Saturday, December 28, 2013

2014 beckons...To change or not to?



You pause at landmark birthdays, don't you? Or that's what the world would have you believe. Time for a different Partha, a different focus? Maybe mellowness with age? At 40, stepping into middle age, is it time for shifting gears? As I sit here and reflect over the last few years, the answer to that does become obvious.

So what has time taught me? A Consultant post in 2008 followed by widespread joy and adulation...5 years later, even in my wildest dreams I couldn't have imagined the distance that has been travelled and the experiences gained, the lessons learnt whether it be via social media or in real life...and my personal learning points? As below....

Empathy and evangelism: The NHS has had a major cathartic moment via Mid staffs, Francis report etc and has brought forward a degree of empathy on social media rarely seen before. Evangelism towards this particular trait has been breathtaking...as if the NHS never did empathy before..lots of Consultants, nurses from the past have only held a wry smile. Empathy is something we learn gradually about but you know what..it is damn tiring to do so 24/7. Somewhere in the middle, lots have forgotten that HCPs, as anyone else, are human beings..same foibles, same passion, same problems and for many, families getting sacrificed at the altar is not an option. Does that make them a less empathetic person? No, it  doesn't.

Power and Influence: As one of my good friends recently said, the present currency is not power, but influence. And my observation? Official high ranking posts are now subject to so many rules, regulations and targets that good people end up doing things, getting involved with issues they would never do otherwise. I know so because they are different individuals when they are free from the trappings of such roles.And that's not for me...change can be brought by influence and that is where its at. Some existing targets are simply meaningless but we persist due to political expediency and beyond our control to influence.

Money and practicality: There is a surfeit of folks willing to work differently. At the end, sorry folks, but the money has run out. Yes I know the Clive Peedels and Jackie Davis will tell you how not having transactional costs would save money, how not having the Trident would help the NHS...the reality? Thats beyond the realm of control of folks like us. They are political issues which at the moment don't look like getting resolved. So let me put this bluntly, the system has, as things stand, run out of capacity. So an honest dialogue with patients is where its at..when there isn't a service available, It isn't because the doctors/nurses don't care or the CCGs are evil people just saving money...they simply don't have enough money. Everyone knows it..we just don't know what to do about it any more. Roy Lilley has been talking about it since I first met him..in 2009.

Leaders and credentials: An explosion of leaders seems to have happened..unfortunately not without much credentials. Lots of talk, lots of meetings, lots of lectures, opinions...but dig deep, these leaders have just moved around from one failing project to another. A good speaker and some funky PowerPoint slides does not make a good leader I am afraid...I recall going to a meeting a few years back on 7 day working when a Consultant stood up as a lecturer and passionately said how important it was to provide 7 day senior cover. Problem? I was his house officer once upon a time and his contribution to the wards in those days? At best once a week. 

So you know what? Here's what I will do in 2014....give 110, maybe even 120% at work..but outside that, even if I have 1 extra hour, its for my family..As a friend said...."Because in the end no one ever says they wished they had 1 hour more for work but many wish for hours with those that matter most"

I am very fortunate to be in a position where I am....a Consultant working across an acute trust and 2 community providers, across 80 GP surgeries and its been an education, building bridges, appreciate all the pressures and you know what? There's no course that will teach you that level of mutual respect between primary and specialist care. It gives the chance to build influence and I have some big ideas, presence of some like minded individuals..it could be quite exciting, Who needs national documents when you can forge your own way? 
And finally? Have honest conversations with patients about where things are as regards money but try and work within the system to see what can be done. Example? Patients complained about lack of diabetes input ver weekends, we worked with Commissioners, used existing Best practice tariffs..3 months later..we are there..thanks to all concerned working together. 
I have spent a significant time listening to leaders talking, debating and then as a unit, we went ahead and created a new model of diabetes care. After being involved in 130 odd CCGs so far all looking at fundamentals of our model, we know what we did was the right thing..to take that jump, stop waiting for a national document...sometimes you believe in your team, believe in your vision and take that step.  

So...why change something thats worked? Fight passionately for patients, look after your family and work with like minded colleagues to effect big systematic changes but within the present financial margins. Exciting times ahead locally....and I am positive we can make some fundamental changes...though appreciate at some point, the systems capacity problem will bite. 

So 2014....Partha Kar has no intention of changing at all...mellow down? Pfft..it's time to shift up a gear. Ready or not...this could be interesting. Lets get down to business, shall we? 

Tuesday, December 17, 2013

Game-changer VI: Make it happen

"Do you think you are ready to go home?"....a cursory question on the wards whilst on the quest for early discharges was met with a mumbled "Yes, sure". Something wasn't quite right...a few more questions dug up the once proud police officer now living in a bungalow looking after his bed bound wife, riddled by stroke. This was his fourth admission over the last few months.."just a fall" murmured the elderly gentleman....adding "I am really trying, honest"...as his eyes moistened, at the sharp end of the NHS, all those powerpoint presentations seemed a million miles away..all those evangelical, buzzing leaders who told us that things were getting better seemed all a bit..false.

There had been no lack in this gentleman's care...multiple involvement from multiple professionals of multiple qualifications...just nothing joined up, all working in their silos, trying to meet their organisations targets and satisfaction surveys. Was he happy with their services? Of course he was..but no one had asked him whether society had repaid him, no satisfaction survey with the system.
It hurts me, especially as I am one of those who tries to live in optimism, tries to create a bubble where at least for a bit it seems ok..and then you walk into the daily grind and the bubble evaporates just like one of those recurring dreams of El Dorado.

The system needs boldness, the system needs big decisions..we all know it,we all talk about it..and then we walk away from it. The debate about the NHS always seems to degenerate into an idealogical sparring while honest conversations rest in the background.

So you know what...it's time for the CCGs to step up to the plate..I have met enough to know that these bodies are filled with honest, caring people who want better care..so I suggest go for it, be bold. Commission services which patients need, make providers work together..you have had your time to bed in, be the nice guy..and by now the basics of what healthcare needs should be apparent.If not, go and find out what works where and stop reinventing the wheel. Beg, borrow or steal a pathway, a specification which has or is working, make local tweaks if needed, genuinely involve patients in it and then ask the local,providers to deliver. If they don't want to, ask them to explain to patients why they can't or won't.


Be bold, take the step forward, make all the organisations work together to  what YOU want. An analogy?When you want to build a kitchen, you don't sit and negotiate with a builder why a toilet would be better. If you need a kitchen, then that's exactly what you need....to GP leads..you wanted power? Go on, show us what you are made of. I am sure plenty will wish you Godspeed. At least then that retired policeman, to whom society owe a debt, will go home, safely

Friday, November 29, 2013

Gamechanger V: Training....where's the patient?


It's simply astounding how disconnected NHS structures can be, how poor future workforce planning can be, how out of sync training can be with modern healthcare demands...there seems to be a lag period..and by the time training curriculums catches up, the NHS and its healthcare needs have moved on, the priorities have changed, the needs of the patients have change.
Lets start with this new fangled love all policy makers now have...it's called "Long term conditions".No longer is it about single disease such as diabetes, COPD, heart failure but no, as the patient has multiple comorbidities, we need to have multiple disease specialists. As a plan? Fabulous. Execution? Not surprisingly....slow. Why? because immaterial of how you brand it, that "multiple disease specialist" a few years back used to be called the general physician. I still recall doing general medicine clinics...all disbanded gradually as we needed to champion specialism. Who used to come to those clinics? Yep, you guessed it, patients with multiple problems, and a GP asking you to join the dots together, get a few disease processes sorted in 1 go. Now as time has phased, and finances squeeze, sending the same patient to a diabetes clinic, then a heart failure clinic and finally a COPD appointment doesn't look right, either from a patient experience or a financial one.

So where do we find these "long term conditions experts?" I can assure you they are a rare breed in the hospital, in fact as lots of junior doctors will testify, early mornings are spent trying to cherry pick specialists patients and wondering who to hand to or grumbling about the "general medicine patients" on the list.
So where are these specialists? Have we now managed to narrow them down only to elderly medicine physicians, the only ones who still look at the patient as a whole? But we only have so many of them..and the demand for them grows exponentially every day. Is it then the GP who does this role? Then again, the pressure on time for them is well documented too. Thus as evident,we have problem with the present...but a bigger problem brews with the future.

