Sunday, March 31, 2013

Plan B

Back from a lovely holiday...and back to work tomorrow. April 1st- Easter Monday- and as per numerous blogs, tweets etc...the end of the NHS as we know it. 

New regulations come into operation and beyond the structural change, as per a lot of pretty senior and important people, what is changing, is the fundamental nature of the NHS..a possible move towards privatisation. And over the last year or so, twitter has been  source of education,listening and reading about opinions from folks who staunchly believe in the ethos of the NHS. Having worked in a country like India, for me personally, it has been nothing but astonishment at what the NHS delivers, let alone simple belief! 
Among the many figures of Clive Peedell,Rob Cheeseman, David Nicholl,Margaret McCartney, Roy Lilley, Jonathan Tomlinson exhorting us to be aware of what we are inexorably moving towards, a single voice stood out simply for its clarity. Clare Gerada. She has been everywhere, trying everything she possibly could to stem the tide. NewsNight, BBC Question Time...you name it, she's there...fighting the battle.And you have to just stand back and admire that level of  indefatigability. But in spite of everything, the juggernaut has rolled on. Hate to use the clichéd term " we are where we are" but what now? If everything is overturned again in 2 years and competition scrapped, maybe we could revise and take fresh guard- but now that the changes are  pretty much in law, what of us healthcare professionals who stay in the NHS from 1st April onwards? Actions such as "early retirement"  isn't an option, "doing something else" isn't one either...so what now for the young brigade? Do we have a plan B?

So the new age is here. The NHS,perhaps open to competition, open to the private sector, open to the world of profit...and are we as doctors ready to adapt accordingly? Do we have the energy, time and will to understand cost, activity, tariff, income? Can we talk in pure financial sense,show to the powers that be, that we do "justify our salary"? Like a silver lining to the threatening cloud, would this open up the door to stop looking at the managers as one from the dark side- and understand how we could work together to "justify" our services? To some, understandably, having to "justify" ourselves is an anathema but the hard nosed business world unfortunately won't take the argument " we work really hard".

Can we introduce another dimension where beyond the patient feedback, it will also be genuinely about outcomes, transparency...so when services go up for tender, as the clinician concerned, you will be able to assure your Trust that with the data, feedback etc you have, this bid will be won, led by clinicians- working hand in hand with managers? Would we as hospital clinicians forget the divide and sit down with our primary care colleagues to understand what running a business means? Would we invite the finance director for a coffee to explain which bits as a clinician we could impact on? Would we share a drink with the contracts team and make sure nothing is signed without full clinical involvement..try to understand the language of new to follow up ratios, demand management they speak in? 

So many questions...but surely its always good to have a plan B? Maybe its me, but I have never approached a project without 3 options- a primary one- and 2 fall back options. All I can say is that all those folks I have just mentioned would be delighted to meet the clinician who is willing to input their views...they are trying to understand our language too.
Let me put this question to you...if the trust signs a contract to a new to follow up ratio or agrees to "number of patients to be seen" without clinical involvement- as the clinician had "better things to do", then come August, when the Trust is due to breach the agreed numbers, guess who the pressure comes back to? So far it has been OK  as next year, whatever be the outcome of the contract, the activity would still come back to the same provider, i.e. your Trust. Now the games changing...what happens if another provider walks away with the contract because they "promised to deliver better" or had a slicker presentation? Yep, YOU are now a cost pressure for the trust without any income...and in a business world, that inevitably leads to one conclusion.

So have a think about Plan B. It doesn't involve anything too complicated...maybe something as simple as buying your departmental manager a cuppa and asking..." what can I do to help?", maybe a beer to your GP colleague "how do you run your surgery?" It's a start- believe me, I have been doing it for nearly 5 years now- been the best education I have had- beyond any Deanery training course or Kings Fund event you will attend. 

A favourite tagline of Hollywood movies is " A storm is coming"...anyone who has dealt with the NHS will tell you this one is potentially the most destructive ever. Plan A to resist it seems to be on the back foot...so whilst we keep our fingers crossed for Plan A to succeed, make sure you have a Plan B in your back pocket. 
As Mahatma Gandhi once said..."Adaptability is not imitation. It means power of resistance and assimilation"....We wait with bated breath as we test the truth of that statement.

