Sunday, December 30, 2012

The year that was....


So a crazy year comes to an end...and it's always good fun to look back, isn't it? You have highs, you have lows...but that's what makes the ride interesting. After all, if you don't have lows, how exactly do you feel the exhilaration of a high?

Within the diabetes world, the Portsmouth diabetes team continued to build it's reputation winning awards for a new model of care delivery..the principle being quite simple...the vast majority of patients with type 2 diabetes to be managed in the community with support from the specialists...giving the specialists the time to concentrate on areas such as Type 1 diabetes etc and hopefully, overall, improve diabetes care. Picking up recognition was great fun, and what was heart-warming was the recognition the fabulous nurses got from it. As ever, the unsung heroes...their joy was one to savour...and when local Commissioners and CCGs also won awards on the back of it...one could let loose a wry smile. One could blog about it with a lot of pride..safe in the knowledge that the hardest part to achieve within the NHS was done...making change. The rest was up to us now, as professionals to deliver. No excuses, no external factors...this was now ours to deliver.But then again, when you work with the folks I work with, you have nothing but confidence that this can- and will be- done.

On a personal level, the high had to be the recognition offered by patients, and specifically one motivated girl who felt I had contributed to her volte face as regards her battle with diabetes. To be honest, I wasn't..I just happened to be there when she was ready for it...but nonetheless, a moment of immense pride..and for that, thank you very much Ninjabetic. I recall the girl of a few years back...and see someone completely different nowadays..the drive, the passion to improve the care of herself and others...one that can only be commended and admired. And the good news?...I meet young people like her nowadays more regularly...folks ready to make a change...my job? Be there..help and support when asked for- backed by a fabulous team of nurses and dietitians.And no, I don't do anything extraordinary...just something that used to be a norm for people who have inspired me over the years.

Social media exploded for me...and even though I have never met the Anne, Hannah, the Sjolunds etc of the world..I learnt so much. Realisation sank in that there was so much to do..but also the fact that this wasn't a single handed fight...the was no lack of patients who were willing to help, nor of fellow professionals like  Elin, Dean, Andy who wanted to make a difference. Beyond the world of type 1 diabetes, Roy Lilley in his usual coruscating ways highlighted what we could do better, twitter debates raged about whether the NHS needed to be privatised or whether the state backed system was one to be feted. As ever, the reality sat somewhere in between the polarised views..as the NHS moved into choppy waters..unsure of it's future.I wrote a regular blog challenging the "super-specialisation" of hospital care which I reckon doesn't take into account multiple morbidities, challenging what a Diabetes Consultant actually does, questioning the deluge of guidelines...oh it was fun!

The lows were there too..one of the brightest light of the diabetes world, Dr Niru Goenka, went out..too early...so much potential, he had so much to give...but alas, it wasn't to be. The outpouring of grief was a reflection of the regard in which he was held but perhaps the biggest tribute we could pay to him, is perhaps getting diabetes care right...one which he was so passionate about. 
Some personal relations, regrettably soured..some perhaps due to my forthrightness, some perhaps unintentional, some perhaps due to a desire to create an aura of mystery...keep the "real" me away,some perhaps because (ironically) I tried to step outside the "normal" Consultant mode of being a bit aloof. Who knows..but either way, to those who felt hurt, it wasn't intended...and I hope to bring a calmer, a more professional approach to the table next year. You learn as you go along, don't you?

So 2013 is around the corner. Resolutions? For sure...and giving a lie to the common myth, I have yet to default on new year resolutions in the past..and don't intend to change that. Some of them are personal and may have alluded to above..but professionally, the focus now shifts to people with type 1 diabetes. At the beginning of 2012, I had promised that at the turn of the year, the new model of care for diabetes care will be in place and people will know about it. I also remember in 2010 someone "important" telling me that changing traditional diabetes care was like taking on mission impossible. 
Now I am no Ethan Hunt but 2 years later, I think that question has been answered. Now to type 1 diabetes....can we change things? Can we make it better? Can we change the perception that this isn't about being overweight, it isn't something that can be prevented? I think so...but want an idea of the level of challenge? Here you go...
The Department of Health have advertised for a series of national posts across al specialities ..Cardiology, Stroke etc..and one among them is "Diabetes....And obesity". Diabetes. And. Obesity. One and the same...correlated, hand in hand. Is it the DHs fault or is it the diabetes organisations (and I include specialist, primary care and patient organisations in it) for failing to separate Type 1 and Type 2?
Perhaps I am being pedantic...but it does give an idea of he scale of the problem..but hey...what's life without a challenge? having the last few weeks of the year has been good...it's been a nice little break...and I feel rejuvenated....ready for a new challenge.

Robert Stevenson once said.."We must accept life for what it actually is - a challenge to our quality without which we should never know of what stuff we are made, or grow to our full stature". Time to test it out...2013 is here....let's get ready for another year full of fun and pleasant surprises. The sky, after all, is the limit, isn't it?

Sunday, December 23, 2012

Do you believe enough in it?

So here we are..Christmas is around the corner...the time for festivity, cheer and high spirits and for a few days, the politics rest, the battles are ceased and its time for the family. Spent the weekend introducing my daughter to Tolkein, my son to the story of Spiderman...and their wide eyed amazement made it all worthwhile. Spent time watching Rise of the Guardians and the proud parents loved the wonder shown by their son at seeing the Tooth Fairy, the Easter Bunny and Santa..all there together...forces of good...fighting the Boogie-man. 

In the background, the world goes on...the same challenges of emergency care continues, my type 1 patients still drop me texts and emails asking for help, the hospital managers still sends out that last weary email asking for "one more push"...life goes on for all concerned. And we try...we keep trying to help. So to turn away, albeit for a bit, from the incessant battle, negativity of the whole system....just to take a deep breath is always welcome.

For those who live with Type 1 diabetes...I don't have T1D, I don't know what it is to live with- and I don't pretend to...but have never stopped admiring the resilience of those who do day in, day out. So far I have started on a journey to see what can be done and am feeling my way around the brutal politics and learned helplessness of the NHS. But not to worry...the quintessential rebel always has loved a challenge. A famous quote goes like this..."Just because something bears the aspect of the inevitable, one should not go willingly with it".Keep the faith ladies and gentlemen...just at the beginning of an interesting journey.

To my friends and like minded individuals who work within the NHS, take time with your loved ones and be proud of what we all do...because at the heart of it all, we want to make people better, we want to make the system better. If for a few days, we can forget all the divide of acute trusts, community trusts, specialists, GPs, nurses....then perhaps it just shows we can do something good altogether. Naive? Maybe. Realistic? Of course!

To all of you out there...a festive wishes- may Santa listen to your heartfelt wishes. 

"Agar Kisi Cheez Ko Tum Dil Se Chaho...Toh Poori Kaaynat Use Tumse Milane Ki Koshish Mein Lag Jaati Hain"...a famous dialogue from a Bollywood movie...loosely translated meant..."If you want something from the bottom of your heart , the whole universe will conspire to get it for you"

I have placed my wish...and I know its gonna come true. What's yours...and more importantly...do you believe enough in it? 

Merry Christmas to all. 

Saturday, December 15, 2012

Shoots of spring?

Maybe its the time of the year...maybe its the smell of Christmas in the air...maybe that's what is making things look a bit rose-tinted..but you got to live in hope, right?

As part of one of the roles I hold, was asked recently asked to look at a Consultant job plan...and a pleasant surprise indeed. Easily one of the best constructed job plans I have seen in recent times, it actually had the same person doing both acute Trust work, as well as work in the community! Yep, no split or coining of that term called "Community Diabetologist". If I have ever seen a title which has been at the heart of creating confusion amongst the diabetes community, it was the creation of that particular term or role. Isn't the hospital part of the community? Doesn't the hospital Consultant have any responsibility in the community? Why this divide?!
So, to see a  job plan which actually recognised the role of a Consultant across boundaries  across the boundaries called primary and secondary care. Heck, there was even time for virtual clinics...recognition of modern technology as tools to improve patient care....one had to let loose a wry but satisfied smile. 