We are planning these models but training still is delivered in specialist silos. Long term conditions? Don't be silly. It's only about diabetes, only about heart failure.General Medicine training? You learn what you do on the wards, attend a few conferences, try your best to get to a few regional training days but always takes second preference to your own specialty..not always due to choice of the juniors but also pressure from their own Consultants. It maybe the priority of the Policymakers and even the patients, certainly not in the training cycle though.
Another example? End of Life care.  I read about Elin Roddys passionate plea to improve this area and with an ageing population, multiple morbidities, increased malignancies..he need to have the skills or even the mental inclination to spend those extra minutes with the family and patient is paramount. what about training though? Is it responsive to the needs of the patients? Is it adapting to the changing population?

So what can be done? Forget the present for a minute and invest some time in the future. There is little point in talking about models for which we are not training our juniors. The Royal college of physicians talks about how they want to bring general medicine back...my suggestion would be to stop talking in waffle and actually get something robust in place. We have specialties who duck out of any general medicine commitment as they don't have   General medicine accreditation. cardiology is a prime example..and Gastroenterology is  trying their utmost to follow suit. I know so as the local college tutor as the cardiology trainees don't attend sessions on end of life care, COPD management...as "there isn't a training requirement". Not their fault, just pressures of time make them choose appropriately. The sadness of that is compounded by the fact that in my training years, some of the best general physicians I met were actually cardiologists. Up and down he country, those who have been left to pick up the baton of patients with multiple problems ( cue Respiratory physicians, elderly medicine physicians etc) feel the heat of this, day in, day out and ask for all to share the load but unfortunately training continues inexorably targeting a single specialty disease process.

So want to change the game? Then tackle training NOW. Do we need more single disease specialists? Debatable. Do we need more up skilled GPs, do we need better trained practice nurses, pharmacists...well..that question is on the same level of is the Pope a catholic? If you want better general physicians or multiple disease specialists in the hospital, then make it mandatory part of training and job plans, not an option. Stop waffling about with polices and do it. And if you don't have the muscle or know how then come to the conclusion that we need more elderly care physicians as long term conditions specialists, up skill GPs and give them quick, fast access to single disease specialists.

Maybe we need to accept that we need to invest a lot of education money into upskilling GPs, use the fourth year of training for targeted LTC training rather than continuing as is...maybe its time to invest in training of specialists to be educators, develop the importance of being there for primary care as a support...how many trainees are specifically taught about teaching skills? Accept elderly medicine physicians are turning into the last bastions of general medicine..and train appropriately rather than force folks to do something they don't.

Either way, a fundamental change needs to happen NOW. No more time for endless meetings of educational gurus mulling over nuances of the curriculum, we don't have the time left for things to happen 5 years later...while the patient needs have changed now.

The worry I suspect is that as trainees we saw this coming 8-9 years ago when specialists started to pull out citing their super specialist skills...the rot had set inside the hospitals..and now its cascaded to the wider community. You reap what you sow...and in case you do want to tackle the future and the multi morbidities conundrum ( which incidentally I see as a success of the NHS way of working) then the time to act is now....Royal College of Physicians/ Health Education England..are you listening closely enough..and more importantly are you ready to tackle the issues head on?
I am sure there are a lot of physicians with a wry smile looking at this attempted resurrection of the general physician in a new garb. The circle of life is nearly complete.

Wednesday, November 27, 2013

The perception of reality


A break from the Game-changer series to reflect on something from last night.Twitter can be so amazing sometimes....one minute you are debating whether the NHS deserves an ideological shift, the other moment you are talking about the importance of early diagnosis of cerebral haemorrhages followed by in depth analysis of the latest slant on the eponymous Spider-Man storyline. And then again sometimes, you just be a voyeur and read some tweet threads.

Recently I sat through a fascinating thread where a few general practitioners debated the importance of public relations. I suspect on twitter we do have a self selected group who may not necessarily represent the vast majority but then again it does offer a sneak peek. Differences of opinions on this thread line were evident followed by one concluding that we shouldn't waste our time on such issues.
And even though I didn't jump in, I had to disagree. In the world we live in, like it or not, perception is key. A shrill continuous banging of drums opposing policies gets you pretty much no where. Let me give you some examples...for starters the Liverpool Care Pathway. We had twitter in an absolute meltdown and all of us who deal with End of life care felt this would not be beneficial. But instead of countering media versions, lots of folks went on the rhetoric, made very valid points...but in the end? the LCP doesn't exist any more. Recently a ward round drove home to me what we had lost...or more importantly what the patients had lost. As a profession we should have done better,we should have opposed the media with charm, our own public relations offensive..we didn't...we decided to depend on the rhetoric,pour out our emotions...end result? No one lost out except the patients and their families who deserved it.

Now let me give you the opposite example..in fact two of them...where good publicity, branding has helped to emphasise something which is so basic but yet so important. For starters, the 6C campaign...I will admit I was among the few who rolled my eyes at it. "Compassion"?? "Care"?? Why would you need to emphasise that? Surely that was fundamental to what nurses do? But over time, it has caught the imagination, it has focused the mind on something basic yet so important...and as the Julie Baileys of this world to ensure  will attest to, somewhere down the line, the basics were lost..so if it needs a catchy name to reclaim the ground, so be it. If thats what's needed to make a nurse stop for a second and get that glass of water closer to the elderly lady, then 3 cheers to branding, publicity and a charm offensive.  

Another one? Kate Grangers "Hello my name is....." campaign.Simple yet effective. Now I have had corridor conversations with colleagues who have found this campaign odd.."why is this even a campaign?", juniors who have felt this to be a stunt ( till they read and learn a bit more about Kate) but there is no denying its impact. It's the basic tenet of a healthcare professional, shows the ability to interact, be compassionate...and again, this campaign for sure has focused the mind on something inherent which somehow has been forgotten,somewhere in the mix lots have indeed forgotten the basics of human interaction..introducing yourself with a smile. Impact of branding and perception? Absolutely amazing.

So back to the concept of perception. Beating the shrill rhetoric of "hard working GPs", "there is no money", "we only live for the patient" maybe indeed your own personal preference and admirable practice but thats not representative of everyone. For every ten amazing GPs, there is also one who has the bottom line of his finances in his mind, who makes pride in the business and profits he runs..I have met them, shared a beer with them. Are they less caring? Not necessarily but neither are they on twitter saying they like their profit margins too.
So..suggestion? Be open, launch perhaps a charm offensive, maybe even come up with something catchy..explain to the public what pressures GP surgeries work to, why it is different , if at all, from a private enterprise..step away from words such as internal markets, qualified demand and talk in plains simple language that patients can understand.
It's a lot to do with perception...a specialist is as much Dr House as much as a GP is Doc Martin. Be proud of what you do, yes, excellence is and must be an everyday thing, it also is something that should be championed and highlighted with pride...dare I say the stiff British upper lip which holds back self praise could be resulting in losing the battle against a savvy media with its own agendas?

I can't preach to anyone, neither do I intend to but there are many ways of attaining what needs to be done for patient care, and I don't think rhetoric is the way ahead. A local example lies in the Super 6 diabetes model. The concept? "Specialists do only a few things in hospitals, rest is by education, virtual and face to face". Sounds like anything amazing? No it actually isn't..it's something we as trainees always chatted about over beers.
All we did was label it, package it, wrote some articles, won some prizes and boom Partha Kar was a "thought leader". No actually he isn't. He is still the brash chap he was, still making mistakes, still trying to do the best but lucky with an amazing team....doing stuff that others are trying...only difference? The perception of what we do...the showcasing of what we do..proudly. No longer in Portsmouth is a Diabetologist the mild mannered person who accepts anything thrown at them, but now it's a team which knows when to launch a charm offensive and when to snarl when patient needs are paramount..irrespective of whether the person at the other end is a Board member, fellow colleague or manager. We are not here to satisfy others egos or do their jobs, we are here to do the best for the patients.

We are here to do best for the patient,so to achieve that you use whatever tools you have in your armoury..and perception is paramount. Andre Agassi once said.."Image is everything"...maybe that's a stretch too far...but a combination of talent and passion , which the NHS has in abundance..combined with a better image...can and will be an electric one.

Primary care is the bedrock of the NHS and rather than the rhetoric, my suggestion would be to seize the initiative and be at the forefront...Gerada set the tone in her inimitable style....who's next to pick up the baton? Who's the one to launch the charm offensive to explain what being a GP means? And if you don't believe that its not needed, then look outside the window...the NHS is slipping away..fast...and if primary care cant save it, then I can assure you, no one can.

