Wednesday, December 17, 2014

GPs...the Hail Mary pass ? Part 2

It's been fascinating having the last blog published...the reaction was as expected- a smattering of "no facts" ; "not wise for an endocrine doctor to comment"; "rhetoric" - and indeed it came from expected quarters. What however was pleasantly surprising was the positive vibes too from GP colleagues and even better were the the suggestions. I kept ribbing about people stealing my ideas for the part 2..but weren't they just fantastic ones? Wasn't it nice to see some sensible suggestions- all from GPS- suggestions which were beyond the rhetoric of "more GPs"; a display of obvious pride at the job GPs do...THAT'S what I was looking for and you know what- the NHS has indeed a future with passionate folks like that in the fray.

Let's cut to the chase- we can tango around the perennial debate whether GPs are independent private businessmen/women or not. To be honest, its immaterial- without blowing smoke up anyone else, 5 years and more of working in the community has taught me one thing- without GPs, the NHS doesn't exist. pretty simple as that. If this was a game of american football, most external folks would be perplexed at the effort the system has put to make sure the quarterback was tired and incapable of making the pass the rest of the team needs. Know what a Hail Mary pass is? Look it up...the quarterbacks are now reduced to that- and guess what, the team is losing and with it, so is the rest of the morale.

So let's get some radical thinking going. Stop thinking that only more GPs will solve it- it won't. Not to mention they are actually not out there...but more of that later. Broaden your horizon and thinking ladies and gentlemen. The RCGP and RCP have now come out with a joint statement how organisational boundaries shouldn't be a barrier to patient care- so why not start actually employing Specialists under yourselves? I hear you say where's the money- well, take some time to understand the fallacy of Payment By Results. It is a system which works well for surgical procedures but has crippled us all, Commissioners included, where Medicine or specifically long term conditions are concerned.

Like him or not, Stevens 5 year Forward View is here to stay- and irrespective of elections, is pretty much the direction of travel. Look at pages 16-20 of the PDF document- is your answer there? Can GP surgeries - if you don't like the word federation- then at least buddy up together and come up with a plan to run a long term condition? Can you show that you can employ nurses, specialists to own the whole process? I am sure I will be called naive- let me counter that by saying that most GPs don't have much idea either about Consultant contracts, Payment by results..look, ask and you shall find. By the way, read a bit beyond on that report, there is another model there too...check that out..and think whether that maybe suitable too...views on that welcome indeed!

I will give you an example- as part of our diabetes work, as a team, we go to each surgery twice a  year at the surgeries discretion. The mantra is very simple. "I" am "YOUR" employee for 3-4 hours or however long you want me  in your surgery. YOU use my skills to improve care of patients under YOUR care- as simple as that. That could be done by education sessions, chatting, seeing patients with you, audits- the call is YOURS. YOU are the quarterback- you tell me which channel to run in. I have a skill set YOU need to use for your own patients- can't be that difficult, can it?

At the moment, most GPs can't even look up beyond their daily work to think broad- I get it. But trust me, there are many like me who want to help, want to keep the NHS afloat as there is a simple realisation- given the efficiency to which GPs run, without them in the pack, you can kiss "free at the point of delivery" goodbye. Love the NHS and its ethos a lot? Then broaden your let's face it...there is no cavalry coming right now. Maybe it will- but it's going to take at least 3-4 you have the time for that? We are losing GPs NOW...when and if the cavalry arrives, what will they be left with?

I could go on and on and am sure will still be criticised for "not getting it". Maybe I don't, maybe I am too naive- but I work with GPs everyday- and I see folks every day who genuinely want to help. The future maybe different..and more on that in the next part...but for now, you need a plan pretty sharpish. Heck, you guys have been throwing plenty of Hail Mary passes...try this one out...a lot of professionals- inclusive of specialists, pharmacists, nurses are ready to make that run. The billion dollar question you trust us?

