Tuesday, November 24, 2015

Game's afoot

Ring out the bells. Splay the festoons. The NHS has got  4 billion pounds..extra. Well, actually, not quite but let's not worry too much about details. The point is the promised extra money has indeed been front loaded..and cut it any way you want, it's there. Simon Stevens laid out his stall, flexed his muscles and got what he wanted. So in simple language what does it actually mean?

Well for starters, it's definitely welcome. Look at other areas and you have to take a deep breath...cuts galore ..so in that context, rejoice indeed. Now the fun begins though...for starters Stevens authored the 5 year forward view, asked for 8 billion and promised a 22 billion efficiency. He got the 8 billion. Then he wanted it front loaded, he's got it too...Now? It's all down to him...reputation on the line...put all his political capital on the line...high stakes indeed.

The problem? That pesky efficiency drive...hugely dependant on 2 things...pay restraint and new models of working. That pay restraint thing is nit going so well..(have you heard that thing about junior doctors) and the Consultants, for once, are starting to stir. Then you look at the GPs...and heck they are pretty pissed off too.
Those new models of care? Well Sam Jones is in charge of that..and good new concepts too- the problem? Can these go to scale? Will a disgruntled workforce play ball? How DO you get a workforce facing pay restraints/cuts to play ball...tricksy tricky.

To put some maths into it. We should have made about 4 billion efficiency savings by end March 2016...if you follow the 22 billion efficiency savings by 2020 mantra. Well, we are 1.6 billion over spent already...the new boss of NHS improvement suggests we will keep it at that by end March 2016. With winter yet to come, gaps galore in rota...one would like to see a feat even Houdini would be proud of.

So 4 billion buys you breathing space..buys you some time in a gasping environment...a bit like a pocket of oxygen a drowning man finds. The question is what next? A massive. Bit hinges on new ways of working...and with the greatest amount of respect to all our leaders, if you haven't achieved that in times of plenty, how do you do so in times of scarcity? Game on folks...it's time to test those leadership skills...history will be the judge for sure.

Finally, that little bit of Public Health and Health education coming outside the ring fence. As a Diabetologist, you can only wince...let's pay more for swanky coronary care units but not to prevent type 2 diabetes which causes the coronary events? Well then...that will be interesting indeed.

So...4 billion...yes- a massive win for Stevens, a breathing space for the NHS...the rest of the efficiency...I am not going to be negative and say no way...but it is going to be very very tricky. I, as part of NHS Survival, have always advocated an independent NHS funding review. I also accept thre have been instances of so- such as Wanless or Barker...problem being there has been no pr-agreement from all parties to accept the recommendations. By 2017/2018..the chorus for that will become louder..and it could indeed suit the government to ask for one in 2019. The question is whether by that time, quality of services would have dipped down too far..or not.

The game indeed is afoot.  A lot of national leaders will earn their corn or move on to other pasties. If they do achieve the impossible, then the nation as a whole, will indeed owe them a big thank you and perhaps also ensure Stevens is remembered as the genuine Messiah.  We shall see.

Friday, November 20, 2015

A poor joke

Utter tripe. Absolutely utter rubbish. Honestly, I don't do blogs when angry but it gets to a point when sometimes you just must. My thinly veiled casual contempt for PowerPoint warriors is well known..and in my last blog, I have constantly alluded to it. If you haven't achieved anything then please, do peddle your wares somewhere else...I have little time for a car salesman.

Add to that list the brigade of those who profess to understand and believe in the ethos of diversity. NHS Improvement announced its Head Honcho...followed by CQC. Then you need to have a look at NHS England, Health Education England, GMC...and you must wonder which exact century does this county exist in? A rudimentary joke of being white and male to get to to the top echelons of power is no longer one...but serious business. It is as if all the powers have decided to stick two fingers up at all the reports, all the chest thumping, fact finding about lack of diversity..and say "So what?" 

