Saturday, April 18, 2015

Choice..the ultimate myth?

Patient choice. Feedback. Opinions. Patient power. How much do we actually mean it? How much of it is actually possible? How much of it is ticking boxes; appeasing some and little else?

The answer uncomfortably is overall, we have just about moved past lip service. And it's assume patient always knows best is a bit debate you always worry how much information the use of a particular ask is based it media driven? Is it due to some ill thought out national campaign? Is it due to industry influence? To make matters even more difficult, we are in an era of what appears to be a power struggle...personally I have found it baffling, but when anything related to care is denied, then not all conversations post that denial is sensible or rational. 
Every one, quite rightly, looks at their care and wants the best..any prioritising by health care professional based on even evidence is then seen as denial and this builds the power struggle.

Some HCPs try to have explanatory conversations which always have the potential to end amicably but again, in a system where health has been converted to widgets, time is one thing most people don't have...cue further debates. Easier to shut the patient out and carry on regardless, right? 
And then there is the fundamental of the NHS..GPs as the vanguards- understandably too- for any further escalation to specialist care. How does that exactly square with patient choice? Let me give you an example..a patient develops type 1 diabetes. Now if I or any of my family developed that, I am crystal clear what I would want. To be seen by a specialist who has trained in type 1 diabetes..let me emphasise..not all specialists have that either in I would want to research a bit, use my knowledge of the system and see someone reputed or good in their work. I will be honest, if I lived in London,I would like to be seen by Pratik Chaudhury..not because he is my mate and we share a common love for whiskey..but because I KNOW he is good. Would I see him would talk to my Gp and basically make sure my care in the NHS was overseen by the best..I would use my position and knowledge of the NHS system to get what's best for me.

Let's now take the example of John Smith. He however has to go to see his GP and even though his choice is to see a specialist, he is now at the point where a GP can decide whether he sees a specialist or not. There is a huge degree of variability around this particular scenario. Some would be aware of their limitations and simply do the needful, while I have also seen many who would refuse. Grounds? Twofold..first politics...not nice to be criticised for referrals to the hospital...don't you know we need to keep referrals John gets caught up in that stream. 
Second? A degree of ignorance as well…isn’t type 2 the same as type 1 diabetes? If one can be managed, surely the other can?  Well actually it isn't. But away from the science of it all, hands up how many GPs have actually trained in type 1 diabetes care.Pop quiz many GPs or Practice nurses are aware what's the eligibility criteria for pumps? Even if they are, do their local team have the service..or even training?
Once John crosses that hurdle, then comes the question how does he know what level of care each specialist centre provides? Any tool or common portal to have a look and make that decision? You must be you go to the local specialist centre...and you take what you get. Do you know whether the local team has someone specifically trained in pumps, technology or even type 1...Nope, surely the specialist knows it, right?

So there lies a fantastic dichotomy of patient choice. Driven by a combination of measuring GPs on referrals made and a degree of ignorance, in the world of type 1 diabetes, choice is an anathema. Should all patients with type 1 diabetes care be under specialists? Possibly. Should they all have access to specialists? Most certainly. Why? Beyond the ego, beyond the efficiency drive of saving PbR costs per referrals, look at outcome measures for type 1 diabetes. Awful is a polite way of putting it..variability is high.

Here's a genuine question to ponder as someone put it on Twitter...does choice and free healthcare actually go together? If patient choice is paramount, then can or should a GP deny referral to a specialist based on cost savings? Does denial of so bring the patient back more frequently creating more stretch on an already stretched primary care system? And more importantly does such barriers end up in patient care being compromised?
When we talk about systems that are efficient, in relevance to a long term condition, we have to talk long term...poor care in type 1 diabetes today results in poor outcomes down the line..look at the money being spent on complications...but yet we worry more about saving referrals on a widget based system today. 

We need to be bold enough to have these discussions openly with patients and fellow professionals. Not pay lip service by asking patient leaders to come along for free and give a talk. Not tick a box, not say we have patient involvement when we are not discussing the genuine elephants in the room. 

As ever, these are my personal opinions and of course is from the angle of a niched population such as type 1 diabetes. Our ultimate responsibility is towards patient outcomes and it is certainly important to maintain relations across the is by the same token, our responsibility to be responsive to patient needs and challenge accordingly the system which makes a mockery of patient choice. Things are improving..slowly...but we need to specify whether it's possible to have unlimited choice in a system where finances are under such a massive crunch..or we have healthcare based on widgets..not quite on relations.