Saturday, March 23, 2013

One number on the fridge door


Its Friday late evening...the 87 year old frail lady, living alone at home, finds herself on the floor. Not sure what happened, she is frightened...and to make things worse, her relatives are away for Easter too. Thankfully she has had all the relevant numbers stuck on her fridge door. Her own GP number stands out there...lovely young lady..but no, she isn't there at that hour. She used to have the number of NHS Direct on her fridge, but that's now changed. Drat. What about 999....but now she isn't sure if she is ill enough. Should it be 111? Oh dear.
So how about the lovely Consultant who knows her so well? Nope, neither him at this ungodly hour, bless him, he does work hard.

I suspect you are starting to get the picture.And then one way or the other, to complete the story,she gets to hospital. Discharged a few days later, she is seen by community nurses, has a visit organised to the falls clinic.....and the saga goes on. All of them..different providers, fractured, fragmented, different IT systems, different referral forms....how many things is the elderly lady supposed to remember? But hey, fear not, competition is here...and we need more of it, more provider, more phone numbers, more IT systems..how could it possibly go wrong?

A few days back,I tweeted an idea, how about if OOH services were run by the local acute Trust? would it, could it work? One provider running emergency or unscheduled care especially out of hours? Worried that this may result in over investigation by those "too clever specialists? Why not the Trust employ or contract to GPs or even use them as advisors? Why have another provider run it with little or no links or access to specialist clinics when needed? In 2004, primary care renegotiated their contracts to ensure their high workload during the day was adequately recognised. Nothing wrong with that except that it blew a hole in OOH care...and frankly I don't care about who shows me what statistics, my personal experience with OOH when my little one was unwell was appalling, the level of nonchalance and poor quality shocking....far better care, more kind and caring people in my local hospital A&E department.Yes the staff there were tired, but they were in one word...amazing.

So why not run OOH via acute trusts?One provider, minimal fragmentation and if one gets to the world of finances, revenue for Trusts helping them to keep existing services rather than losing money to yet another provider?
For a change, rather than being agent provocateur, this is a genuine thought and would love to invite opinions and thoughts as to why this wouldn't work...where are the flaws, what is being missed. All I know is that the present system of OOh care is simply put, not working.
Want to hear something clinical? ok here goes...locally, a new provider won our OOH. Within 7 days of them winning the new contract, as local Clinical director of diabetes, I emailed them offering support for any patients with diabetes who may need support OOH, eager to explore options, see what we could do to avoid admissions. After an initial "oh yes, that would be fabulous", any further contact from the personnel involved? Diddly squat...while I see admissions which I know could have prevented by offering next day slots or sometimes simply by education or advise. I know my type 1 patients and I could indeed help prevent admissions, in fact with direct access to patients to my email, we do indeed do...but purely out of good will, not in a planned, contracted manner.So you know what? If the local acute Trust ran this service, I know for a fact they would have access to my clinic slots or a chance to speak to someone as to whether the admission could be provided....because I on behalf of the department would have provided it. Does every patient with a hypo or blood sugar more than 20 need to be admitted? No they don't.

Now wouldn't it be nice for that elderly lady to have one point of contact, one phone number stuck own her fridge she could just call when she was frightened...one person who could assure her, visit her and organise a specialist or GP review if needed?
So.....do punch some holes in this plan...tell me what the problems are and I will sense check it and see how we can work our way around it. If we are moving to a culture whereby chronic disease, quite rightly, is going to be managed more in primary care setting ergo under community trusts, then by the same token, acute care should be held primarily by the local acute trusts?  Once we get past the problems, then a generous amount of innovative commissioning, a dollop of will to "make it happen" with some generous sprinkling of mutual trust between primary and specialist care....and you know what...you may just have a gourmet dish.

Either way, it's worth a try...as presently whichever way you look at it, the OOH system is broke.And till that is fixed, no amount of daily or even twice daily Senior ward rounds will help to prevent inappropriate admissions to hospital beds, The locum doctor who has turned up from "somewhere" to run the OOH services without little knowledge of local services has invariably one or two answer to the patient,,," go to A&E" or "call your GP in the morning".

Just a blinking shame that the elderly lady would rather be in her own home that night...Easter hadn't brought better weather, it was still too cold.She wished there was one number on the fridge who she could call...and who would join all the dots for her.

Maybe the Easter Bunny would help her next year.

Sunday, March 17, 2013

Its a start

Another Diabetes UK annual conference came to an end...the 11th one I have attended so far. My views on last year were mostly about how the old guard were still there...were they hanging on, keeping the surge of enthusiasm out or were they trying to guide the diabetes community through tricky territories?