I was discussing this with someone who casually mentioned..."But hey, look how well you have done?" A learned, educated, well versed in modern political correctness lets go of some inner thoughts. Well, genius, let me tell you whose help I needed to get to where I have..my own. Faced comments about "we don't employ your type in the South" from "respected" Consultants and I have gritted my teeth..determined to show to all that it didn't matter..I would work doubly hard..I would earn my corn. My disdain towards many in authority comes from many hard years as a junior doctor facing casual discrimination, turned down from jobs...and one always hoped that someday it would change..someday it would get better.

I sit here in 2015 and I don't know what bothers me most. The 2 fingers from the top tiers towards the workforce or the searing hypocrisy about having to do equality and diversity courses as part of my essential training. Read the report of Michael West...nothing has changed in 20 years...but hey the outcome is "we must try harder". I have no doubt Stevens, Keogh, Mackay et al are amazing guys who will do a fabulous job but are you telling me the whole country had absolutely no one who was a woman or of a different cultural background who had the same quality? No one at all?

I am a big supporter of a campaign called "HeForShe" and in my household, there is not an iota of difference between my son and daughter. It's because I have seen and continue to see - at interview panels, at casual chats..the throwaway comments about women and their "penchant for getting pregnant"; how "bad it would be for the continuity of the department" and it absolutely makes me boil with anger and disappointment...indeed is this the world to which my daughter will walk into? What kind of archaic bilge is that?

So to all managers, politicians, doctors, leaders or whatever title you possess...please...do equality and diversity if you genuinely believe in it. Please don't tick a box and feel your soul has been saved. At least let's bring some honesty and say that if you are of a certain type, we would like you to do so far..but please don't try any further. Otherwise as recent appointments have shown, it's just a joke...and a pretty poor one at that too.

Have a good weekend, won't you?    

Friday, November 13, 2015

Respect the outcomes

Irreverence...always has been my calling card. Many a times it's been mentioned and to be honest, I have never been one to hide that either. A question automatically comes...do you respect anyone? To perhaps the utter bemusement of some, I actually do..and unquestionably so. Let's take the world of diabetes...foot care? Mike Edmunds. Paediatric diabetes care? Fiona Campbell. Pituitary disease? Will Drake. There's actually a theme there...it's called outcomes and what they have done. Technology? Iain Cranston- I work with him, see what he does, the respect is total, it's unflinching, it's unshakeable...and it doesn't have to be someone old or in a position of authority...take pumps...without batting an eyelid, it would be Pratik Choudhury..it's the work they do and the outcomes they get. A theme there...respect has to be earned. A position means nothing to me, never has, never will. It's about what have you done.

What about in the wider world? Well, in the NHS, to be honest, it's most Chief Executives I know. We throw brickbats at them from the sanctuary of Twitter or a blog, but let's be perfectly clear...these guys take an enormous amount of beating- and collectively, all of these folks decided to take the hit on financial issues rather than compromise care, not hire locums, not go to agency staff when needed. For that, respect is high..it's about the outcomes they have decided to deliver..not on the spreadsheets but on the issue of care. Sam Jones, Umesh Prabhu some other names stand out...bold enough to step up to the mark and not being a paper leader...enough time in my world to have respect for that.

So what about its relation to World Diabetes Day? It's relation is to what we could do, as a community to do exactly that...improve outcomes. A fixation on targets, a non evidence based approach to diabetes care has brought us to the state where as a country about 60% of diabetes patients are having their basic checks...yes..that's 60%. We are in a state where we froth over technology and Google glasses when we over treat the elderly and cause hypoglycaemic events, hospital admissions and much harm. Someone, albeit admittedly in a different context, mentioned recently that some medicine need to be taken without evidence. No- that's called homeopathy.

As a country, what stops us as a community to saying we can improve this, and we will stop doing unnecessary stuff? The tariff system associated with QoF targets ( once a great tool now a mere hindrance for an ageing population) has left integration firmly on the glossy power points. Only a few handful of excellence sits amongst us all....integration has stayed away from reality. Patients implore us just to talk to each other..we still struggle to have IT systems which interact smoothly between hospitals and rest of community.