Saturday, April 11, 2015

The efficiency cocktail

I am not easily impressed but I must say I am now. Simon Stevens, the NHS boss has indeed achieved something few have. I have liked the 5 year forward view thoughts from a clinical perspective - as if you see it from the prism of my specialty, it lends itself well plus has looked like a genuine roll of the dice to see if integration can be done by changing the structures...not to mention it was a nifty bypass of the Lansley act. So clinically I was interested and then having seen Samantha Jones take up the helm in guiding the Vanguards and a brief chat later, yep, clinically I certainly see it having legs...if..and that is a big if...if there is genuine appetite amongst all the stakeholders to commit to the process.

However I have been more impressed as to how with elections looming, the "give us 8 billion" has become something all are either being forced to commit to...or having to find ways of doing so. It's amazing as before the 5YFV, no one actually knew what was needed, apart from "give me more"... And then suddenly we had a figure. Hidden beneath that is the rest 22 billion needed in efficiency which I will come to later..but at least, we are starting to get finite numbers promised by politicians towards the NHS..a different debate whether it will be delivered,how etc

The obvious flip to that is if that 8 billion does arrive, does the onus for delivering the rest 22 billion fall on the NHS? We ( and I know many will claim Stevens doesn't speak for them..but as with any organisation, the man is our CEO and that document was probably one of the most lithe and sensible ones I have read in a long time) asked for a certain sum of money and said we would find the rest in efficiency. Would the politicians be emboldened enough to say "ok's your if you can't find 22...sorry..your fault, not mine"? Fascinating in its own right but I must applaud the fact that Stevens has at least managed to get the politicians to commit to something's a start compared to "just give us more"

Then comes the 22 billion...some believe it's possible, a lot believe it's easier to actually discover life on Mars. We shall see..I have my doubts as anyone else..for starters, if I was a hospital trust finance director I would be pretty worried. Better get cracking quickly to be a PACS..or its gonna be time to poach others work. In the mix is 7 day services...oh such a heady cocktail...factor in shrinking tariff and you can see where the efficiency drive will be aimed. To complicate things, comes the signs of provider revolt..already due to have a bearing on repeat admission tariffs..what a sumptuous cocktail we indeed have!
Did anyone say we should have less managers? Well, it's probably time to stop churning that nice sound byte. We need some good managers..and never more if we are to get anywhere near those efficiency numbers. Not to mention the fact that even if you take away all those nasty managers, it will still give us a decimal fraction of the 22 billion

And let's also see what comprised a significant chunk of efficient savings last time..ah freezes...more to come? Consultant contract there's another battle ground..thought to be fair that's probably aimed at the 7 day services and see whether it can be delivered without a huge rise in cost. Isn't that cocktail tasting marvellous? GPs according to a survey have said they don't want 7 day services with all other pressures, we keep looking for Narnia for those GPs sitting around...the pressure cooker is building.

So there we have it. 8 billion asked..and looks like we may get it...and if we do, then we won't necessarily be in a position to blame politicians...but that's only part of the picture with the bigger challenge of 20 billion to get.
We have pinned a lot of faith on the new models in 5YFV and fingers crossed, some of them come up. Not many have faith that the efficiency money asked for will happen...and indeed there are some who believe that the NHS is so big that money will come, from somewhere as "it always does". We shall see but it would be foolhardy to say this could be a helluva ride for quite a few of us. My view? Yes it's theoretically possible to get close to that but it needs massive changes on huge scale, changing mind sets etc but when I see how little we have achieved with 7 day service or integration due to conflicting interests etc, the reality worries me. A lot.

Do I envy any manager, clinical or otherwise, under pressure to deliver efficiency....Nope...but I will sit and sip on a cocktail and wish them all,the very best. From the bottom of my heart.    

Saturday, April 4, 2015

The last 5 years...

Elections are around the corner...and it's always great to listen to all how their working life has changed or not in the past parliament..and it made me think...what about us? The Portsmouth diabetes team.. and..what about me? How has it been in the last 5 years...shedding off all the views you hear, the angst...taking a step has it been really?
What I will put down in this blog...can I PLEASE make a disclaimer? This is my view, my personal one, my personal experiences...untainted by my political leanings, beliefs or otherwise. This is what we as a team did over the last 5 years.