Sunday, November 24, 2013

Game changer IV: Bring the public in

I was thinking of this post being one on general medicine within hospitals, that area of pitched battleground for most...but that will have to wait till the next one. As for this one, I am going to touch upon that most interesting of subjects...patients. We keep on hearing about putting "patients in charge"- I will leave all politicians out of this to avoid an idealogical debate (as most things nowadays descend to) so lets concentrate on the professional leaders who keep saying they mean to. Throw in the mix the conversations from patients as to how they would like to be more involved and you have a heady cocktail. There's always been the assumption that doctors, managers, nurses ergo folks who run or are part of the NHS know best and its always interesting to see whether that is actually true. Indeed there are attempts to involve the patient in pathway developments but lets try and extend that theory. How about we really try and let go? Would it work? Too dangerous? Well, lets theorise and see, shall we?

How many patients actually know what a referral to the hospital costs? How many know how much their follow up costs? Could we open all that up? There has been talk of individualised budget- a minefield to decide how to actually cost it and set it up but even if you give an individual a budget, what happens when that is spent? Can we let the patient decide? Are we bold enough? My type 1 patients could ask why the NHS doesn't fund all to have CGMS (Continuous Glucose Monitoring System)..well I could but it means I will have to stop delivering something else to balance the costs. Who decides that? The patients as a group? What would my pituitary patients then say? What in fact would my Type 2 patients on a dialysis machine say? Lets talk about some numbers. A new patient appointment gets my department £239 while each follow up about £99...an amount which is not constant as that rate is going down year after year- while the staff costs are same if not more. Add in the pressure from Commissioners to reduce costs each year and you have a shrinking pot to play with. 
So yes of course I would want to have 7 day service, psychological support for all, CGMS for all...but without any money available to invest, I can deliver those by only one way...drop something else. In the world of diabetes, the other choices are, or at least for my team...pregnancy service, kidney dialysis service, foot diabetes service...what do we do...go Big Brother style..put it up to the public vote and say "You decide"..?

The other question is does each patient approach it from their point of view? When I had the problems with my back, I instantaneously felt that this had to be most important issue that needed to be sorted. I suspect its the same for anyone who has themselves or has relatives with mental health, long term conditions, neuropathic pain or a pituitary tumour...which explains all the patient charities jostling for space and attention. Does he who shout loudest get the biggest slice of the pie or is about which celebrity you have to back your cause? Stephen Fry beats Amelia Lilly hands down any day...does that make mental health more important than Type 1 diabetes..an interesting conundrum indeed.

So how about we actually throw open the gates indeed as regards tariff? Not talk to patients in sanctimonious terms as to how we "all should work together", how "its about the process", how " we all need to come together"..and actually showcase the financial problem we are in? The master plan that we, as doctors, managers can manage finances has clearly not worked, so why not open the books to patients...perhaps they may come up with suggestions we haven't thought about? I certainly have no clues and I can assure you nor does the majority of leaders in the NHS. 

The financial grapple is something all Chief Executives and Finance Directors worry about- without any obvious solution in mind..so why not try something different? I for one, would be up for it..invite patients with diabetes and open the departmental budget up- show the challenges, ask for ideas and then perhaps we may have a way ahead. If not, at least we would have stopped fuelling expectations that we can deliver everything. If any patient organisations are up for this...lets try it out...could be an interesting 2 way experience. 

But continuing the way we are without actually explaining to patients the financial nitty gritty, simply spouting grey terms that financial problems will be overcome by "tackling inefficiencies" is wrong and will go nowhere to facing up to the challenge this country is about to face. You think you have a problem now? Forget the "spectre" of privatisation...there is a bigger problem at hand...simply put...the money is running dry..so any help from the users of the system should be grasped with two hands, if offered.

The question is...we talk about patient involvement...how much do WE seriously believe in it?

Saturday, November 16, 2013

Game-changer III: Ward priority and transparency


So we all want to run a hospital smoothly as regards patient flow, don't we?Then as part of the Game-changer series, may I suggest to leaders to step out of the power points, step out of the meetings where they keep reading and listening about regular senior review of patients and actually make it happen?

We talk about regular senior presence, so why isn't that a core part of teams job description? Lets be bold, make it very simple...each team must have regular senior presence...lets start with 5 days, shall we? We want 7 day service in the NHS while we still haven't worked out how to produce regular 5 day senior doctor presence on wards, have we? Again, if the core business of the Trust is to ensure safe smooth flow of acutely ill patients, then it must be the core business of teams to have senior presence on wards each day. Consultant job plans are not that difficult, its just that most medical or otherwise managers struggle to actually get some to perform to agreed job plans, thus the need to revise the Consultant contract again. Not needed in my view, if you have the tools to be open and transparent about job plans and the requirement to be on the wards. What would the senior do? Make sure each new patient is seen after transfer from MAU, make sure all other patients under the teams care is either viewed or plan discussed with juniors..make time to meet patients relatives, and oh yes, be there for your juniors. For lots of physicians, it sounds like an alien concept, but ask our ITU colleagues, they have been doing so for ages.

In job plan terms, depending on acuity and number of patients, you need 3-6 hour per day on the wards...in Consultant contract language, that's 15-30 hours / week or 4-8 sessions/ week i.e. less than 1 Consultant dedicated to the wards to do what should be the primary reason you are affiliated with an acute hospital. Yes, I am oversimplifying it but there are teams who would rather prioritise their clinics and their procedures and leave the wards light..stick to 2 ward rounds / week.."It worked when I was a junior, surely it will now?"...cue over stretched juniors, cue no time for training, cue sick patients not having regular senior review, cue blockage in system and frustration from front door colleagues..who get frustrated at the lack of focus on flow of patients but rather on specialist work.

So, want to change the game...yes, of course primary care can do better, yes of course, community teams can pull patients quicker, yes of course, some patients who come to A&E could have another place to go to...but all those excuses a valid one AFTER all hospital teams make sure they prioritise their ward teams. Lets go one step further, make all job plans transparent..make it mandatory that all teams show commitment to the wards, show commitment to patient flow...of course it's much more attractive to go and do the specialty work such as a pump clinic or an endoscopy list...but then again, in a climate where we know regular senior presence is of such high importance on so many levels, that should not even be a debate. You do what needs to be done for patients and in a hospital, there is no bigger need than ensuring that sick patients are reviewed each day by a senior.

I am no preacher but only saying things what I have put in place for our team. A regular senior presence on the wards for our team is a non negotiable issue for all Consultants...whatever be the case, an 8 am presence is essential. Do I have other commitments...yes...a host of commissioned services within the Trust along with 2 community contracts...so spare me when other specialists insist their elective activity is too much. What has that resulted in?  one of the quickest turn over of patients, a firm which consistently comes top on ratings by juniors as regards education, a team which stays within EWTD hours. Why the inconstancy all around the NHS then? Is it because we like to pamper to certain individuals or is it because we have traditionally designed systems based on what is our convenience rather than what suits the patients? Of course a physician likes to start at 9am..it's because its convenient. We do so at 8 am..and has made our lives much more simpler..yes, on a social level, does involve juggling kids drop offs etc..but if you want to start the flow of patients in the hospital, you start early, not late..and certainly not when suits us.

For starters, lets do that.Make job plans open to all, make them transparent, make it mandatory that each team provides senior review each day on wards and if they are not, then do some genuine performance management...not one of those which sounds amazing, shows lots of revenue generated but doesn't take into account what the patients feel or what your juniors think of your inconsistent presence. And if individuals are not delivering whats in their job plans, then step up to the plate and find out/ challenge where  they are when they are getting paid by the taxpayers money. As regards departments who are facing increasing pressure regards elective work, my advise? Plan the wards first...and then if there is a shortfall for the wards, then try and build business cases..engage in workforce planning...but don't make the war your second choice.

In healthcare, what the patients say, what the patients need has to be paramount and for that, you make the changes that need to be done..not pander to egos, not make job plans as per individual likes.
So you want to sort patient flow within hospitals? Make some ground rules, be real leaders, step up to the plate.and deliver. That is what being a Game-changer is all about. So...do we attend yet another meeting to hear about the obvious...one more time or should we step up to the plate?

Saturday, November 2, 2013

Game-changer II : Redefining specialism?

So how bold are we willing to be? We talk about integration..a much vaunted and noble intention which perishes at the foot of tariff, multiple providers and the financial bottom line. But at least the discussions are ongoing...love it or hate it, you can't deny one thing, the restructuring of the NHS has brought to light some serious debate about roles, patient care...was everything ok before all this happened? Ask Francis, ask Berwick, ask Keogh...the changes have been long time forthcoming. You can disagree with the principles of no holds barred competition but the focus to give patients a voice, have safety high up on the agenda, challenging GPs and Consultants..nothing wrong with that, nothing at all. Anyone who feels these are non issues and had no need to be tackled...one suggestion..don't let your political belief or ideology blur the need for some long over due debate about patient care in the NHS.

So in the Game-changer series, lets discuss acute Trusts first. Are we ready to seriously discuss the role of an acute hospital? It's an acute care hospital, so lets think about where all specialities should sit. 