And that's not only it...back in July in Philadelphia, I had loudly wondered amongst similar minded colleagues why all the numerous organisations couldn't get together to create something that all Clinical Commissioners could use as a template to redesign diabetes care...why couldn't we have a think tank involving EVERYONE? So, in December, when a draft document with all the right ethos and issues incorporated lands in your email inbox, you know things are happening. By design or accident or simply due to pressure from data or patient organisations..or perhaps even a degree of a need to self-protect...organisations have joined forces to create something. It may not be the end all and be all...but to have a document which had ALL the organisations stamp on it...a very satisfying moment. 

Throw in some further recent phone conversations I have had with several CCGs...and there is no denying that there is a distinct thaw in relations between all parties...there seems to be the recognition that specialists need GPs as much as GPs need specialists...and at the end of the day, bring them to a table..cut past the politics...the grumpiness, the demeanour of being a "hard-ass"....once it dissolves down....yep, they all do want to make things better, in spite of being weighed down by the finances, the politics of the NHS, the ever changing paradigm....managers, doctors, nurses....they all want to do the right thing. Is that a bit too much of the rose tinted glasses...perhaps so...but somehow it just feels a bit different. Maybe the last few years since the drive to change diabetes care has exhausted everyone ability to simply "posture", maybe between all the uncertainties of the NHS changes, people may simply have seen it as an opportunity to give it a try. Who knows the reason...frankly who cares...as long as the right thing happens!

I am someone who has criticised organisations for sitting back while patient care has suffered..but at the same time, always happy to laud those who do shake off the past and try afresh. And to that end, ABCD, NHS Diabetes, PCDS and Diabetes UK...well done all for making the right call. These are interesting times...and lets make no bones about it, as cheery as one wants to be, tougher times are to come. 

But at least something is being tried, something different. Last week, was part of an interactive meeting where people from different sides of the "divide" had to spend time together and come up with a "model of care". It was stage-managed, and yes, there was lots of mirth...but people actually talked to each other...without any prejudice or judgement..it seemed  at least even for those few hours...they were..at least....trying.

Simply too much optimism? Too much of the Christmas spirit? Or genuinely something different? Time will tell...but for now..I am happy to accept them as the first "shoots of spring".I know the pessimists will always say that it could all be nothing but a false dawn and one swallow doesn't show a spring etc etc..but hey, Hope..as they saying goes...always...and always springs eternal.

Thursday, December 6, 2012

The perfect storm...



Sunday. And on call physician of the day. When I was in my training days, that meant an occasional call, once in a blue moon by the on call registrar to discuss an ill patient, little else. Not anymore...now it's an occasion which causes trepidation....because you know the phone will ring...and on cue, it did. It was the duty manager, someone I knew, someone I knew to be a "good egg"...so when with a hint of desperation she said the was a queue formed outside the Emergency department and she could do with some help, what's the doctor of the year to do, eh? This wasn't the time to debate what I could do by going in, this wasn't the time to discuss about the geopolitics of the NHS, to debate whether out of hours services were not unto scratch...sometimes it's more simpler to shrug your shoulder and drive in. So I did.

What struck me were the staff. In the midst of the media blitz which details in gory details the ward sister who had mentioned that they were "immune to patients suffering", I met a bunch of nurses in that department. For the 4 hours, I spent with them, you had to stand back and admire what they were doing day in, day out. Many years ago, as the medical registrar on call, used to go to that department quite regularly and they remembered. There were the odd jokes about how my dress sense hadn't improved, the banter about whether I had come off the golf course...but to the patients in the queue or in the department, they were simply put, fantastic. Would I have any hesitation in having one of my own, god forbid, come to this department and be seen by one of the nurses? Not in the slightest.
Sure there was the disgruntled doctor, angry and cynical at the multiple changes to the system, the feeling of not being listened to, the frustration ....but nope they didn't flinch from reviewing that patient which needed to be seen. It was battle stations...a far cry from the world of chronic disease, a world of long term conditions. This was quick, fast and the pressure to meet targets was suffocating...a continuous feeling of trying to keep your nose above water. I met the duty hospital manager, trying to make patients flow quicker...looked tired, but still smiled...wanted to help...everyone seemed to want to do the right thing...and everyone had their own pressures to deal with.

And the instinct for anyone under pressure, especially when you know you are going flat out is to look for something else. Not just where I am..but everywhere in the NHS. I speak to colleagues elsewhere and the pressure isn't unique to us...its all pervasive, everywhere.

At the front door, it was about "inappropriate patients" being sent in by those pesky GPs..how dare they opt out of out of hours? Truths and half truths make up our lives..and when you want to look for reasons...you start believing in anything. You have patients who don't need to come in...sent in by NHS Direct to come to the hospital. For headache. Some clever algorithm had flagged "possible cerebrovascular event...while 3 questions from a trained doctor reveal she was under a lot of stress at home and it was related to tension.  You also see patients who come to the department because they didn't know what to do...and then you also see lots of patients who came to the hospital..because they are simply put...sick. There is no Telehealth, no community service, no slick mobile technology which would have prevented the elderly lady with drowsiness from a severe urinary tract infection from coming in.

Then you have the belief that no patients are being discharged...so the myth machine says it's because Consultants aren't doing their reviews. The reality is that with social care funding under continuous pressure, the capacity to send patients home gets squeezed by the day. How do I as a Consultant look at the elderly lady in the eye and tell her to simply go home when I know that she is better suited in a different housing environment and isn't safe where she is? Do I simply say I have treated you for your chest infection and my job is done? If so, then I have failed to do what I promise to do every day....it's not the numbers that matter..it's the person in front of you. I try to do that in my young diabetes patients...why would the patient on the ward be any different? And I worry everyday now about the risks taken...will she be safe, was that discharge too quick?

Don't get me wrong..the are ways we can improve..we can get our communication with primary care better, we can have more resources in the community, we can stop specialists from cherry picking their patients and ignoring that patients have multiple morbidities blissfully ignoring the days spent training in general medicine, we can tackle patient expectation more robustly, we can educate people why one should attend an emergency department..I am afraid that will only achieve a fraction of what we are all trying to do. It's no ones fault...the problem is we have an ageing population with multiple morbidities and a shrinking social care budget. We all keep hearing how community care needs to be bolstered, but with finances as tight as it has ever been, that can only happen at the expense of the acute trust.Factor in the perverse incentives of payment by results etc...and the need to have the locality hospital afloat to do even basic elective work and have an emergency department etc....you can't take the money out either. Throw in that all the increased admissions and reduced discharges encroaches on a trusts ability to deliver elective work, their lifeblood...and the vicious cycle crystallises into the incessant pressure all of us feel ourselves in.It just feels like playing chess..when you have just been "checked" for one more time...and inevitably leading towards that final "checkmate".

I am a born optimist..always have been, always will be...but on Sunday, I looked at all those tired faces of the doctors, nurses, managers..all trying...but with the fortitude of the boy on the burning deck. As a chronic disease specialist, I wished I could help in some way and we are trying by moving into the community etc...but the reality is gnawing. In spite of all the stories, and the half truths about doctors and nurses not being professional enough, my personal view is that the NHS has survived so long simply due to the extra bit most folks put in..day in, day out. That extra 5 or 10 percent, spread over so many professionals have carried the NHS for a long time.

What do we do when that drops down to even 100%... what do we actually do? The "storm" is no longer "coming".....it's well and truly,...here.In fact, it is nearly....the perfect storm.


Tuesday, November 27, 2012

The essence of mortality



Life is a very weird thing. All about ups and downs, peaks and troughs and then again in between, it tends to be about priorities. Can you avoid the troughs if you prioritise correctly or is it good to be made sometimes aware of your mortality?

I am not an atheist, though do tend to enjoy Ricky Gervais present views on them, but then neither have I ever been a God fearing person. Always been a bit sceptical, you see, especially during my school days. Being brought up in a catholic school was always interesting..Jesus seemed like a very cool bloke but somehow the resurrection bit never quite caught on. A young mind who was engaging in biology and chemistry somehow never quite understood how someone dead came alive. The dissected frogs never did, neither did my grandad or my uncle who passed away during those years, so the skepticism was healthy. On top of that was my devout family, believing in the Hindu gods and deities, which to me were always a source of enjoyment, not religious fervour. You see....Hindu gods were always associated with festivals, new clothes and lots of food. For any humbugs who thought Christmas can be a bit tedious, you haven't seen the Puja season on Calcutta. A kaleidoscope of colour, noise and pure fun. What exactly had God to do with it?

