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.