Friday, December 26, 2014

Mastering the fire

It's been a magical year..so many highs..so many to look back and smile..  but inevitably the major highs have been the ones linked with friends and family..the times spent together, the holidays with friends, the special weekends with all in London, surprise birthday parties in Southsea, celebrating my daughters 13th...it's all been linked with family..there's been a theme there, hasn't it? 

From a team perspective, its been another year of progress, battling the perceptions of diabetes being a Cinderella service, trying to focus on patient care, trying to avoid harm and as recognition arrived - whether it be via the Kings Fund report or Diabetes UK, realisation started to dawn that we may just have done something which has the potential to be special. It's been a personal vindication being asked by other CCGs to share what we have done- sniffy comments from many seem to have turned to a bit more of a grudging admiration. You look, listen and smile. Getting old,you see, to remind all of the past negativity towards changes made by the team..

Lots of highs...doing the Mary Mackinnon lecture- what an honour - what a privilege- hope I did some justice to that great woman; rolling out 7 day service for diabetes care; HSJ honour for acute services;moving out of general medicine to prioritise diabetes care; a mention as a social media pioneer..all good recognition for a hard working crew- and as ever, the need to "make things happen" has caused frictions.
There has always been a key question for me...Improve patient care and sacrifice a few things for need of haste or take your time, try and get all on board and spend a bit more time when so many suffer while you wait for egos to settle, politics to take a back-seat...do you worry more about the relations with your colleagues or does the hurt you see when you see an insulin error enough to make you stand up and growl one more time? In a culture where it appears that relation maintenance are of a higher priority than patient care, clashes are inevitable. Avoidance of that takes time and patience...do our patients have that time while we as patient advocates have yet another meeting? Tough questions for all of us, aren't they?

It's difficult to do so..and thereby lies the crux. You want to do things swiftly in an era of silos, vested interests..you will rub off people the wrong way. The decision is whether patients can afford the time you tale or not- and for 5 years and a bit, that has not even been a question or debate in my head. A simple rule in life...not here to win a popularity contest...here to improve diabetes care...but how long do you keep pushing the edges?

There have been lows too- perhaps not so much individually apart from personal ailments (touch wood) but also a growing realisation that social media has its more mischievous sides- apart from the realisation that it can do plenty of good- it has also given avenues for some to build up reputations without actually doing much. A change of stance, a new buzzword, a new hash-tag, different titles- and the personality of self has grown- with little changing for patients.It irked..but strangely, in a cathartic moment..it has stopped irking me. Personalities such as that will always exist- they always have..social media is just another forum for the ones who have to justify their existence.It involved a Kings Fund meeting - Mark Newbold and Vijayanath- and something they said...it certainly is time to prioritise

As has happened many a times in my life, by luck or default, on a personal have arrived at a position where there perhaps isn't many more battles to fight locally..the chips are in place- the time is now for delivery- and we have some awesome staff to do so. It has indeed been a long goodbye trying to step down from the department role- but I think we are finally, hopefully, there . It is time for family, a time for a calmer soul..a time for perhaps a more charming side, rather than an angry side. The plan was always to blitzkrieg the local system for the first 5 years with energy, passion and drive...6 years in..its time for the next phase.

What will that bring? I know exactly what it is- it was always part of the bigger plan..what does need adding to it is the need for family time, a bit more laughing and jousting at home. This Christmas day was one of the best I ever had...main factor? We were together- all day- as a family.

Wish you all a fabulous 2015...I know it will be...Let the next phase begin. The fire still rages..mastering it will be fun. Will the softening of the edginess dilute the impact or is the firebrand reputation strong enough to allow things to progress? Let's touch base again in 1 year, shall we? 


Friday, December 19, 2014

GPs...all up to you Part 3

Last blog was fun wasn't it...some high praise indeed from GP colleagues...a lot seemed to like it...but this will be the last in suggestions..because it's time to stop, time for those who do this job themselves a bit different..and for one last time? No, it's not more GPs.
Let's take time to look at an alternative universe...there is no more GPs around to fill posts, no locums, most have retired...what actually happens to the health system? Yes, we can scream and say it's all gone Pete Tong...but what would that force the system to do? What would happen if there were no more GPs? The system will have to look for alternatives..did I hear you say no one else can do what a GP does...yes, I agree...but needs must and in this alternative universe, they ergo GPs don't exist..so what now?