How about for a change we try something different? How about, we, as specialists, say it's time for us to improve things? Not point lazy fingers but genuinely try? Do Vanguards provide an opportunity to flatten the barriers..or have we dismissed them already as another fictional policy? How radical can we be? How passionate are we about system wide improvement of care? How motivated are we to judge ourselves, not anyone else, on outcomes? Not HbA1c, not number of hospital appointments, but hard outcome measures...amputations, retinopathy, myocardial infarcts, hospital admits? How about we measure our hospital services based on how many incidences of insulin errors we have stopped in hospitals? How many specialist centres can stand up and say in antenatal Diabetes care they have achieved the St Vincent declaration?  1989...we promised the outcomes of a pregnant woman was to be the same as one without diabetes...26 years later, what has stopped us from doing so?

Negativity is around us..but we need to be careful that we don't suck ourselves into a echo chamber. Every day I meet people who a doing some amazing work, but in silos, in pockets...we must get to scale...we must be able to flatten the hierarchies and improve care.

On World Diabetes Day, why don't we all as a community say we will genuinely try and improve outcomes? Measure ourselves on the reasons why we went to medical or nursing school? I didn't go there to drop a number, I went there to improve amputations, lessen admissions....and that's what we should be bold enough to measure ourselves on. Do you know why? Because if you do so, you bring many of the doubters on board. Doubters not very dissimilar to me when it comes to "names" and "personalities". The title means little to me if you can't show me outcomes ..without that..it's empty rhetoric at best. We, as a community, should be mindful of that..when we say we wants patients to work with us, work together to improve care..it must, and absolutely must be more than empty rhetoric. It must be based on genuine outcomes, outcomes that improve care..outcomes that justify why we do what we do.

Let's give it a try...next year, this day...I shall hopefully write a blog mentioning how far we have come since November 14 2015.

Happy World Diabetes Day.

Tuesday, November 3, 2015

Bigger Picture

An email pinged into the inbox today..."Have they got to you?"...was the heading. With intrigue I opened it to a query why my blogs had stopped- had to assure that it was down to something more basic...my parents were visiting- and simply put- was just enjoying some family time- and as ever, was warm, fuzzy and simply...lovely.

It did make me think though about the culture we live in- where in spite of multiple conferences, hashtags, "Francis", self styled defenders of patients safety etc etc...such an email does come along. Either way, to reassure, nope, no ones muzzled me- and to be fair, none in management have never ever asked me to tone things down or stop writing.

So to this blog...and I must talk about Pete Deveson- and I must say the fella did make me sit up and listen. It was at the BMJ Big Debate- and in the middle of all the fun and laughter, the jokes and banter, Pete talked about "Learned Helplessness". Delivered with panache, fun but with a striking message underneath, he talked about how many had forgotten the art of speaking up when needed. Many a times,  I am told how its about the "Bigger Picture"..how our leaders can't say things openly because the bigger picture is more important- and I must admit I am starting to struggle with that. What does that actually mean- a bigger picture for the person themselves or a bigger picture for healthcare?

Keith Willett recently spoke at  Kings Fund conference- Director for Acute Episodes of Care or the Emergency Czar in old parlance. I watched on twitter as he spoke about the challenges, spoke about recruitment, spoke about working differently...and I waited..and waited..waited for this clever intelligent leader to utter one word about recruitment crisis, low morale, junior doctors...but nothing came along. What does that mean...he thinks the emergency care crisis is solvable without improving morale or tackling the recruitment issue...or is there a bigger issue at hand I am not aware of?

Sir Bruce Keogh recently spoke at "Agents of Change"...he spoke about leadership, challenges, issues to tackle..and I waited..waited..waited for 1 line, 1 word about junior doctors, waited for something about mortality issues- and I kept waiting. Let me get this crystal clear- read my previous blogs- I actually hold him in high esteem- I suppose it sucks even more when one of your heroes let you down. So what's the message for budding leaders? Keep quiet or is silence tacit admission of support?  Or is this all a form of learned helplessness? Or is there a bigger picture?

