Saturday, September 27, 2014

Life without the NHS

So what exactly would happen if there was no NHS? And by that I don't mean the badge or the name because I suspect THAT will always stay..its the principle of "free at the point of access irrespective of social background etc etc". What would actually happen? Social media, newsprint is abuzz with the theories, primarily because it's becoming a battleground for the politicians and with elections coming closer, the noise has just got a bit more shriller.

And everyone has an opinion. People who have never worked anywhere else have an opinion, people have an opinion with wild fantasy laden, anecdote based remarks, people use study which suits them to make a point..and as ever, a practical based debate is impossible. Recently on twitter an event was held called "Without the NHS" and some of the tweets were quite interesting, fuelled with passion, laced with political beliefs, a few laced in reality but majority by those who believe it should stay as it is.

So, let me give you a perspective - having worked in a country where there is no such socialised medicine. Let's get some basic facts straight. The principle that because the NHS is free thereby ts the best medicine ever is frankly odd. The reason the care is such high quality is because of the staff and the care they provide. When folks say their relatives were saved because the NHS is here...believe you me, folks are saved by caring healthcare professionals all over the world, every day, with high quality care..irrespective of what the system is. So what would happen if the NHS became insurance based or the principle of free for all went? I will tell you what will happen. Overall care will not suffer..it will simply become 2 tiered. Consultants, GPs..their families will continue to get high quality care because they will be able to AFFORD the insurance. For a significant number, it will, simply put, become a care system where they will pay and recieve care to the extent they can afford.

Hurts doesn't it? Tugs at your ethos of socialism? Let's flip this then...how do you feel when the UK to continue provide high quality care raids other countries in desperate need of nurses and doctors to fill up their own stocks..simply with the promise of a better life? Fair? Or does the principle of socialism stop at the UK boundaries? Or does the responsibility end with donating to Children In Need or something equivalent? Tough isnt it? I have worked in a system where I have seen people sell their utensils to buy medications, take huge loans to fund an MRI, get sucked into a world of corruption where the ones who could afford did and still does afford the best treatment money can buy..and though this may sound harsh...sometimes, even better care than what the NHS can sometimes provide.

I have seen the darker side of what "healthcare based on your worth" looks like and I cannot, simply CANNOT stress enough the importance of keeping the principle of the NHS intact...not the NHS, but the principle. Today its a political battleground and promises being made will only stop the slippery slope for a bit, not halt it. Primary care is crumbling, hospital Trusts are struggling...its decision time folks...NHS..free for need or free for want? And Life without the NHS or the principle? There are many and many on twitter and rest who will be fine without it...but there will be many out there who will struggle...big time. I will not regale you with my tales of working in an Emergency department in Calcutta...you won't want to know it, trust me. But when you have 2 folks gasping for breath, no nebulisers around you, 1 oxygen tank- and then you also work somewhere where most people are worried about the 4 hour target rather than a tubing of oxygen...let me tell you this...you don't want to lose the principle.

The NHS will always stay...but the slope has started..some procedures already banned, some products already being pushed by companies to "buy as its amazing"...been there, done that..and it wasn't nice wearing that T shirt either. Fight for the principle- its worth it.

In simple plain terms? You have no idea what you have got- or what you are heading towards. As a professional, I will always try to provide the best care- whoever employs me...but as regards the rest? Crunch time is here. 

Sunday, September 21, 2014

Lest we forget

I am all for innovation and working differently. In fact, the diabetes team where I work is well known for being at the cutting edge of working differently...check the articles, the awards, the feedback from local patients,primary care, CCGs...it is a fact that the diabetes team from Portsmouth are always up for trying new things, new ways of working within the existing financial constraints and envelopes....so the last thing you can accuse  me of being a cynic towards innovation.

But some things are now starting to grate...there's now been a few meetings I have attended, seeing a few twitter chats, a few workshops I have been to...where I think people are now being misled, deliberately or otherwise. How many times have you heard this..."working together is the way ahead"; "collaboration", "value based leadership"...aware of all of them, understand them all...but to indicate that will solve the problems of the NHS is simply put..misleading at best, irresponsible at worst. You create the impression that it's the intransigence of some which is preventing progression of healthcare and money isn't the key factor..when it is THE factor.

