Wednesday, July 17, 2013

Kate and Leopold

I really like Kate Middleton. I do actually. Forgetting the debate about republicans and royalists, she always comes across as a nice pleasant girl who conducts herself admirably..especially in the light of the unpleasant intrusion of the media in her mother-in-law's life and its horrible conclusion. And love or hate the royals, William and Kate do look like a nice couple, relaxed, enjoying themselves and more importantly not making a fool of themselves in the public arena. So you wonder why in a health related blog I am talking about her?

Well…it’s simple…the NHS has never needed her more than it needs her now. The coruscation of the NHS via the media is now well and truly on, figures and facts are being bandied about, denials, cross-denials, accusations, petty party politics, a playground spat as to "who loves the teacher the most" (substitute teacher with NHS)..and in the midst of it all, a long needed, much awaited debate about the improving of patient lives grinds to a halt. And the media does what it does best…a cynical taking down of the morale of the majority of hard working folks- who keep getting more disengaged..at a time when there is so much need for folks to be more involved, not less.

So we need to give something to the media…something to take the Eye of Sauron away..so we can get to the business of sitting down and seeing what can be done to improve patient care. Look at the areas beyond the debate about HSMR and ask why the basic core of compassion is becoming short supply. Have a grown up debate as to how we address staffing issues when the squeeze is on financially- and the biggest area, nay only area left to cut costs is by reducing staffing..how does one deliver quality care in such an environment.
So we need Kate, the NHS needs Kate, the nation who sometimes forget what they have in this country as regards healthcare, needs her. The royal baby needs to arrive soon, we need to bask again in the feel good factor, we need the media eyes away from the NHS so that constructive debates can happen.

What then about Leopold? You thought I was just fitting in the title to make it sound catchy.. a play on the Meg Ryan/.Hugh Jackman film? Nope. The word Leopold comes from a mixture of Latin and German..and it means something close to “as brave as a lion”.

And in the context of that, it must be Bruce Keogh. If you have to read a report which is concise, to the point and makes you understand why a clinician should be leading the changes in the NHS, read it. And I have a huge amount of respect for him. He tells you a story of how much he values the NHS and realets how he felt that when he had an accident in South Africa. I was there in that city at that time- and 24 hours after that, when I had the opportunity to chat with him, all that burnt through was a genuine need to make things better. And he is taking some brave steps..investigating hospitals for areas where they are failing in, highlighting staffing issues….all of which will sound like music to the thousands of staff working at the coalface. How many times have we moaned about the staffing issues, raised concerns about patients…and finally we have someone at the top agreeing with us all. Bravo I say!!Leopold is the only way to describe this effort, in an environment where the debate is more of schoolground politics rather than all concerned sitting down and agreeing the way ahead.

The story is as simple as it gets. The money in the system, as things stand, isn’t enough and to make ends meet, you have to drop wages or simply put, cut staff and shut hospitals. Cut wages- you risk losing the workforce or their morale. Cutting staff causes harm in patient care (read Sir Leopold’s review) while shutting hospitals isn’t politically expedient. Only other way is to raise taxes, stop doing something else in the public sector (how are those nuclear submarines looking), consider things like the Tobin Tax….but if none of those are in play, the system is jammed. We talk a lot about telehealth in meetings but no one knows how to explain to the staff that this will result in reduction of staff numbers- and we wonder why adaptation is low.

But at least, the first sincere salvos at having a constructive debate have been fired by Sir Leopold. Now we need Lady Kate to deliver (excuse the pun) and then we will hopefully find some time to have a sensible debate about what can and cannot be delivered to the highest quality- away from the rhetoric, away from the hyperboles. One lives in hope..or to put it simply, we must. Because once the storm passes, we owe it to all those who may have suffered needlessly and who didn't care what colour the politics was. They deserved better care and just maybe, Kate and Leopold can help us along the way.

Saturday, July 13, 2013

The future? Who cares..

I work really hard..harder than I ever have. Nope, that's not me but a common refrain from anyone you sit down with for a coffee or a beer with. Every sector says that with conviction. If you had any doubt, then have none. The squeeze is really and truly on. And with the money shrinking, the need to do more clinical work with the same or less money. Spin it any way around but the money just simply doesn't add up any more. We are heading towards an uncertain future where the gap in demand and money available is so stark that crystal ball gazing is fraught with the risks of making one give up. Politicians dodge the obvious or maybe they are just priming the public for what's coming. Rationing is here, no longer one for the future. We have non evidence based pushing of cheaper drugs not due to clinical reasons any more but because each penny now matters.