So it does make you wonder what causes things to happen. Do you see it as Gods way to "take you down a notch"? Or is there a Guardian Angel who wants to make sure a career with potential is not frittered away? Or is it just simply a case of being in the wrong place at the wrong time? Or is it it could be so much worse...so see it as a blessing in disguise? The optimist struggles with the pessimist, the resilience struggles with the resignation...

The guardian angel theory is an attractive one. I, for one, have been incredibly lucky. Kind friends and family think it's my "quality", "talent"...I know myself how big a part luck has had to do with it.School, college, jobs,family,colleagues...an incredible stretch of luck which has contributed so much....at times it does feel someone has been looking over me. The first few years as a Consultant has been a whirlwind...making friends, enemies..taking on issues...most of them deliberate...partly to force changes in the system, partly to make an image as a renegade, someone outside the mould...someone who could bring some change. But in between all that, I have looked for something to focus on to, make it my mission....and then I focussed on the Type 1 side of things. And I have loved every single moment of it...it felt...right. It felt like the right battle to fight...it felt like the one thing I wanted to make a difference in. And I have jumped into it full on. National politics, changing models of care...I have been involved...but somehow has never given me the joy that immersing myself in Type 1 diabetes has.

And I don't want to lose that. Troughs in life are supposed to give you an appreciation of your peaks....and over the last few days....it certainly has. A good friend called me "resilient"...maybe so...but it still hurts. But you know what...isn't that why you have parents? It doesn't matter whether you are 9, 24 or 38....sometimes a hug from your parents is all you need. And to open the door and see them standing there for me...in the pouring rain after a flight of 10 hours..meant everything.

So we build again. We try again...and focus on the things that matter the most. I think I can make a difference to diabetes care, especially in Type 1 diabetes....and not in any mood to give all that up. I have made a few promises to myself over the weekend...a few challenges have been set. Thing is....I have never lost a challenge....and I ain't ready to give that record up yet.

Tuesday, November 13, 2012

The utopian world of Type 1 Diabetes


14th November 2012. World Diabetes Day is upon us. 

So what is this? Another day where we pay lip service to improving diabetes care...or genuinely an opportunity for change.....that is the million dollar question,isn't it? Type 1 diabetes care is my passion so seeing all the initiatives being launched this week by the Diabetes Consultant organisation,ABCD and patient organisation, Diabetes UK, have been very encouraging to say the least.
Finally, there seems to be a recognition that not "all diabetes are the same", a realisation that interventions directed at Type 2 diabetes, in essence a public health failing, does not work in Type 1 diabetes, a pathology over which the patient concerned has no control..perhaps even a coming together of organisations to find the group of people buried under the sheer weight and magnitude of Type 2 diabetes. the group of people who have been called the "lost tribe"...not sure I have seen anywhere patients asking for a debate as to whether primary or secondary care is "better placed" to look after them...

It also set me thinking, prompted by one of the people I have met on Twitter....she asked me to write a blog about "anything to do with diabetes"...and it gave me the opportunity to dream. For a few moments, forgetting the politics, the challenges of finances within the NHS, forgetting the hypocrisy of the world we live in, the political correctness which stops us from challenging colleagues when poor care for Type 1 diabetes is provided...for a brief momentum I ventured into the world of utopia where money and politics didn't exist.

The question I had in my mind was very simple...in this utopian world, how would I provide Type 1 diabetes care for patients as a hospital specialist? So I threw that question out into the twittersphere...and it was fascinating to read the responses...and I came up with what I would like this ideal Type 1 diabetes service would look like.

For starters, no assumptions would be allowed...no assumption that primary care wasn't equipped, no assumption that all the patients wanted to be seen by specialists, no assumption that specialists knew best. I would love to have a system whereby patients can choose their own doctors, GP or specialist..in short, someone who provides good care, an empathetic ear, someone who doesn't pre-judge or treat them as a "number".

I would like all patients to have access to specialists on demand ergo use virtual method ( email, social media, texts) to contact specialist nurse or doctors when they have problems. I would like them to have the ability to self refer themselves into a centre if they were worried, and access to educational drop in programmes on topics which are relevant to them according to their age group..it maybe something as simple as "growing up"., or as "complicated" as "what to do at music festivals". I would also like these patients to feel their GP is trained and educated in Type 1 diabetes and if not, then the patient has the right to move GPs or self refer to the specialists! Beyond ordinary clinic set ups giving access to dieticians, nurse specialists and doctors, there would be access to psychology support,access to pump services...as and when needed or asked by the patient. Pre-appointment, each patient can choose the topic they want to talk about....if it wasn't about "hba1c levels", so be it..if it was about talking just about "alcohol and night-outs...why not?

In this utopian world, the would be no silly debates whether a Type 1 diabetes patient can have blood sugar strips and indeed, they can choose whatever meter suits them best. If due to any reason they come into a hospital,they will always have a specialist team seeing them within 30 minutes, if not less, have a dedicated ward for patients with Type 1 diabetes and oh yes, a service which runs 7 days a week, not 5 days.
Each admission to hospital would be reviewed by the specialist team internally to assess whether it could have been prevented...and whether the patient was appropriately treated by all healthcare professionals within the hospital.Specialist teams would also work with local schools, universities and councils to raise the profile of type 1 diabetes, improve awareness and education....

Am sure have missed out lots, but for starters that will do. So...possible or just fantasy? As someone who has been dealing with NHS finances and have got a reasonable service in place....there are some bits here which needs negotiation...but you know what...the amazing thing is...the majority of those is do-able.....yes..absolutely do-able.

We profess to have service which listens to patients..I would challenge that concept. Robert Tattersall once said.." It is very easy to manage diabetes...badly". We seem to have chosen the easy way out...is utopia actually achievable? is it simply about money? I would venture to say it probably isn't...much of it is also due to attitudes, cynicism and the resistance to doing things..differently.
But talk is cheap...it's easy to fantasise and put down in a blog concepts of fantasy...is that what I hear you say? So here goes....today on World Diabetes Day, I promise anyone with Type 1 diabetes this. I can't change the system in this country overnight but certainly can make things happen where I am. 
I look forward to the next World Diabetes Day...as I intend to turn around and say...it wasn't a fantasy, it wasn't utopia I was describing...its reality...and it happens in Portsmouth Hospitals NHS Trust

Happy World Diabetes Day folks. This coming year..it will be different. I promise you that :-)

Tuesday, November 6, 2012

Pride and Prejudice


We live in interesting times. Times of cynicism, times of mistrust, times of suspicion. Times when it's all about having polarised opinions. Simple example? read about the furore unleashed about the Liverpool Care Pathway. Something which was designed to help patients die with dignity is now labelled as the "Death Pathway" by the Daily Mail. It's now like a frenzy. A junior doctor trying to raise the issue, trying to get a petition signed..is now facing abuse from trolls on social media sites, threatened with personal harm. We are the society we have chosen to be.

In between all that, it was an absolute pleasure to be in Warwick this weekend...being part of a 2 day meeting aimed at new Consultants and senior SpRs in diabetes. This was generation next...and they wanted to do something...different. Yes, there was frustration, yes, the was a level of angst aimed at primary care, but there was the desire to try something different. Members of the faculty consisted of Jiten Vora, Melanie Davies,Tony Barnett and Cliff Bailey...figureheads in diabetes care who have made their reputation based on years of contribution to improving diabetes care. and then the were the guest speakers..Kathy McLean and Azhar Farooqui...giving examples of how primary and specialist care are trying to work together etc.

At some point..as Professor Farooqui was outlining the process of changing diabetes care in Leicester, the words "Super Six" came up...it was part of the Leicester redesign...and I had to sit back and smile. I heard the faculty acknowledging at various points the work we were doing down on the South Coast...and I felt so proud..not because of what had been done, but because of the distance we had travelled. The Super Six wasn't some magical concept I had dreamt of, people had talked about it, written about areas where specialists needed to be involved..I had simply been in the right place at the right time. Right set of commissioners, right set of colleagues..and voila, we had our model of care in place. So..a lot of pride...a significant lot.Couple that with colleagues you have trained with raising a glass to you at the bar or senior SpRs coming up and thanking you for "fighting for the specialty"...and yep, a lot of pride Awards mean a lot but when senior peers, folks you have grown up respecting acknowledge the work you do..it means a lot more than anything else. Just behind the accolade of being recognised by a patient...but not too far!