As part of my travels, I see projects all around the country, some fantastic ones, which all agree with, including CCGs..but can't move due to lack of start up funds. The are some fabulous 7 day working plans..again..jammed due to lack of start-up funds. For sure, there are inefficiencies in the system..use of technology could be better, interaction could be better...but to say money isn't an issue is blatantly false, It is THE issue...the question is whether any money invested is tied in specifically to transformational work or not. Last time, the cash injection came, it got squandered. The most recent one has been about meeting targets...where's the one needed to transform services?

For all those who speak about working together, if you are in a system when one provider has a profit, do you hand it over to primary care ( where it is needed) or put it into social care budgets or do you make sure your own bottom lines are flush to make yourself look good? If this is one system, surely the budget is also one...one that should be accessible to ALL parts of the system? But it isn't...and that's what grates when I hear folks talk about working together. Working together is not about having group hugs but actually helping each other with finances...got the chutzpah to do that or are we still stuck on eloquent words?  To say 7 day services can be achieved without investment or compromising on elective care is unrealistic and let me repeat myself, promoting to many the view that's it's down to a few HCPs unwilling to work on weekends. I work in Portsmouth Hospitals and on a weekend, at any given point of time, there are, just within Medicine, 8 Consultants on the floor. You want more, you either have to get more or make sure they have time off during the weekday, which compromises the clinic, lists they would otherwise do. Why?Because that person does actually have a life outside his work and may actually like some time off. Do I hear someone say "but weekdays are so much better to have time off"? That's also the time when the kids are at school and the Consultant may actually enjoy seeing his kids...to paraphrase someone...people get ill all the time, you are a father only once for your kids.

So, I ask all such vocal evangelists to maintain some perspective and responsibility.Hinting that if you don't do weekends, you are less patient centred is a desperate attempt to send many on a guilt trip, which is fundamentally wrong.

Let me end giving you 2 perspectives. As a clinical director, we have put in place fundamentally different ways of working in diabetes within acute and community trusts...with my natural sashay of arrogance, let me add that if you haven't heard about that,then suggest you do. We also have 7 day diabetes service in place..something most trusts don't have ( yes, including some of our leaders who talk about patient care being at forefront of everything)... And let me be categorical about this...this has been done by a combination of changing culture, working differently AND INVESTMENT. In case you missed it...the word is INVESTMENT.

As a person and a doctor, let me put this perspective. I love my job, love working in my department,have always done weekends, have a supportive Executive team who "get" diabetes...bar some usual work related politics, I am passionate about improving diabetes care and am most happy seeing patients. I also believe that my patients would hopefully testify to that too.But if I am asked to choose, my family will always, and always come first. If you think that makes me a less caring doctor, then shame on you for making many dedicated doctors and nurses feel that way.
We all have responsibilities as leaders...but however well intentioned, our own evangelistic passion and vision should not consume others in that flame. That would be something we should all bear in mind.

Next week:  Life without the NHS...beyond the scaremongering...

Tuesday, September 9, 2014

Picking cherries

It was always the thin end of the wedge. The day one specialty was allowed to have the option of opting out of general medicine because they were "special". Anyone worth their salt knew what was coming..and lo and behold...the leak on the dam gradually just kept getting bigger..and bigger..and inexorably we keep sliding, or even hurtling towards an inevitable conclusion.

History would suggest the cardiologists took the first plunge in spite of objections from others and that very day, whatever the reason, the camaraderie amongst physicians ended. One group was deigned to be more special than the others..they would have their own rota,their own service, their own cherry picked patients. Flip the coin and you actually see that also made sense for patients with cardiac problems, Up and down the country,many hospitals have swashbuckling cardiology units,swanky, efficient, slick..let me even use a management speak for a second..Lean. Financially it made even more sense...in a world of PbR where every single catheter gets costed and put on  a spreadsheet, the more stents you put in, the more profitable the unit became..the more the swagger of the cardiologists..they were the top dogs in town...and Frankenstein was born, the camaraderie was gone.the cherry pickers were in town.

Then one by one, they all left or are in the process of.....Rheumatologists, Dermatologists, Gastroenterologists...procedure was king, procedure meant money, procedure was sexy..a bit more IV zoledronic acid, a bit more bowel screening...Flip that coin again and you see patients have indeed benefitted from that..some absolutely remarkable departments. I personally have had amazing service from Rheumatology and can in fact see the benefits too...why spread yourself thin when you can do so much better in your specialised area? Why indeed do something else when your own specialised area lacks, you see patients suffer..because YOU are doing "something else"?

