Great Expectations

There comes a point when it will have to be said. Duck it as much as you want, avoid the issue as much as you want, try and twist the media as much as you like, there will come a point when some one has to put their hand up and dash the great expectations of the public. The great expectation that as things stand the NHS will continue to provide everything and more; the great expectation that errors will cease, the expectation that communities will be equipped to keep people at home away from the cold corridors of emergency departments, the expectations that GPs can do more, junior doctors can work harder, specialists will do more...at one point, someone will have to let the cat out of the bag. That there is no more money to give everything to everybody at the highest quality possible.
And it doesn't matter how many conferences you attend about "working together"; how many meetings you be a part of exhorting the "servant-leadership model", how many flyers you read about integration of health and social care. At the end of it all, any economist worth their salt will tell you this..unless there is more investment, it simply, is not do-able any more.

The latest drive within hospitals? 7 day service. Any dispute it needs to be done? None whatsover. Skeleton staff over weekends compared to weekdays have been known to harm patient care. So have no doubt that 7 day cover is a must. But we have forgotten one simple fact...how does one move to 7 day service when even the 5 day service isn't sometimes good enough? We want Consultant reviews over 7 days a week...but a great idea only when they do so 5 days a week. Many a places this doesn't happen- either because they are busy with their other scheduled work or are doing something not quite within their job plans. their respective managers know that to move to a 5 day service review, something will have to give, something will have to stop. We decide not to...ergo we can't do 5 day cover in a uniform basis...but we are having conferences on 7 day cover. We are looking at workforce implications...we are talking loudly as to how we are about to universally embrace 7 day working...but no one has any answer whether it will get blocked at the financial stage or does something else stop. A good example? I can do 7 day cover but that would mean me also taking time off to compensate for my week day work..which means cancelling my type 1 diabetes clinic. Something suffers, something gives.

All this while the expectations keep getting fuelled. Politicians of any colour or even commissioners need to be honest, need to be bold to engage with the public to say we have no more money left to pour in. Funding has flat lined ..and yet we keep talking about how we are going to make it happen. The thing with visionaries is that they rarely do the implementation- and the NHS is now in a bind. Nurses have kept on saying they are short on the wards..but its evidently all about working differently, cutting waste or some other speak which sounds clever but increasingly means little to departments and staff who have no other "waste" to cut or cannot work any more differently.

So please- some honest conversations please with the paying public. As a Consultant, I get paid to spend 46 hours per week at my work, my average runs at about 70. And I am not unique either. yes, there are the bad apples but the majority of staff whether they be GP or nurse or specialist are exactly doing that...working far and beyond what the pay package is...trying to bridge that gap, trying a bit harder to meet the great expectations.

A good jockey knows how far to push a horse..at one point, the whip ceases to work..and the race is lost. I am a born optimist and our department fizzles with pride, passion and the desire to make a difference. Not so unfortunately everywhere. Most places have folks over worked, over stretched, resorting to black humour to fend off the tide of media diatribe against the whole profession...and still we don't do much to calm the levels of expectations fuelled. Instead we jump from one bandwagon to another. I am passionate about making a difference to people's lives but let us, please, be realistic. In an era where cost cutting is such a huge drive, in a era where every department has to show examples where they have to meet a Cost Improvement programme target every year...please..lets be realistic, start to have honest conversations about what's achievable and what's not.

I will finish with the words of JFK.." The great enemy of the truth is very often not the lie, deliberate, contrived and dishonest but the myth, persistent, persuasive and unrealistic".

Phase 2

Was just an idea, nothing more..floated by our departmental dietetic colleague, Sue Beaden while we had one of our Type 1 diabetes team meetings about "improving the service". And then it developed...the rest got involved, I did what I do best...the publicity, the showcasing...and as if in a blur, the day arrived. An event where patients could meet with all concerned, the specialist team, the community team, psychologist, podiatrist and in the new NHS the GP commissioner and his team. No lectures but a genuine chance to interact..listen..learn..develop.Sounds like fantasy? Sounds like something those umpteen conferences and leadership course exhort us to do but without any concrete examples? Well, it did actually happen. I am not going to spend time here saying what it was for patients with type 1 diabetes...simply because I don't have type 1 diabetes. If you want to hear their thoughts or even the thoughts of a parent of child with type 1 diabetes, read here and here.