But then where there is pride...how could prejudice be far behind?  

I have given up being surprised or being caught off guard by comments passed about our local amputation rates or questioning our model. However it is only with a sense of irony you read emails from said detractors CCGs about advise as the "specialists won't engage"... you can only let loose a wry smile. "Too big for his boots" has been a refrain too from some quarters...but hey, I wasn't aware this was a popularity contest. If I wanted to be in one, I could perhaps just have taught a dog to dance...

But then again, prejudice can be of different forms, you see..so the latest one which questioned whether I actually should be doing this as I wasn't "indigenous" did make me grit my teeth. Having dedicated myself to improving healthcare in the UK, having paid all my dues by training right from the basics...a question about whether I am "local enough" is always...interesting. And it did bother me for a day..till I suppose it sunk in that it's probably one of the last cards for detractors to play. As I said...we live in interesting times, don't we? 

Prejudice is about others feeling obliged to make comments..and boy I have faced a few..."how's the spin going?"..."didn't know you had trucks with that organisation too"..."your Consultant group or should I say mercenaries"..."it's not really that good, is it?"....all very interesting, all very spiteful...all very...negative. Time and positive outcomes, not to mention recognition via awards have dimmed the barbs, but It has made me wonder "why"? Is it because it's something new, is it because people don't like change..or is it something a bit more base..something else which has never reared it's head in my career?

Life has a funny way of hardening you up..and thankfully the positive vibes from friends and well-wishers  do outweigh the negativity.  I have an unquenched zeal to make things better....and it will clearly be an interesting battle of the opposites which is likely to be an everlasting feature. 
Penning a document on the role of Consultant Diabetologists in the new NHS....one thought crosses my mind. Am I just a glutton for attracting controversy....or is it an irresistible desire to amend the status quo which isn't benefitting patients?

Time, I suppose, will pass that verdict..."indigenous"...or not. Till then...there is a battle to fight.On a day when President Obama gets re-elected past all the Republican vitriol, playing on prejudice..there has to be...there must be hope.

Thus, to look ahead to the challenge ahead...lets simply quote Dwayne "The Rock" Johnson..."Bring...It...On". Indeed.

Wednesday, October 31, 2012

Civil Wars


A few years ago,Marvel comics launched a series called Civil Wars...which went on to become a landmark series, a benchmark in story telling not only its depth but in the sheer shocking nature of it. It was,simply put, where all  heroes went up against each other. In short, the system of how superheroes were to be monitored was changing and it ended up creating chasms in the superhero community...making enemies of friends..Spiderman up against Iron Man, Captain America against the Thor. Some stood on the sidelines...deciding not to take sides, but eventually all got involved..one way or the other. It was brutal,ugly...but to the readership it was one heck of a read, an amazingly entertaining ditty to sit and be a part of. Sounds familiar at all to anyone? 

2012...the NHS changed, some decided to bravely go where no one had gone before, some vehemently opposed it...but then it all came to pass. The bill got passed and we ended up where we are. Will it revert? Will the NHS be torn apart? Will it be all doom and gloom? who knows..maybe so, maybe not...but somewhere in the middle of all that, well meaning doctors ended up being entrenched against each other. Don't believe me? Read the entries on twitter from well meaning folks. 

GPs sneering against their own colleagues who are trying to make best of the present situation, open apathy, disdain towards folks who have been brave enough to take up the cudgels...all quite disturbing really. I fully respect the views of those who don't like the way the NHS is heading but to suggest all those involved in being CCG leads are politicians in disguise or want more money or simply naive...sorry folks..that's blatantly disrespectful. Don't like what's happening? Fine..by all means challenge the system or the ones who have made the changes...but why the ones who are trying to make things work under the most uncomfortable financial situation the NHS has ever seen?

Maybe I am just biased, just simply lucky to have folks who are Commissioners who are also doctors and are willing to have an open, adult conversation. For those who feel it was all "OK", here is an example. My first meeting as Clinical Director to discuss diabetes services was with someone, who in those days was a lead in Chronic diseases. No medical qualification to boast of..so it was understandable when the person concerned expressed surprise that there were 2 types of diabetes. The problem was actually then refusing to believe this was the case..and putting it down to me trying to expand the diabetes services. A mention of psychology services was met with the comment.."now you need a shrink too?". To be honest, it was not possible to have a clinical conversation with someone like that...someone who was simply worried about how referrals could be dropped without setting up anything else in the community. "GPs get paid enough...let's make them earn it" was this persons parting shot...so excuse me for embracing with glee the opportunity to sit down with a fellow doctor and explain how we could actually make a difference in diabetes care.Dont get me wrong, we need managers and good ones..but their job has to be to manage, not to dictate the health economy..for that you need a clinician. And perhaps the "failing" of the present system is that we have swung from one end to another..rather than trying to find a happy medium.

So we are where we are. Yes, there are parts we don't like, parts we are uncomfortable with, parts with which ideologically lots of us don't agree with...but hang on a second when you say "all was fine". It wasn't..there were some bits which were absolutely crap..for want of a better word. And these guys who have taken up the cudgels...give them a chance to see whether it can be done any better.

This Civil War type of scenario really needs to stop. Specialists are,in a perverse irony, actually enjoying not being a part of it...remember those angry responses from specialist organisation as why they couldn't be part of local CCGs? That clamour seems to have died down...as people have started to realise how difficult it actually is, how difficult it is to plan services in the health economy, balancing the needs of the acute trusts, pressure on primary care, have some sort of accountability over GP practices in their roles as "independent business units", not to mention local politicians and their demands and needs. Want to downgrade a local hospital...try facing the media or politicians...perhaps the same ones who have sanctioned the change in the NHS Bill and have suggested that "more resources need to move to community". So guys and gals...relax and instead of starting to appear like a baying bunch of wolves waiting for it all to fail...maybe step forward and give these folks a helping hand. Rather than saying inane things like "there is no need for a community nurse".. do actually see how that nurse can actually help your practice nurses deliver better care.

I am getting slightly tired and fed up of the negativity that surrounds healthcare..is it simply a British thing or is it an urge not to see anything succeed? The Olympics however have given me hope...this was an event which was shrouded in negativity...but then the sheer levels of success and determination of those athletes made us all believe. maybe, just maybe a similar thing will happen in the NHS..maybe those doom mongers will actually fade into the background...maybe the positive stories will shine through..maybe folks will stop tying to find the negatives in every success story....maybe...just maybe...we will get to a happy medium between managers and clinicians. And don't give me that tosh that these guys aren't committed. For starters they are more committed than a GP who refuses to open his books even when data suggests that poor patient care is being provided or the specialist who believes that the patient should dance to his or her tune..and its all ok to create a wall of inaccessibility around themselves.

I won't tell you how the comic book series "Civil Wars" ended. All  I can say..is that I live in hope.In the words of Martin Luther King Jr.."We must accept finite disappointment, but never lose infinite hope". I do indeed live in hope.

Wednesday, October 24, 2012

A night in Guildford



Driving can be tiring, can't it? As much as I try to be environment friendly, the hassle involved does force one to inevitably turn towards the car..at least one could cut down on the rail delay, check in for airports etc etc. However, deep into my marathon 2 day journey involving Portsmouth, Nottingham, Leicester and Guildford...somehow it didn't feel all that cosy anymore. There was still a last leg travel left, back to the comfort of ones own house,own bed...and many a time on the M25 the fleeting thought passed, considering to take the turn back to Southampton..back to returning at a time when I would be greeted with unbridled delight from my little ones and be revelled with stories of how Optimus Prime would easily beat Ben 10 or indeed the conquests of the school netball team, ably led by their captain.
But no, I decided to soldier on..as ever, a mental note about taking the little uns to see Madagascar 3, an added bonus for them with that extra scoop of ice cream....but Guildford it was at that point. Second year of the Quality in Care awards backed by all the big organisations in Diabetes care, supported by Sanofi..the year before, we had come second in a couple of categories..I still remembered being texted by one of my colleagues about it last year..to which my response had been typically "Partha"...." good, but that means we have room to improve, right?". Still recall my senior colleague smiling back when we met after that asking what exactly I have for breakfast or lunch or dinner!