Saturday, December 13, 2014

General Practice..beyond the anger? Part 1

GPs are least on social media they are.Look at twitter or any social media for that matter, apart from anything else, any suggestions to even do something, have a debate about anything different descends pretty much within 3-4 minutes to total a pack, you get absolutely overwhelmed by someone "out of touch", someone "who misses the point", someone being "protective about their patch"...140 characters condenses strong emotions into what appears to be rude, recalcitrant and disengaged. But hey, its always worth a discussion because lets be honest, its not working, is it? The dangled carrot of more GPs seems more like hunting for the El Dorado gold- while the reality on the ground is that most trainees are not picking this specialty, many do NOT want to be partners...a reality check is always important and no, you can't force anyone to be a GP.

It must be said however that there is a difference with people I meet day in, day out though. I interact with GPs every day- all across 80 surgeries or more- and rarely if ever I see angry folks. In the main, they are pleasant, keen to help- yes, tired, brow beaten, aware of increased pressures but importantly very appreciative that they aren't the only ones. The british sense of humour is ever present- and I do enjoy a lot my time spent with them...maybe twitter is skewed. The issue however is that this isn't a complete rarity. The system now has ground all into such a corner that now you have what one could describe as trench mentality. Yes, I am a Consultant in Diabetes but I have been fortunate enough to hold different roles in community beyond diabetes, within hospitals in unscheduled care to understand that there are many-, many others who are as busy as anyone else. District Nurses, Community nurses, ED doctors, MAU their feet, busy, horrendously busy, tired faces- and if I am being brutally honest? As I have said before, yes GPs are busy but so are plenty others- its not a monopoly on the level of busy-ness neither is there a prize or competition out there to win. The system is squeezed, money is short, politics is huge- we are ALL under pressure.
There are 2 views at looking at this- and let me make this clear- these are views from GP colleagues themselves- NOT from ivory towered specialists or managers or anyone who has no experience of General Practice. View A is that people are well paid on a public tax funded structure, amongst the top 5-10% of the whole population, armed with a pension scheme which is gilt edged and now that the pressure is on, there are too many complaints. Be grateful for what you have, do the hard yard, earn your pennies and retire happily. Do the job you trained to do- and accept public srutiny is more- and get on with it. View B is its all too much- work has descended on GPs without agreement, without resources, public expectation has been fuelled and its time to take a stand and say "Enough". Time to stop doing X, Y and Z.

My view? Either views are too entrenched. I will be perfectly honest- if you want more people to join GP land while at the same time, you consistently say its too much- you forget the basic psychology of the generation we live in. This is no longer the Baby-Boomers or Generation X who would grit their teeth and do it in times of pressure- the next generation is a mixture of Generation Y and Generation "Me". We can critiicise that as much as we want but for that generation, work life balance is extremely important. I know lot of people turn their nose up at it- but I never ever fault anyone for that. THAT'S the world we live in- THAT'S what we have to work with- so if you want to attract more to a specialty- you must balance out your views- YES absolutely make it clear its hard, tough- but also show how amazing GP life can be- how rewarding it can be- how much work life balanace there can be...its can't be all bad, can it? Your present angst at the system shouldn't result in the future being bust, should it? And let's be honest, if GP surgeries collapse, thats pretty much the end of our beloved "free for all" NHS.

So...apart from the nebulous Narnia-esque idea of "more GPs" there actually any solution to the crisis looming? The future path for the NHS has been outlined in the Stevens report...does any of the clues lie there? More importantly, is there an appetite for this amongst GPs? Can they genuinely be in charge and think beyond their individual surgeries? In my next blog, I will throw open some questions ...

Finally,those who feel strongly against any of the thoughts above or in next blog, my appeal..have a proper debate, not a condensed angry one in 140 characters...but let me be perfectly honest, more GPs isn't going to solve the NHS conundrum- and will only act as yet another finger in the dyke.