Individually, has the new "new" NHS affected me? The reality is no- it hasn't. My basic salary has stayed static but personally its not gone down- and I always appreciate how lucky I am to have a job which offers that. There have been enough activity for me within the hospital and community to keep me busy- apart from other local and national stuff- so personally, nothing much has changed. I am pretty sure I speak for my colleagues too on that one. Perhaps the fundamental reason for that has been is that neither am I a GP nor an ED/MAU physician who appear to have taken the brunt of the changes. Tell you what has changed..we have locally in Southsea been a pretty cohesive bunch amongst Consultants and GPs..all I can say is that its more difficult to have the GP colleagues out for a drink...they seem to either turn up in the second half of the football matches..or not at all- and look overall a bit more tired, a bit more browbeaten. I will be honest, I have had my tired moments but mostly due to individual choices to do more rather than the persistence of the day job.

As a clinical manager, I must admit to not being exposed much to the previous system- but I have found it beneficial to have GP colleagues with clout who have been willing to listen. I have heard in the past, PCTs being full of managers who didn't want to approve projects- but have met the same individuals who have been pretty instrumental in making things happen for us as a team- we have shared a camaraderie, had lots of jokes and doing business with them has been fun. We have overhauled how we do diabetes care, majorly built on our relations with GP colleagues, raised the profile of the department, expanded the workforce of the department  and slowly and steadily, the outcome measures for patients seem to be turning. Early days, but let's see.

The tendering has been challenging but been through that too- and worked with all potential providers and then the individual winner to keep the service going- it has been an experience, perhaps an inconvenience and in the world of long term conditions, would love tendering to be held fof for a certain period of time, the projects given enough time to breathe, settle and then deliver.What can you do with a 2 or 3 year contract in diabetes..well pretty much nothing! I look at the Derby model struggling to survive and again, appreciate the fortune we have had with local Commissioners etc

The confusing bits have been the myriads of new bodies- who seem to be willing to help but am still to be convinced that there isn't reduplication. We used to have the National Patient Safety Agency- in our world, was an important  body..that disappeared. NHS Diabetes was a good organisation- that disappeared..and now we have networks, clinical and academic, senates, NHS IQ, NHS leadership academy...they all seem to be tripping over each other a bit- in my opinion..a bit of streamlining would perhaps be helpful! I don't know about other regions- but as regards diabetes care in our region, none of them have contributed much in the last few years- sorry guys- just saying as I have seen it! Look forward to being corrected in the future but I do get the feeling that we have too many bodies who most people on the ground struggle to benefit from.

So in short, perhaps the old system wasn't all bad, most certainly needed a bit more clinician involvement- but perhaps bit too much of an overhaul was done. Baby with bathwater syndrome needs to be avoided in future .

In my next blog, I will put down my views what would be nice to see happen in the next 5 years but as a summary, personally its been a mixed few years. A lot achieved, a lot done- if we get some stability, I promise we could get much more done too! I can't look back and say that it's been awful or amazing...its been mixed but perhaps tilted towards the positive....maybe call it a B -

Reading and hearing much of what is going on in the wider world, perhaps that's something to look back at with pride. Here's to the next 5.

Saturday, March 28, 2015

Unity past the rhetoric

Unity. Or lack of it in any shape of form. Pretty much defines what doctors are all about. Maybe it was ever thus, perhaps the world of social media has made it ever so more visible. A lack of unity when there was need above all..not for their own self preservation but purely to keep the NHS afloat. Elections are coming and without any surprise, the rhetoric is flowing thick and fast..depending on your political leaning, it gives you abundance of glee or despair while the majority who try to see things beyond political rhetoric simply shake their head at yet another sound byte aimed at the public, ramping up expectations. 

The Reds say they will guarantee 48 hour GP access, have 8 (or is it 10?) thousand more GPs. They will also give extra cash raised via the mansion tax. Key flaw? The mansion tax, even if it comes into being, won't be so till 2017 at the earliest, while the NHS gasps for money now. More GPs? Yet another sound byte perhaps in an era where recruitment is tough, jobs are tough, Antipodean adventures are on the up- so unless there is a secret door to a Narnia like place where there are GPs available on a shelf, well, you get the picture. A 5% cap on private providers sounds good...only the competition rules of EU may frown upon that, not to say why doesn't that involve all? If Trusts make profit, reinvestment should be in system, not just their own hospital, right? Then again, how many providers do you know who have a 5% surplus? 