Well, one option is the NHS collapses simply due to the financial implication as it has been proven beyond argument that GPs are cost effective resources. So what now? We go insurance based? As a Consultant, that's not a bad option. Yes, it's rubbish for the population but we are in an alternate universe where we don't care about them, so hey presto, the Consultants or specialists are raking it in now. Let's be honest, if you have diabetes, and capacity to pay insurance, would you go see a GP or a diabetes specialist? Forget about cost effective medicine, evidence based...you would want to see a specialist. Don't believe it? Look around the world...look at the subcontinent...health systems are desperate including insurance companies to set up primary care...just to get some semblance of control. I know so as have been involved with organisations looking at setting up primary care in India etc....led by GP leaders from..hold your breath..the UK. Trying to show the way, ah the irony..don't you just love Pythonesque humour?

What else? How about this? Not enough GPs..struggling...hey how about I tot up all the hours used by the practice nurses to do diabetes care, give up the QoF points for diabetes and the local Trust runs diabetes for you? You don't have to see a single patient with diabetes ever. Did you say multi morbidity? Heck, most diabetes docs are general physicians too..we can do it all...just relinquish the money,..that ok? Palatable? Well, if you don't like last weeks suggestion, that's the alternative view...read up again the Five Year Forward View. Think fast amigos..make your choice soon.Either take up the leadership or be led. Your shout. The cavalry of extra GPs may arrive a tad too late to rescue the show.

But we don't live in that alternative world, I actually would like the NHS to survive as a free at point of care system? Is that a personal wish? No...I am blessed enough to afford insurance and give me and my family the best treatment, the best specialists needed. Work wise, again, if GPs collapse, ah well, I go down the PACS model, employ more specialists, and boom, bobs your uncle, innit?  So what if all can't afford it, I am better off..so what the heck? Right?
Well, no..wrong actually. Why? Because I have worked in systems which isn't free for all and it simply isn't fair. Health is a basic right for all, as is education and as lovely as it would be for me individually, I would love to think a little bit broader for me. The present system rewards me well enough, thank you very much.

So I am going to end this series by exhorting all GPs to spend even an hour a week by trying to convince even one undecided trainee to take up your chosen profession. Show them why you are proud. I get it ...the media have dissed you, I get it ...politicians don't like you..I get it all. I also know there's a huge collective of fantastic folks who are immensely proud of the work they do. Do whatever it takes to encourage people to join. See what is being published in Pulse..see what medial students are saying. Check the Deanery gaps...you are losing the recruitment battle hand over fist. Say it loud, say it proud..its a good ,proud profession...heck if you want a specialist to do it for you, ask and I will help.

And you know why? Not because I feel sorry for GPs, not because I am trying to suck up to anyone...but because I am more keen on making sure the NHS survives. Because ladies and gentlemen, if you can't recruit and it collapses, I will be fine. Many, many other...simply put...won't.

I will stop throwing my tuppence in anymore..and I wish you all the best. It's a tough battle and certainly not an easy one to win. But if you ever need an ally, you know where to ask. It would be easier to say "not my circus"...the problem is it actually is..as if you all collapse, you bring the whole house down with you.

Wishing you all a Merry Christmas x 

Wednesday, December 17, 2014

GPs...the Hail Mary pass ? Part 2

It's been fascinating having the last blog published...the reaction was as expected- a smattering of "no facts" ; "not wise for an endocrine doctor to comment"; "rhetoric" - and indeed it came from expected quarters. What however was pleasantly surprising was the positive vibes too from GP colleagues and even better were the the suggestions. I kept ribbing about people stealing my ideas for the part 2..but weren't they just fantastic ones? Wasn't it nice to see some sensible suggestions- all from GPS- suggestions which were beyond the rhetoric of "more GPs"; a display of obvious pride at the job GPs do...THAT'S what I was looking for and you know what- the NHS has indeed a future with passionate folks like that in the fray.