It's a tough one, isn't it? On one hand, you have the patients who don't fit into a niche, on the other hand, you want specialists doing 7 day service, helping out in the community, running their services slickly..something had to give, didn't it?And once you have precedence and indeed success, the thin end of the wedge was only just that. The success of Cardiology spawned the way for other specialists to adapt the same approach. Problem? Now we have an elderly population with multiple problems..single disease pathology doesn't exist anymore...how's that game of chess looking now?

It's also a vicious cycle..the ones who pulled out, left the others to carry the system of general medicine ..the smaller their pool became, the more disgruntled they got,torn between a desire to do the "right thing" of helping the patient without any label or triage...while mulling how to improve their specialists services.And no one is exempt from the habit of cherry picking.Acute physicians don't tend to look after patients more than 24-48 hours, rarely follow patients through on other wards...don't blame them..they have multiple fronts to fight. Some clever clog recently said at a meeting they weren't trained to look after general medicine, their training was special...the physician in me, the trainee in me who had worked through hospitals which didn't have acute units..cringed. Elderly medicine know they are getting or about to get swamped..as the age of the population increases, so everyone sets their own tramlines..age cut offs, greater than 1 morbidity,etc etc..again, no ones to blame..you are just trying to fight the tide with existing resources...make sure as the cherry pickers leave, they don't get swamped.

I have always maintained that we should have a simple rule..either all in..or all out. All in makes it equitable, all out makes it clear that we have to redefine how unscheduled care works. I have long held on to the romantic belief that the cherry pickers would be stopped and it has been lovely to see the College harbour that view...but one thing I have learnt in life...there are some battles which you need to learn to walk away from.In the battle between lets help all and lets make care for people with diabetes better, finally, specialism won.
For a system to say that a patient with a heart attack or a patient with an alcoholic liver disease is more precious or special than a patient with diabetes in ketosis is simply..wrong.  For a long time, it has been the issue of "he who shouts loudest"...but finally it is time for the white noise to stop. 20% of patients in hospital beds have diabetes..they deserve better, much better than what they are getting now..they suffer poor care partly because the specialists within the hospital have held onto an altruistic romantic notion while others have left and mock them for their naïveté. Swaths of areas in the community need better diabetes care...something which the specialists could and should support. Something had to give, didn't it?

Medicine is going one of two ways..either all will come back in and share their burden of general medicine..or hospitals will be run by acute medicine and elderly medicine, admittedly with resource- either transferred from other teams or perhaps even new investment..with specialist input along the pathway from all specialists. I suspect it's the latter...but would, be delighted to be proven wrong. Till then, we have a responsibility to improve care for people with diabetes..and I am more than happy to fight their corner every step of the way at any meeting or forum.

There will of course be some who don't agree...but it is indeed the direction of travel we all are heading towards...and much kudos to management for supporting the vision and looking ahead. As a team, we are immensely proud of the community set up we have and how that is seen by many as one for others to emulate. I have a feeling we may just done the same for working within hospitals....and could be a fundamental step to improving care for patients with diabetes admitted to hospital...for any reason..anytime of the day.  

Wednesday, September 3, 2014

All hail the leader

It's been fun recently..deliberately raising some provocative questions to see the responses but more importantly perhaps to showcase that there never is a black and white answer to anything..as ever..without any puns intended...they all are but shades of grey. However, one topic stood out..a topic which threw open all sorts of comments...the question was whether "Leadership" was now a cult,an industry and it's been fascinating to see not only the views but the folks who have contributed to it....the question has been in my head recently and it was intriguing to see so many agree.

I must admit to getting a bit confused nowadays...as everyone around me knows..I am a big fan of folks "stepping up to the plate" but recently..I genuinely can't understand any more some of the language used. Here are some terms..."Moving forward"; "Working in synergy";"distributed leadership";"empathetic vision"...and let's not forget "patient centred care". As someone commented on twitter...how many other types of care is there? Now before I get condemned to being someone who just needs to attend some courses on leadership, my question is what actually defines a leader. I have heard things like insight, determination,empathy..I have even heard that actually everyone is a leader. Well, here's a newsflash..I know plenty of professionals who actually don't want to be a leader...quote unquote.."just want to do my job well..and go home". Does that make them less of a person? Nope..I know them..and would have myself treated by them..eyes closed because they are grade A professionals. So what is leadership now? A tag? A title? Something which makes us all feel important? Is it about who shouts loudest? Or is it about someone who has shown outcomes which have improved patient care?