Tuesday, December 2, 2014

Walk on the Wild Side #WoWs

There's one thing that should be made mandatory in the NHS nowadays. A week doing another persons job. At every level. Especially when they have a opinion about how other people should work. The NHS is rampant with leaders now and the problem with that is that somehow it installs in these folks an ingrained thought process as to how another specialty or another profession should run.
To be honest, I have no issues with that IF there is experience of working with that team, shadowing the team, trying to understand the team, the pressures...but nope, there is indeed little of that. Forget about doctors giving advise to nurses how to run wards (and heck, there's plenty of that) but it's between doctors themselves. And if I am brutally honest, I have gone down that road too in the past. Flush with a new title and the love of being given a management role, I have advised others how to do their job- without getting to grips first as to how their daily lives are.

But it pains me no end to see everyday, everybody having an opinion about something they have no experience on.  Overheard this conversation at a national meeting..a respiratory colleague says that if the cardiologists did less private work, they would find time to do general medicine. How does he/ she know that? Has he/she seen their job plans? No of course not. But surely the prototype of a cardiologist swanning off to do private work was correct,right? Well not really, as it turns out some of the interventional cardiologists do a 1:4 back breaking rota, up most of the night. When another pointed this out gently, response was illegible but they swiftly moved on to how lazy the other physicians were. Dude...just do your own work, ok? See how you can help your own department or heck, here's a suggestion, go and shadow your cardiology colleague for a week. Why assume there is no greater dedicated soul than yourselves?

The trend continues...the culture of ward rounds reinforces that...the sneering comment from the Consultant about one of their fellow specialists or a disparaging remark about a GP..still far too common place. juniors walk away inculcated in the tribe mentality...the machismo of one specialty trying to out-testosterone another. And it happens everywhere...GPs are as much to blame with the old stereotype jokes of Consultants and their fancy cars, the golf wonder why we are a divided group of folks...heck we have no respect of each other, let alone anyone else. What chance does a nurse or a manager stand?

So here's a suggestion to all the leadership quangoes...try and see whether the best experience possible for doctors is to shadow each other's colleagues. Ideally we want them to do the same with nurses and managers so they appreciate their pressures too...but let's not make that big a leap of faith. Trying to get doctors to change their ways is notoriously difficult so let's try something simple...a GP shadowing a Consultant and vice versa, A cardiologist shadowing a Diabetologist, a vascular surgeon shadowing an orthopaedic one...maybe and just maybe we may all develop a little bit more respect for each other, understand that there are patients out there who exist beyond your own specialty and need the expertise of your colleague too. Once we learn to respect and value each other's work..perhaps on the off chance, we could extend that learning and understanding to nurse colleagues, pharmacists, managers, finance folks...all of whom we have a disparaging and disrespectful comment for..of course, it's only banter,isn't it?

Go and develop that..heck..even make up a hashtag for that..seems to work for most about #Walkonthewildside or #Wows. Go on, you can have it for free. 

Saturday, November 22, 2014

Step Up. Or Step Down

I sat in the room- and looked around while sipping on my umpteenth coffee for the day. I was surrounded by folks I had trained with, passionate individuals who were Diabetes Consultants all around the country- and the frustration was palpable. This wasn't a meeting of folks who weren't interested, disenfranchised..those who has refused to come out of their "ivory towers"...those who simply sat in committees and nodded were folks from whom the energy and passion to improve diabetes care- simply put- burst through in abundance.All keen and ready with ideas, thoughts- willing to work within, with- whatever was needed to do- primary care colleagues to improve care locally- and simply blocked and frustrated by progress.

During the day, we had some great discussions, thoughts exchanged, speakers who represented acute trusts, CCGs...and finally near the end of the day, one of the speakers hit the nail bang on the head. "You need to raise your identity within the Trust"...and there it simple as that.