The Blues say they will guarantee 24/7 NHS a service among many other things..a laudable view -in fact Sir Bruce has been working on that for a number of years...but recently his frustration with lack of progression was clear to all. NHS IQ continue to hold events, the reality is that it's stalled and present drivers ain't working. How would the extra time from Consultants be funded? Well no one is really sure not to mention,attempting to squeeze contracts by driving pay down will risk alienating people from taking up the role ( Hello New Zealand!) thereby a lack of staff and we have a Catch 22. Then there is the little matter of trying to enforce contracts..middle managers up and down the country probably have just had a cold sweat at the very thought. Sack the uncaring bastards..errmm..who does their job then? Good sound principle and no debate about the need but folks, what about the plan?

Doctors, actually let me change that, healthcare professionals need a sense of unity..a voice which will engage with the politicians and ask them to stop - irrespective of colour- at their attempts at meddling. I don't believe in the rhetoric that politicians, in the main, are corrupt..I do actually believe they want to serve,so something inherent in them must believe that we as healthcare
professionals cant do this properly..maybe the onus is on us to work as a team and show that given the budget, we actually can. Free from restrictions of our own little financial restrictions, genuinely believing their is only one pot and realising that to make a "profit", someone else has to take a loss. If you have only £10, there's only 1 way I can make £ nicking £1 of you..right?

A bit of unity would be nice...enough has been written about the recent Resilient blog and enough blogs written in would be nice to actually have a sense of solidarity, perhaps disagree with the method if it isn't your cup of tea, but at least agree as a group that things are that bad that committed professionals, who have gone on to do this work with as much love for patients as anyone else, have had to publish a list to generate debate.  You may not like it but have a look at Facebook ...its teeming with support too...the heat is on so much that we actually are having camps such as patients vs doctors. Try and move away from the concept of being either the one who knows all,by all means, but don't swing the pendulum and say we are servants. Say that enough, you will get treated as one. I am neither a demigod nor a a trained individual, well paid by the system, trying to do the best job I can, to the best of my ability...that's pretty much it. A bit of unity again on this front would be nice, wouldn't it? 

So ladies and gentlemen, a bit of stock taking, a bit of calm..all here to do the job..and the last thing we need is infighting amongst ourselves and certainly not chasm with patients. Stand together, irrespective of your political beliefs and ask the politicians that they don't need to do the rhetoric. We talk about finances and as has been mentioned by Roy Lilly a number of times, what has swept under the carpet is the 22 billion efficiency drive on its way. Did you say what it is? Well, you know that Nicholson Challenge? Well this is mark 2..but with all the low lying fruit gone.

Tough times, ladies and gentlemen...a bit of unity could go a long way. Divided we actually don't fall as doctors...that's the irony. As doctors, we will always find a place to work..such is the world economy. Divided the NHS falls...and if that does, so goes with it equitable healthcare. Unite, make the case and a plan what extra investment would show, perhaps stop asking for more of your own ilk all the time...everyone needs more from the prism of their own profession.

Your call whether your political preference tops your desire to keep the healthcare system this country has. Clocks ticking....
Or is that all a bit too much for us all?

Monday, March 16, 2015

Optimism...with caution

It's a world of fascinating dichotomy at the moment, isn't it? The colleges have asked for political parties to commit to the 8 billion the NHS needs to survive, no main stream have agreed to it..while on the back burner sits the issue of having to find 22 billion of efficiencies. Even if one finds that 8 billion with the appropriate political will, the eye watering efficiency number would make most finance directors reach for their bottle of Gaviscon. Then we have a presumed crisis of leadership as the right leaders potentially would find the money, only if they knew how to lead. Parallel to that we have the "shiny" brigade...striving to improve the emphasis on empathy, trying to spread the feeling of doing good, while at the same time, we have Kirkup suggesting silos, professionals turning a blind eye to poor care..dichotomy all around us.