So could we improve on the year before? As it transpired, we did indeed. A few more awards and it was great to see the team go and pick up the award, beaming, happy, delighted to be recognised...the NHS doesn't say "thank you" enough. More encouragingly, our Commissioners also won an award...maybe it wasn't just hype, maybe the model,we all worked together on, did have legs, maybe it was working...maybe external folks actually believed it wasn't just the razzle and dazzle of Partha..maybe it would eventually provide good healthcare.

And then the other attendees and winners. A pleasure to meet Zoe...someone who has been part of my education on social media, helped me understand what we without diabetes will never quite but perhaps pretend to. It's certainly opened the way for me to try and organise a psychological support service for our local Type 1 patients....simply put, we learn everyday, don't we? There were others, some new faces, a lot of old faces...but perhaps what stood out for me was the team from Derby. A solid team who clearly revelled in each others company, the architects of a fascinating model of care in Derby...and finally much deserved recognition. More strength to their arms indeed! We have been up "against" each other in different award events recently...and someone commented "always you two, eh?" I don't know but perhaps it shows the strength of what we have all achieved locally? If all grand slam finals are competed between Federer and Nadal, it's hardly their fault I suppose. in the tennis world, their presence brought forth a Djokovic and a Murray...if the same analogy is reflected in the diabetes world, it can only be good for patient care...just like one style of play doesn't win you everything everywhere, neither does one model of care work everywhere...local clinicians hopefully will be galvanised to create their own..and that is where the potential of the QIC awards is. Everyone likes recognition and perhaps seeing other centres doing well will act as an inspiring force to do something themselves or even learn from each other. Who knows..we do live in hope, don't we?

And then it all came to a close. A slick event handled by Louise, coordinated ably...it gave the opportunity for the winners and others to mingle, socialise, chat about present politics in diabetes care...Sanofi was out there in force. Altruistic or with a business frame of mind?   I will let you all decide that one. The people I know personally,the Becky Reeves, the Caroline Horwoods....I would hate to think its simply the latter, I would like to believe that the system isn't that corrupted that we are being sucked into this world of outright cynicism...but then again, Ben Goldacres book does make uncomfortable reading, doesn't it?

And then as with anything, there were the stuff that made it just a bit sour..A "respected" person sidled up and opined there was a reason why some centres won awards with a hint of disdain...and left that comment hanging. I wouldn't want to know why..I would like to believe it's due to the quality.
Another gave their view on our model, our service, my style.." was I too big for my boots?", "did I ACTUALLY get along with my GP colleagues?"...and I smiled...Jealousy has to be earned, hasn't it? When the old guard get worried about a 38 year old from Portsmouth..you know that something's spooked them...maybe their safe position as national gurus while their own local services melt away are threatened, maybe they don't like non conformists...who knows...and frankly? who actually cares? As I always say, if the old guard find it difficult to deal with the inevitable changes and the energy of youth, step aside. We are ready to drive the change..get along for the ride or simply put, stand down.I am doing this to improve patient care, not to massage egos, right?

So it ended..and I did that final trip back home..with some mixed feelings..happy at the team recognition, happy at the purpose of the awards, still keeping the faith in Big Pharmas pledge to have changed and sad  about the state of diabetes, the internecine corrosive politics which is in danger of putting our specialty into a self destructive spiral. But thankfully the evening also showed a growing collective of folks who want to make a difference, patients such as Laura, Zoe, centres such as Derby, Portsmouth....and together, we will.

It was with great delight when I walked in late at night to see my daughter still awake...she knew I had gone for an awards night...excitedly asking me.."Did YOU win? Did you?"

It's at that moment, with a lot of pride, I said.."Yes, my princess, WE won. We indeed did".



Tuesday, October 16, 2012

From America..with love


The plane touched down on the sun kissed tarmac in Seattle early evening and we were there. A rag tag bunch of clinicians and managers from four organisations and multiple clinical commissioning groups around Hampshire got together in an effort to learn from bits of the US healthcare system, anything to take back, anything we could adapt to the NHS...and before the detractors go up in arms, no, it wasn't about creating an insurance based healthcare. No, this was a trip to Kaiser Permanente, an acclaimed healthcare organisation in the US, this was a trip to Microsoft to see what we could learn as regards IT system, this was billed as a fact finding mission.

And heck, wasn't it just such an eclectic bunch of individuals. In a health economy built on the principle, or at least nowadays, of competition, there were individuals from four different organisations..and politics and mutual suspicion lurked on the back of the minds of some. Organised by the charismatic CEO of one organisation, was this a genuine trip to learn, was this a trip to work together to improve the local health economy...or was it simply an elaborate publicity gig to convince the payors about the benefit of one organisation above other competitors? A grin crossed my face that I knew pretty much all the key players, an advantage of working with all providers..or as one wit put in "working without Walls". My belief that organisations don't matter, the individual passion and drive does..seemed to be borne out in front of my eyes...and it made me smile. Long way travelled...but a satisfying look back is always allowed from time to time, isn't it?

So we toured the states of Seattle and San Francisco. Got dazzled by the technology in Microsoft, stood and looked with awe at the prototypes of IT in development...and most importantly marvelled at the energy and forward thinking of Bill Crounse at Microsoft. Only young folks have energy and understand IT? You had to be there to listen to Bill explaining the use of IT and social media in healthcare with passion and energy.

We went to different healthcare organisations, visited hospitals of Kaiser Permanente...and ended up being very grateful for being asked to be part of this trip. 3 things stood out for me at all the visits, among all the conversations we had, all the queries we had answered.....firstly, the challenges are not dissimilar across the pond and we, in the NHS, have much to be proud of. We do so much more than what our system can provide...and the NHS continues to and probably will continue to survive on the concoction of hard work, sprinkled with passion and commitment, served with dollops of love.
Secondly, an IT system to die for. We ergo the NHS spent billions trying to create an IT system and frankly failed. what we saw was a clinicians dream. It didn't matter where any health care professional worked, it didn't matter who the patient saw, where, how, why...it was all there on ONE IT system. To us in the UK, it sounds like a dream..to the professionals working in San Francisco, it was a way of life.

And finally..the big one. Yes, there were others to learn from ergo how their general practice worked, how they "targeted" the ones with multiple morbidity, gave them more time, had more faith in their community nurses....but the big one was those 2 dirty words..."performance management". Frankly it was amazing to see doctors willing to be measured against predefined criteria. Somehow in the UK we spend more time defending ourselves as doctors rather than accepting that some of us do not serve our patients well. Any criticism of general practice is met by evangelical resistance from Clare Gerada and others. At no point is there acceptance that things may need to change, not all apples are perfect. Same for specialists..we are all doing a "fabulous" job...really? are we? All of us, without exception?? Do please behave!
All health professional maintain direct contact with patients and colleagues via email and are judged on their response time. Someone like me or Jim Hogan who do that as part of their clinical practice are feted as "visionaries"...we win awards for "being there for the patient". No, ladies and gentlemen, what we do is what we all should do, all should adapt as part of their working lives. We do not make the patient bend to our own lives or it's comfort..we do this job as public servants trying to help those who need it. Are we ready for ourselves to be measured against that? 

I asked what happened if people weren't compliant or were failing persistently. "We try reasoning..then we ask them to leave.You can't continue if you are not serving the patient", said the Chief of Medicine with a gentle yet firm smile. And there it was...how many GP or Consultants are even measured, let alone asked to "move on" because they couldn't deliver clinical based outcomes. Walk into a clinic and the performance results of each doctor is visible, public, out there for all to see....we are far, far behind that. We would rather spend time stating how "incredibly hard we all work and how difficult the patients make lives for us...in fact we need more resources"....The NHS continues to carry dead wood.

And finally, the group or the rag tag bunch of folks who started off as organisational representatives. Those "hard ass" Commissioners out to pinch money, those "conniving" competitive providers trying to take us over ,that "scheming" organisation down the motorway daring to challenge our status...all their representatives...over the week..they all became...just..human..and good fun. I am not experienced or knowledgeable enough to pass comments on the organisations...but tell you what..their representatives all burnt with the same passion...to make things better. We laughed, we joked, we drank..and we also sat and mulled over how we can make things work better for the patients in our economy. People slipped out of their organisational shell..John became the "Integrator", the "Ice Queen" just became Sue, Gethin educated us about the joys of singing ( you don't want to know), Derek slipped into the Silver Fox mode, Jenny reminded why Spider-man was nearly my favourite hero, Jim qualified for dad of the decade...and it was just a genuine joy to have been a part of this trip. I learnt a lot about healthcare, I learnt what we could do better...but most importantly I walked away making a lot of similarly minded, passionate friends.