Let's cut to the chase- we can tango around the perennial debate whether GPs are independent private businessmen/women or not. To be honest, its immaterial- without blowing smoke up anyone else, 5 years and more of working in the community has taught me one thing- without GPs, the NHS doesn't exist. pretty simple as that. If this was a game of american football, most external folks would be perplexed at the effort the system has put to make sure the quarterback was tired and incapable of making the pass the rest of the team needs. Know what a Hail Mary pass is? Look it up...the quarterbacks are now reduced to that- and guess what, the team is losing and with it, so is the rest of the morale.

So let's get some radical thinking going. Stop thinking that only more GPs will solve it- it won't. Not to mention they are actually not out there...but more of that later. Broaden your horizon and thinking ladies and gentlemen. The RCGP and RCP have now come out with a joint statement how organisational boundaries shouldn't be a barrier to patient care- so why not start actually employing Specialists under yourselves? I hear you say where's the money- well, take some time to understand the fallacy of Payment By Results. It is a system which works well for surgical procedures but has crippled us all, Commissioners included, where Medicine or specifically long term conditions are concerned.

Like him or not, Stevens 5 year Forward View is here to stay- and irrespective of elections, is pretty much the direction of travel. Look at pages 16-20 of the PDF document- is your answer there? Can GP surgeries - if you don't like the word federation- then at least buddy up together and come up with a plan to run a long term condition? Can you show that you can employ nurses, specialists to own the whole process? I am sure I will be called naive- let me counter that by saying that most GPs don't have much idea either about Consultant contracts, Payment by results..look, ask and you shall find. By the way, read a bit beyond on that report, there is another model there too...check that out..and think whether that maybe suitable too...views on that welcome indeed!

I will give you an example- as part of our diabetes work, as a team, we go to each surgery twice a  year at the surgeries discretion. The mantra is very simple. "I" am "YOUR" employee for 3-4 hours or however long you want me  in your surgery. YOU use my skills to improve care of patients under YOUR care- as simple as that. That could be done by education sessions, chatting, seeing patients with you, audits- the call is YOURS. YOU are the quarterback- you tell me which channel to run in. I have a skill set YOU need to use for your own patients- can't be that difficult, can it?

At the moment, most GPs can't even look up beyond their daily work to think broad- I get it. But trust me, there are many like me who want to help, want to keep the NHS afloat as there is a simple realisation- given the efficiency to which GPs run, without them in the pack, you can kiss "free at the point of delivery" goodbye. Love the NHS and its ethos a lot? Then broaden your horizons..as let's face it...there is no cavalry coming right now. Maybe it will- but it's going to take at least 3-4 years...do you have the time for that? We are losing GPs NOW...when and if the cavalry arrives, what will they be left with?

I could go on and on and am sure will still be criticised for "not getting it". Maybe I don't, maybe I am too naive- but I work with GPs everyday- and I see folks every day who genuinely want to help. The future maybe different..and more on that in the next part...but for now, you need a plan pretty sharpish. Heck, you guys have been throwing plenty of Hail Mary passes...try this one out...a lot of professionals- inclusive of specialists, pharmacists, nurses are ready to make that run. The billion dollar question is...do you trust us?

Saturday, December 13, 2014

General Practice..beyond the anger? Part 1

GPs are angry..at least on social media they are.Look at twitter or any social media for that matter, apart from anything else, any suggestions to even do something, have a debate about anything different descends pretty much within 3-4 minutes to total anarchy..like a pack, you get absolutely overwhelmed by someone "out of touch", someone "who misses the point", someone being "protective about their patch"...140 characters condenses strong emotions into what appears to be rude, recalcitrant and disengaged. But hey, its always worth a discussion because lets be honest, its not working, is it? The dangled carrot of more GPs seems more like hunting for the El Dorado gold- while the reality on the ground is that most trainees are not picking this specialty, many do NOT want to be partners...a reality check is always important and no, you can't force anyone to be a GP.