One more bit in the mix is the fascinating situation of the makes me smile when people rail against those who do private someone explain to me what PbR has now become? See more patients,turn the wheel, for each activity, you generate money for your Trust..did you say we were all in this together? How many trusts do you know who have made a profit and then handed it to primary care or social, they rather invest that in developing maybe another wing or an IT project to improve "their" services, not necessarily the system. In between all that, an institution like Barts is now on its knees...leadership and shininess won't sadly help what actually is's the injection of cash. Who's feeling confident about that 22 billion efficiency savings now?

So as a clinician who has spent a significant time in management, looked at enough balance sheets, it's darned difficult to be overtly optimistic, believe that a solution is around the corner...but having said that, there always comes along a few things to lift the spirits a bit, give you a bit of hope that we aren't sliding inexorably towards a health system where availability of quality will be dependant on your wealth. It's tough though..the world of healthcare in the UK is already having encroachment of companies putting their products on the market, outside the NHS, creating a 2 tier system..those who really need it, can't afford there much to arrest the slide?

Thus it's with a degree of optimism, I have looked at the Vanguard projects..a new and interesting development. Am also fully aware that this already has had its cynics but with the challenges mentioned above, we need some major game changers...could this be one? The trick as ever is to implement the clever words, the glossy power points into reality..and then the toughest bit, to sustain. Can the vanguards do it? Time will tell but certainly it's something new, something different.
In American football term, it's as close to a Hail Mary pass as it gets...we need to decide as a community whether we engage with that constructively or simply sit back, criticise and just ask for more money. I am an optimist and I want to see how this works, how it can be sustained, how theses can work without breaking the local trust or imploding primary care. Whether right or wrong, it's different, it walks away a bit from silos and it's worth a try for sure. Best of luck to the ones who lead in's not easy to put your heads above the parapet..for that to be's now about implementing and sustaining..and maybe also know when it's going wrong and being big enough to stop. It's not about your local trust expansionism or even a GP cohort taking control of the system...but about whether the patients are served best..whatever garb it maybe in as.

The other bit has been the recent Diabetes UK Annual conference..maybe one of the best I have attended in recent times and I won't spend much time talking about it ( Read a great piece here) but what struck me was the change of mood...there seemed to be more of a mood of optimism, a more stronger willingness to improve care, a better mood to work together..I loved mingling with the patients amongst all the HCPs...but the best bit for me was the energy I saw within the up and coming trainees. I am enthused by their views, their desire....we, as a community, must let these guys flourish..they are not uncomfortable in mingling openly with patients, having a debate about care....I like that..I really do.

Meeting so many people I knew via Twitter (Anne, Roz,Mike etc) was fabulous..talking about what we have done over 4 years in Portsmouth was proud, trying to share the importance of SoMe to many was fantastic...but mo than anything, it was the desire to share, interact as well as say to many HCPs...please do go and engage with patients..beyond what you can learn. Share with them our frustrations too, the issue of the finances, what choices we have to my experience, people understand, people have time for being honest and in the main, appreciate the work we do within the tightening constraints

So, times a changing...we need realism..we need to understand the finances aren't stacking up and all we can do is to collectively raise the voices loud enough for the politicians to listen. Till then, we must and I stress, must, work collectively. We must look at efforts of new working with positivity but also be a friendly critic. Let's not shun the ones who are trying the Vanguards but let's try to be constructive..we are all trying to do this for the let's try..while at the same time, keep the open dialogue with the patients about challenges we face. If our politicians can't say due to whatever reason the problems the system faces, the. It becomes our role to do so. Yes, we have much to learn from patients but at the same time, it's a 2 way street and opening channels gives us the opportunity to share with all our issues too.

Times a changing..approach it with a degree of optimism, shall we? Cos without that, what else do we have left?

Tuesday, March 10, 2015

NHS Change Day...the good, bad and...

Be have started reading the blog with a degree of intrigue or trepidation- depending on whether you believe in the principle of NHS Change Day..or not- right? It's not unknown that I am a cynic to a degree though my past blogs have tried taking the route of friendly criticism rather than disdain. So let me ask you to be a bit disappointed- this blog isn't to rabble rouse but an opinion from someone who has been a Consultant for 7 years, someone who works both in acute and  community providers, someone who has traveled the breadth of the country talking about "working differently" a bit of experience of change.