The explosion of social media has created a lot of keyboard leaders..a natural progression from the keyboard warriors..the ones who have an opinion about anything from Wenger's transfer policy to Obama's healthcare in 140 characters or less. And its interesting to hear them...because I don't understand some of the words used. I have been doing management for 5 years now- so the question is ..am I a leader? Well I am a member of FMLM..so am I? I work with the Kings Fund, does that make me a leader? Or is it because I have won awards and made a few lists...that makes me a leader? Or is it because I drop hints on twitter that I am bloody awesome? Or is it because as the lead of a team, we have something in place which is the envy of many? Either way, never done any leadership course or degree..so what does that make me..a freak? Someone who isn't part of the leadership cult..or does that disqualify me?

All interesting questions..but you know what? It rarely matters..as most of these leadership courses can teach you little..because most of the speakers have actually done little bar move from one post to another..with debatable improvements in patient care they have achieved. If you want to be a leader and make a difference, here's my tip..do good to the person in front of you. Start small...learn from folks, even outside the NHS, who have succeeded and see what they brought to work that made them and their team successful, delivered outcomes..and learn one simple thing about any leader you respect. They are all grey characters..persona with strengths and flaws..whether they be Churchill, Gandhi, Alex Ferguson or Shankley. Don't try to attend a course and be told to be perfect...that leaders must be pristine, have all the skills at the same time..No.if you do that, you put on a pretence which people see through. Rather find some others who complement you- and build your team. That, my friends, is what distributed leadership is about...it is about working as a jigsaw together and being accountable together.

So the next time a list comes out, look at it and think why they are there. As for me, I always ask one thing? If I am not on the list, is it because I upset someone by being forthright..as my ego and cockiness would just be surprised that  I am not there...OR if I am on the list, then is it because someone had to tick a box on ethnic backgrounds to make up the numbers and show how diverse they were? The sad bit? I am genuinely not sure any more.

Next week: The Cherry pickers of the NHS 

Saturday, August 23, 2014

Pied Pipers

Fancy a trip in a time machine? Why indeed not? If you ask around, then most agree the past was better, something about the present never seems right, the oft quoted phrase.."In my days"...so hop on..and let's zoom back to 2004.

The venue: Royal College of General Practitioners. Occasion? Discussion of diabetes care. In the audience- the who's who of diabetes care, discussing how to improve diabetes care. And times were good...there was money in the system and there was,evidently, big need to improve diabetes care. There was a recurrent theme- it was time to break the stranglehold on diabetes care of the hospitals, the Consultants. I was there, a junior Registrar- listening and trying to understand the politics of it all. And then it happened. A GP stood up, announced his title (quite impressive, more so perhaps he claimed or perhaps did have the ear to the "policy-makers") and said this.."I cannot see the point of having diabetes centres- all that resource should be in primary care". Lots of debate ensued but interestingly a lot of GPs in the room stayed silent....was silence a sign of acceptance? The revolution had begun.

Let's zoom forward...its 2009...one of my first public meeting with GPs in our local CCG...we intended to float a new way of working..Partha Kar was the new kid on the block- and it was part of an overall area wide strategy session. Loads of GPs in the room, lots and lots of important and grass-roots in there. I sat in the background- waiting for my session- and then my name was called out. I stood up- and recall having to walk the length of the room..and all I could hear was a murmur. Not many had met me then...and as I walked, you could hear the comments with little effort to hide them..."Another new plan eh?"; "Must be about protecting Consultant patch"," Who is this boy?"..a slight gritting of teeth as you walk up- the mantra in my head buzzing firmly..."Work with them, I must make them believe"...Got to the stage- and the GP leader turned around to the audience and said " Partha will now explain the point of having a diabetologist" with a smile, nay, a smirk. Disdain? Perhaps. Disrespect? Perhaps. Ignorance? Read on and I will let you decide.
My answer back was simple.." How's your skill at working with pregnant diabetes patients?" Pause..nothing much back.."Or for that matter Insulin pumps?". A moment of silence followed by.."Well, I will give you THAT". A murmur rose again in the room. We continued, we sparred, we debated and the birth of our model happened..but the majority stayed silent.

2010...an evening meeting with a group of GPs...explaining our model..and a lady introduced herself..again, another grandiose title, another leader..who opined that the new Health Act was finally the "time for GPs". The years of underfunding was now past...the time to strip hospitals bare was here now..to fund GPs. I smiled and wished her the best. The other 7 people in the room...stayed silent..looked uncomfortable...one mentioned something about the importance of a local hospital...but then concentrated on her drink. 