My blog is about one from the professionals point of view. Firstly, as the team lead, you had to stand back and pay respect to the team who had given up a Saturday morning to be there. Voluntarily. Without any remuneration. Coasting, did you say? Some of the sound byte generators needed to be at St James Hospital on the 11th May. So at the risk of repeating myself, it is nothing but a privilege to be allowed to lead such a team. Is there a better job out there? Perhaps. Is there a better team out there? No chance.

Then came the event itself..the feedback received has been excellent...but from my own perspective, it was a pleasure to see Laura stand up and speak. Clearly a source of inspiration for many- an example of what can be done if one wants to. Our team's job as with Laura is the same for everyone with type 1 diabetes.."we are here when you are ready; we are here when you need us". As part of the speed dating exercise I hopped around 7 tables..8 minutes felt so little...but so much was learnt. the need for 24/7 cover prompted by errors in spite of all educational tools thrown at other areas of hospital, the need for supporting primary care better, the need for avoiding reduplication of results, the need for better information exchange with primary care, the need to explain to primary care that Type 1 and Type 2 are different pathologies...this wasn't our national "leaders" telling us, this was patients, for whom we do this job, telling us to make it a bit easier. In between them, there was some glowing feedback about the service, other members of the team..I already knew Iain Cranston was one of the most patient focussed doctors I have ever met..hearing that from one of his patients made it even more concrete. In one word, simply put...humbled.

The event itself could not have been better timed either as events reflected in my last blog emphasises  Lots of kind words, emails and texts have been sent to me, expressing support, some theorising about conspiracy theories, some stating it's time to look after only one person- myself. Which does need clarification...there has been no skulduggery, high end Machiavellian politics, prejudice which has resulted in me losing out.Even if there was, I have no desire to know more either. To suggest so is to demean the person who has got the job. On the day, the better person won. End of story.

Its time to move on and make this the best diabetes service in the business, one based on patient thoughts, ideas and one which shows good outcomes.My flirtation with management outside diabetes is over, and has helped me to focus back on an area which clearly needs much more to be done, locally and nationally. In this new era of the NHS where boundaries are being blurred, if we can develop a service of pride, why be limited to only Portsmouth and Hampshire? Why can't we lead the change and cascade the ideas to everywhere else? Why indeed can't we get to the level of say Bournemouth, Leicester or Sheffield everywhere?

The BMJ Awards night suggested we were one of the top 4 teams in the country both in diabetes and Leadership. I took time to speak to the winners- and what stood out were their outcomes. So the next step is indeed about just that. The patient conference was the first step...this is Phase 2 of my Portsmouth Diabetes team project.

We will, indeed, one day, be the best. With a team like that behind me, there is no way that won't happen. I absolutely promise you that.

Reflection

This blog is personal. More than 25000 reads in total on previous entries but this one was for my own reflection, a time to use the blog for a bit of personal catharsis. An evening when I had come back from work with mixed feelings and as I took a sip from my glass of Talisker swirling around the ice cubes, its was good to pause. And write.

Been Clinical Director, Diabetes for nearly 4 years now, plenty of awards, innovative model in place, appreciation from patients...thought the time was right to make a move to something different. Yes, there were still challenges in diabetes but just felt I could do more for patients within the community and hospital if I went for a bigger role. And relished the idea of taking on a bigger challenge...armed with one motto...if patient care was to be compromised, then no doctor, manager or nurse was big enough or had a reputation fearsome enough who I couldn't take on. But alas, not to be. Maybe the passion was too much, maybe it was the age, maybe I was too outspoken, maybe it was politics, maybe I simply got stitched up (how could I possibly lose out?)...lots of thoughts swirled through my head as the disappointment sank in. 