Can we make this all work? Can we battle the tide and have a sustainable health economy? I don't know....but I do know it won't be for lack of trying. Amongst a bunch of folks with drive, foresight and experience, I ran the risk of sitting out like a novice...but like minded folks always find a way to get past that...and so it came to pass.
Mrs Sarti....thank you for the invite..it's been a genuine pleasure and a privilege.Now for the tougher part...to keep those relations going, work together...and somehow...make it happen. Let's give it a try, shall we?


Sunday, October 7, 2012

The B effect

Long flowing jet black hair...tall, dark, brooding...top button invariably open, sometimes a medallion flashing....Nope, that's not me walking into a meeting or starting an early morning ward round...there was actually one man who epitomised and rightfully deserved the moniker of the "angry young man". He mesmerised the masses...but more importantly, he mesmerised me. The way he talked, the way he sat down, the way he growled, the confidence...I only watched with amazement. I wanted to be "him".

And this week heralds a landmark day in the life of that man..so this blog is dedicated to him. And to be honest.this blog isn't for anyone else to be honest, but just me. In fact, most people I work with, most people I know in the UK won't even understand what this is about. But trust me when I say, all of those I have grown up with, the lads from Bosco, the friends from NRS, my cousins...all of them will understand this one very well indeed...

His name was Amitabh Bachchan and believe you me,he was a GOD for all boys growing up in India. There wasn't anyone bigger than him, there wasn't any other movie star you wanted to ape. The Bachchan of Don, Laawaris or even the latter day Agneepath was just something you watched and aped in your daily life. Were there better actors? Perhaps. Did I care? Not a jot. And I always dreamt of being that persona...the quintessential anti-hero, never backing down from the establishment, the dark hero with the heart of gold...surely celluloid could be replicated in real life? For those who don't quite get the magnitude of his popularity, take Clint Eastwood, Sly Stallone, throw in Tom Cruise- all at the height of their popularity and then for the younger crowd, add in that Vampire chap who definitely seems to have mixed up his celluloid and real life and why not throw in that Bieber chap too...now add that altogether and multiply by ten. What you have is what Amitabh Bachchan enjoys in India...even on his 70th birthday.

And then life happened...those days of bunking school and college to make sure you were there for the first day, first show...passed on. Exams, career took over..and I arrived here in the UK. I started work in the NHS..nervous, trying to make a mark...slowly gathering knowledge..everyone always told me to "fit in".."remember this is a foreign land..don't upset anyone"...and so I tried. Soft spoken, always careful not to annoy anyone.Different from the swagger of Partha Kar in those heady college days... Till a day in the canteen of Worcester Royal Hospital.
A particularly bad day at work, a usual back breaking shift of a junior doctor..and I had gone down to the canteen to get some "lunch"...5 hours post "scheduled time". There was a queue..but I trundled up to the counter with a sandwich, hoping I could just buy and run back to the wards. The response?.."Get the f%*k in line"...and something snapped. With a growl, I came out with this sentence.." The line begins...from where I stand". It was an immortal line uttered by Bachchan in one of his movies..and that line from me dripped of arrogance and cockiness..and was followed by instantaneous regret.....but something magical happened that day..the man in the counter backed down.

And the story began..the ultra cocky, aggressive Partha Kar was born. Life since then has taught me many skills, taught me when to hold back, when to use charm...but the start of something magical was down to that celluloid hero.Today, due to fabulous colleagues, a lot has been achieved. A lot of recognition nationally- but my character has developed and adapted, but still maintained shades of the celluloid persona..which I have revelled in. Don't believe it? Watch this and this...and make your own mind up :-)

Sounds ridiculously silly in hindsight...but the long hair, the growl, the swagger is me still being or enacting out the dream of being Bachchan. I am 39 soon..but the teenager who loved the Big B has lived on. I am a Consultant in the National Health Service in the UK...doesn't mean I won't have fun while doing it.

Dear Mr. Amitabh Bachchan..a very happy birthday to you, sir...it has been a pleasure growing up with you.



Thursday, October 4, 2012

Lightening rod....

“You just are paid too much”….if only I could earn a penny the number of times I have heard this nowadays, sometimes in jest, sometimes with a degree of malice..I would perhaps genuinely be able to live the lifestyle all these folks think I actually do. But its' come to pass..Consultant salaries are now fair game. We get paid "too much"- a common refrain…the more the financial belts tighten, the more the mind has got focussed, the more the rhetoric has been drummed. The Consultant salary suddenly seems to have become the lightening rod to criticise, to target. The one to be responsible for the financial woes of the NHS.
It’s an interesting argument..in an NHS where a significant portion of cost is behind salary and Consultant salaries are one of the highest, you perhaps can see the argument. The problem however is that it’s an agreed national contract and payment is per that. Cynics would say that the contract was “wrong”,”too much was paid”…problem is we are where we are and any attempt to break out of that (have a look at the “South West Cartel” trying to break away from national contracts) have so far bitten the dust.What's ahead? No body knows.

So what about it? Are we actually paid too much? Well, the problem as ever is not cut and dry. A vast majority of Consultants argument has been that if we actually stuck to the contract, the NHS would have been far worse off. Lets take my example- I get paid to work 44 hours per week. Factor in the weekends and on call work- and during a working week, I am actually supposed to work for 38 hours. Simply put, that’s a 9-5 job Monday to Thursday and 9 – 3 pm job on Friday..yep, an early finish on a Friday indeed. Problem is I have clocked myself doing,over 3 consecutive weeks, 54; 62 and then 54 hours…free service to the NHS on an average 10-12 hours per week. I would LOVE  to do a 9-5 job 4 days a week and an early finish on Friday…its just that my job doesn't allow that. Ah..but I have also heard that I am not an "average Consultant” (whatever that means)…again we have a problem. Actually the majority of people I know actually do that, if not more…issue is I am vocal about it, the majority does get on with it, shrug their shoulders at the jibes and carry on with a cynical, albeit rueful smile. 

However,as ever, and as with anything else, we have our bad apples too. I have also sat with folks who feel they are being paid "peanuts". Seriously?! A six figure salary on a public taxation system and that’s peanuts? No sir, you just need to cut your cloth according to your demand…stop aspiring to drive a Bugati..you are not a Rock star .you are a doctor. In this present climate, be very careful of statements like that...Bob Diamond once said he wasn't paid enough..the rest is history.
I will be honest- I get paid well but believe I work and earn every single penny of it too. At no point of time will I say I am not getting paid enough…issue is those individuals who spout the nonsense of "not enough pay" taint the rest of us…make us the “Bankers of the NHS”..the fat greedy ones.

And then there’s the ones who clearly are working less than what they are paid for…the ones who claim they are “teaching”..while simultaneously doing their private work. A tiny dishonest minority who mar the reputation of all, damage the credential of the “hard working Consultant”. A tiny minority who need to be challenged and frankly asked why they want to continue working for the NHS or indeed at the same salary. THAT is the job of management..find them, challenge them..and indeed they do not deserve their salary. But please do not use a broad brush to say the majority do so. I would be first in that line to challenge them- and would be keen to make sure such folks who do mar the reputation of the average hard working Consultant is actually shown the door. Want to earn more privately? Go forth and prosper...just don't do it at the same time you are being paid on a public taxation system, eh?  

To any trainees in medicine and folks who are new to the job.. and is reading this….a personal appeal. Don’t ever be sucked into the mindset that the salary isn't enough..it is…just make sure you earn every bit of it. Take the title away, take the pizazz away, take the accolades away…remember you went to medical school…to help get others better. 
Don't cheat the system..we are the new generation who can redefine the reputation of a Consultant..so lets go ahead and do it. Just stick to those principles…and no longer you will be a lightening rod for critics who look at your salary with envy…but will be someone who will be respected for what you do. 
Trust me..been doing this for 4 years now…it has been a privilege to be able to serve. 

