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.