I will give you an analogy..in a crack football team, you have the divas, the high profile show ponies but without whom you won't actually win anything. So you look after them well and make sure they perform for the team. In NHS speak, would that be your interventional cardiologists, orthopaedic surgeons? Stop mucking around...look after them well and make them the jewels in the crown..make sure they only go and moonlight for another team when they have fulfilled their commitment to the team that pays for their salary.

Next comes the defence...the unsung heroes, the ones who actually deliver the game, each mistake highlighted...in NHS speak would that be the Acute Physicians, the ED folks? Again, recognise them for the hard work they put in, the long unsociable hours and make them feel wanted. 
The next thing a good team needs? Some good midfield generals...some folks who can run the show..make sure the attack and defence are connected, marshal the troops...in NHS speak, they are called Medical Managers. Train them properly, not just someone who puts their hand up, select those leaders and recognise their roles. Any successful team needs a fantastic back room staff...that would be the managers, HR, non allied health professionals. 
And the rest? You either have them on the sub bench or think whether they need to be in the team or not. Did you say a good team needed a good manager? That's the Executive team..who if good have the skills to make a good team a world beater.
Have a think...what's the purpose of an acute hospital? Its to deliver safe, efficient, kind and empathic care to someone who is acutely ill...isn't it?

So can acute Trusts have that boldness in them to open the discussion where some specialities should sit? Can we have a debate where chronic disease specialists should be? Why not in the community with acute trusts buying from them services that genuinely needs to be in an acute hospital? Would our GP colleagues develop a federated model and have LTC teams sit with them? A seamless organisation- integration not in name but in reality. Or even with community providers..a community based pathology needs to be based in the community- not in an acute Trust...that's what the refrain is- so are we bold enough to flip that model on its head? Or are acute Trusts bold enough to own the whole system and have an acute hub and a chronic disease hub?

Think of a future where bar a few genuinely acute specialities, everything sits in the community with acute trusts using services from this community hub as the patient needs. You want a mixture of specialties available as and when especially with patients living longer and with multiple morbidities...well...here you go...no perverse "referral costs me money, so lets plod on". 
The thing that stops this is the survival of hospitals and the perverse irony is that they will possibly survive as an acute care centre if departmental budgets, job plans are all thrown into the mix and CCGs are bold enough to look at that future. Without that as long as the system have made Trusts slave to the financial margins and tariff, then they have no opportunity to innovate and we keep trying to force multiple providers march to the same beat..but in a game of competition, someone will lose as regards finances...and who wants to lose when the repercussions are so high?

So what about the unscheduled care or flow of the patient through hospital you say?....well..more on that next week..but for now...ponder that one....forget all the politics and money for a second...but where SHOULD your specialty sit..not for your convenience but what would be the right thing for the patient lost in the maze of multiple providers? In your heart..you know the answer. 

Till the next week where we throw some ideas regards an acute patients journey in a hospital...before we think what could be done with Clinical Excellence Awards...no harm in dreaming, right? :-)

Sunday, October 27, 2013

The Game-changer part 1

We are in the throes of a Monty Pythonseque level of inanity at the moment. Ideas swirl around as to how to salvage the NHS, conspiracy theories lurk out of corners, the optimists try their best to paint a rosy outlook, the doom mongers scare the rest into a corner...its actually an incredibly interesting place to be in. In the midst of that, the money struggles to follow the patient. We talk..and debate..and mull..and conjecture..and we all then agree that the money needs to flow into the community..and then we all resoundingly fail to make it happen..why? 

Simply because there is no buffer...there is no investment to make in primary care with a gradual reduction in acute Trust capacity. The need for reduction in acute trust is NOW without the infrastructure in primary care being set up.The acute Trust then desperately tries to use the existing tariff system to make sure they don't suffer financially. Take the example of coding...for patient care, it should serve one and only one purpose..help to build a data base of conditions, help to use to measure areas of improvement, help to measure outcomes..nothing else. What is it today? A tool to ensure the Trust gets paid for the work done. Cue suspicion from CCGs about gaming, cue mistrust why GP referred patients go to A&E..PbR works very well for procedural initiatives..but falls apart when trying to map the complex journey of a patient admitted with chest infection- who also happens to have diabetes and heart failure - and then also develops a urinary tract infection before being discharged.
Problem with the plan? You can bill the CCG as much as you want...once they even get past their suspicion, if they have to pay up, that money to you, Paul, will only have to come from Peter. There ain't no more money Sherlock...it's a separate debate whether there is money in the "system" (yes I have read Jacky Davis book); but as things stand, the CCGs certainly don't have a magic pot to throw money at acute trusts.

And then we have another fundamental problem. Its called lack of respect or understanding of others work. We have leader after leader- and I do use that term loosely- who go up, claim to represent the masses and spout unachievable desires and options. Example? I have been involved in meetings where so called primary care leaders have stood up and said they don't need diabetologists. I will be brutally honest- that to me, at that time, smacked of disrespect, politics and arrogance. But I have now changed my opinion..3 years into our model of care, having been involved with 80 GP surgeries, I understand one thing..those leaders represent their own warped views maybe in order to cater to political sound bytes or their own careers. I have yet to meet a single GP colleague across the country who actually does the day to day job and treats diabetologists with such utter disdain. On the contrary, all visits to surgeries I am involved in nowadays are simply enjoyable- sitting and talking to like minded colleagues, colleagues who are swamped and just are grateful for some specialist help- on demand, when needed.
Problem? Those so called leaders are the ones who are involved in policy decisions which the majority don't agree with.

Exactly the same for specialists...seen plenty of diabetes Consultants who have treated and continue to treat GP colleagues with utter disdain ...their experience of working in GP care? Nil. Nada. Zilch. But still they lead organisations, still they continue to sit on policy boards, produce documents whilst their own patches ask for help from other areas. Did someone say national CEA awards? What's the blinking point of being a leader when you haven't even shown credibility where you work and all the junior doctors feel you are a laughing stock? 

So we have an interesting juxtaposition of a false economy plus leaders approaching system wide problems from a speciality angle, not to mention some with a distinct whiff of lack of credibility.Plenty of documents about how change can be brought but no ideas to implement. So you know what..I reckon either this will all drift along or there's one big game changer on it's way. Something fundamental will change because this is unlikely to drag on for ever. In the interim, lots have chosen to get their head down, do their job and go home and a handful few are trying their best to stay ahead of the curve.I personally have always enjoyed the daily debates, the politics that one needs to manoeuvre to improve clinical care but I also know that I am a bit weird too. The majority find it tiring, find it draining, find it insulting to explain to yet another external management dude that they are leaving their guts behind every day and not the stereotype painted by Lancelot Spratt. 

So we muddle on, the air gasping atmosphere of acute Trusts being sucked into a financial hole, the shrinking PbR tariff..all adding up to talented energetic people muddling on...trying to just do good for the patient in front rather than have time for the system. I am personally blessed to have a team around me who have an infectious amount of energy..another award to add to the collection on a national level...the only diabetes representation amongst the public, private and voluntary sector. But there's a growing realisation that without a major change, such innovation driven by teams will only be exceptions, not the norm. 

Muddling on is the default position till something fundamental happens....and maybe it's time to discuss those openly..question is are we ready for it? So...shall we start?

(To be continued......)





Sunday, October 20, 2013

Time and patience

Time. A commodity which seems to pass us by at a frightening pace. Maybe never more poignant than when I see my daughter..seems like it was yesterday I held her in my arms gingerly taking her from the midwife...and today as I see her taking that extra minute in front of that mirror flicking her hair...time passes us all by, doesn't it? And another week went past in my work life and I am trying to make everyone count...take it in small silos...small steps ahead..adds up to perhaps a bigger change..we shall see, won't we?

Being physician on the wards is always a fascinating experience...interacting with juniors, taking time to do some teaching..sometimes we Consultants forget what a smile, what a arm around the shoulders mean to all those folks working so hard. I had one of the best Consultants ever and never ever did he have anything but a smile for us as juniors- however hard the day was. And I try..sometimes its difficult but I try..you always know that translates into your juniors putting that extra bit in. And you struggle to see anyone who shouldn't be there..primary care are taking more risks, the front door deflects more...resultant folks on wards are genuinely ill or have nowhere to go to. Either their health or the system has failed them, not individuals.