4 years later, its now pandemonium city. Leaders have tried their best to create pathways, create tramlines which restrict the type of patients who can go to hospital...they now need to go somewhere- so the GP surgery it is. The expected holy grail of money follows the patient remained an El Dorado..and suddenly the patients were there, the money wasn't. Diabetes was a prime example, perhaps even a forbearer...extrapolate that to all specialities and why is anyone surprised that GPs can't cope? Pathway to refer back also closes with clinics being disbanded, so where indeed does the patient or the GP go? 

5 years taught me a lot in management...what it also taught me how the silent majority are not part of decisions made. The fault lies with both- self styled leaders who dictate for others as well as the majority who chose to stay silent..perhaps even keeping the faith that resources would follow. Diabetes care has suffered as a result..there isn't even resources or time to do simple 9 care processes (just wait till the recent National Diabetes Audit comes out- makes for woeful reading)..let alone anything else. In the main, diabetes care is delivered by practice nurses- and by god, they are struggling. Struggling to even do basic stuff, let alone do professional development, keep pace with the changing times, new developments, evidence based medicine....

So to all leaders who ask for "more GPs"...that will solve little. There is need for increased resource in primary care, time for education- and perhaps even think of specialists in primary care. More importantly, it certainly is time to stop leading GPs off the cliff by agreeing to yet another pathway which is designed with only one intention..less patients for hospital. That has little or nothing to do with patient care but translates to more work for primary care with little added resource...if you don't understand that simple economics, then drop that title, stop attending the meetings and go help your colleagues in their day job. The rest? Stop being silent..otherwise that cliff edge now isn't too far away.

Next week: "The Leadership gravy train"

Friday, August 15, 2014

Eeny Meeny Miny Mo

I loved him in Good morning Vietnam...there was always something about the clown with a tinge of sadness in him..and it wasn't just comedy. If you wanted to know about his acting chops...watch one of the classic Chris Nolan movie..Insomnia..head to head with Al Pacino and Hillary Swank..simply an artist. So had to wince a bit when the news flashed about Robin Williams..another celebrity taken away due to mental health issues...and the issue got the focus it has always deserved, some good and measured; some downright awful and morbid..but it got the attention. More closer to home, Shaun Lintern who is not afraid of rocking the boat (Shaun, that Superman logo isn't you...try a Bat symbol...much more of a rabble rouser) published his investigative findings on mental health issue and it's provisions...and makes for grim reading.If you haven't read it, suggest you do..crisis? Nope it's close to apocalypse now. As a physician, I know so from ward rounds..Shaun's work just confirmed it.

The million dollar question however is what now? As I mentioned to a few colleagues, pick ANY service and you will see holes, some more than other, but holes none the less. And to every single person I have asked one question..but the answers have been ethereal, abstract, wrapped in buzz words, catch phrases...none, I repeat, none of which actually solves the problem.
So here is the question...we know mental health needs funding...in our cash strapped environ...where will you get it from? In the spirit of multiple choice questions, try this...

Option A: Raise taxes (Pros: will throw more money at system, according to some ONLY way out; Cons: Look at the wastage within the NHS ?..sure more money will solve it?)

Option B: Abolish competition, make it a monopoly (Pros: transaction cost saved,procurement issues lessened etc etc; Cons: lack of it may raise issues regards where the drive exists to improve..any attempts based on data is anyway neutralised by most poo-pooing them on basis that its either a cock up or a conspiracy)

Option C:  Prioritise services; accept that to provide high quality services, you may need to prioritise some above others (Pros: Gives opportunity to develop those services properly, not pay lip service Cons: who chooses the second tier services and based on what?)

Option D:  Do nothing and stick to camps based on ideology and have a shouting match.

Option A may happen..but where do you stop? Keep on raising it with demand and need growing exponentially? Option B: Perhaps gives you a release as a one off saving ..still not convinced how that drives quality..but then what? We do the cycle again?
I put in Option C simply because we already have that steadily, if not by stealth. Lots of areas have procedures not funded by the NHS or needing permission."Free at the point of delivery"? Or "Free at the point of delivery chosen?"

Here's a question...what's more important ..mental health services or diabetes?Cancer treatment or well funded primary care? Midwives or treatment of Psoriasis? Tough, isn't it? But the answer is simple...based on who you are asking. If you have debilitating rheumatoid arthritis, for you, that's the service of prime importance...it may not be maternity services.For the mum struggling with a 2 year old who has type 1 diabetes, it will, of course, be a fantastic type 1 paediatric service, it may not be a COPD outreach service or a dementia service. And then there are the charities..quite rightly driven by the prism of their own views.