For me, this year was more about taking stock, trying to consolidate all that had been done over the last few years...there was no need to stand up and declare to anyone else what "Portsmouth had done"...hate us or love us, we were there, firmly on the map.  Some embraced warmly, some gave a grudging nod, some old friends were keen on comments with barbed wires, some feigned ignorance, some new friends openly admired the work done. 
And finally there was perhaps proof, at least, in my own mind, that I was getting older. Sarcastic comments no longer warranted a spicy response, this time it was met with a smile and wishing them well in their own areas. To be honest, my commissioners are happy, our departmental position within the acute trust is secure, we have fabulous relations with our primary care colleagues...not to mention an ultra-fabulous team of nurses in the community and hospital....did it really matter what external people thought any more? No- it actually didn't. As Francoise Sagan said "To jealousy, nothing is more frightful than laughter"..so there wasn't much point any more ,not this year. The Portsmouth diabetes centre was now on the map- one of my tasks when I had taken over as Clinical Director, was done.

And then there was, what I thought, the high point of the conference...a session done by patients. Our local Ninja was there- and I also had the opportunity to listen and bump into so many (Hannah, Alex, Zoe etc) who I had interacted with on twitter. Great presentations- but more importantly, immensely brave, one had to ask why not a bigger forum? If there is anything that I would ask the organising committee to consider for the next conference, give the patients a bigger forum. HCPS need to learn , listen from what patients want. Only a few handful are on twitter, so what better forum than the annual professional conference? Do it guys...we can get things so much better. So many HCPs came up to me to ask how we were doing what we were doing...I have only one word.."listen". 

And then there was the appointment of Jonathan Vallabhji as the new National Clinical Director of Diabetes...and for once I must say I agreed wholeheartedly with this. My views on lots of folks being in high positions- without a semblance of good care where they work - and mostly perhaps for their own kudos - is well known. But this was different..a breath of fresh air..if given the right tools and support, he can do some good. I shook his hand and he asked me- do I have you behind me?  No, my friend, I am right beside you. If you want anything done to improve patient care, just ask. 

A lot of time was spent discussing with folks I respect, about the future, my future...was it time to move on from a leadership role in diabetes? The team is set, the model is set, enough resources, reputation, type 1 diabetes service in development...time for a fresh approach after nearly 4 years? Time for a new challenge for me? And that's where the conference has always come into it's own for me..the ability to network- apart from socialising with the team I work with. 
This year, the conference seemed to be just that bit different, just some early signs that perhaps this wouldn't be only about HCPs soul searching or brow beating..it would also be about listening to patients.

Its a start, guys...lets see where this takes us.

Monday, March 11, 2013

Accountability..what are you waiting for?

Accountability is the new buzz word,isn't it? Recent events have put the term in sharp focus and over a round of drinks,a  few friends were discussing how one could define it for doctors in general. Truth be told, who are we to dictate to politicians or managers about what accountability stands for when our own definition continues to be perhaps a bit hazy. And it indeed is a conundrum..how DO you define accountability for a doctor? Inevitably the question came to me as the youngest Clinical Director amongst the crew..how had I defined accountability for my colleagues?

So far for me, accountability has come down to 3 and only 3 basic things. I can't comment on general practitioners except my own view has been that I don't subscribe to the view that ALL GPs are hard working and NO one provides poor care. Leave alone the politics of it all, statistically it simply isn't possible. I may not be that old but have spent enough time in the system to know that the vast majority of GPs do indeed provide great care, but there are some who simply don't. Saying " all" do it is akin to saying all Consultants are amazing. Lets not try and make doctors into heavenly beings- we are as much human as the other person- and we are as much fallible as any one else. Don't believe it? Don't take my word for it- come to twitter and listen to the public.

So, point 1? Accountability as per job plan. In short, the taxpayer pays a significant salary to a Consultant. Job plans, if done well, should be able to define where the Consultant concerned is supposed to be at a given point of time. So, for example, if a Consultant is not there doing his ward rounds at 8 am on a Monday morning as per his agreed job plan, then there can only be two plausible explanations for that. a) He is busy doing other clinical work- in which case back to the drawing board as regards job plan and he has too much on his plate or b) he is doing something else not related to the hospital. The vast majority will indeed be a) but there's also a group which nonchalantly embrace option b). And if he or she is found to be doing something else (let's say, private practice) at the time the NHS is paying for their time, that, in simple parlance is called, fraud. Tackling that is important and such incidences, simply put, are inexcusable.