Recently I wrote a blog for CQC- and on balance I still felt it had a role...and then it goes and commits the most spectacular own goal ever. Hike your price up in an environment where money is gold dust- hike your price up for which evidence is still flaky, hike your price up in a tax funded system when patient care is stalling....CQC says it isn't their fault- but the DH that they are passing on the costs. What stops an "independent body" from publicly pushing back- learned helplessness or some nebulous big picture which escapes mere ordinary mortals?

We have exposes being run by HSJ- like the Daily mirror and Sun into NHS gaps- honestly- don't have to do anything fancy- just pop along into your local trust and you will find gaps. What stops from collectively raising the question of prioritisation or funding? A bigger picture? I can raise a national campaign tomorrow showing gaps in diabetes services bigger than "safe staffing"- what will it achieve if you haven't tackled the basic question? A few kudos for a few, a few blogs and then we move on to the next gap or crisis. Bigger picture anyone?

We criticise others about silos-we ourselves live in our own- and till we collectively ask what needs to stop, its all futile- and a circular debate in an echo chamber at best. Ask yourself this: You want safe ward staffing- fancy stopping screening for diabetes to do that? You want access to insulin pumps- fancy stopping funding shinier CCUs? That, ladies and gentlemen, is what the bigger picture is about for the health of people. Beyond that, the bigger picture is one of individuals and their ambitions.

In Sanskrit there is a saying .."Maunam Sammati Lakshanam"...it means "Silence is Half-consent". Have a think of the Big Picture tonight, won't you?

Sunday, October 11, 2015


Somewhere down the line, we have most certainly forgot to treat our colleagues as adults.

No, I am not even being mildly sarcastic about it. It's a fact- ever since the junior doctor contract erupted, the plethora of views have been fascinating to observe- but there comes a point when we, as a community, must respect the position adults,as a group, are taking. We call them "junior" doctors but they are anything but- these are people who in any walk of life would have been respected for what they are..after all, these are people adult enough to decide to have families, people adult enough to have mortgages- yet somehow many have decided to treat this particular workforce as anything but. I will tell you how I see my "juniors"- adult colleagues who are helping me do my job. Along the way, if I can help them develop- even a fraction to the point I got from my Consultants- well, that's very good indeed.

But why? If you look at the various issues, the pay factor comes into play- and I am tired of hearing comparisons between different professionals- and I mean everyone. Stop comparing junior doctors to a cleaner- or a banker. Different jobs, responsibilities etc etc- stop that- that helps no one, and disrespects others, let alone doctors themselves. There are far bigger issues- most notably- hours and its protection. Is there a degree of hysteria around it? Perhaps- but note many who have leapt in with advice, don't do the job themselves. It's a bit like advising Rooney to take the corner properly when you wouldn't have even made the school team. Would I give advise about right payment to a journalist- no- because I have no idea how much slack they have, how honest they are or even how hard working they are.

Let's be crystal clear on this- if our junior colleagues AND nurses held to their contracted hours or asked to be paid for for every extra hour worked, that 1 billion deficit would have looked decent in comparison  The counter? It's a vocation- so you must. Let me point out a fundamental flaw in that logic. Look at the Oxford dictionary: "Vocation: A person's occupation, especially regarded as worthy and requiring dedication". Or "A  strong feeling of suitability for a particular career or occupation". Anything jump out? Let me give you a clue- its about making people feel valued- make them feel valued- the vocational aspect comes to the fore. Some seniors point out to the hours they worked- yes indeed, different circumstances, without the burdens of administrative issues, with the perks of free accommodation- with the golden pot at end of rainbow such as Consultant salary, permanent contracts and a guilt edged pension to look forward to.Sorry did I forget to mention CEA points?
We aren't offering our juniors those- or in the process of taking those away/reducing them- so where exactly does the vocation aspect come from? Not valued, less security to look forward to...vocation, strangely enough doesn't pay your mortgage.