Th debate has raged...why this tag, this label in a climate when Kirkup and Francis exposes the NHS warts and all, why this initiative when whistle-blowers are yet to be given their just due..why even pledge to do things when we should be doing some of those pledges as part of our usual work? It's been fascinating to see both sides of the spectrum as the proponents have said this is exactly what the NHS needs- something to help it heal.

So how has it been over the last 12 months? Let me give you a personal perspective, my experiences, my dealings with NHS Change Day...

The Good:  There has actually been a lot of good. It would be wrong to doubt the commitment of those who have volunteered their time to do this, it inherently comes from a desire to improve things- and that, in my view, should not be sneered at. 
I appreciate I have been provocative but among all the people involved, I know a few, don't know quite a few too- but there burns, unquestionably a desire to improve things. It comes through in blogs, their willingness to engage on twitter and a fierce willingness to stand for the value of the NHS. So yes, there has been good- there has been a collective of the willing to "make it happen".As eloquently as ever, Damian makes his point- and indeed is a good one, a balanced one. It gives you, perhaps an insight into what NHS Change Day should be- a force for good, maybe not to the taste of all- but most certainly an ally for all of us who want to improve care- albeit in our own way

The Bad: However, as ever, every initiative will have its drawbacks- and the biggest one - which has been picked up, time and again, has been the "with us or against us" view- shown up on twitter or otherwise. 
It is getting better but efforts to engage or question has met with varying degrees of defensiveness or surliness. Recently when I asked "convince me" one of the answers was "why do you think we need to convince you?"...well, for starters, I am a Consultant in the NHS who is trying darned hard to improve diabetes care- so do, please try. 
It made me smile but that is exactly what has switched off a lot of folks too. You want to be inclusive, do it properly- not by surly thoughts in 140 characters.  Finally, for this category- a huge play has been made of volunteering- the NHS is surviving on good will and volunteering-it has been ever thus- and will ever be.Someone on twitter said.."we all find time, so should you"...a retort to that would be simply juvenile

The Ugly:  Actually there is no "Ugly"- when you have a group of people trying to improve good- there can't be anything "ugly" about it. But there is one thing- its' called the "Hijack". Last year, in my blog, I had mentioned the importance of the original founders holding on to this concept- right now, it's now an NHS IQ project- or at least that's the perception. That makes it all shiny, official, pretty but also laced with words and jargon most people can't understand or switch off to. Some of the biggest workforce in this country or at least the spearheads are Consultants and GPs. How many do you see actively engaged in this? Is it because they don't care, don't have time or simply have had enough of NHS speak jargon which means little-as per their past experience with NHS IQ and the ilk?  Is NHS Change Day now simply a project run by official body which has hijacked anothers concept? Is it alienating people or drawing more to it? That's the question that the organisers need to think about or consider. Do the "hubbies" believe this is their project anymore- or as one of them asked me  not too long ago- "should I stay with it anymore-as it feels like being taken over"?

In the world of twitter, NHS Change Day is a big thing- in the real world, it perhaps isn't. I have done a snapshot of 50 staff recently- inclusive of medical students, Consultants, nurses (senior and junior), number of folks who had even heard of it? 3. Twitter is NOT  a reflection of the broader world- if it were, the HSCA would have been repealed, the Liverpool Care Pathway would have stayed, the NHA party would have been in Downing Street and oh yes, Madonna would have retired. Mutual backslapping or tweet chats may convince yourselves, not the broader world you need to convince

So, pause, think and see how you can take things forward. Try this simple example. Where you work- can you, hand on heart, stand up and raise patient safety concerns without concern of reprisal? Are all the modalities of safety for patients covered? If not, charity begins at home. Hold fire on changing the whole NHS. Just change 1 thing where you work- let that be openness regards patient safety. 

The day you can do that, you can call that day NHS Change Day. Till the day we can prevent the James Titcombe's from losing their loved ones, a clever tag will remain only that. So feedback from a Consultant? A good project which has legs but needs to be more inclusive, a bit less jargon-fuelled and perhaps even less centrally driven by a national body- try that and you may, just, win some of the doubters over.Doing good doesn't have to be done in any one particular way but it wouldn't be a bad idea for all those forces to at least have a loose alliance - the endgame seems to be the same- would make sense to do it together. 