So we come to an inevitable cross roads..and frankly I do not envy any policy maker, any politician who has to make those calls...it's always easy to criticise than to do...and will forever be. But time may it be too far away before society is called upon to play this game of MCQs..as tough as it will be. What started as a fantastic development of socialised medicine now comes to a crucial juncture.
The fundamental question is..will we make the decision based on sound facts, reason or are we going to be driven by emotions? Are we going to be able to make a tough decision which will not make all happy..or are we going to roll the dice and see what comes up?

Time stands for no one...and this question will keep coming back..again and again. So have a think..when you are asked the question..Choose wisely. Better that than a game of eeny meeny miny mo..right?

Next week: "GPs, vacuous leadership and inevitability of strife"

Thursday, August 7, 2014

You never forget

It's an emotive topic...the topic of colour...prejudice based on the colour of your skin and I recall listening to the experiences of my parents in the UK back in the 70s...people refusing to sit next to them on buses, bosses in the NHS being open that Indians shouldn't be in "high positions"...and then I look back at my journey and it's a darned difficult topic to discuss or talk about.Reports such as "Snowy white peaks of the NHS" are a reality check, a discomforting feature for many..an uncomfortable truth which grates with many, but a reality nonetheless.

And I will tell you why it's difficult for me to discuss this. One one hand, here I am, rabble rouser-in chief, made my reputation for good or worse in the world of diabetes, stepping down from a 5 year tenure as Clinical Director when most people begin...would I have been able to do this if there was a severe colour bias? On the other hand, is it not because I have some friends I work with, who have been comfortable with me being the lead albeit the youngest of us all,a group for whom colour has meant little?

I say so as throughout my career, there has always been instances...you never forget...my dad always used to say, and still does say to me..."don't aggravate people, it's not your country after all, colour bias will come through in the  end".. And I have for ever tried to rail against that...I was born here, I contribute to taxes, do everything any British citizen would need to do..this is my place too, right? But you never forget..you never forget a senior Consultant telling you while you are looking for a substantive registrar post that it was better to apply in the Midlands as that where "your type stood more chance". He/She of high fame..great endocrinologist, great doctor...slip of tongue, didn't mean what was said? Who knows...but you never forget,right?

For those who have never faced any race bias, being questioned on the basis of your colour, you will never understand the impact of it..you just won't.  Every single word uttered grates, makes your teeth grit, and depending on your personality, either creates a fire to consume all or a state of resigned depression and acceptance that colour is a bar and there isn't much point in railing against it.You never forget...I recall a conversation with a nurse specialist and a research registrar while at Diabetes UK, many years ago..during my tenure as a trainee..we were talking about job opportunities...2 educated women, high flying and in the course of time have become well established too...their collective view..why didn't I "bugger" off from where I came? Was it a joke? Was it tongue in cheek? Who knows...all I do know it stuck..you never forget,do you?

Patients are no dissimilar either...you think racism is associated with poor socioeconomic conditions and lack of education? Au contraire amigos, some of the most educated have said things in clinics, in ED,on the wards which have elicited mostly a witty response back...("You are a Chink,aren't you?" "No, actually I am Indian..the high cheekbones are just features of my dashing good looks"...keep it deadpan, Partha, keep it deadpan)...but they stick..you never forget. Beyond the veneer of polish and education, the nastiness of racism bubbles away.Society has made it more difficult to be explicit and open about your inner feelings but it bubbles away, ever present..it exists in a different garb..what did that report on the snowy white peaks say again?

To be honest however, for me, that has always acted as fuel. Fuel to prove that I belong, as much as anyone else. On the contrary, it makes me wryly smile to see any achievements which perhaps inwardly makes the covert racists wince. I see educated Consultants, holding positions of power and authority making fun of accents, the way people dress, the food they eat- and now ensure they dare not repeat it again- at least not in front of me. Don't demonise UKIP when the so-called educated ones harbour similar feeling albeit beneath the facade of  charm.
You never forget the barbs...you never forget who threw them..and you never forget as well that a few rotten apples don't make the barrel bad. The reality however,still is that you have to work that bit harder, that bit more differently to make a mark..everyday in the NHS. Some deal with it by battening down the hatches, some stop caring and some relish the challenge of the odds. Either way,as with anything, documents will do only so much, bold statements from Simon Stevens will only go that far...we shall see with time whether the NHS or for that matter society has it in them to narrow the divide.

Till then, you never forget.