It must be said however that there is a difference with people I meet day in, day out though. I interact with GPs every day- all across 80 surgeries or more- and rarely if ever I see angry folks. In the main, they are pleasant, keen to help- yes, tired, brow beaten, aware of increased pressures but importantly very appreciative that they aren't the only ones. The british sense of humour is ever present- and I do enjoy a lot my time spent with them...maybe twitter is skewed. The issue however is that this isn't a complete rarity. The system now has ground all into such a corner that now you have what one could describe as trench mentality. Yes, I am a Consultant in Diabetes but I have been fortunate enough to hold different roles in community beyond diabetes, within hospitals in unscheduled care to understand that there are many-, many others who are as busy as anyone else. District Nurses, Community nurses, ED doctors, MAU doctors..off their feet, busy, horrendously busy, tired faces- and if I am being brutally honest? As I have said before, yes GPs are busy but so are plenty others- its not a monopoly on the level of busy-ness neither is there a prize or competition out there to win. The system is squeezed, money is short, politics is huge- we are ALL under pressure.
There are 2 views at looking at this- and let me make this clear- these are views from GP colleagues themselves- NOT from ivory towered specialists or managers or anyone who has no experience of General Practice. View A is that people are well paid on a public tax funded structure, amongst the top 5-10% of the whole population, armed with a pension scheme which is gilt edged and now that the pressure is on, there are too many complaints. Be grateful for what you have, do the hard yard, earn your pennies and retire happily. Do the job you trained to do- and accept public srutiny is more- and get on with it. View B is its all too much- work has descended on GPs without agreement, without resources, public expectation has been fuelled and its time to take a stand and say "Enough". Time to stop doing X, Y and Z.

My view? Either views are too entrenched. I will be perfectly honest- if you want more people to join GP land while at the same time, you consistently say its too much- you forget the basic psychology of the generation we live in. This is no longer the Baby-Boomers or Generation X who would grit their teeth and do it in times of pressure- the next generation is a mixture of Generation Y and Generation "Me". We can critiicise that as much as we want but for that generation, work life balance is extremely important. I know lot of people turn their nose up at it- but I never ever fault anyone for that. THAT'S the world we live in- THAT'S what we have to work with- so if you want to attract more to a specialty- you must balance out your views- YES absolutely make it clear its hard, tough- but also show how amazing GP life can be- how rewarding it can be- how much work life balanace there can be...its can't be all bad, can it? Your present angst at the system shouldn't result in the future being bust, should it? And let's be honest, if GP surgeries collapse, thats pretty much the end of our beloved "free for all" NHS.

So...apart from the nebulous Narnia-esque idea of "more GPs"..is there actually any solution to the crisis looming? The future path for the NHS has been outlined in the Stevens report...does any of the clues lie there? More importantly, is there an appetite for this amongst GPs? Can they genuinely be in charge and think beyond their individual surgeries? In my next blog, I will throw open some questions ...

Finally,those who feel strongly against any of the thoughts above or in next blog, my appeal..have a proper debate, not a condensed angry one in 140 characters...but let me be perfectly honest, more GPs isn't going to solve the NHS conundrum- and will only act as yet another finger in the dyke.

Tuesday, December 2, 2014

Walk on the Wild Side #WoWs



There's one thing that should be made mandatory in the NHS nowadays. A week doing another persons job. At every level. Especially when they have a opinion about how other people should work. The NHS is rampant with leaders now and the problem with that is that somehow it installs in these folks an ingrained thought process as to how another specialty or another profession should run.
To be honest, I have no issues with that IF there is experience of working with that team, shadowing the team, trying to understand the team, the pressures...but nope, there is indeed little of that. Forget about doctors giving advise to nurses how to run wards (and heck, there's plenty of that) but it's between doctors themselves. And if I am brutally honest, I have gone down that road too in the past. Flush with a new title and the love of being given a management role, I have advised others how to do their job- without getting to grips first as to how their daily lives are.

But it pains me no end to see everyday, everybody having an opinion about something they have no experience on.  Overheard this conversation at a national meeting..a respiratory colleague says that if the cardiologists did less private work, they would find time to do general medicine. How does he/ she know that? Has he/she seen their job plans? No of course not. But surely the prototype of a cardiologist swanning off to do private work was correct,right? Well not really, as it turns out some of the interventional cardiologists do a 1:4 back breaking rota, up most of the night. When another pointed this out gently, response was illegible but they swiftly moved on to how lazy the other physicians were. Dude...just do your own work, ok? See how you can help your own department or heck, here's a suggestion, go and shadow your cardiology colleague for a week. Why assume there is no greater dedicated soul than yourselves?