I have commented earlier on the evangelist few GPs who speak for no one and have caused more harm to diabetes care than anyone else. There is no getting past trumpeting that diabetes can be done in the community by primary care ("and no, we don't need specialists")- swaths of patients moved out- without much support from specialist teams- and now we are all suffering- most importantly- patients with diabetes simply sue to the sheer volume as well as variability in diabetes care provided. But as regards specialist teams, the damage to them has been done by their own leaders who appeared toothless in the face of the changing world, struggling to justify their existence and consequently sacrificing the identity of diabetes teams within Trusts. As soon as that was done, their role,as deemed by their own medical colleagues became to be to do jobs no one else wanted. They got tied into Acute Medicine, General Medicine- anything really while politics played its part, other medical specialities explained to powers that be how amazing their own speciality was...diabetes got sidelined- and a combination of lack of cojones, leadership, timid personality and an element of self protection- all combined to turn diabetes teams into "teams which did what others didn't".

The irony of that is telling now...when the opportunity has arisen, when the community is actually opening its doors, when CCGs are perhaps looking at models of care, when even Simon Stevens is talking about working in the community....the diabetes teams have nowhere to simply its the fundamental question...if you don't do "what others don't want"...who the heck does it?

To be honest, I actually sympathise with every acute trust with that dilemma. It isnt their fault that diabetes leaders were and continue to be rudderless- without any direction to what a specialist should do within an acute trust. It isn't their issue that diabetes teams have indeed opted to do other work afraid of commiting into the community- and it isn't their fault either that most are starting to see the light- yet perhaps too late. Every acute Trust would of course love to see their own Consultants improve care in the community but their dilemma is simple- they need to look after the patients within the Trust too.
I don't blame other specialities either- they are doing what anyone else would. I don't think its with any dastardly preconceived plan to screw diabetes teams- but simply using the opportunity to showcase their knowledge and show how they could improve care - the cardiology example shows the benefits of focussing on speciality. That's life, that's politics- that opportunity was taken- its the fault of us as a diabetes community that we sat back- so its really difficult to now wringing ones hands when our leaders have failed so badly- not just their colleagues- but also the very patients they are supposed to serve.

The team was recently commended by a judging panel- comprising of the RCP- in the acute sector innovation in the HSJ Awards. There was a specific reason why I went for that- it wasn't the lure of "yet another" but making the point that a diabetes team could show innovation within the acute sector- without simply doing what "others didn't like". It's telling to see us as the only diabetes team within the acute sector tells its own story, doesn't it?

So to all those leaders of the diabetes Consultants, here's an open tip...stop wringing your hands, showcase to acute Trusts and CCGs what a specialist can offer within a Trust and the wider community. Show in the brave world of Accountable Care Organisations, Primary and Acute Care System, the diabetes specialists has an immense role to play...maybe even suggest who would do the jobs outside diabetes care that present folks do within trusts, so Trusts aren't compromised either. Free the diabetes specialists to work with primary care, create the PACS- enhance the reputation of Trusts further..the opportunities are endless.

If you can't, then stop organising conferences, meaningless meetings, producing documents of worthless value. Suggest you save the polar bears and step down. There's a reason why there isn't a flood of trainees opting for this speciality...they don't even know what kind of jobs they will have to do in the future. If you can't even justify your own existence, there's little hope for you explaining the role of a specialist- let alone improve patient care.

Go to work on Monday...maybe even ignore the next CEA round- look in the mirror and have a think whether you are doing justice to the role of being a national leader in diabetes. The options are indeed very simple. Step Up. Or Step Down.

Saturday, November 15, 2014

Contract games part 2: Think..TEAM

It always makes me bemused when we talk about yet another contract. We fail to actually monitor, adhere to, understand the present contract so to suggest yet another modification will solve it all is steeped in naivety. Most managers I have encountered have not actually gone through a gruelling course or understanding of the Consultant contract -which isn't their fault- so to expect them to monitor and hold people to account is also a bit simplistic, if not fool hardy. The Consultant contract is fundamentally different from say a GP contract or a nurse contract- so to use the same tools to dive efficiency- if that's the new buzzword - not to surprisingly doesn't work

So to some suggestions- not too radical- and indeed have been tried in some places with good effect- whilst also keeping morale high. But it involves help from both sides- not just managers but also Consultants themselves- the billion dollar question,as ever, is are they?

