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.