The trend continues...the culture of ward rounds reinforces that...the sneering comment from the Consultant about one of their fellow specialists or a disparaging remark about a GP..still far too common place. juniors walk away inculcated in the tribe mentality...the machismo of one specialty trying to out-testosterone another. And it happens everywhere...GPs are as much to blame with the old stereotype jokes of Consultants and their fancy cars, the golf courses...you wonder why we are a divided group of folks...heck we have no respect of each other, let alone anyone else. What chance does a nurse or a manager stand?

So here's a suggestion to all the leadership quangoes...try and see whether the best experience possible for doctors is to shadow each other's colleagues. Ideally we want them to do the same with nurses and managers so they appreciate their pressures too...but let's not make that big a leap of faith. Trying to get doctors to change their ways is notoriously difficult so let's try something simple...a GP shadowing a Consultant and vice versa, A cardiologist shadowing a Diabetologist, a vascular surgeon shadowing an orthopaedic one...maybe and just maybe we may all develop a little bit more respect for each other, understand that there are patients out there who exist beyond your own specialty and need the expertise of your colleague too. Once we learn to respect and value each other's work..perhaps on the off chance, we could extend that learning and understanding to nurse colleagues, pharmacists, managers, finance folks...all of whom we have a disparaging and disrespectful comment for..of course, it's only banter,isn't it?

Go and develop that..heck..even make up a hashtag for that..seems to work for most things..how about #Walkonthewildside or #Wows. Go on, you can have it for free. 

Saturday, November 22, 2014

Step Up. Or Step Down

I sat in the room- and looked around while sipping on my umpteenth coffee for the day. I was surrounded by folks I had trained with, passionate individuals who were Diabetes Consultants all around the country- and the frustration was palpable. This wasn't a meeting of folks who weren't interested, disenfranchised..those who has refused to come out of their "ivory towers"...those who simply sat in committees and nodded sagely...no...these were folks from whom the energy and passion to improve diabetes care- simply put- burst through in abundance.All keen and ready with ideas, thoughts- willing to work within, with- whatever was needed to do- primary care colleagues to improve care locally- and simply blocked and frustrated by progress.

During the day, we had some great discussions, thoughts exchanged, speakers who represented acute trusts, CCGs...and finally near the end of the day, one of the speakers hit the nail bang on the head. "You need to raise your identity within the Trust"...and there it was...as simple as that.

I have commented earlier on the evangelist few GPs who speak for no one and have caused more harm to diabetes care than anyone else. There is no getting past that...by trumpeting that diabetes can be done in the community by primary care ("and no, we don't need specialists")- swaths of patients moved out- without much support from specialist teams- and now we are all suffering- most importantly- patients with diabetes simply sue to the sheer volume as well as variability in diabetes care provided. But as regards specialist teams, the damage to them has been done by their own leaders who appeared toothless in the face of the changing world, struggling to justify their existence and consequently sacrificing the identity of diabetes teams within Trusts. As soon as that was done, their role,as deemed by their own medical colleagues became to be to do jobs no one else wanted. They got tied into Acute Medicine, General Medicine- anything really while politics played its part, other medical specialities explained to powers that be how amazing their own speciality was...diabetes got sidelined- and a combination of lack of cojones, leadership, timid personality and an element of self protection- all combined to turn diabetes teams into "teams which did what others didn't".

The irony of that is telling now...when the opportunity has arisen, when the community is actually opening its doors, when CCGs are perhaps looking at models of care, when even Simon Stevens is talking about working in the community....the diabetes teams have nowhere to manouveur..as simply its the fundamental question...if you don't do "what others don't want"...who the heck does it?