1. Annualise departmental job plans: 

Put all PAs in one pot- maybe tricky in bigger department but not impossible. As a manager, explain to the team that the Trust is paying for X sessions and thus its only fair to monitor whether X are being delivered or not. Give the onus on the department- we talk about working in teams- well then, give the department the ethos of a team. It's THEIR responsibility to deliver- as a group- let them sit as adults and come up with plans- let them sort their team annual leave, study leave out and outline the sessions they will be doing.
As a manager, don't just rock up and say "Its short guv"- give heads up- send the departmental lead quarterly updates where things sit with sessions- a pat on the back if on track- again- to check internally if short- why short, is there a busy month coming up which will cover the shortfall or is it someone within the team not pulling their weight? Let the team sort it out. At the end of the year, its the team which will be responsible for the outcome to the question- "Have you delivered the sessions the Trust has paid you for?" Together you rise, together you fall

2. SPA time- as a team:

Again, SPA is not some mythical beast. If teams are saying they have, lets say, 12 trainees to supervise- no problem- of course check with the postgraduate lead- as to whether they are indeed the supervisors- and have a system of checking even with the trainees whether they are actually being given the supervision? What's the point in having SPA allocated to your time and then not having time for the trainees if most of the time is in DCC? May as well be open about it- again- let the team choose which members of the team are better suited to deliver training, research...I have been involved with education long enough to know many are not interested in teaching or why allocate that in their SPA?

3. Outcomes- as a team:

There;s little in job plans to measure outcomes- why not? To suggestion 1...there is little point in doing all your sessions if the outcomes suggest that you are not benefiting patients- who would I rather have as a doctor- a surgeon who does 5 cases in 3 hours but with a higher mortality than someone who does 3 cases but lower one? If its the same case mix, then its the second one for sure. Think broadly- again- let the department be asked what THEY would like to be monitored on- a team effort- and once they agree- that indeed is the monitoring- why indeed not?

4. Transparency of job plans:

Finally, make all job plans, outcomes agreed- sessions being done transparent. At the moment, hospitals are filled with folks who think they work the hardest and by default everyone else is lazy or at least less busy than them. Its like there's an award for being most miserable, downbeat, looking tired...if you smile and say "it's not too bad"...the immediate thought from the other party is "lazy so and so.lets look at their job plans". Let's make it transparent...just because you work in emergency department doesn't make you less busy than if you work in an Endoscopy suite or Rheumatology make job plans open- let the miserable ones review it and come to a more open conclusion- stop the sniping, make teams expand from just departments to have a more divisional feel

Its about treating adults as adults. Discuss, negotiate with them what THEY believe their outcomes should be, don't foist on them. Discuss with them why they can't work as a team- use job plans to create the ethos of camaraderie- get THEM to rise above departmental disputes. Learn from sports- disparate characters get together to make a winning team- Consultants are no different. But once THEY have agreed to be monitored on X, Y and Z, then give managers the tools and understanding to have regular meetings to discuss them.

We in the NHS have a phenomenal capacity to over complicate things and then to change something which we couldn't implement in the first place. It's not really that complicated- it needs strength, tenacity, determination and a strong feeling of mutual respect.

That, I am afraid, isn't something that we have in huge measures in the NHS- sadly we seem to spend more time thinking of new fancy terms to resurrect old power point presentations. This isn't the time for packaging old wine in new bottles- we need a new brewery.