I don't want a strike- but do admire the unity of junior doctors. Apart from a few with their own views-biased as they are, there isn't many left who feel the junior doctors ask is unfair. It isn't about pay but about safety. It isn't about money but recognizing that in 2015, a woman taking a break to have her family doesn't make her any less a "high-flyer"- and most importantly, in an environment where you need the workforce to deliver any efficiency, imposition of unilateral views is daft and unnecessary. The letter from Mr J Hunt shows a willingness to take it forward and to someone who enjoys negotiating, there appears areas to sit and discuss. BUT it does need to be accompanied by removal of any threat of imposition. Threats and negotiations aren't good bedfellows- ask the middle East

Finally, its about being treated as adults. Our junior colleagues are being treated poorly- and whatever be the belief, we should as a whole, recognise that. Not denigrate, not sneer- point out politely what could help- but treat them as adults. Be a friendly critic- as I have always said, not about the pay (wrong argument) but about safety and equality. But I don't mind if that's not listened. Do you know why? Because they are adults.

And adults must and should have a right to choose and fight for their future.

Saturday, October 3, 2015

Inspired maverick

It's been actually a lovely few weeks. No I am not joking..it really has been..on many levels. Weeks which have been laced with meeting new people, learning about new things..to the cursory question one gets when one meets someone after some time.."How's things?" The answer, truly has been "Not bad at all".

The request to meet Simon Stevens came out of the blue and admittedly, a pleasant surprise. There's only so many times you can believe your own hype so I suppose an invite from the head honcho is always welcome. Without going into too much detail, the personal meeting was informative , enlightening, not to mention actually quite educative- away from the bubble of 140 characters opinions on Twitter, it was nice to talk to the man who runs the NHS. Clear thinking was a feature apart from the calmness - sometimes you learn about leadership much more from personal meets than any leadership course can teach you. Stevens has his share his detractors- would anyone in that role but he had encouraging words for someone much down the food chain- I liked that..it made me think again where I could help as regards type 1 diabetes in this country.

Interspersed in those weeks was an obligatory trip to meet some CCGs, yet another tour for the Super Six diabetes model- and once again, met with many a people who had the will, but not necessarily the finance needed upfront to get things moving. A transformation fund - if monitored well- could indeed unlock many a door..austerity has brought forward a fleet of new thinkers...the system needs to support those, not deflate their energy when the NHS needs them most. What was nice was to see the belief that diabetes care needed to change, and change needed based on needs of patients, not as a money saving exercise.

A trip to Ireland brought many joys not to mention to observe some amazing work being done by Neil, Lesley and Athinyaa- what struck was not only the talk- but the actual ability to walk. I will be honest- in my travels and different roles, I meet many, many folks who are brilliant at doing the talk- but pretty ordinary when it comes to delivering- certainly not these guys. It was wonderful to watch over dinner the sparkle in the eyes- as the discussion was about how to do it, less of what wouldnt make it work. If you really want to see something special in development- based on sheer energy and infectious enthusiasm of a team- take a trip to Londonderry- many many diabetes centres could have much to learn from them.

In between clinics etc also came a trip to Hertfordshire- at the request of a friend- to talk about diabetes and the role of inspectionthe fear factor as regards CQC was palpable- and thats the feedback the CQC needs to take on board. It has the potential to be a critical friend- a power for real good- as well as being something leaders within organisations can use to improve care. A force not to be feared- but for that to happen, all parties need to change a bit. What however struck me was the 2 patients who spoke to an audience of more than 200 HCPs. The message was loud, it was clear.please stop judging us, please work together. In 2015, that cannot be that big an ask. A loud message to me what needs to change across the country!