To be honest, I actually sympathise with every acute trust with that dilemma. It isnt their fault that diabetes leaders were and continue to be rudderless- without any direction to what a specialist should do within an acute trust. It isn't their issue that diabetes teams have indeed opted to do other work afraid of commiting into the community- and it isn't their fault either that most are starting to see the light- yet perhaps too late. Every acute Trust would of course love to see their own Consultants improve care in the community but their dilemma is simple- they need to look after the patients within the Trust too.
I don't blame other specialities either- they are doing what anyone else would. I don't think its with any dastardly preconceived plan to screw diabetes teams- but simply using the opportunity to showcase their knowledge and show how they could improve care - the cardiology example shows the benefits of focussing on speciality. That's life, that's politics- that opportunity was taken- its the fault of us as a diabetes community that we sat back- so its really difficult to now wringing ones hands when our leaders have failed so badly- not just their colleagues- but also the very patients they are supposed to serve.

The team was recently commended by a judging panel- comprising of the RCP- in the acute sector innovation in the HSJ Awards. There was a specific reason why I went for that- it wasn't the lure of "yet another" but making the point that a diabetes team could show innovation within the acute sector- without simply doing what "others didn't like". It's telling to see us as the only diabetes team within the acute sector category...it tells its own story, doesn't it?

So to all those leaders of the diabetes Consultants, here's an open tip...stop wringing your hands, showcase to acute Trusts and CCGs what a specialist can offer within a Trust and the wider community. Show in the brave world of Accountable Care Organisations, Primary and Acute Care System, the diabetes specialists has an immense role to play...maybe even suggest who would do the jobs outside diabetes care that present folks do within trusts, so Trusts aren't compromised either. Free the diabetes specialists to work with primary care, create the PACS- enhance the reputation of Trusts further..the opportunities are endless.

If you can't, then stop organising conferences, meaningless meetings, producing documents of worthless value. Suggest you save the polar bears and step down. There's a reason why there isn't a flood of trainees opting for this speciality...they don't even know what kind of jobs they will have to do in the future. If you can't even justify your own existence, there's little hope for you explaining the role of a specialist- let alone improve patient care.

Go to work on Monday...maybe even ignore the next CEA round- look in the mirror and have a think whether you are doing justice to the role of being a national leader in diabetes. The options are indeed very simple. Step Up. Or Step Down.

Saturday, November 15, 2014

Contract games part 2: Think..TEAM

It always makes me bemused when we talk about yet another contract. We fail to actually monitor, adhere to, understand the present contract so to suggest yet another modification will solve it all is steeped in naivety. Most managers I have encountered have not actually gone through a gruelling course or understanding of the Consultant contract -which isn't their fault- so to expect them to monitor and hold people to account is also a bit simplistic, if not fool hardy. The Consultant contract is fundamentally different from say a GP contract or a nurse contract- so to use the same tools to dive efficiency- if that's the new buzzword - not to surprisingly doesn't work

So to some suggestions- not too radical- and indeed have been tried in some places with good effect- whilst also keeping morale high. But it involves help from both sides- not just managers but also Consultants themselves- the billion dollar question,as ever, is are they?

1. Annualise departmental job plans: 

Put all PAs in one pot- maybe tricky in bigger department but not impossible. As a manager, explain to the team that the Trust is paying for X sessions and thus its only fair to monitor whether X are being delivered or not. Give the onus on the department- we talk about working in teams- well then, give the department the ethos of a team. It's THEIR responsibility to deliver- as a group- let them sit as adults and come up with plans- let them sort their team annual leave, study leave out and outline the sessions they will be doing.
As a manager, don't just rock up and say "Its short guv"- give heads up- send the departmental lead quarterly updates where things sit with sessions- a pat on the back if on track- again- to check internally if short- why short, is there a busy month coming up which will cover the shortfall or is it someone within the team not pulling their weight? Let the team sort it out. At the end of the year, its the team which will be responsible for the outcome to the question- "Have you delivered the sessions the Trust has paid you for?" Together you rise, together you fall

2. SPA time- as a team:

Again, SPA is not some mythical beast. If teams are saying they have, lets say, 12 trainees to supervise- no problem- of course check with the postgraduate lead- as to whether they are indeed the supervisors- and have a system of checking even with the trainees whether they are actually being given the supervision? What's the point in having SPA allocated to your time and then not having time for the trainees if most of the time is in DCC? May as well be open about it- again- let the team choose which members of the team are better suited to deliver training, research...I have been involved with education long enough to know many are not interested in teaching or supervising..so why allocate that in their SPA?

