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.