A lovely few weeks- much seen, learnt- and much positivity around too- in spite of the virtual meltdown we face as regards finances. Austerity has clearly inspired some thinking differently- the question is whether its come about 4-5 years too late- we shall see. There is indeed a lot of chaos but within that, the question is whether it offers opportunity too. My passion is for type 1 diabetes care-a nd the energy seen over the last few weeks has indeed rubbed off a bit. To all the people who matter whether it be Simon Stevens or Samantha Jones or Martin McShane or Jonathan Valabhji, my message has been crystal clear. Sitting on my laurels is an easy option for me- but the energy and desire to do things is now. 

So thank you to many who have inspired- I hear plenty of medics shying away from leadership- I will publicly buck the trend and simply say..Here I am. I, along with many others such as Pratik, Emma, Natasha etc, want to improve type 1 diabetes care- and the time is right with all technology, patient power at a nice critical mass. 

Shake off the cobwebs- and ask away. Brave enough for some mavericks? 

Monday, September 28, 2015

Reach for the Stars

Aspiration. A word that galvanises many to think of what we could do. It is however a fine line though. Take my own football club..Liverpool. Past glories abound and every year, the hope builds that maybe, just maybe, this would be the year. Aspirations are high but time has been a good builder of temperance. Now we talk about rebuilds, we talk about getting into the top 4...compare that to Barcelona...it's pretty simple...win everything you play in.

The NHS is in an interesting bind of its own. the pride of many who work in it is palpable, any suggestions that you may not be doing to the utmost level ( check any negative CQC report and responses) and we all bristle at the very whisper of it. Inwards, I suspect we all know we aren't doing as much as we can and different reasons are given for it whether it be vested interests, inability to work together, culture...the biggest one which does come through is of course finances.

This is where a dichotomy seems to have emerged with organisations within the NHS. Let's take NICE for example- a respectable body who looks at the evidence and makes recommendations. The problem is the aspiration doesn't quite match the resources or even the ability to deliver. Any think tank or health economists will tell you we are in a financial crunch and struggling to deliver what we have..so how would it be possible to deliver more? Therein lies a fundamental question.
Take for example the recent NICE Type 1 guidelines. One which would be a dream for anyone with type 1 diabetes...but to deliver it, something needs to stop or there needs to be some investments. I absolutely take the point that working to evidence base etc would help stop complications- but in the world of diabetes, that's about 10 years away...so where's the resource to invest to save?
When you ask NICE, their response is "It's not our job to give you the how". That makes it tricky because at the moment, no one quite does either. The problem is that NICE guideline manages to raise the expectation that those guidelines will be delivered- and when that doesn't happen..cue anger, angst..take it out against the HCPs who are the face of the NHS to many...drop in morale...the cycle continues. None of the policymakers, twitter champions etc actually face the patients...its the staff who are the face of the NHS.
CQC is another example. It sets the standards, then judges you based on that. However,when you ask them how with the financial crunch..their answer is pretty similar to NICE. "Not ours to give the how". It's an interesting position to take especially when all these bodies are funded by the NHS itself and not quite external per se.

So what would help the debate? Anything involving the public gets divided along political lines which as relevant as it maybe, hardly furthers the debate. Professionals raising their voice are sometimes branded as being of vested interest- so efforts continue at pace to try and get the public and professionals together. However think of this..how much would it add to the table if organisations such as Monitor, CQC, NICE all did their roles but with a caveat that these are aspirations which needs a financial review to deliver? It would certainly strengthen the focus as well as be fundamentally strong voices? All bodies with their respective roles but working together for a sustainable NHS. Too tricky?

I want Liverpool to win the Champions League...I want them to be Barcelona. But I also know that to do that, we need injection of finances to get the best players etc. and if that doesn't happen, I will learn to be satisfied with a trophy here and there and perhaps a top 4 finish. The question is where do our aspirations for the NHS sit and do we all have a responsibility to reach for the stars? If we do, then it's about time, all national bodies had a think..because if it comes down to the wire, they may not have much to inspect or create guidelines for. Or the crunch of money will shut them down too.

The choice isn't that tricky. If we believe in the NHS a and improving patient care- which is indeed the basic role of all those organisations too- then it's time to reach for the stars..together.