Point 2? Accountability for the services. And it does get a bit tricky here. How do you measure a Consultant's worth as regards outcomes? It maybe a tad easier with say, general surgery- what are your mortality rates, morbidity rates etc but falters when general medicine comes to play. Length of stay is used as a marker but I can get the best LOS in the country but the highest re-admission rates...doesn't make me a good doctor, does it? In our department, one of my colleagues recently said that his "antenatal diabetes service was excellent". In my usual cavalier style, I said "Says who?" Because as far as I am concerned antenatal diabetes is about delivering a safe mum and baby, little else. To his credit, he went away, collected data on neonatal high care admission, caesarian section rates, infection rates etc. Perfect. But as mentioned, this area is indeed complicated especially in services where multiple providers are present and the Consultant is part of only one little niche of it. 
If you switch to GPs or even surgeries, here's an example. In our region, out of 52 surgeries, a couple refused to engage with the community team in spite of umpteen emails and phone calls. They didn't need any diabetes support. In my book- to be honest- fair enough. Then it boils down to how those surgeries perform in contrast to their neighbouring surgeries. If they are at par or better, then clearly they don't need specialists and well done on them. If however they are failing, then its simply stubbornness which is resulting in patients suffering poor care. We shall see- but as far as I am concerned, in our part of the world, I make no distinction between primary or specialist care. The distinction mark is whether you provide good care or not. As simple as that.

Point 3? Accountability to the public i.e. the people you do it for. What do they say about you? Lots of debate continues about the right tools for it (is it a randomised feedback form to 50 patients, is it the Tripadvisor style "I want Great Care")...the point is not what you use to collect the data, but whether you do so honestly and what you are willing to learn from it. A caveat as always- we also need to bear in mind that as clinicians we also make decisions which are in the best interests of the patient- which also may not please the patient. A negative feedback thus needs to be in context too. If we only go on point 3 to judge doctors, feedback done on ED doctors after a Friday night may not be seen as necessarily "patient-focussed".

That's pretty much it, isn't it? Why overcomplicate the whole process when all the public who funds our salaries wants to know one thing "Are our taxes going to doctors who care and strive to make us better?" To all the evangelists who have their hackles raised as soon as something negative is said about clinicians, remember this. For ever thus, it was the good eggs who stayed longer and worked harder and ground themselves into the ground more...to cover for their failing or skiving colleagues. If you work in a team, then all need to play their part. Trying to root out or improve a poor performer makes the team stronger, not show the whole team in poor light. Of course there are many ways of tackling poor performers but the process has to be transparent. I am tired of people taking potshots at the NHS based on some poor performers and to be honest, I am tired of carrying them. We all know who they are, we talk about them regularly under muttered breath, we moan about them when we get home...we may as well open up a transparent system of accountability.

Thomas Paine once said " “A body of men holding themselves accountable to nobody ought not to be trusted by anybody" After all, if YOU are doing all the right things, what exactly do you have to worry about?

Wednesday, March 6, 2013

The margin ain't there

You read all the twitter feed...the angst about the privatisation, especially the worry about what would happen if all services were to be opened up to tender...and you wonder...How many of these folks have actually been through a tendering process, especially in the "new" NHS? Have they ACTUALLY been through one or is this simply scaremongering? Usual resistance to change or just dyed in the wool socialists who simply don't like the private sector? You wonder, don't you?

But you know what...I have some news for you. I have actually been through a tendering process..start to finish. Yep, right from the process of detailing the service, seeing the specifications drawn up, understanding the money on offer and then it finally being advertised. This wasn't a huge service tendering but was important enough. A diabetes community service being tendered in a region where there was none, A service being set up where a quantum leap was being made in NHS speak...moving from the traditional model of "refer to hospital at your discretion" to "refer to hospital only for specific things" and the rest being managed with support, education etc. And I sat and watched as bidders appeared. A couple of NHS organisations and a number of private organisations, some of them who are household names, some of them I had never heard about.
As the enthusiastic local Consultant, I reached out to all of them, signed clauses of confidentiality about their model designs and for me, was a fascinatingly amazing learning experience. Did the lady from Virgin speak with forked tongue or sported horns on her head? Nope- she seemed as normal as any manager I had spoken to in the NHS.But it was interesting to see all the players, fascinating to see how poorly equipped some of the NHS organisations were to exist in a competitive world. It wasn't their fault, it was just that it seemed they weren't...ready. You would believe that they would know more about services, financial realities, possibly more than the non-NHS ones...ermm..nope. 
One manager I spoke to seemed to know the answer to everything..10 minutes into the conversation it was abundantly clear he knew diddlysquat. He had no idea of the demographics of Portsmouth, no idea about GP surgeries, the relations...but he still..had..a plan. And if the local Consultants were not keen to engage.."he would subcontract others". Excellent.The non NHS organisations? Same problem. Any idea? Nope. One even wanted to do everything virtually- including foot clinics. "Why can't a patient Skype you showing their foot?" You had to wonder whether Skype extended to checking vascular supplies or whether we teach the patient to do it themselves. Dear God.

