Tuesday, October 7, 2014

Wrong tack?

So shall I dip my toe into this water? Challenge the RCGP and thereby the GPs..or are they a separate entity?  Let me set my stall out at the very outset..don't know about politics but amongst the mates I have grown up with, those who are GPs, I see less of, they arrive late for the football games, look a bit more knackered, so this isn't a debate about who works hardest. Let me be perfectly honest, most GPs, I know work harder than me and unlikely to have as good a work-life or as Mark Cheetham likes..work-family balance.Thats not a condescending sop to balance for what I write below, but as I see it day in, day out.

Nope this isn't about that...this is more about the pathway or tack adapted by the RCGP akaThe Royal College of General Practitioners... it's made me wonder...is the RCGP more of a collegiate institution or a trade union? I say so without prejudice but mostly from point of view of my own college which has tended to adapt a "hands off" approach to political changes,for good or bad..though in all fairness, their engagement as regards the future hospital has been laudable to say the least.

But the RCGP in recent times has slightly baffled me as quote unquote one of my GP colleagues "it just says more GPs". Which in itself is an interesting position in my book, as the ethos behind that seems to believe that more GPs will solve the problem while on the ground, if given a choice,for right or wrong,I would probably have more practice nurses, more community DSNs...whatever be the case, certainly more primary care staff, not necessarily "just GPs"

It is at this point I can already hear murmurs saying what qualifies me to speak about such an issue? The answer is probably not much but am giving a perception, from the outside if you may, that the position sounds too siloed. Put patients first...absolutely 100% with you....But not by saying lets just have more GPs. Not by saying "give money from hospitals"...believe you me, hospitals aren't running in rosy balance sheets either. I appreciate I offer perhaps a narrow siloed view but diabetes care isn't going to be resolved or improved with more GPs...more primary care staff...absolutely 100%.
As an analogy, you will never find me go out and say we should have more and more diabetes consultants...not certainly when we still haven't evolved enough to work differently and learn to help primary care more, rather than do our clinics in the traditional way,still ducking behind the spectre of information governance and shying way from patient access.More on that chestnut later.

Which brings me to the next point...on one hand, the clamour is for more GPs..on the other hand, posts can't be filled, people are leaving,social media is abuzz with burnouts, GPs themselves encouraging others to leave,tough working life..all this publicly played out...impact? I teach medical students and the proportion of folks considering becoming a GP continues to dwindle. Recently I asked on twitter what makes a GPs job attractive and there were some wonderful stuff,absolutely inspiring..heck...if I had my time again, may have gone for it myself. So why the lack of balance? Yes jobs are busier but to say working conditions haven't improved from say, 20 years ago, isn't right either, is it? You can't attract generation next by being negative...careful you don't end up being the reason why no one wants to do primary  care anymore. Those who work with me know that without being condescending, I am very public and open about my admiration for GPs but a bit of balance is needed.

I can only offer tips from history...recruitment in our specialty a few years back was low, with poor job prospects...there is a session at the Annual conference in diabetes UK called the Consultant/SpR session which happens every year. And year after year, as an SpR, I went there and heard people just moan, talk about how life was bad, negative..and a bunch of us sat in the audience and vowed to change that. The SpRs had a 10 minute slot and we decided to showcase the positives in front of everyone...give it a bit of balance and energetic people like Emma Coull, Pratik Choudhury, Marc Atkin went up on stage and said "No" to the negativity..and people started walking way from that session feeling all was not lost, positives were the too. It's our job to inspire generation next, not to push them away. Yes, of course realism, not shying away from the toughness but a bit more balance too, right? It's great to say we will "make" people do more generalists, "make" more GPs....one fundamental flaw? You can't make anyone do anything they don't want.


The NHS will struggle to exist, not because of political restructuring or any other reason, but simply will collapse if we don't have a robust primary care. The wizards have only a few spells in their magic box....if the gatekeepers stop to exist, the facade of sorcery may well be under threat. A campaign designed in the right spirit hopefully will not end up alienating the rest of the workforce...let alone the next generation. Politics is a part of what we all do...but in that game, hopefully the campaign doesn't t do more damage to the future of primary care. Have a think.

Saturday, October 4, 2014

Up to YOU

One of my colleagues recently mentioned that I had strayed away a bit from diabetes in my blogs...looking back, perhaps she does have a point...so let's get back to it this week- shall we? After all, politics and the NHS along with its challenges will always be there. Let's be honest and keep aside our political leanings for a moment...or if you are overtly optimistic, you may actually believe that the 8000 extra GPs that one party has promised from Narnia will help to provide the 7 day GP service the other party promises. Maybe they are actually working together, right? The elusive hunt for that wardrobe to Narnia is going to go on for a bit- so enough time to get back to that...for this week, let's get back to diabetes, shall we?

The National Diabetes Audit just got published -I am not going through the data - have a read….makes for sobering reading doesn't it? Yes, there are flaws with data, yes-there hasn't been enough data submitted...but cut it any way- if you had diabetes, you would be pretty worried 

Let's take the first one...we are talking about BASICS here. Nothing too complicated, nothing about evidence based medicine, nothing about evil Pharma promoting their drugs….these are basic checks that anyone with diabetes should have- as simple as that- and the national data around it is astoundingly poor. So what shall we say- primary care is poor? Let's take a reality check- shall we? Due to the evangelism of a few who are in committees, below is what primary care has now been asked to do regard diabetes care:

Screening / Diagnosis / Education / Early Intervention / Looking after co-morbidities / Seeing patient in home environment / Intensification /Complication Screening / Counseling / Appropriate referral / Keeping them out of hospital

Extrapolate that across all other disease areas- and the one thing that is crunched is...yes…..you guessed it….time. How much extra resource has moved to accommodate that sea-shift….very little to be honest. So you would have thought a golden opportunity for all national bodies to get together and look at working together- wouldn't you? Or do specialists take this an opportunity to suggest that they need more specialists....patients should never have been sent to the community? Do GPs say that they need more GPs and it would be fine? I will let you be the judge of that.

Let me be as honest as possible- Diabetes care in this country is in the hands of practice nurses- and if we want to improve care, then we need more educated and supported PNs, NOT GPs, NOT specialists. You don't need specialists to see everyone in hospital but need them to be as educators, guides to making sure the basic check is happening. Not that complicated, is it? It is however when national organizations work in silos, in isolation- all asking for more of their own. The National diabetes Audit has been running for a few years- responses from the national bodies such as ABCD (Association of British Clinical Diabetologists) have been tired, lazy, siloed…I predict a report as to how there is a plan to improve things…how long do you need to actually do so? The NDA hasn't shown much improvement over last few years....so what next? Another report? Where’s the public lobbying, where’s the setting up of educational events looking at addressing this basic issue? Why isn't this primary aim?

So to those who do diabetes as a speciality, let me say so clearly..it is YOUR responsibility to make it better- not anyone else. If you are waiting for national bodies to do it, you have waited, we have waited, I have waited…it’s not coming ..or if its coming, its not coming fast enough for the people who matter. YOU are the advocate for patients with diabetes, so engage with the Trust, work with colleagues, learn from others, go visit other places, find out what they do- and make the change that’s needed. YOU are the one who can work with patient organizations like Diabetes UK to help drive up basic care in the community, work with the practice nurses, build bridges with GPs, say you are there to help, not to judge. 

In the words of Martin Luther King.." Change does not roll in on the wheels of inevitability, but comes through continuous struggle". It's upto YOU as someone who does diabetes as a job to decide whether you want to lead that..or there is little point in doing audits, is there?


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"