekend safety- which ABSOLUTELY was a very important debate we needed to have- sensibly. We didn't, and buried under hubris and posturing, a significant patient safety issue which should have been up for debate- is now lost in the mists of ego and pay.

However, even if one assumes this is just a pay dispute and nothing else, even with that on the anvil, the disdain shown towards women has been breathtaking. I, as a senior clinician, cannot condemn it strongly enough and for anyone who has women in their lives in whatever shape and form- while being complicit to this- should go home and either continue being a mysogynist dinosaur or say sorry to their mother, wife,girlfriend,daughter or sister for treating them with such disrespect

How is this even possible? Some tell me its ok in the eyes of the law- well then as the saying goes, the law is an ass and needs re-looking. Sounds more like a Whitney Houston song- "Its not right, but its ok" I will be very honest, I don't care what concessions happen, don't happen in the contract- I don't even care much about the Saturday hours on a priority scale- but I do want a contract which puts a man and a woman on an equal scale.

It is a crying shame that in 2016 I am even having to write a blog on a topic which should be consigned to the shameful chapters of history. And any leader who sits on the top trees of the NHS, and have been part of developing this contract- well- do please go and rectify this without delay. When I saw HSJ launch campaigns to have women recognised I joked about how this is needed in 2016. I retract that as now I understand why- its because the NHS is still full of dinosaurs who need to wake up and understand what modern life is all about.

Or please either step down and let someone modern do your job.Or at the very least- take some advice.


Saturday, March 26, 2016


Its a tricky conversation to have. Can anyone else do your job? Doctors are always caught in a bind- in fact- even within medicine, people find it a tricky conversation to engage in.
Lets say you say "No, I don't think anyone can"- you run the risk of it being a comment laced with arrogance. If you say "Yes, I think they can" - you run the risk of being asked what exactly is the point of having "you". Factor in then the discussion about evidence of quality of care, the cheaper labour and suddenly as ever, a sane discussion loses its thread and becomes embroiled in idealogical discussions.
For a moment, I am going to ignore the uninformed ones who spout their views without any basic understanding of medicine. I don't grudge them that- whether they are journalists or just opinionated hacks, in a democratic country, they must and should have their right of opinion- however ill informed they maybe. I pass opinions on how Klopp should run Liverpool- that neither makes me someone with credence on that matter, nor someone to be taken seriously. Its an opinion- which is and should be open to debate- at least in my view

Lets focus on those who are in charge of NHS policy- and hopefully better informed. lets focus on health care professionals who are of the view that doctors and nurses roles can be done- partially or fully by the alternates- a different grade of professionals. The question is many fold- are they trained? Are they qualified? Will they deliver same quality of care? Or are they just lesser paid than us?
It's also a question of what history teaches us- or what we, in the NHS chooses to learn from it.

About 10 years or so ago, the cry was to move diabetes into the community- because it was "simple". Because "anyone could do it". Sorry- GP colleagues- but at that time, many GP leaders stood by that - wanted it to happen- the sheer volume arrived but as time went on, GP colleagues understood the sucker punch they got delivered. The patients arrived- the money didn't.Whatever be that policy merit, today 10-15 years later, a majority of diabetes patients don't get their basic checks done. Slice that data anyway you wish- but its not really that fabulous.

Would specialists have done any better? Maybe not.Should they have taken the initiative at that stage and engaged with primary care better? Perhaps- and many ifs and buts- but the sole reason for that "Move into community/Anyone can do it" was down to one thing only- cost savings or cheaper labour. People who didn't necessarily have the required training or finances were asked deliver the impossible. Cue where we are today. Are primary care trained in Type 2 diabetes? Much better than the past and an ever improving feast. Are they trained at any stage about Type 1 diabetes? No- categorically not. But the drive to push patients into community/save money gave us variable care throughout the country. No one made any distinction even based on training of the professionals- it was all about "Move it out".

The fault for that? Didn't sit with the policy makers- in my opinion, it sat with us-as a community- where instead of playing our own siloed cards, we should have asked for assurances regards safety, primary care should have been clear about resources/support etc. We didn't- and we are here where we are.
So can others do our jobs? Of course- anyone can- with the appropriate training. Reducing cost indeed is an important plank- but not at the expense of quality or patient safety. The aim to reduce cost now could potentially translate into further costs down the line via errors, lesser quality care etc.