And the policy-makers wheeze on still doing power points about how it will all be fine, how new technology will transform healthcare. And then they wonder why people are so slow to adapt it. Want an example?..Ok..here's one.

Telehealth...will it work..the evidence is mixed, the jury is out but in an environment where healthcare has been drilled into a financial number, why would you want to adapt a system which reduces "income" for your Trust- and which simply translates into a cut of salary or staff? Lets shed the holistic belief that we work for love..charity and benevolence goes only so far but when it comes to your salary, your mortgage payment being hurt, your kids school fees pressure, your holidays suddenly facing the prospect of Bognor rather than Belize...charity or the penchant of adapting technology flies out of the window. 
All policy makers forget one thing...great to give lectures but all the Telehealth models are based on 1 thing.. the golden promise of saving money...a reduction of costs to the system...ergo reduction of income to the Trust..ergo reduction of staff in the department. Now who wants to adapt something that would compromise their job? No one's stupid, no one's silly...and we go around in a merry go around again and again.

So in a Consultant contract the squeeze has affected that part which never quite brought or will bring much money...and hey the NHS is all about that. Its called SPA...Supporting Professional Activity and in that is included something that Consultants do..teach, educate, be a mentor, be the role model for the juniors to look up to...create the future. And that has now reduced to a minimum...juniors are relegated to folks doing the day job, doing the dementia screen, helping the Trust meet their CQUIN target...who has time to sit down with a junior with a coffee or even put an arm around the shoulder when the day becomes a bit too much for that junior? Problem is I rarely see a non-clinician understand what that part of that job means. Teach?! Pastoral role?! No- go and do some clinical work...who has time for the future when the present is in chaos?

So the responsibility for that or ensuring that this ever decreasing area is protected sits with and must sit with the medical managers. In my department, I fiercely protect it as well as monitor it...what's the point of having SPA if you aren't going to do what you are paid for? And I do it one and only one thing in mind...my own future. When I am old and need to be looked after, I want to have some compassionate, good doctors who have time for me..not ones who tick a few boxes, check whether I have dementia and then chased out of the hospital as their working hours have finished. As ever, doctors have been poor at explaining what they do in the non clinical hours...no we don't all just play golf...but amidst the squeeze, we try and find time to build the next generation. 

For the sake of the future of our patients, as medical managers we must stand up for what's needed and what's not. In the recent GMC trainee survey, our department came up as one of the best in all areas. And there's no non-clinician in this world who will make me change what we do as a team. Yes we are clinicians but we are also teachers. And I leave with you a quote which encapsulates what a teacher means in the words of Paulo Coelho " What is a teacher? I'll tell you: it isn't someone who teaches something, but someone who inspires the student to give of her best in order to discover what she already knows.” And we must not give that up..ever.

Monday, July 8, 2013

Diabetes ain't easy

I was watching a Jeremy Hunt interview recently..where you couldn't fault him for the logic he put forward as regards improving patient care. Sure, depending on your political leaning, you could question the motive or applaud him for grasping the nettle, but the principle was spot on. He mentioned that sadly the NHS still has incidences of the wrong limb being amputated and that needs to be resolved. Had to be tackled and data was indeed aimed at the bigger principle...improving patient care and safety. I personally wholeheartedly support this but beg to differ as to whether triangulating everything to the Consultant is the way ahead. Do we risk elevating the Consultant once again to the God-like pedestal...with Him lies everything...or do we use this to force the Consultants to take up the baton of accountability, be the leader of the whole team and service? Maybe...but we shall see..but anyhow I digress.