3. Outcomes- as a team:

There;s little in job plans to measure outcomes- why not? To suggestion 1...there is little point in doing all your sessions if the outcomes suggest that you are not benefiting patients- who would I rather have as a doctor- a surgeon who does 5 cases in 3 hours but with a higher mortality than someone who does 3 cases but lower one? If its the same case mix, then its the second one for sure. Think broadly- again- let the department be asked what THEY would like to be monitored on- a team effort- and once they agree- that indeed is the monitoring- why indeed not?

4. Transparency of job plans:

Finally, make all job plans, outcomes agreed- sessions being done transparent. At the moment, hospitals are filled with folks who think they work the hardest and by default everyone else is lazy or at least less busy than them. Its like there's an award for being most miserable, downbeat, looking tired...if you smile and say "it's not too bad"...the immediate thought from the other party is "lazy so and so.lets look at their job plans". Let's make it transparent...just because you work in emergency department doesn't make you less busy than if you work in an Endoscopy suite or Rheumatology make job plans open- let the miserable ones review it and come to a more open conclusion- stop the sniping, make teams expand from just departments to have a more divisional feel

Its about treating adults as adults. Discuss, negotiate with them what THEY believe their outcomes should be, don't foist on them. Discuss with them why they can't work as a team- use job plans to create the ethos of camaraderie- get THEM to rise above departmental disputes. Learn from sports- disparate characters get together to make a winning team- Consultants are no different. But once THEY have agreed to be monitored on X, Y and Z, then give managers the tools and understanding to have regular meetings to discuss them.

We in the NHS have a phenomenal capacity to over complicate things and then to change something which we couldn't implement in the first place. It's not really that complicated- it needs strength, tenacity, determination and a strong feeling of mutual respect.

That, I am afraid, isn't something that we have in huge measures in the NHS- sadly we seem to spend more time thinking of new fancy terms to resurrect old power point presentations. This isn't the time for packaging old wine in new bottles- we need a new brewery.







Saturday, November 8, 2014

Contract Games part 1: The battle

So it's now a Mexican stand off. The senior and junior doctor negotiations have broken down- both parties have walked away. Both parties have accused each other- and its played out publicly - sometimes a bit undignified, sometimes like a school playground- I suppose depends on who you follow on social media. I have been a clinical manager now for nearly 5 and a half years- and I have always particularly taken interest in job planning- which is why the debate fascinates and intrigues me.

On one hand, you will hear the frustration of managers about the inability to pierce through job plans, the multitude of national body recommendations as regards job plans which doesn't always help with delivery of Trust needs while Consultants will also turn and say that if they were held strictly to their job plans, and they decided to walk away when the clock struck "X". the NHS would collapse. The reality is that both sides actually have a point. Did I hear some say "how dare you- have YOU any idea how hard I work?"...well..calm down and read on.

The present Consultant contract is actually a simple one.The last changes moved to a sessional based contract divided into Direct clinical Care along with Supporting Professional Activities. The national contract was that in a 10 session job, 2.5 were recommended and agreed to be SPA. Fact is most trusts or new appointments breach that and as the College advisor asked to review job plans- thats pretty much a standard answer I give to all- the SPA isn't enough as per national contract requirements. Don't quote me on this but as I understand Foundation Trusts are under no obligation to heed that recommendation. Happy to stand corrected by Human Resources teams! Anyway, so this SPA- most managers don't quite like- reason? Well- it actually if rarely generates much revenue for the Trust or helps to deliver clinical care. The flip of that is this..it incorporates time needed for teaching, education, revalidation, audits, clinical governance..all those things which don't get you revenue (No sir, that's not on PbR) but actually means a lot for patient care.

This is where it all gets a bit complicated. Educational bodies recommend that job plans should have 0.25 PA per trainee- 1 hours / week- sounds amazing for the trainee. So if you hold that to the tee- and then factor in the College recommendation as regards time for revalidation (you need that to be a safe doctor) then all you need is 4 trainees to supervise, revalidation time and boom, your SPA is over. What actually happens? The Consultant tries to squeeze in the other relevant bits such as audit, governance in there- the time for training squeezes, juniors feel left out, training standards drop- and the cycle is complete.