Saturday, November 8, 2014

Contract Games part 1: The battle

So it's now a Mexican stand off. The senior and junior doctor negotiations have broken down- both parties have walked away. Both parties have accused each other- and its played out publicly - sometimes a bit undignified, sometimes like a school playground- I suppose depends on who you follow on social media. I have been a clinical manager now for nearly 5 and a half years- and I have always particularly taken interest in job planning- which is why the debate fascinates and intrigues me.

On one hand, you will hear the frustration of managers about the inability to pierce through job plans, the multitude of national body recommendations as regards job plans which doesn't always help with delivery of Trust needs while Consultants will also turn and say that if they were held strictly to their job plans, and they decided to walk away when the clock struck "X". the NHS would collapse. The reality is that both sides actually have a point. Did I hear some say "how dare you- have YOU any idea how hard I work?"...well..calm down and read on.

The present Consultant contract is actually a simple one.The last changes moved to a sessional based contract divided into Direct clinical Care along with Supporting Professional Activities. The national contract was that in a 10 session job, 2.5 were recommended and agreed to be SPA. Fact is most trusts or new appointments breach that and as the College advisor asked to review job plans- thats pretty much a standard answer I give to all- the SPA isn't enough as per national contract requirements. Don't quote me on this but as I understand Foundation Trusts are under no obligation to heed that recommendation. Happy to stand corrected by Human Resources teams! Anyway, so this SPA- most managers don't quite like- reason? Well- it actually if rarely generates much revenue for the Trust or helps to deliver clinical care. The flip of that is incorporates time needed for teaching, education, revalidation, audits, clinical governance..all those things which don't get you revenue (No sir, that's not on PbR) but actually means a lot for patient care.

This is where it all gets a bit complicated. Educational bodies recommend that job plans should have 0.25 PA per trainee- 1 hours / week- sounds amazing for the trainee. So if you hold that to the tee- and then factor in the College recommendation as regards time for revalidation (you need that to be a safe doctor) then all you need is 4 trainees to supervise, revalidation time and boom, your SPA is over. What actually happens? The Consultant tries to squeeze in the other relevant bits such as audit, governance in there- the time for training squeezes, juniors feel left out, training standards drop- and the cycle is complete.

What about the Direct Clinical care? Again, areas of greyness- job plans suggest you start clinic at 9- finish at 1230- have 30 minutes for patient letters etc- there you go, 4 hours done- go home. Reality? Ask around- pretty different...don't get me wrong- there are indeed individuals who take the proverbial BUT that's due to poor management or supervision by the clinical managers. A few bad apples don't make the whole barrel rotten. The debate or cycle continues. Then there is the desire to standardise- why does Dr X see 10 patients while Dr Y sees 18 in the same time? From a managerial point of view- why cant both X and Y see 14? Simple really- thats because they run different clinics with patients of different needs. A patient with pituitary pathology will take anything between 15-20 minutes while a patient on an insulin pump may require 30 minutes- 45 minutes. Standardise that...and you fail both groups of patients.

Finally, the area of debate- "normal working hours" as per standard contract is 7 am to 7 pm- the latest contract round wants to make "normal" till 10 pm. An area of amazing greyness mixed with a whole load of politics. Rather than having a proper discussion, most centres around "If you don't agree to this, then you are not patient centred". Lots of folks who actually dish out that advise don't work 7 days themselves but couch themselves in leadership garbs and showcase themselves as inspiring individuals.Always easy to lecture when you don't do it yourself, isnt it? It's a bit like me suggesting Messi should have curved the ball around the wall, rather than going over the top...
Some Consultants also join the camp..check them out- either their kids have grown up and moved out or they don't have much of a family to go to. A few people's evangelism shouldn't burn the dedication of many.I hear plenty say- it is amazing to have a Monday off instead of Sunday- yes perhaps so- but you know what- at that time, my kids are at school- and I want time with them- not be twiddling my thumb on my own at home. Tricky isn't it? Took this job to help, not be a martyr.