So we don't want to see wrong limb amputations- quite correctly too...and recently I asked a group of senior and junior doctors what they think should happen if a doctor concerned does indeed do this? Struck off? GMC censure? Lots of debate- but in general the consensus was it was unacceptable whichever way one looked at it. It was a "Never Event"...an event each acute trust strives to ensure never happens. In fact there is a list of them from the Department of Health...events which have been deemed to be the white line teams shouldn't cross. I will even quote the definition for you..."Never events are very serious, largely preventable patient safety incidents that should not occur if the relevant preventative measures are put in place"
And there's 25 of them...look through them...all make perfect sense.."maternal death due to post partum haemorrhage after elective CS"; "misidentification of patients";"wrong route administration of chemotherapy"...and ensconced among them in point number 9 is.."maladministration of insulin". Number 9 no less, not even bottom of the list...so someone must have thought it to be important enough. The folks to whom I was doing the talk to expressed surprise laced with incredulity..."same level as wrong limb amputation?!!"...and in a nutshell, summarised perhaps the general attitude towards patients with diabetes in hospitals. 
Don't believe me..think I am just being a diabetologist waving the flag of specialism?...OK...read this from a national audit .."in a 5 day period, within hospitals, more than 60 patients developed DKA which results from a severe shortage of insulin".In short, these patients, due to one reason or the other were not given their insulin. Ah, so you don't believe data either? What about patient experiences? Have a read of this from Nick Guerin..makes for a sobering read doesn't it?

So what is it that stops us from improving things? Do the rest of the fraternity not care much about diabetes? Is it the belief that it's "nothing that serious"? Is it the belief its not that "important"? Is it because we instantly associate diabetes with being overweight, pretend not to understand the difference between type 1 and Type 2 diabetes? Did someone just say "education"? I can promise you, no absolutely guarantee you the problem with that is the sheer sustainability as well as trying to keep on top of the fast turn over of nurses and doctors on wards. We have a crack inpatient diabetes team..well staffed, education laid out in all formats possible..and yet, we can't eliminate all..perhaps we never will...but somewhere the attitude also needs to change. Type 1 diabetes patients deserve better than an untrained orthopaedic junior refusing a  patient their normal medications..also known as insulin..also known as the drug which keeps them..simply put..keeps them alive.

So where to next...keep plugging the education...but perhaps turn up the heat a bit? At any given time, about 15-20% of hospital beds are occupied with patients who also have diabetes- admitted for a variety of reasons. We owe it to them to do better, or perhaps even show a bit better understanding of the disease rather than a cursory shrug of the shoulder.As per the audit, not every hospital has diabetes inpatient teams...thats fine..as long as the other teams show the responsibility to look after those patients. So..either learn about the disease process, know how to look after them..or step aside and create room for people who know more than you. We locally are very lucky to have a high quality 5 day cover and our mortality data, error rates etc compared to neighbouring Trusts supports this...the next step is to see whether we can do so for 7 days...but now I think the time has come to add an extra edge to it. 

Next time there is an error or mismanagement causing harm, it maybe now down to individual or team accountability. Educational supervisor, Deanery, GMC...as far as it goes. After all, you would do the same if Mrs Bloggs had her left leg amputated rather than the designated right one..so why should it be different if Mr Bloggs goes into DKA because someone forgot to give him or prescribe his insulin? It does, after all, carry the same weight as per the DH Never Event list. 

There is a time and a place for working together, having group hugs...there's also a time and place where the need of the patient supersedes the need for professional bonhomie. To all those who read this and are involved in patient care, next time you see a patient with diabetes and not sure what to do..ask someone who does.For those Trusts who don't have inpatient teams, either educate the present staff or think of having one,seriously. No time for a cowboy or a cowgirl...just remember if you get it wrong, in spite of all the protocols, educational materials and courses which you have chosen not to attend... the local diabetes team may come hunting. 

As the local diabetes lead, I am also the person who is supposed to be the advocate for people who have diabetes. So..attend those educational programmes, get yourselves familiar with the on-line protocols, ask the nurse specialist who covers the ward, ask me...anything you want...but try and avoid making a fatal mistake. As otherwise, I will, indeed, come looking. Promise.

Monday, July 1, 2013

The Number Games

Joseph Pultizer once said.. “There is not a crime, there is not a dodge, there is not a trick, there is not a swindle, there is not a vice which does not live by secrecy”…and probably has been the mantra which has been at the core of the NHS latest effort at transparency. At the heart of what Sir Bruce Keogh has stood for..the effort to be transparent, the effort to be open, the effort to shake off the damning Francis report, the desperation perhaps to rise from the plethora of bad news..Mid Staffs, Morecombe Bay…they keep rolling on, don’t they? Harrowing accounts of how the NHS failed those it was set to serve, scapegoats being served out, hung out to dry….