In between a travel to the BMA House for the parliamentary think-tank for diabetes care. Listen to the government and opposition lay out their vision, the challenges..listen to the National Clinical Director for diabetes outline his priorities, listen to Barbara Young asking all to "get on with it", listen to a primary care champion argue the case for QoF...too many challenges, too many problems? The world seems to be too preoccupied in colourful power points, too engaged in outlining the challenges..the same ones I heard about 5 years ago...I attempt to inject some positive thoughts in..."Stop mulling over the problems, ladies and gentlemen...its time to do..and its possible". Patients in the audience nod, an elderly patient who happens to be from Portsmouth says she knows me...places a hand on my shoulder and says.."Don't stop. Show them the art of what's possible"...makes taking those extra tablets to help in the journey worthwhile.

Another drive later in the week to London meeting an umbrella organisation dealing with musculoskeletal pathologies...what could I possibly contribute as a diabetologist? No idea but outlined what we had done for diabetes a chronic disease but always a pleasure to see patients, doctor leaders etc around a table trying to improve care. They weren't just sitting and moaning..they were trying. Hope springs eternal, right?
Finally, a 2 day meeting bringing primary care and specialists together discussing diabetes care, discussing the way forward, discussing what social media could bring to the party, how engagement of patients could help build services, discussing working within existing financial margins, listening and challenging Martin McShane...once again, an event where the art of possibility was spread, the ethos of can do was hopefully cascaded. My parting shot to all? Try...it may not work all the time...but you got to try. Life's too short..no point in looking back and thinking what if...when you have the opportunity to try now.
The week then finally ends...with a beautiful and touching email from the mum of one of my patients who I had seen struggle every day and now is a mum herself of a lovely baby.It taught me what parents go through with their kids and the unstinting and nonjudgemental love mums have for their daughters. Makes every single day of this worthwhile, every bit that special...no national award or accolade can replace that warm feeling you get when an email like that. 

Finally,a request to all patients with diabetes. On social media, I read, listen and appreciate the frustration with the system. But like me, there are several who are trying. I know them, I talk to them, I met some of them this weekend too. The reason you don't hear about them is because they are less flashy than me, more humble and like to progress their work without making a show about it. Each are trying..using a comic book analogy, Iron Man's approach maybe different to that of Captain America but they are trying to do the same thing. But as with all things, these things need time. There are years of inertia, institutionally held beliefs, mistrust between primary care and specialist care, financial restrictions, organisations, continually changing goalposts which takes time to negotiate and cut through. 

So all we ask for is a bit of patience. We will, together, with your support, change it. But give us some time..I know the past has not been great....but we can't account for that..but we are certainly trying to make a difference to the present and future.
In the words of the Christian author from Carnage Titullian.."Hope is patience with the lamp lit". We are trying to make sure this isn't another false dawn, another false hope...time and patience is what we ask for in return.

Sunday, October 13, 2013

Go for it

Amidst all the personal travails, worries and awareness of one's mortality and age, came last week..a week to lift you out of any form of mood dampener one could go through.
Firstly, I spent a day in the North East of England touring a few CCGs namely the Gateshead CCG and then the Northumberland /North Tyne CCG talking about diabetes care, sharing our local experiences, trying to help others avoid the pitfalls, alerting them to the obvious obstacles...and through the day, I met so many ..Consultants, GPs, Commissioners, managers, Senior management of acute Trusts...none of whom had anything in them but the unflinching desire to make things better. They wanted some opinions but they were there, around the table, sitting as one..putting a lie to the oft stated facts that Commissioners and providers just wanted to stay at each others throats. 
Yes, politics was there..but as I listened to the nurse passionately evoke what care meant to her, as I listened to the Commissioner trying to make best of resources available...it was an uplifting experience, knowing this wasn't people just confined to power points or colourful charts, they were trying..heck, they were...to get things better. Consultants were there exploring options as to how they could work in the community with their primary care colleagues...no one needed another flip chart to map out the problems, they wanted answers..and frankly? They were nearly there. They didn't need me there but maybe perhaps an assurance that after 2 and a bit years of the battle-scarred armour holding, just a word to say...it will work. 

Don't get too risk averse...take that leap of faith, ladies and gentlemen, go on..go for it...lots of folks depend on that. Nothing gained till ventured. So Sam, Sarah, Helen,Steven, Katherine,Nick et al...top job all...carry on the fabulous work- and any-time needed, pick that phone up! Alison and Bryan- thank you for your hospitality and amidst that the opportunity to meet with a similar minded long time friend and colleague, Pete Carey. Had age dimmed the fire...munching on the bacon sarnie for breakfast...the answer came back sharp and fast...No it hadn't. Formation of a merry band was another step closer...

Next came an education event for Diabetes specialist nurses- with my session being on use of social media and how it could help with diabetes care. My first question to the audience was how many of the attendees were on twitter...expecting to see not more than a hand or two in an audience more than a hundred. A genuine thrill to see the number of hands that did go up...it was happening!! So, gritting my teeth through the pain, it was all about showing what nurses can do on twitter..talking about the nurse leads on twitter, @wenurses and then showing what engagement with patients on twitter could do, how it could help to improve diabetes care, what lessons could be learnt from reading blogs from patients with diabetes, learning about their trials, tribulations, what we can do...and no, not everything was about money. Poured a lot of heart and passion into it..and going by the influx of DSNs joining twitter that night, maybe, just maybe, the change in diabetes care can be influenced from the grass-roots. Again, that audience was packed with folks who needed to be let go...unleash the potential..get past the daily frustration and do what they all are so raring to do...improve diabetes care. Change is coming..I do believe it is :-)

Finally, the annual Quality in Care Awards happened. Last years experience was fantastic and this year, the department got short listed in 3 categories and even though, no top prizes and just a "highly recommended" certificate, was supremely delighted due to two counts. One was that all 3 projects were developed, led and entry put forward by 3 of our nurses...if that isn't leadership, initiative and a desire to improve, I am not sure what is. Kudos from my end and as our Super Six model beds in, this is the second phase as the acute team concentrates on making the "Six" the best in the business..so delighted that some recognition this early on. However my main delight was at seeing our neighbouring Community Diabetes team (West Hampshire) led by Kate Fayers and Caroline Atkinson pick up some richly deserved accolades. I have known them long and one cannot measure the level of unstinting dedication they have to improve diabetes care...so accolades long time overdue. The next day, I saw Caroline- and saw a million watt smile on her face. See what recognition of hard work does to morale?

This week has been hard..and at the end of it, came the biggest cultural event in our ethnicity..known as Durga Puja...met up with some amazing friends, spent time with family and prayed for good health for all amidst the usual blitzkrieg of lights, sweets, music etc. And as I sat with a lovely glass of Talisker, I looked back at the week and smiled. Who said diabetes care was without a rudder? Things were happening..yes, they were slow..but they were certainly happening. Maybe the national organisations have been slow off the blocks but at the grassroots? Conversations were happening, the effort to engage with patients was on.....the fire is burning bright...we just need to keep it going.

So to all those who have joined twitter, to all those who read this blog, I can only encourage you to carry on. Inspirational people involved in diabetes care abound- whether they be a healthcare professional, patient, Commissioner or otherwise. Find them, learn from them..and do what you passionately believe in. In the words of Michaelangelo.."The greatest danger for most of us is not that our aim is too high and we miss it, but that it is too low and we reach it".

Ladies and gentlemen, sky's the limit. Go for it.

Thursday, October 10, 2013

SPA...what's the worth?



It's one of those things which sharply divides people, one of those topics which brings out the doctors trade unions out in a froth, hospital management barely conceals their disdain and as time has passed, as the squeeze for money has escalated, the battle lines have become more vivid, the cries more shrill, the antagonism even higher. 3 letters...also known as SPA...short for Supporting Professional Activity.

So let me explain what in simple terms that means. When the Consultant contract was redrawn, it was decided that 10 hours per week would be needed (in a standard 40 hour week) for this work. That would involve among others teaching your juniors, making sure your own knowledge and competence was up to scratch i.e. you were keeping up with the changing world of medicine etc, clinical governance,research and in some cases, time for management roles. All sounds easy so far..but as we moved into the NHS world of money, profit, revenue...what dawned on all concerned was that this time actually brought little or no money back to the Trust. You could see the Trusts point of view...depending on your seniority, that could be anything between 25-40 K/ year investment by the Trust..without any return whatsoever. And which business in their right mind would want to invest that amount of money without any return? Crazy isn't it.

So flip the coin...back to the argument that health should never be about money and profit...in which case, how do you NOT allocate a Consultant time to teach juniors, be their educational supervisor, have a pastoral role..develop the next generation? The argument that this brings no money is also a bit faulty as medical schools actually pay Trusts to deliver education to medical students, so steady with the argument that this brings no revenue. Same for Deanery...money does come, though perhaps nowhere near what clinical activity based on PbR will bring..but there is the responsibility to teach. I did not take this post just to do clinics and go home..I also did so because I have a passion to help build generation next.