And oh yes, do it with a smile on your face. It's worth every single minute (or penny) of it.

Wednesday, September 26, 2012

A ninja..and a hero


"Rewarding our health heroes"…that’s what the local newspaper said..or perhaps was the tagline of the awards ceremony. It was an amazingly lovely surprise, when one learnt a few months ago, that I had been nominated by one of my patients, Laura Cleverly who had decided to give me far more credit than I have ever been due. For sure, she is a “changed” person, for sure, she is engaged with her diabetes and is trying her utmost to deal with it, for sure she is a Ninja..the creator of Ninjabetic…but to credit me for that, albeit heartwarming, has always come across as more of a disservice to herself. Its not every day that someone manages to pick themselves up and turn their lives around. To me that shows amazing self belief and a never-say-die spirit, which is only worth applauding and appreciating.

Came the big night and I sauntered in, wearing a suit..continually adjusting my tie. Hate those noose like things….I always thought they affected my coolness…but it was a black tie dinner. Ho Hum..sometimes I suppose you do have to conform! And then the awards ceremony started…we went through a gamut of awards- community team of the year, ward of the year, pharmacy of the year, GP surgery of the year…but what touched a chord was the “Unsung hero” of the year. Someone had nominated the chap who every day religiously made sure the hospital grounds were clear, clear of the cigarette stubs in front of the No Smoking signs of the hospital..that ever present sign that public awareness messages are still not fully successful. But it was nice to see him recognised…and when Fred Dinage, the compere of the evening asked how he felt..his reply was simple but true…”Happy, but just doing my job”…ahhhh the NHS…continues to battle on with significant amounts of hard working, non complaining people topped up with oodles of passion for their jobs and dollops of love. Carry on working folks.

And finally, as if to showcase hierarchy still existed well and truly in the NHS, the hospital doctor award came up right at the end...billed as "the big one"..or maybe it was a sign that doctors..still..inspite of all the negative publicity, still held a special place in the heart of the general population.
Up went the runner-up…and then all I heard was the word Winner…attached to my name. Rest was a blur..remembered walking up on stage (was my tie ok?) and accepting the award. Chatting to Fred…answering his questions with something clever and humorous….but admittedly was a blur. Spoke to the local news Health reporter, Priya Mistry, about what this award meant to me…and it was done.

As I sat down in my chair, it sank in…320 odd Consultants in my Trust and a patient nomination had won me the top prize amongst them. And I felt something I rarely do…a whole lot of humility. Closed my eyes and thanked all those who had stood by me, supported me during these years…my wonderful team with whom I have such a pleasure of working and that silly girl Laura for thinking I even remotely deserved this. So many more challenges in front, so many to cross…the instinct was to say that others deserved it, I had much more to do..and I know for a fact that there are far more hard working Consultants than me in the Trust, far more dedicated….but this I do humbly..accept. 

I never set out to be a Hero…my persona, inherent arrogance, penchant for staying outside the tramlines makes me a perfect fit to be an anti-hero…never a hero.I aint any hero.... But its heartwarming to know that I have helped to change someone’s life..and frankly, not many of us get the opportunity to do so. This isn’t “just a job”..this is my life, my passion..and to be recognised for that is extremely appreciated. Thank you to the Portsmouth News for organising the event and it’s a big tag to live up to. I can’t say that I can help everyone, I cant say I will succeed always..but for sure I will give it one heck of a try. As Groucho Marx said “I intend to live forever, or die trying”. And with ninjas standing by my side, it's going to be one hell of a ride.

Thursday, September 20, 2012

I will miss you

Sometimes life has a funny way of giving you perspective, doesn't it?

10:01 am...an email arrived in my inbox this morning. Still vividly remember the time..as checked it in the hope that it was a spam email. But it wasn't. It said Niru Goenka had passed away. Everything I was planning for the day, everything I was hoping to do, the new battles for nurse hours...just went into suspended animation. I had to read the email again. And again. Please..must be a joke? An inappropriate one? But it wasn't. It still held out the haunting message, still held out the same message which just gave me an awful feeling. Niru Goenka?? He was just a few years older than me..what the heck,,,but it was..alas..true. More messages poured in..and it was true, one of the brightest lights of diabetes care in this country had gone out. Just like that.

I wish I could tell you reams of stories of how we spent nights together drinking, chatting...but I can't. Niru was a friend but not a close one. 2004  was when I first met him..I was the Chair of the Young Diabetologists..and I remember bouncing into this Asian chap, a face full of joy...walking up to me..and saying what a great initiative the YDF was..and if I ever needed any help,"just ask" is what he said. Over the years, I have met Niru multiple times, listened to him speak, read his articles but for one reason, he will always be special to me.

I have always mulled about sharing this with the wider world, wondered whether this was too personal, too dark..but maybe today is the day. 2012 March..a very difficult time for me professionally..and possibly the most I have ever struggled...struggled with losing friends, senior and junior Consultants taking sides over certain issues, feelings of betrayal, anger, being lonely and the more the situation escalated, the more it burnt me. I had enough...and I was ready. Ready to create a new enterprise of "Young Guns"..and there was no one I was ready to listen to. I was Partha Kar..once my mind was made up...I had never gone back...never walked away from an enterprise. To hell with the old codgers, to hell with the ones who had turned their backs...I was going to forge my own path. 30 young guns signed up..all ready to press the button. 

And then one evening my phone rang. It was Niru. A long chat ensued..I vented..I shared my angst...I talked to him about betrayal....I had had enough. And he listened. And at the end he said a lot too..and finished with these words.." The future is ours Partha..why create something else? Lets get our own patches sorted..then we can tell the rest what to do. You know we can do this together.Trust me on this one. Let it go. Put your energy somewhere else". And I don't know why...but I listened to this calm , sensible fella...for the first time, I stood down. And just like that...I was at peace...with myself, peace with everyone else. Niru Goenka had somehow, just with his words, done what so many had failed to do. 

I never knew Niru that well..but I have yet to meet anyone who didn't like him. Universally liked and loved is a clich├ęd term..but for Niru it was so true. A wise head way beyond his years, a gentle soul with a passion to improve diabetes care which burnt through and someone who was dedicated to improving training...he was special. 
I wish I got to know him better. I wish I had the chance to work with him more. I wish so many things...but right now...I wish and hope..that wherever he is, he is at peace. Never got the chance to say it, Nirupam Goenka...but thank you for that evening which meant so much to me, helped me grow a bit more. I am sure the whole diabetes world will miss you...but right now, while writing this blog...I miss you, my friend. Rest well x

Saturday, September 15, 2012

The impossible debate


Its nigh impossible. Actually correct that. Its impossible. Its impossible to anymore have a rational discussion about the NHS. There’s very little room for manouveur..its either, as a tweet from a colleague mentioned, a jewel in the crown, a national heritage, something to be proud of, nothing should be changed..or its absolutely the pits needing a complete overhaul.

The reality,as ever, continues to be somewhere in the middle. It is, have no doubt, a fantastic institution, built on sound principles…but it doesn’t provide high quality care everywhere with the same level. Some of it is down to variation in quality of staff, some of it is down to lack of patient engagement and a lot of is down to finances. A mature adult debate about all those issues seem to be impossible to have and we continue to duck them, continue to be blinded by facts, continue to be sucked into politics with the NHS, as ever, being a lightening rod to attract polarising views and opinions.

A question about variation of quality raises hackles of many…we all feel we work the hardest..but read any patient blog, they are full of as much praise as much as criticism..different staff, different attitudes. But we struggle to raise those issues in public..we struggle to debate them, simply shy away from them, wrapped away in the theme of “we have to work together, we have to go forward together, we must not upset anyone”…to me…that’s a fudge..we “work together” to make patient care better. If there is genuine evidence that someone is not working hard enough, providing poor care consistently, then sweeping them under the carpet is not about “working together”…this isn’t a childrens party where we must get all the kids to play together..this, last time, I checked, was far more serious- and we must be able to debate that.We must be in a position to challenge that and stay true to the core of improving patient care...and if that upsets a few poor performers, so be it. When was the last time you saw Alex Ferguson be afraid of throwing a player out who did not perform well or wasn't part of the team's ambition to be the best?!