But to be perfectly honest, I ended up losing out to a top bloke, a respiratory Consultant who breathes patient care at all times, believes in the ethos of general physicians...simply put, very similar to me, just a better candidate on the day. I won't lie...its all very "cool" to say "its fine" or"never wanted it anyway" and keep rocking the banner of nonchalance...but the fact is I was disappointed, bitterly disappointed. Not because I lost out, but because I genuinely wanted to help, make a difference. I remember trudging back to my office with all sorts of reactionary thoughts in my head and within the next few hours, 2 things happened.

To begin with, one of my colleagues who has known me since I was his Registrar and then subsequently his research registrar,came into my room with a cup of coffee. He sat down with me, and he said exactly the things he knew needed to be said. A gentle pat on the shoulder and 10 minutes later, I smiled...and in one flash I was reminded why this department has always been so dear to me. As the news gently spread around the department, one by one, the nurses, HCA, admin staff came in, some armed with black humour, some with a hug...some simply with "their loss, our gain"- and it was just...lovely.They cared- this was my family away from home.

Then I opened my emails and 3 things sprung out. 2 emails- one from Dorset CCG and another from Brighton CCG asking advice about our model of care and another one from a private healthcare company looking for a chance to discuss "options". In one word, opportunities were there...mine to choose and pick from. 

As they say, one door shuts and another one opens. Maybe its a sign- maybe my job within diabetes isn't done- maybe I need to take the department to the next level; maybe I am destined to stay within a chronic disease such as diabetes...maybe in this world of CCGs etc the potential of diabetes care- cutting across boundaries is endless. Either way, not what I had planned or hoped but then again 39 is perhaps just too early to be Chief of Medicine, if ever at all, for me. Its uncharted territory but so it was when I took over as the lead for diabetes. 

Mourinho has always been an idol for me...cocky, self assured, winner, reviled by many, respected by his team...but on the day arguably the greatest manager in the football world retired, perhaps destiny says I am less suited to winning trophies with different clubs...but rather go for multiple awards with one particular one. Time will tell- for now, Dr. Mark Roland, new Chief of Medicine, Respiratory Physician - best of luck with the new challenge. Rest assured, the diabetes department will deliver their side of patient care needed..and more.

Angels Or Demons

I have watched. I have listened. I have read. Many a times over actually. Over the last few months, pretty much all quarters have been taking flak in the media. Cynics would say a concentrated effort to denigrate the profession as a whole and allow privatisation in...countered by the individuals who have lost loved ones in tragedies such as Mid Staffs to say this has been long overdue. Either way, nurses against doctors against managers..even more in depth has been the GPs against GPs..GPs against specialists...a divided profession has struggled to mount any meaningful defence of their livelihood...back in October  I had blogged about  "Civil Wars"...months later, there seems little signs of that abating.

Amongst all that, it has been interesting to see the nurses being put through the mill..suddenly the Florence Nightingale's were being torn apart...bit by bit. The RCN launches a spirited defence...but perhaps their case tainted by what went before with Mid Staffs...and the juggernaut has rolled on..slowly but surely corroding away the good will built up over all those years. Molly Case, in her passionate speech at the recent RCN congress perhaps encapsulated the turmoil nurses are going through..frustrated that all their efforts, day in day out, in the face of adversity, are now being denigrated in the face of either political agenda or perhaps the fault of some colleagues..or even perhaps both.

My interaction with nurses? On a daily basis...on the wards and in the unit in which I work. Different personalities...but everyday I see them there...at work. Nowhere near paid what Consultants or GPs are paid..but nowadays doing a lot of the jobs traditionally the medics used to do. Case in point? Diabetes care. We can beat around the bush as much as we want but within primary care, without practice nurses, diabetes care is dead in the water. GPs neither have the time- and in lots of cases,as per personal experience, even less expertise than their practice nurses. Without them...no generation of QoF, no money..big problem. As part of our work, apart from appreciation of GP workload, one has also learnt to take a bow to what practice nurses do for diabetes care. 

What about hospitals? Well..within our "award winning", "ultra amazing" "forward thinking" diabetes department, the most essential commodity was, is and always will be our nurses. As Clinical Director, I expend a lot of time and energy "justifying" their role to management..why? Because I know if I lose even part of them, this services goose is well and truly cooked. Same for the community work we do...without Jane,Debbie,Ali and Gwen...this pioneering model will,simply put, not work.