Same argument for revalidation...in this day and age, who wouldn't want their doctor to be properly revalidated? Yes, no money comes back for that...but if you don't get yourself up to scratch, how do you ensure good clinical care is being delivered? Consultants also argue that time spent on SPA helps to develop services which indirectly translates to increased revenue for Trust...catch 22,isn't it?

The problem however, in my opinion, isn't there. The problem lies in all quarters. Firstly, lets pick the Consultants. It would absolutely be fine if all Consultants actually did what their SPA asked them to do. They may get that money but show no interest or time in teaching, being a good supervisor or even engaging on issues such as governance. 2 reasons for that...group one..their clinical work is so huge that there is little time for such work and group two...they go and do something else. Job planning of Consultants haven't been as robust as they could have been for group 2....thus group 1 keeps bailing out group 2, gets more tired, frustrated,bitter at the unfairness of life..while group 2 carry on regardless. The circle is complete.
Here's a few things...if someone says they are educational supervisor to 4 juniors, then their measure should be what those juniors actually say..is that individual there when needed, was he/she good etc? if that's not the case, then fine...thats for the job planning panel to decide where to use that individuals time. The issue being that group 2 are in a minority but that minority is enough to tarnish the majority...what was that again about rotten apples?

Second problem? National bodies. For Gods sake, stop eating quail eggs in plush rooms and say something robust rather than putting out wooly statements which doesn't help Consultants and management. Say clearly how much time an individual needs for revalidation...the present statements are so wooly..no wonder everyone gets confused. Is it 2, 4 or 6 hours for revalidation? BMA..calm down when you say everyone MUST have 10 hours/ week for SPA..if they don't want to teach, doesn't have much time for much education, then surely it needs to be asked what those 10 hours are for? Educational gurus..come out and say something..don't whimper in the background but make the case strongly why education is important, why it is so critical we do not forget generation next. Part of being here today is also about preparing for tomorrow, isn't it?

And finally, as regards management...don't make it sound like Consultants are doing nothing in those 10 hours. They didn't individually negotiate those terms, its a national contract..they are just following the rules. Have an understanding what SPA means, attend a few courses if need be and then go and challenge if those are not done. Don't arbitrarily scattergun...if its a business you want to run, then like it or hate it, without those Consultants, you have no business. If you are not happy with your best player, you don't just go and whip him, you make sure you get the best out of him. SPA shouldn't be a term of disdain, it should be a term which actually means something..it should be something which can be flexible. can we be brave enough to give each Consultant, say, 4 hours for revalidation and then negotiate with local educational leads, governance leads, research leads,clinical managers as to what else should be given in SPA time? Then actually measure whether thats being done rather than give them that time in perpetuity? Some may need more than 10 hours, some may need less...but can we have that flexibility and discussion based on what that Consultant wants and department needs? Till we feel grown up enough to have that discussion, we will continue to stumble along along sharply divided lines.

I write this blog today as a manager (Clinical Director), an educator (Royal College Tutor and Teaching Liaison Clinician) as well as a clinician who loves to teach ( am educational supervisor to 6 trainees). And I worry what the shrill divided lines are doing or going to do to our generation next. We must get these discussions going as soon as possible..otherwise we risk engulfing even noble stuff such as educating into a simple profit-loss equation.

Wednesday, October 2, 2013

Run Rafa Run



Have you ever seen Rafa Nadal play? Television never quite gives you the whole picture but at close quarters, it is just unbelievable. Every shot from the opponent is hunted down, every ball is chased down, every pass is attempted to be returned however hopeless the cause. Breathtaking, amazing...and he has always been my fav because of that. Acute Trusts remind me a bit about him nowadays. However hopeless the cause is, the chase is on..however improbable the target, the determination is there. Problem is in a system whereby the acute Trusts have always been the Federer, the one with the silky touch, the one with the flair, the one who doesn't need to overtly exert due to inherent natural resources..its a tough call having to revert to a Rafa style. I wont even go into the daily struggle as regards emergency door has become but I am going to talk about finances.

Just like QoF has been the lifeblood of GP surgeries, so has been PbR for trusts..and all was well as the money available simply meant the more you turned the wheel, the more you generated. Staff salary bill? No sweat..you do more, you code better, the Commissioners/PCTS will pay. Do more multidisciplinary clinics, the tariff is more..hidden behind the veil of patient care, multidisciplinary clinics sprouted...do more, get more..what could possibly go wrong with that?

And then 2010 happened...the squeeze began. PbR tariffs started squeezing, so let me give you an example of what that meant. Say you get 100 quid for the trust to see a patient and you see 10 patients..easy sum..you as a trust get 1000 quid.  So the tariff changes to 90 quid..now you need to see 11 patients to generate roughly the same amount. No extra time for present staff..so to balance out even the existing wage bill (I am not even going to begin to overcomplicate issues with overhead costs added to wage bills), patients need to be seen quicker or as management whiz kids will tell you..more efficiently..in the same time. If you cant and stick to seeing 10 patients, then you have a loss of 100 quid per clinic..add that up..only way a business can survive? Yep, drop the staff...and what does that lead to? Less patients being seen...ergo more pressure on primary care. But did you say we could see more patients? Hang on..the Commissioners have got QIPP to reduce activity within Trusts. Some places have also got capped contracts..so doesn't really matter how many you see..you still get paid for those 10 patients..whether you saw 11 or 15. Did you say you could see more inpatients and get paid more for that? Nope, one of the only ways Trust can cut costs? Strip beds...and I wont even go into describing how tricky it is to have more beds with same number of junior doctors. Run Rafa Run..one more time.

Another one? Multidisciplinary clinics...better PbR...not any more..its being flattened out quick and fast. Let me give you an example...the PbR tariff for a single or multidisciplinary tariff for diabetes patients used to be significantly different...now they are exactly the same.  Not the Commissioners fault..they are implementing what has been given. Impact?Clinical evidence and NICE says that all patients with foot ulcers should be seen by MDT clinics. MDT clinics cost more to a Trust as you have 2 professionals to see the patient together and thus both have salary wages. But if the tariff is the same for a single professional clinic, then with a business  hat on, why bother? May as well bring the same patient twice to see 2 professionals separately..more money...but clinically? Wrong. Thus the incentive to do even the right thing clinically is being squeezed.Rafa..down the line..go on son.

I could go on and on..but if this was pure business, then I need to stop doing some things right now. I can turn this into a profit using present rules in a flash but as a doctor I cant and to emphasise strongly, wont. One more one from a general medicine point of view? When I go through finances with a tooth-comb, there are some patients I should simply refuse to accept because they cause a loss to my department...why would I want to risk putting my staff at risk? Try saying that to the 87 year old lady who has got past her acute medical issue but cant be discharged as social services haven't got the budget to deliver what she needs asap. Length of stay more than 48 hours? A loss in financial terms..Clinically though? Cant send her home sorry guv..went to med school also to have a humane side. Rafa...its on your backhand...puff those cheeks out...make another run.

But its not unsolvable...the system needs a revamp...question is who is innovative or bold enough to do it. With the revenue dropping and salary bills as they are, the crocodile jaws just get wider..we all talk about difficult decisions but struggle with them, as at the bottom of everyone's hearts, people know that there is not much left as regards managerial layers to strip off, no more assets to sell, no more efficiency savings to be made. When CCGs came to being, I remember some comments from GPs on social media..how they would get the money back from those evil acute Trusts..alas the penny has dropped now...even if the money to acute sector is shrinking, it is not being redistributed to primary care either.

We are now starkly in the territory of staff cuts, like it or not. Link that with the Francis report..and that ball down the line seems not worth chasing, doesn't it? But can acute Trusts be bold enough or even be allowed to make the first move? Competition rules and the existing of community trusts have lessened the potential to take control of community settings or services so why not join hands regards where certain specialties should sit? Are certain specialties better being under community trusts and look at non tariff based ways of working? It doesn't matter how many phone-calls you took...what matters is whether they made a difference to patients, right? See whether those specialties can be housed by the community trusts, buy some time back depending on what input needed for acute trust functioning? Use SLA, TUPE..so many options to explore. This isn't anymore the time to be cautious or conservative..if we don't get staff placed appropriately, we will lose them and harm patient care. Stop other real estate areas being used to build more hospitals...no..use existing ones a bit more effectively, work with nursing homes, work with residential homes...what can be done? Pay people for time, not get someone to bean count how many emails they have answered and pay them per email....so many options to explore. Stop recharging internally each others departments...you are in ONE trust...you rise and fall as one. Its a nigh impossible art trying to fathom out exactly which subspecialty has had what contribution to a patients journey...if only healthcare was that simple.