I will finish by a simple example- as a specialist, I do NOT see myself seeing every single patient with diabetes. I however do see the value of a specialists seeing patients such as antenatal diabetes, foot diabetes etc- as I don't want untrained people having a "crack at it".That's not arrogance- thats simply being clear about my skills. We talk a lot about airlines and their safety- I am pretty sure no pilot would be hesitant about making it crystal clear that the flight attendant may not have a go at it.As a specialist, beyond the specialism, I do have a role as an educator and support for 1 care- guiding others- but there will always be bits that no one else can and more importantly should do.

Can the alternates pave the way for the future? With the training. quality assurance -perhaps so. However, if money is the driving factor behind that-at the expense of compromising patient care, then as a healthcare professional, its not cockiness to raise a dissenting voice.

Its a thin line between confidence and the saying goes.."Arrogance is thinking you are above everyone else; Confidence is knowing no one is above you".

Saturday, March 19, 2016

Sugar and Spice

So it's happened..a Sugar Tax. Let's get this straight at the the outset. It's a good move and the fact that it has happened needs to be applauded.
Yes, on its own, it will do little and needs to be part of a bigger issue; yes, there could be many political reasons why it has happened...but the point is it has happened- and for sure, it's a start.

Whatever your views about them, the campaigns and work done by Jamie Oliver, Aseem Malhotra deserves admiration, even if it maybe grudging, if you aren't their fans. Simon Stevens, again, isn't everyone's cup of tea but with this backing of the sugar tax and prevention programmes, at least, he has shown a commitment to try and do something. One could again argue about impact, suitability, evidence etc but let's take a step back and look around us...obesity is an issue. Not just in the UK, but globally and there is a public health issue at stake. Everyone is welcome to their own opinion but as someone who looks after a lot of Type 2 diabetes patients, their complications and foremost as a parent, well done for it happening.
The next steps will be crucial to see the tangible benefits and there will be a consultation period ( Diabetes UK have already confirmed they will input) to try and ensure no one is disadvantaged by this. The issue? We can't say the system does nothing -then spend energy and time berating them for trying something at least.

Now to an issue which has been a reflection of the times. The media have gone heavy on it...."sugar causes diabetes" and understandably has managed to upset many a folk who once again have felt all diabetes lumped into one.
First- the facts, obesity is linked to Type 2 diabetes, doesn't "cause" it. It certainly doesn't cause Type 1 diabetes, neither does it cause any of the genetic types. It's perhaps a bit easier for me to observe this from a neutral position as I don't have any form of diabetes at the moment but fully appreciate the angst the association it generates.
If you have type 2, the instinctive assumption is you have "too many cakes"...when it may not be factually or scientifically correct. If you have type 1, it certainly is enough to make you angry as for starters it's not something you wanted to happen, then to be painted in same brush understandably riles many a person and carer. If you have a genetic type of diabetes (and some of them don't even need treatment) you can only sigh.

However, maybe it isn't right to blame the media. They catch on to perception that exists- or perhaps allowed to exist by many. Patients try their utmost but my question is what the NHS does to allay that opinion. Let's look at some things...let's say the "National Diabetes Prevention Programme". In its own, a laudable project but where is the distinction? For anyone who hasn't read medicine etc, the message is diabetes is preventable, isn't it? If we are saying Type 2 is preventable, why haven't we,as a system, specified that?
Where were all the big guns of diabetes care when the name came along? Did they forget to represent all the other types? For that matter, where indeed was I? The fault may not be with others.

How about the title of "National Clinical Director of Diabetes & Obesity"? Again, a great role and some amazingly laudable work being done...but if I was a media person, is it too much to make the association that diabetes and obesity are interchangeable? We, as a system, accepted that, so why blame media now? You can call them ill informed but much much before that, the misinformation sits with us,as providers and commissioners, it's about language, it's about responsibility and it's about doing what is right.

In 2016, my attitude has been pretty simple...let's try together. If mistakes are made, correct them as best as you can, but most importantly? Let's work as a collective. We, as specialists, are the sole voice within the system to improve things. It should be patients but unfortunately it's still a rarity. We have perhaps moved from the total disregard to a cursory presence on some boards. The David Gilbert's in the world are rare, and more strength to them in their efforts but we have a job to help as well as be the advocate for patients, help with the misconceptions being cleared, help with raising awareness.

Much to be done and it's time to be calm, work together and do so one step at a time. It's going to hard, it's going to take time but I am not planning on going anywhere in a rush.To all those with Type 1 diabetes and/or their carers, I can't say I feel your pain when obesity and diabetes is mentioned in the same breath. But I do see the visible angst and I get it why it's the case. Work with me, Pratik, Emma...we are trying..give us time and stand by us.

I have a feeling times are changing ...I genuinely do. So let's keep the collective...strong.