Friday, March 6, 2015

The reality of leadership

Leadership is always a tricky one. Debate about what it actually means always is interesting as it brings out a range of views- starting from "its all about values" to "its a natural skill not all have". Then you get into the areas of discussion such as "we are all leaders in our own ways" and suddenly it becomes a cosmic discussion while at the same time, review after review tells you the NHS lacks leadership, especially of the clinical type.
Sometimes we confuse the term leadership with charisma and thereby it becomes even more a leader about whether they have delivered outcomes or is it just the inspire factor? Is Obama a leader or just a charismatic speaker? Views differ...and we never quite get anywhere.

For the cricket  affectionado, think of Stephen of the acclaimed leaders in the world of cricket. To some, he was lucky to be in charge of some of the greatest players in 1 team..whats so tough about leading that sort of team to victory? To others, he brought together a disparate group of brilliant individuals and forged a team, one of the greatest ever. To others, he simply bullied other teams, used every tactic in the simply achieve one goal...a win. To many more, he was n incredibly kind hearted man who did some amazing work for children with leprosy in Calcutta...little kids for whom he was just Steve-da, an affectionate term for brother in local lingo.A leader? A bully? A philanthropist? A legend? All about perspective, isn't it?

So what about the NHS? Firstly, what makes a great leader? Someone who has forged a great team spirit but not delivered patient based outcomes? Someone who has happy staff, happy patients but not much in way of delivery? Someone who has developed amazing services for patients but not bothered much about keeping others happy? Some would say we need all of that...but history has taught us time and again that not to be true, not to be rarely possible. I see many leaders quote Gandhi at the drop of a hat. History will tell you he was perhaps the biggest rebel for many Indians but one of the biggest troublemakers for British Raj. One man's freedom fighter is always another mans terrorist. Leader for some, troublemaker for another. All about your perspective....the debate continues.

The question is always why so many clinicians stay away from leadership roles. Well...what would attract someone to it? In general, for right or wrong, there's a few factors, either in isolation or combined which draws an NHS Consultant towards these roles. They are...Glory, Power, Altruism, money. I appreciate we would all like to believe that altruism should drive us all but it ignores the reality of life. Money isn't much of a driver for many firstly because the financial reward is pretty average for leadership roles to start with- not to mention it's not really a huge issue for folks who are in the top 4% of the country as regards salaries go. As ever, there are exceptions, but financial reward is hardly a draw.

What about power and glory? A huge draw for many and whether we like it or not, the NHS is awash with folks like that. Let me be crystal clear..that doesn't diminish what they can offer, their passion is worth emulating and there are examples of great care driven by individuals such as that- but for them, glory, either self or the department has been a major driver. I will be honest, time may have tempered my desire but I started my leadership journey because I wanted to put Portsmouth on the map of diabetes care, make it one of the best.
Time teaches you the biggest currency isn't the title you hold, but the influence you carry but hands up, that has been my personal driver. Which brings us to altruism- there will always be people for whom that carries a significant part...the problem with that is the sustainability and also the ability to balance your personal life. The NHS is astounding in its ability to ask those who do a bit do a bit more more time for the patients. Every one of us has a limit..everyone of us has a life..altruism only goes so one point, the rubber band stretches, it snaps..and in 1 fell swoop, you lose the power of altruism as well as that individual.

The problem as always is of the NHS a being awash with leaders without track records..good speakers, good motivators but a bit thin on the ground as regards delivery. We spend too much time describing a shiny world, spreading the goodness of optimism but it needs balance. It needs realism, stories of leaders failing, stories of how the first hurdle was the toughest one, how adversity is a part of life in the NHS and how lack of resources are impeding progress. Did I hear someone say "Resilience"? More different words crop up but we need to be more realistic about what we are asking our optimism filled, leadership cadets to do. Otherwise in the real world, disenchantment sets in quick and you lose even the ones who have been inspired by your slides on a pretty PowerPoint.

The million dollar question is whether all the leadership bodies can walk away from a mutual session of backslapping after an annual session or Twitter chat..feel that's enough to justify their existence or whether a new ring of leaders will come through armed with the knowledge of what both success and failure looks like. The NHS needs clinical leaders...and it's running out of volunteers pretty fast.  An edge could be a cutting edge of the new could also lead to the face of a cliff. Leadership is rewarding, can be fun..but it's tough and spiked with failures too

Temper the optimism with realism...and then the future looks a bit..better.

Next week: NHS Change Day...progress or another year of banality? A personal view..