Its a dichotomy which all clinicians struggle with..surely money problems for the acute Trusts isn't why they went to medical school? It is though..and people always ask me why I get involved in managerial politics...I will be honest with you...that, my friends, is the only way you can make sure the staff is maintained to provide care to people..people who you want to get better..people who you went to medical school for.

Nadal never gives up..thats his calling card...I aint in any mood to give up the fight either...we need to be bold. PbR should be consigned to history..let us clinicians, managers and the rest work together rather than worry always about how much money to generate or lose.
Give acute Trusts the freedom to think broadly..this ship is not doomed..yet.

Wednesday, September 25, 2013

24/7

Everyday. Everyday the NHS fails us. Everyday it also saves us. It's a daily cocktail and in this age of social media, this age where any international event is dissected and analysed by millions within minutes of its occurrence, the NHS is nowadays fodder.
Its a heady mix..with lots of people with lots of interests. Take your pick..there are the social crusaders who believe nothing in the NHS should be private (have you heard that all recent NHS contracts have gone to private providers? Well...have you actually seen some of the quality of bids from NHS organisations??!); there are the right wingers who believe its a system which bleeds us dry and bar basic healthcare, you get care what you can afford; there are the data demons who dissect numbers and have pitched battles about HSMR (Jarman's crusade) and not to forget the ones who have suffered either due to a loss of close ones (James Titcombe) or the ones who have been shunned by the system and still fight a daily battle against the establishment (David Drew,Kim Holt).

Amongst them all are also scattered the ones who are the daily users, seeing the fractious battles, unable to make their mind up as to whether the NHS is all good, or all evil. Grateful for what the NHS has done for them but at the same time hesitant about raising errors in the fear that it will be used to bring down their beloved NHS a bit further..it's a tricky balance, a Hobson's choice. Damned if you do..damned if you don't.

Let me give you an example. A patient with diabetes gets admitted to the hospital- what kind of care does he or she get? In one word? Variable. It could be fantastic, it could be average or it could be downright poor. Not just me saying it- but if you do want to know, read here,here and here.One of them is in my own hospital- where care, simply put, was substandard. Not an isolated incident..it happens...is it because the people or staff don't care? Is it because they don't know? I don't know the answer to that but to all the educational evangelists out there, there is no lack of protocols, educational events, no lack of effort....what there is a lack of is an access 24/7 to a specialist for advice.

To patients who suffer, I say this, raise it. As a team, I don't see it as a personal criticism but as feedback, nay, even ammo to convince the powers that be for the need of a 7 day service. For me, its an opportunity to learn..how am I supposed to get my service better if I don't get honest feedback? I have noted twitter conversations- the worry about repercussions, the worry that the teams will take it "personally", brush off criticism- and I don't blame them. Forget patients, look at what has happened to doctors within the system who have raised their head above the parapet...pretty much a career destroying move.. hopefully they will find their rightful place in history with time. To patients of mine who read this- I can only say this- raise issues openly. Will you be victimised? I can earnestly promise you..."Not on my watch". I can assure you in the most open way possible that we will try everything within my powers to get things right. Tell me what's not working and as a team, we will do our utmost to make things better.

So we have a challenge to improve things especially out of hours and on weekends.It is fantastic, even humbling to keep on getting on award short-lists but at the same time, that doesn't translate into us putting our hands up where we fall short.We have a fantastic diabetes inpatient team- but alas, they are only as good as within working hours, only as good as the limits of Monday to Friday. The dichotomy for me lies in the belief that general medicine is a core of what I do- and pardon me for heresy, but walking away from the sick 87 year old because she ain't bleeding goes against the ethos of why I went to medical school.
So.we have a plan...we indeed do. It involves the Consultants working on a 1:4 rota; it involves our specialist nurses now moving to weekend working...and we will get there. I have been touched and humbled by the willingness of all to help...there hasn't been strong reservations..there seems to be a huge appreciation that patients with diabetes get a raw deal when we are not around..and we must do something to improve things. For those who believe the NHS staff should just treat this as a vocation and spend all their lives looking after patients, have a heart. The same nurses and doctors have families, children, need weekends to spend quality time..just like anyone else.
Initial conversations have been positive..and it all seems, so far, to have traction within the management hierarchy. The frustration remains that we threw everything we had as regards education..and unfortunately we still haven't been able to take away errors which are simple but so devastating for the individuals concerned. The quick turn over of staff, doctors and nurses alike, hampers any education process and even now, still in the minds of staff, diabetes is never quite as an emergency as a bleeder or a chest pain. Only the person who has a severe hypoglycaemia or an episode of ketoacidosis or the carer will know how untrue that is...so it's up to us to change the face of diabetes care, not anyone else but simply us. Watch this space..it's coming- and yes it will happen while we keep our general medicine commitment going too.

I wouldn't say the work in the community is done..but for sure, progress is being made..the process is in place, the users seem satisfied and outcomes look positive. The next logical conclusion is to see what we can do for 7 day cover of the hospital- and maybe in the near future, even the community..who knows what the future holds?

One of the greatest innovators ever once said.."We don't get a chance to do that many things..and every one of them should be really excellent. Because this is our life. Life is brief..and then you die, you know? And we have all chosen to do this with our lives. So it better be damn good.It better be worth it". In my career, I haven't always got it right, I have on occasions even failed some.. but in a time when one is acutely aware of one's mortality, there is no time to wait for tomorrow. One must try, one needs to come to the finish line and say "I tried with everything I had".

Wish us, the Portsmouth diabetes team... luck. The collective goodwill of so many cannot be in vain. 

Saturday, September 14, 2013

Smoke but no fire

Waited expectantly for this one. After all it was the Royal College of Physicians. Ignoring all the snide remarks from doubters about the College being an "elitist" organisation, one "out of touch"..I hoped, perhaps even prayed for a robust, ground breaking recommendations as regards the "Future Hospital". So it came to pass...and expectedly jumped on to it. Without fail, the PR machine whirred into gear..twitter was abuzz about the amazing report, the path-breaking findings..so one read it..even while in the middle of a busy day. 

So what's the verdict? Well from my point of view , unless the last few years didn't happen or all my conversations with colleagues are in a dream world, then I have struggled to find anything which any physician wouldn't clamour or ask for. They all make absolute sense- recommendations hinging on clinical judgements, based on patient needs....the problem? Absolute tiddlywinks about how to implement them. 

Let me give you one example: "Once admitted to hospital, patients will not move beds unless their clinical needs demand it". Brilliant...well said..and there is no physician who will disagree with that. My question to the ones who put that down in those glossy prints...how the bloody hell do you do that? In the middle of the night when the front door is heaving and there is the pressure to somehow transfer a patient out of A&E to ensure the 4 hour target is not missed, the 88 year old lady gets moved from the base ward to an outlier ward- not because there is any clinical need but because a bed is needed. You could argue the patient in the queue has a clinical need, but that 88 year old lady? Nope- none whatsoever. Still moved irrespective of whether the clinical team had suggested contrary to that. So any suggestion how to do that ergo avoid the patient move, how to help the poor flow manager? Er nope, the college stays silent.

Want another one? OK.."There will be a Consultant presence on wards over 7 days". Again, superb..no question or debate about that. Patients need it- and indeed some specialities who are blessed with numbers do indeed do this. So how do you make that uniform? Well, its possible but the present conundrum is this. To achieve 7 day cover, you need to "time shift" work of existing personnel...which simply put means that those who do the weekend will also need a bit of time off in the weekdays (shock and horror, Consultants actually are human beings and have families too)...which means that unless someone else is backfilling their job, their outpatient work has to be cancelled. I hear about "priorities" and colleagues in the front door thunder about where ward consultants should have their priorities. Let me distil that one then..I get paid enough..I don't need a single penny and am more than happy to work 7 days a week. Do please, someone let me know which pituitary clinic or adolescent diabetes clinic I should cancel and let the patients know. What all these front door policy makers sometimes forget is that for the patient who has a pituitary tumour..me cancelling their clinic appointment is no less traumatic than the one in the front door of the hospital awaiting a senior opinion. Not sure? Ask anyone with that pathology.