Everyday during my travels, I meet nurses...frustrated, shackled by bureaucracy .but still itching to do some good. Every day I meet them and I wonder what we,as doctors, as their colleagues, can do to help. I suggest we try and perhaps stand up for them a bit more. At each individual level, whether it be the ward or your unit, make her or him feel a little bit..special. Let them know how precious they are to your ward, to your unit...I have said this before- and within all the 3 Trusts I work with, know how publicly I declare that the nurses are our linchpin.

My suggestion? Look after them a bit more...as medics, we, like it or not, have the comfort of our salaries to fall back on after all the politics..not to mention how difficult it is for any medic to lose their job. Our nurse colleagues unfortunately have none of those safety nets. We talk a lot about GPs and Specialists working together...and indeed that is very important...but for starters...from tomorrow, just ask your department or surgery nurse, how YOU could help. It maybe something as simple as making them a cup of coffee in the morning...maybe just a chat...but we, at these times, where divide and rule seems to be the mantra of the day, must, absolutely must find some time to stand by them. Not behind them. By them.Give them the freedom and belief to do what they need to do, what they joined this profession to do. 

Believe me, it doesn't take long but the dividends reaped from a happy nursing work force as regards patient care is more than worth its weight in gold. 

Forget the media tags. Neither are they angels, nor are they demons. They are, in the most, individuals who just want to do good for their patient.So go on...give it a try tomorrow or when you are back at work..a few extra minutes for your nurse colleague..

In the words of Arthur Williams.."I am not telling you its going to be easy. I am telling you its going to be worth it".

Just do..something.

Last Wednesday I travelled up to Gateshead. Not to enjoy the scenery but invited by the local CCG to discuss diabetes care. They had read about our local model and wanted to know more…so off I went with my slides which went through our local journey since 2009. The story of negotiations, the story of umpteen meetings, the new changing NHS resulting in changing personnel, need to engage, shake off the image of the Consultant stuck in their “ivory tower”, those long hours away fro the family, the nights of self-doubt gnawing at one’s impenetrable self confidence…nearly 4 years later, the results are starting to trickle in. And so far, so good. Cautious optimism is probably the way to describe it best…the usual cavalier version of Partha Kar would love to say “told you so”..the slowly ageing, a bit more battle hardened version wishes that the leap of faith taken was not in vain. Innovators fail…but the present NHS provides no time for that. No time or even forgiveness for failure.

We did our introductions around the table- and I was fascinated by the mixture of people there…there was the finance person and general manager from Medicine, there was the acute Trust Consultant, there was the CCG lead, the CSU staff, the Commissioning development manager…they were all there….in one room. And what struck me was the sheer will to try and “make the necessary change”. We discussed ideas, I answered all the questions- then someone seemed to have a light bulb moment within the finance team…and looked like something had unlocked. The meeting concluded with a lot of positivity, set times to take things forward and I left passing my best wishes on. The hardest task begins thereafter….trying to convince the vast swath of primary care to work differently, the specialist team to be open to the idea of virtual support, the need to show hard outcomes but it was a start. There was hardly any animosity in the room, yes, the usual banter amongst Trusts and CCGs/CSU…but little malice. These guys wanted to make it work.

It is amazing how far apart that world is from the constant talk of failure, obstinacy and obstruction one hears, whether it be on social media or in conferences. There seems to be an abundance of folks who want to do the right thing, but somehow struggling to do it. Conferences specialise in speakers having sound bytes, policies specialise in stating the blinding obvious…but somehow there is no doing. Somehow everyone wants to wait for the system ot the model to be “perfect”..I say…No…sometimes it takes a leap of faith. Go and do it. Talk less. Just do. Try and use the “N” in the NHS and learn from each other. We somehow need to learn to separate the ideology from the reality. Somehow you get the feel that ideological passion from some quarters wants either everything to work perfectly (didn't we tell you privatisation was good?) or pretty much nothing to work smoothly (told you privatisation was evil). You know what? There are plenty of people who aren't polarised in their views, they occupy the middle ground, look at the ideological rhetoric with a healthy degree of cynicism and just want to do some good for the patient. Just because you want something to work in the “new” NHS doesn't make you an anti socialist, there is also the off chance that person is keen to make it work in spite of the pressure on the system.