In the end, we decided to go with the NHS organisation and the rest has been history. Did we do it due to some socialist love or in depth love for the monopoly of the NHS? No. It was simply because the NHS ones seem to understand that there is no margin left to make a profit on. The tariff system is so close to the edge that to make profit you can only do one thing. Cut services, cut the nurse time, cut the admin time, reduce the Consultant input...there is no other way. There is no margin to gain in the NHS- thats the stark reality of a tax funded system.

So you know what? I don't wish this tendering process on anyone. And believe me, neither do the CCGs if they can help it. Some will be seduced by the lure of the private bidders, but in the end, without profit, those companies have no reason to stay.And I don't blame them for it. Would you run a business if there is no profit? So maybe the system needs to give the private organisations an honourable way out. Because ladies and gentlemen, from a Clinical Director who has dealt with finances,tariffs, contracts, new to follow up ratios for 4 years...trust me...the margin ain't there.

Friday, March 1, 2013

Institutionally Inhumane

The blood boils. Honestly, it does. Twitter can be a lot of things and one of them is being exposed to retweets and some of them run the risk of hitting a nerve. So there it was; a retweet from Sarah Calkin, news reporter for HSJ whereby she mentioned that a "Healthwatch England Board member says #Francis report suggests the NHS is "institutionally inhumane".

And all that I felt was a surge of anger. Anger at whoever this individual was, anger at such a blasé statement, the sweeping generalisation of it all, anger at the system which had allowed this to happen..that such statements can even be considered, let alone made. Mid Staffs was a catastrophe, a failing of epic proportions and my individual angst is well documented. There is nothing to defend, nothing to put forward as an excuse apart from promising individually never to let that happen again. Yes, finances and targets were a big factor but what has been galling was the professionals who somehow, somewhere got immune to the suffering..forgot why they decided to choose this profession, the long hours etc in the first place.

But "institutionally inhumane"? Oh come on, Do give me a break. Unless I work on a different planet, I come to work in a sector of the NHS every day morning. I work in a department , where apart from Consultant colleagues, we have numerous nurses, dieticians and administrative staff. And not a single day goes by, where I am not touched or pleasantly surprised by the extra mile gone by someone. That maybe the receptionist asking the elderly lady whether she needs a cup of tea while she awaits her transport or the nurse who stays back, in spite of childcare issues, as she has to phone a patient back. I go to the wards and I see junior doctors ignoring their working hours directives to make sure all the jobs are done or a patient has become ill. I see ward sisters genuinely disappointed when an agency nurse has made an inadvertent error and takes the time to sit down with the patient to explain. I see nurses missing their break to sit down with the grieving relative of a patient who has passed away. Inhumane? Not quite.

I fully appreciate what CureTheNHS is about and indeed more strength to their arms too. But let's not use all this to turn someone's sufferings into a convenient sound byte.
Yes there are changes to be made. Yes the culture needs to improve but don't call this organisation institutionally inhumane. A significant majority go to work every single day in the desire to make someone else better. They battle the politics, the structural upheaval, the economic crunch, the incessant pressure to attain targets....and they still do their job, as best as they can. Lack of humanity is not what they bring to their job..and certainly not where I work every single day. The staff, especially the nurses, have taken a battering in the media and the pain shows. These are good people, trying to do a job in trying circumstances. In between, in such a vast system,mistakes will happen and it's for the processes and support to make sure we minimise them as much as possible. However, no amount of courses, protocols or directives can "teach" you humanity. That's inside the individual.
So next time, any smart Alec wants to come out with some sound byte to please their political master or indeed wants to jump on the bandwagon of NHS bashing, think twice. On one hand, we rail against privatisation and bringing other providers and competition..on the other, we want to destroy the morale of the staff delivering the present system.

So you know what, its now time.Time to make your mind up ladies and gentlemen. Either we say the present system is unfit for purpose, the staff are inhumane, money grabbing philistines and we must bring in alternatives OR we say this is the best possible system but we need to make changes to ensure patient care is never compromised.I know my choice. Your turn now...but be quick. We are running out of time...fast.