What about patient engagement? Now that’s a sacred cow..which we again, struggle to discuss. This is an amazing healthcare system based on a public taxation system and sometimes when you have so much, you tend to forget what benefits they bring. When a patient doesn’t turn up in my clinic and I ask them next time why…a shrug of the shoulder accompanied by " had other things to do, doc" makes me sad. It makes me feel that I could have given that slot to someone who genuinely deserved it and heck there are plenty of them out there. It makes me think of places where I have worked, such as Calcutta, where a patient would sell their belongings to have a chest X ray done, it makes me think of my time in a village in West Bengal where the only drug available for chest pain is paracetamol. We have so much in this country and yet we choose to abuse it, choose to shrug our shoulders. Diabetes UK,the bastion of patient group in diabetes care, has recently shown data mentioning that 60% of patients haven’t hit theor cholesterol targets..accompanied by a statement saying that most GP surgeries though have hit their "targets" which results in payments to surgeries. Sure, thereby opens the debate about the fallacies of performance based payments, sure theres something not right..but what about the patients who don’t take their tablets? What about the group who turn up in clinic and say that “diet isn’t their thing?”. Is it always the healthcare professionals fault..is it always about the right information not being passed on..or is it sometimes about an adult patient making a conscious choice not to follow the advice given..as that the decision they have made? Again, a debate about that is impossible to have..as out of the woodworks steps the evangelical patient groups…I have no problems with them..but come on guys…a sensible debate and a bit of reality check too?

And then finally, the biggest of them all...finances. The fact is that there isn't enough space either in the community or in the hospitals for an ever increasingly ageing population with multiple morbidities, a population whose expectation continues to be fuelled by what they read in the papers and doctors in hospitals heading towards specialism with primary care left holding the baby in most cases. Here's an example, Dan Poulter, a new entrant in the Health Ministry team, a doctor himself, recently said that hospitals weren't on the brink of collapse as most hospitals were running to 85% occupancy..and the NHS had enough beds to cope. Well, Dan..I don't care about politics...but...mate, man to man, doctor to doctor, join me on my daily ward rounds, when I am covering the wards, spread over 11 different wards..and if you find one patient, just one, you can discharge quicker than I can, with existing provisions in the community and most importantly safely, I will work for free in the NHS for the next 3 months. Promise. Scouts honour. I am one of the quickest guns as regards discharges go...and on a daily basis, I take a calculated risk..on a daily basis, I inwardly cringe at the pressure I am putting back on my primary care colleague..and then I hear that it isn't about the resources. Lets stay away from politics on this one, shall we?

Come on fellas..come on you folks who understand issues better than me...why not contemplate that we don't have the resources to offer everything at the same level of quality all around with the same money available? Or at the very least have a sensible adult debate about it? But alas, we can't. I keep on hearing words such as inefficiencies, cost savings, productivity, innovation...which at the end of the day sounds more like doing the same thing, perhaps even better...but with the same finances..or less. 

Of course, the majority of professionals are hard working, of course there are patients who miss their appointment because the letter ended at the wrong address..and of course there is wastage in the NHS which can be minimalised...but at some point..after you iron out all of those..there simply just isn't enough to do everything. Or at least, that's my view. Can we at least raise that issue? Can we at least debate that? Can we at the very least raise those topics...touch upon those sacred cows..or do we wait till it's all reached the point of no return? 

Or more worringly...are we not debating those..because we are already there?

Thursday, September 6, 2012

I am special

"Is there any blood anywhere"...drawled the person at the other end of the phone. "Sorry, what blood?"..asked I, an SpR in my second year, 2 am in the morning, slightly puzzled why the Consultant physician on call was asking me about blood when I was trying to discuss a case of meningitis with him. Maybe there was something obvious I had not done?  "I said..is there any blood anywhere"...this time..the voice clearly had a bit more menace, a bit more edge, a bit more growl. Far from the Partha Kar version 2012, I mumbled.."Ermm..not really...why..?". The answer that followed is still imprinted in my mind..." I am a gastroenterologist...don't phone me if there is no blood"..followed by a slam down and the lonely dial tone purring away. I looked at the phone...pretty much mocking me...turned around to see a friendly Emergency department Consultant. My face must have painted a picture, as she, even in the middle of an uber busy department, stopped..and asked me what had happened. I related the incident..she smiled..gave me some much needed advice..and before walking away said 2 things..." You know there's not many generalists left any more...and by the way, your Consultant..he is actually a good doctor..he's just a bit special". The first bit I didn't quite get at that time...(I mean..come on...surely we are all physicians?!)..the second bit was odd as somehow it made the fact that a Consultant didn't support his registrar "all ok".

Fast forward to 8 years later...and the NHS, as we still call it, is struggling. Reports are pouring out suggesting we need more generalists, better trained general practitioners as unfortunately as much as we would like to, the patient coming in through the door rarely has one pathology any more. The "olden days" used to have general medicine clinics, general physicians..the ones who use to "specialise" in having the bigger picture, the ones who could join the dots, the ones who could come up with the clever diagnosis.

And then specialism happened..properly. We all became specialists..doing only a little niche, little else. The Cardiologists left general medicine, no longer were they dual accredited..they only looked at the heart. The dealt with heart failure but if it was due to a pulmonary embolism, it now had to be the Respiratory physicians issue. If by chance, the patient had a minor bleed secondary to the warfarin, they had to be seen by the Gastroenterologists, if, heaven forbid, their blood sugars were high, call the diabetologists....and if they had anything resembling silver hair, it would be a travesty if the elderly physicians weren't looking after them.

So what the heck happened to us as physicians? I take my hats off to Medical Assessment Unit colleagues who still do and understand general medicine but are being reduced to triage doctors due to the incessant pressure of either discharging them or moving them to another speciality. But medicine isn't that easy...not everyone fits nicely into a category, a pre defined speciality, do they? The patient sits and watches while physicians argue and debate abut who they can see, who they cannot...while time ticks by. Consultants face off against each other like big beasts in the Savannah battling over a waterhole...while juniors walk around looking embarrassed, awkward..not sure what to do.

Lets look at the "moral" argument. For once, if we stand back and accept that we are ALL physicians..then maybe it would be easier..but nope, that would be perhaps far too complicated. I have no problems with anyone being a super expert..but that shouldn't translate into one forgetting the reason why they got their degree in medicine. For sure, there is specialist training, for sure no one can "pop a tube down the throat" like you do...but does that preclude you from forgetting how to treat something that doesn't fit into your chosen niche...say...cellulitis?
How about the "money" argument? Well..how about this...most physicians  have been trained in their speciality AND general medicine. Did they get paid while they were doing their training? Well, of course...and a tuppence for guessing who paid them to be trained in general medicine along with their speciality. Correct..that would be the taxpayer. So in that case, let me ask this simple question...when someone "not quite in your speciality category" comes under your remit but has a general medical problem...do you walk away saying "I am special"..or do you apologise to that patient for wasting their taxes, which were spent on training YOU to learn about general medicine too?

In super hospitals or big regional training centres, absolutely 100% there needs to be super specialists. Don't get me wrong, I don't want a cardio-thoracic surgeon to be dabbling in gall bladder surgery, I don't want the ace pituitary Endocrinologist to be looking at a DVT...I would rather they saw, diagnosed and treated all the tertiary, complicated referrals they have as a centre of excellence. But for District General Hospitals?? Please..do give me a break. Be a specialist in your outpatient clinic, be a specialist on the wards too...but for gods sake, don't please say you "don't do anything else". Its dishonest to your own training, its dishonest to the public who have paid for your training. And believe you me, it will help a lot of GPs to know who to ask an opinion on the person who has multiple pathologies rather than make 4 referrals for 1 patient.

I have said this before..and I have no qualms about saying it again...who looks after that old lady with multiple pathologies who doesn't fit into a pre-defined speciality category? The answer isn't "lets play a game of poker to see who blinks first and accepts the patient"...the answer is all of us, as physicians do. The ability to do so is what makes us "special"....Or maybe Chuck Palahniuk, author of novel Fight Club had the right idea..."We are not special. We are not crap or trash, either. We just are. We just are, and what happens just happens". Maybe its time for us to stop taking ourselves so seriously...and just do what we are supposed to do.Now that wouldn't be a bad start, eh?