And finally, the best one..the one where the College really needed to show strength."Generalists and specialist care in hospitals"... Come on guys, tell us who the generalists are!! 
Why in a DGH cant you say ALL need to have a generalist role? Why should a cardiologist or a gastroenterologist be separate and be "special"...should I use the same ethos and walk away and be a "specialist"..or do the patients admitted with DKA not warrant highly enough compared to a patient admitted with chest pain or a bleed? Why can't I provide a 7 day service for all diabetes patients only too? This is where the document underwhelms and fails to deliver...fails to grasp the nettle and lay out what the vision is..fails to give Trusts or managers the wherewithal to change the way service is delivered.Did you say there is a lot of bowel screening to be done? By all means do so (though one wonders about the evidence base) but please when in a DGH, stop pretending you are in Guys or St Thomas Hospital. Its simple..either its "all in" i.e. ALL specialities contribute OR its "all out" i.e. ALL run their own speciality on-calls and leave the acute physicians and geriatricians to deal with the rest.You can't have it half way house- as the present situation is...causes friction between colleagues, a 2 tier system, burn out, morale...all the negatives you can think about..you got it.

So the overall view? An ambitious, well meaning vision...but without any clues as to how to deliver all of the recommendations. A lot of smoke but sadly, little fire.The future? Some will happen, some won't..in some places the debates will rage on and in some places, some specialities will be coerced. Uniformity across the NHS? No chance. A hospital can do all it want, all it can..but till the budgets between health and social care are fused, till the targets are fused, then simply put, in an ageing population with ever increasing morbidities, a future utopian hospital will always be that...one for the future. 

Tuesday, September 10, 2013

Cobblers

Cobblers. Absolute cobblers. That would be one way of describing what's going on now with the 4 hour target. So you know what..I am going to say it..the 4 hour target issue is simply put..unsolvable.
Negative? No zeal to embrace a challenge? No- none of that...just simply practical.So you ask what does a chronic disease specialist understand about the front door and 4 hour targets?
As it happens, perhaps a little bit. In our Trust, happened to be the lead for the Emergency pathway...when I started our acute medicine colleagues used to work till 5 pm; when I finished, they worked till 10 pm- in shifts. Made a lot of friends in that department that Christmas! I have worked with Turnaround teams, have worked with ECIST (Emergency Care Intensive Support Team)- not once, but twice..factor in that as a team, we visit 80 GP surgeries nowadays through the year and have first hand experience of pressures GPs are under..and yep, have some knowledge. But you know what? For the first time in my career, I have completely walked away from that side of things. You know why? Because over 4 years a realisation has set in, this is nigh impossible to crack. Not because of "lazy colleagues", "process issues"...but simply because it feels like Ground hog day.

So you want some thoughts from someone who has seen all this, been in the middle of all this? Some suggestions or observations? Well, here they are:

1. 4 hour target: Making this the bastion or beating stick for the local acute Trust doesn't work. A patients journey is intrinsically connected to community trusts, social care, primary care set up. If none of the others are subject to the same targets, why on earth would they have any initiative to crank up the pressure or deliver to the same level acute Trusts do? As a result of this "isolated" target, acute trusts try and put pressures on areas only they have influence over- cue poor flow managers running around, cue inappropriate discharges, cue elective work being dropped...all of which only causes bad blood, fractured relationships...and the merry go round goes on.

2.Multiple avenues: Stop creating more and more avenues for patients to access. Either they are poorly thought out or implemented. Cue people still attending A&E inspite of money spent on these other venues. Stop blaming patients for attending A&E...if thats what they are choosing, stop the multiple channels, bloster A&E, put the resources there rather than spreading existing resources thinly, depriving the local A&E and causing more of a backlog.If the NHS is about patient choice, then maybe listen to the patients? Yes, it would be fantastic to have all GP surgeries working 24/7, but a) lets be practical about it. They are doctors and human beings plus not twiddling their thumbs and b) its going to take some serious time and megotiations to achieve that..so till that El Dorado is achieved, some support for the local A&E would be nice.

3. Publicity: If you are going to tout A&E as a place where 95% will be seen within 4 hours- and mostly by seniors, then don't be surprised when patients prefer to go there. It's natural.So either decide to make A&E the only hub or go easy on the publicity blitzkrieg. Evidently we want the NHS to believe in the principle of "markets". Well, in a "market" system, you don't build a swanky shop and then spend time educating "customers" not to go there.

4. Tariff: Beyond the quality issue, Commissioners see A&E attendance as expensive. Well, anyone thought of changing the tariff? Money makes the world go around- maybe even something radical like fusing budgets between all local providers, make a common target...hang on..its not radical- people have been talking about it for..years.

5. 24/7 Consultant cover: If you genuinely want that, stop playing silly politics and either invest OR decide which work needs to stop. I am happy to do all sorts of cover and don't need an extra penny- but do please let me know which pituitary clinic or adolescent type 1 diabetes clinic you want me to shut down. I work on average 60 hours a week- and frankly, don't want to do more, even for more money. If you want me to be there at 2 am in the morning, then I need some sleep next day morning. I can't do a clinic-its dangerous- and as amazing as I am, I need sleep- like any ordinary human being. So let me know which clinic to cancel or provide me with resources to get another colleague. For the patient who needs help with their pituitary tumour, that clinic cancellation is as important as the person admitted at 2 am.

6. Finally, STOP reinventing the wheel. Stop bringing continuous flow of new people- well meaning no question- who think they have a brilliant new idea. They don't- its an idea other people have had, tried..and failed. Find out what plans were there, what worked, what didn't work. I see plans nowadays being advocated on twitter etc gleefully as the "new thing". I hold my head in despair when I check my emails from 2009-2010..same plans..same glee,,followed by "lets find another idea".

Am sure there's plenty more..but unless something big and radical happens, I can tell you for a fact that this winter will be back to the wall stuff. Till then, all power point talks, all plans are nothing but hot air and playing politics with the NHS.

Actually no, its all just...cobblers. Absolute cobblers.

Saturday, September 7, 2013

The other side

The whirr of the MRI machine cuts through one's thoughts. Lying in the tunnel was interesting..I am not claustrophobic but the whole experience indeed is one of close quarters. And my thoughts drifted back over the last few days. The symptoms were getting a bit worse, had waved it off as just a manifestation of stress..but something was niggling...this had happened before but this time, it just didn't want to go. When in between ward rounds, I had to stop for a break...it was easy to disguise it as a coffee break..I knew the time had come. Did the NHS click into gear? Can I say it was amazing? To be honest, I don't know- as I was seen by a friend who happened to be a Rheumatologist. A quick fire X Ray followed by a thorough review..and next stop was an MRI. In the back of my mind, the symptoms over the last 2 years were adding up...and somehow I knew what the MRI could show.

So it came to pass..and it is interesting to be on the other side. So far in life, ailment free, never one to bother my GP...the signs and symptoms had been waived away. I was Partha Kar..the swashbuckling Diabetes Consultant out to change the world...who ever had time for symptoms? Me? Problems? Seriously..wasn't I supposed to be the healer of all problems myself? And didn't you know about my achievements over the last 5 years...go find someone who has done as much as me..you blasphemous heathen!! Anyhow, the results when revealed gave rise to little emotions..all I remember my Rheumatology colleague asking.."what do you feel about that?". Honestly? No idea..not the faintest idea what came next...before the practical side kicked in. There's always a solution to a problem...so must this have...what were spinal surgeons for after all?

But what was quite touching was the small bits that happened over the last few days..the Radiology department making time and space to squeeze me in an incredibly busy schedule, the personal touch shown by the radiographer when ushering me in. It was all very easy sauntering in from my morning clinic, strutting down the radiology department corridor for the MRI...life takes a different perspective when you are then sitting in a gown on a trolley waiting to walk into the scanner. A Consultant colleague came along...Daren and I talked about NHS politics, we laughed about finances, we cracked a joke about football..but I remember at the end Daren saying.."Don't worry mate, just be calm, it will be fine"...beyond the fa├žade of being cool, had he seen my worry? Showed my departmental colleagues the results..a few par for the course black humour jokes followed by a swift appointment with a spinal surgeon scheduled by them early next week....it's all been a daze.An evening chat with a school friend who is now a Orthopaedic Consultant..reassuring, calm..all people focussed on helping out a friend. Maybe the image I have in my head of just being seen as an arrogant brat is perhaps not always the way I am perceived. Maybe, just maybe.

And then beyond all, you come home and be with your loved ones..who know that the worry is niggling..that the pain, the involvement of the nerves, the muscles, the arteries and the background knowledge of the human anatomy gives a constant reminder of what lurks in the background. Beyond everything its the assurance of them being there.They know you and an extra hug, an extra word of assurance..always there..always available when needed. I write this blog more as a distraction while sipping on a glass of vino. A movie night with the family is to follow...the next few weeks will be interesting to say the least but with friends and family like I have? It will be a doddle.

In the words of Samuel Smiles.. " Hope is like the sun, which, as we journey towards it, casts the shadow of our burden behind us".  In that case..let's...play.