Now I know Sir Bruce- I have met him- and I think his passion to improve the NHS is indeed something to be inspired by. There is no questioning his desire to create transparency but one think I have learnt in management is this. If you want to use data to do performance management and drive up standards, then you have to battle past a treacle of cynicism, a basic mistrust of NHS data, an ingrained belief that the “data isn’t right”. Because if you show data which is then peeled apart and shown to be wrong, you have not only lost face, but also lost the troops. You have lost their trust that the data you produce is meaningful, that it actually is about patient care and not just about ticking some boxes. So when the vascular data came out, I did indeed feel emboldened to believe that perhaps, just perhaps, the powers that be had indeed got it right.

And then I opened the Telegraph. Sensationalised was the fact that a certain surgeon from our local Trust had the highest mortality rate in Aortic Aneurysm repair. Nearly a third of his patients had died..shock and horror.…how do we allow such poor surgeons to operate? The Daily Mail screamed the same thing. Problem? This person hadn't done such surgeries since 2010/2011- and is a specialist in carotid endarterectomy..his mortality rate there? A mere 0%. The Vascular Society made amendments to their document later in the day- but by then the damage was done. Collateral damage, said some. Part of the learning process said others. Its always easy to be philosophical when your own name isn't being dragged through the mud, isn’t it?

Moving away from the individuals, lets look at it in a scientific way. Here is a quote from the document concerned: “Often information about the severity of disease is added to a risk adjustment model but a minority of patient records in the dataset were missing this information for one or two variables and, to avoid dropping these patients from our analysis, we did not use these variables for risk adjustment”
Seriously??…no account of severity of illness? No account of quality of pre and post op care? No account of coexistent morbidity? You now account a death directly to a Consultant..the other members of the team don’t matter any more? Those surgeons who have performed “well”..where’s the recognition for the team around him? The anaesthetist, the nurse, the physiotherapist, the GP..all of whom factor in the 30 day post operative recovery? What use such data then?

Let me give you a personal example. How do you measure me as a doctor? Our local amputation rate was poor in 2010..so does that mean I am to blame as the departmental lead? No responsibility of the nurse specialist, practice nurse, GP..all of whom are involved in the patients diabetes care? No responsibility of public health- who still cant get a grip on smoking which is known to make amputations worse? Anyhow, lets assume that makes me a bad doctor. Now how about patient feedback? A patient kindly nominated me and I won Hospital doctor of the year..so now I am a good doctor?

The reality is that medicine is complex and you cannot just take a marker out of thin air and fix it to a Consultant saying all of the process is a cross for him to bear. You want to measure and have transparency? Then do so for the team. Measure the outcome of a vascular team. Measure how they perform together. It is a crying shame that the evangelists are quick to quote Formula 1 racing and airlines as models to emulate- but forget to stay away from individuals rather than team while estimating performance. Jenson Button maybe a fabulous driver..without the right team and car? Struggles to qualify. I was there at Silverstone...no one called him a poor driver...they said he needed a better team, a better car.

My worry? It switches off people from learning and using data to improve patient care. Cynicism sets in. Gaming begins. To get your mortality rates down, don’t touch any patients with a higher risk. Here’s some simple but scary maths. 10 patients have complicated problems…if a skilled surgeon operates on him/her,, 5 may survive. His mortality rate? 50% ergo BAD surgeon. Walk away from them all? Mortality rate 0%  ergo GOOD surgeon. Who loses? Those 5 patients and their family who could have survived due to the daring and risk taken by the surgeon concerned. 

Be very careful what you wish for in the name of transparency. A lot of things are at stake here. Reputations; morale; the ethos of teams and above all, patient care. I am a big believer in transparency- heck, I perhaps am the only Consultant in my Trust who has no issues with his patient feedback being on-line- but do so properly, not to satisfy any diktats or tick a box. 
One final request to the data evangelists. Don't take any opposition to such poor data as obstruction to transparency. This isn't the invasion of Iraq...where you are "either with us or against us". This is some advice about using datasets appropriately. We all fight the same battle of improving patient care.

In a line from the Book of Pages…”Telling the difference between transparent and invisible is an acquired skill. Until you've practised, you can't make the choice between looking through and looking at”. 

Amen