So ladies and gentlemen, give it a try. Look after the patient who sits in front of you or in the bed in front of you, look after the staff you work with or for, smile a little bit more- and try and make the best of what you have. It’s going to get tighter but “no chance of improving patient care”? Don’t sell me that line. The British, I was always told had an inner sense of self criticism, stoicism, the black humour element…all of which are in abundance over social media- but I was also brought up being told that they had a spirit to stand up against adversity, any adversity. We have attended enough meetings, heard enough about integration, collaboration, coordination…now is the time to do something. A little less chest beating about how’s its all going to go up in smoke. 

By all means, support the NHA party if you wish, by all means sign up petitions if you wish- but also go find a manager or a GP or a counterpart in your trust- and see what you can do to get patient care just that bit better...over a cup of coffee or even a friendly beer if you wish. Either way, just do something. Why not use the time a bit differently rather than blame the "system"?

To quote Castro “It does not matter how small you are, if you have faith..and action”. So very true.

One chance

Today was the start of something new. Another new project from the Portsmouth Diabetes centre. It was the transition clinic for type 1 diabetes patients from the paediatric side to the adult side....and based on feedback from the patients, we had decided to try something...different. 
Gone were the standard clinic set up, gone were the waiting room waits for the parents and kids....awaiting to be transferred to a new team of doctors and nurses. This was going to be different. The parents came along with their kids and the adult and paediatric teams mingled with them in the waiting room. Polite introductions, baby steps for the new folk into the department..metaphorically letting go of their parents to walk into an unknown area...the adult teams split up, some sat with the parents over a coffee, reassured that they would look after their "little ones", some sat with the young teenagers offering an insight into the new gadgets, use of social media, gave them a welcome pack...and you know what? It was..fun. 

Changing the clinic set up based on what our patients had told us..was fun for us as healthcare professionals..perhaps one of the best days I have had recently at work. There was no politics,no Francis report hanging over ones head, no dispute over mortality data, no chest thumping about privatisation...this..simply..was doing what we were supposed to do..look after people who needed some help with the pathology they hadn't brought upon themselves.Yes, this was diabetes, but it wasn't because they were fat, it wasn't because they didn't look after themselves...this was type 1 diabetes.

And while driving back from work, it made me think what sort of a unique position I find myself in. Its a realisation of how incredibly lucky I am..lucky to be in a position to influence a system which could make, perhaps,not all, but even a few people live their lives a bit better. I grew up in Calcutta, lucky to end up in the UK where people sometimes forget what they have. Work in a rural area of Bengal and you will realise what this country offers. Either way, amongst millions of people, a select few get to be a Consultant in their chosen speciality ..and I did. I am paid well..I have an amazing department, surrounded by amazing colleagues, supportive Commissioners...do I have any right to moan? No, I don't. Why waste time doing that when I can spend time trying to negotiate better care for the patients with the payors or set something up based on patient feedback?

Sometimes people forget the opportunity they are handed in life- and I have been given one. The choices are either to sit back, moan, entertain oneself in the false belief that all was well in the past..or work with the system...as for whatever the reason, patients being in charge of their own disease pathology or care is nothing but a distant mirage. We pay tons of lip service but frankly do little. So..as a Consultant...if I don't stand up and fight the corner, who actually does? People say I am always cavalier...I say show me a department which every single day stands up for their patients. People say I speak too highly of our team...I say show me a bunch of nurses who can better the ones I work with. 

One chance.. that's all life gives you...and who knows what's around the corner? The time to change is now, the time to stand up for ones patient is now...not later. Later may never appear.....and I don't want to turn around in 20 years and say "I should have done better". It's not my place to spend time criticising others services..but you know what, if we all simply tried doing the right thing for the patient where we work...I guarantee you the sum total will be amazing. 