It makes me smile when I see lots of folks quote Gandhi- how he dedicated his life to making India free...can I suggest you check his life story too? There are reams written on his lack of family life, his destroyed relations with his children. History has an odd way of suppressing the faults of those we believe so much in- read a bit more- you will find plenty of interest. Let me be honest- I don't want to be like Gandhi- I would just like to be Partha Kar- with my flaws- trying the best I can do at work- and then going home, enjoying my life with friends and family.

However, there is actually a way around all this as regards contracts- or at least in my opinion. It involves both sides - clinicians and HR/managers working together, being adults and open about solutions, a bit of give and take on both sides... the question is are both sides actually ready for that?

(To be Continued in Part 2)

Friday, October 31, 2014

From the heart..Thank You

Pride is good, isn't it? When you get something right, you have to be proud, isn't it? Today when I see our local model of care being recognised either by Diabetes UK or the Kings Fund, I don't make any bones about how proud it makes me. No one- and I repeat- no one has seen the long evenings, the extended negotiations, the charm offensive, the time with the family sacrificed to do only with one thing in mind...the model of care needs to change..patients deserve better, much better.
Yes, the NHS is cash strapped, yes, we belong in silos, yes, we all like to believe we are doing a fantastic job and yes, we baulk at the thought that the NHS may not be delivering great care sometimes...but there are many and many folks out there crying out for better care. And I have my own inimitable style..tried to change years of working, years of obstinence, lack of mutual respect between primary and specialst care..and 4 years later? Excuse me for taking a moment to look back..and say " We got there...ladies and gentlemen, we got there".

This blog isn't about explaining the model - there are now enough literature on it- it works on 2 simple principles...Firstly, diabetes care sits in primary care- so support them, help them- on THEIR terms, not ours. Secondly, the changing role of a specialist...moving away from just being a specialist to being also a support, a friend in need, a helping hand and an a realisation that for primary care diabetes is only a fraction of what they support, help...don't criticise, there when needed. Honestly,its not that complicated- never was. No this blog today is about taking off the veneer of arrogance and saying thank you...saying ladies and gentlemen..without you, it simply wouldn't have happened. I have been the public face of it, the spokesperson, the person to showcase it..little else..the credit for this belongs to many others.

Firstly my amazing colleagues..for years my Consultants...then folks who believed in my vision, never unhappy with me taking the spotlight, allowing me to show boat, drive the changes and keeping implicit faith. Darryl, Mike and Iain..its has and is been nothing but a colleagues, my mates, folks I intrinsically trust with anything...gentlemen..thank you.
Then what about our nurses? What can I say...I can't repeat myself enough..they ARE the lynchpins of what we do...amazing women who do a job I can only stand back and admire...ladies, a group hug from all have been just simply who have shown it can be done.
I must acknowledge my primary care colleagues who have received us with open arms- across 83 GP surgeries. everyday has been a learning experience..simply being stunned by the workload...and silently making a note the care being provided. Thank you has and is fun...great to work with you indeed  :-)

At this point, I must say I tire of the managerial bashing I continuously hear. Let me make this crystal clear..without some good managers to work with me, none of this would have happened. Firstly Melissa Way, then Sarah Malcolm..if you want to ever know why we need managers, go and see what they have done for us. Local CCG leads have been great...people always ask how we have done what we have..well..without such forward thinking ones like Jim Hogan, Andy Douglas, Paul Howden et al, would have stayed confined to a powerpoint presentation - for sure

Finally, our patients...I have observed, learnt, taken feedback, accepted the challenges thrown and been my driver to implement what we have done. We haven't solved everything but are always open to being challenged, always open to change and improving things further. The above may indeed read like an Oscar acceptance speech but I don't know of any other forum to thank you so many who have made all this come true.

Ladies and gentlemen, genuinely, from the heart...for once taking off the aura of arrogance, letting the ego rest for a bit...just wanted to say thank you to all. I wouldn't have even dreamt of getting where we are when I started my job in 2008..and wouldn't have without you all. Partha thank you. From the heart. xx