In the words of Roosevelt "Far and away the best prize that life has to offer is the chance to work hard at work worth doing". It just maybe worth giving it a try. Because all you have is just one chance to make it happen. As simple as that.

Perceptions part 1: GPs & OOH

Dabbling in unscheduled care has been fun. So much of a learning curve but one regularly also sprinkled with bemusement as to how entrenched some myths and beliefs are. Thus, going through the history of the NHS over the last 10 years or so, has made for fascinating reading!

One of the enduring beliefs and spoken in sometimes hushed tones, is the impact on unscheduled care  when GPs renegotiated their contracts and pulled out of providing 24/7 care. In ethos such 24/7 activity was a noble one, but in practicality, one which got tested to the limits due to rising demands, expectations and burn out rates. Medicine being a holistic profession is an oft used term, but the reality of a burnt out, fed up doctor is that such a professional perhaps is of reduced use to any patients. So, negotiations took place and for a loss of 6K per year, each GP had the option to withdraw from out of hours care in 2004 ( do correct me if I am factually wrong, folks out there!)

I have two ways to test issues in healthcare..if it related to the patient, it's " what would I do if this was my relative?",while if related to business issues, "what would I do?" This being of the second type, the answer is resoundingly..Yes. Put it this way, I get paid approx 5-6K per year for being on call and if the option to stop being on call OOH or weekends were there, I would consider it too. And that's inspite of my physician on call being far less onerous than, say a surgeon or indeed a GP doing OOH under the previous system. Crucial difference? I am employed by an acute Trust who simply won't even put that on the negotiation table, while GPs, however you view it, were and are individual business units- and one may argue, better negotiators too.

And if one looks at it, then who wouldn't take up the offer? With the day job being stressful enough, for the loss of 6K from an already existing good salary package ( especially for GP partners) the option was to drop out of nights, or indeed weekends. So they did and the money taken from the GPs were to be used by PCTs to develop OOH care...and bang we walked ourselves into a monumental problem.

Problem 1: Gross underestimate of money. From a negotiation point of view, offering to take only 6K was ridiculous apart from the fact that it never estimated accurately the amount of work GPs actually did OOH. Result? GPs walked away from OOH "marvelling" at this negotiation "skills" of the other party while the money now released was woefully inadequate for PCTs to provide decent OOH care, a fact borne out time and again since 2004.

Problem 2: Fragmentation. we lost all form of continuity, multiple providers came into being, multiple options were thrown up, IT systems became fragmented and most alarmingly of all, the patient simply lost all clue trying to understand which avenue to explore OOH when ill.

Problem 3:  Rise of untested methods. telephone lines, virtual methods came into being. Some were successful, some were not, but in short, they were untried and untested and for about 10 years or so, the NHS has continued to experiment. I am a fan of Tele-health but only in the right setting. If you are going to use Tele-health to reduce emergency care,then frankly, that's going to be a losing battle. Example? If you are short of breath due to your asthma, do you want to play with a device or do you want to see someone who can assure you, give you the advice needed etc? On the other hand, would the patient like to use it when reasonably stable to consider tweaking their medications based on an algorithm- which in turn may reduce their chance of admission....now there's a possibility that may work. But as a tool for OOH care? Nope, unlikely to be that useful.

So that's my piece on the oft shared myth that GPs pulling out of OOH care has resulted in collapse of OOH care...it probably has, but there are lots of caveats to it. 

Could the negotiations have been better? Possibly Could the money taken be ring fenced appropriately? Possibly. But we have now arrived where we have. 

Perhaps the silver lining is that hopefully with GPs in power, they will appreciate the lessons of history. The question is whether the family doctor will come back into play if all the fragmented money in play being used on so many providers is put in one pot. my view on that being devolved to acute trusts is known,...but whichever way you cut it, without the family doctor involved, whether it be on an individual basis or as a cooperative, the OOH system won't work. 

We as a system need them back in play and whatever we need to get them to bring them to the table, we should use it.The last 10 years have taught us most other untested systems have not worked to varying degrees. Why not consider bringing back the system which did work, but perhaps with a better recognition of what the work involved? Love them or hate them, GPs are the linchpins of the system. 

Back to the table then,please?