What about the Direct Clinical care? Again, areas of greyness- job plans suggest you start clinic at 9- finish at 1230- have 30 minutes for patient letters etc- there you go, 4 hours done- go home. Reality? Ask around- pretty different...don't get me wrong- there are indeed individuals who take the proverbial BUT that's due to poor management or supervision by the clinical managers. A few bad apples don't make the whole barrel rotten. The debate or cycle continues. Then there is the desire to standardise- why does Dr X see 10 patients while Dr Y sees 18 in the same time? From a managerial point of view- why cant both X and Y see 14? Simple really- thats because they run different clinics with patients of different needs. A patient with pituitary pathology will take anything between 15-20 minutes while a patient on an insulin pump may require 30 minutes- 45 minutes. Standardise that...and you fail both groups of patients.

Finally, the area of debate- "normal working hours" as per standard contract is 7 am to 7 pm- the latest contract round wants to make "normal" till 10 pm. An area of amazing greyness mixed with a whole load of politics. Rather than having a proper discussion, most centres around "If you don't agree to this, then you are not patient centred". Lots of folks who actually dish out that advise don't work 7 days themselves but couch themselves in leadership garbs and showcase themselves as inspiring individuals.Always easy to lecture when you don't do it yourself, isnt it? It's a bit like me suggesting Messi should have curved the ball around the wall, rather than going over the top...
Some Consultants also join the camp..check them out- either their kids have grown up and moved out or they don't have much of a family to go to. A few people's evangelism shouldn't burn the dedication of many.I hear plenty say- it is amazing to have a Monday off instead of Sunday- yes perhaps so- but you know what- at that time, my kids are at school- and I want time with them- not be twiddling my thumb on my own at home. Tricky isn't it? Took this job to help, not be a martyr.

It makes me smile when I see lots of folks quote Gandhi- how he dedicated his life to making India free...can I suggest you check his life story too? There are reams written on his lack of family life, his destroyed relations with his children. History has an odd way of suppressing the faults of those we believe so much in- read a bit more- you will find plenty of interest. Let me be honest- I don't want to be like Gandhi- I would just like to be Partha Kar- with my flaws- trying the best I can do at work- and then going home, enjoying my life with friends and family.

However, there is actually a way around all this as regards contracts- or at least in my opinion. It involves both sides - clinicians and HR/managers working together, being adults and open about solutions, a bit of give and take on both sides... the question is are both sides actually ready for that?

(To be Continued in Part 2)

Friday, October 31, 2014

From the heart..Thank You

Pride is good, isn't it? When you get something right, you have to be proud, isn't it? Today when I see our local model of care being recognised either by Diabetes UK or the Kings Fund, I don't make any bones about how proud it makes me. No one- and I repeat- no one has seen the long evenings, the extended negotiations, the charm offensive, the time with the family sacrificed to do only with one thing in mind...the model of care needs to change..patients deserve better, much better.
Yes, the NHS is cash strapped, yes, we belong in silos, yes, we all like to believe we are doing a fantastic job and yes, we baulk at the thought that the NHS may not be delivering great care sometimes...but there are many and many folks out there crying out for better care. And I have tried..in my own inimitable style..tried to change years of working, years of obstinence, lack of mutual respect between primary and specialst care..and 4 years later? Excuse me for taking a moment to look back..and say " We got there...ladies and gentlemen, we got there".

This blog isn't about explaining the model - there are now enough literature on it- it works on 2 simple principles...Firstly, diabetes care sits in primary care- so support them, help them- on THEIR terms, not ours. Secondly, the changing role of a specialist...moving away from just being a specialist to being also a support, a friend in need, a helping hand and an educator...plus a realisation that for primary care diabetes is only a fraction of what they do..so support, help...don't criticise, help..be there when needed. Honestly,its not that complicated- never was. No this blog today is about taking off the veneer of arrogance and saying thank you...saying ladies and gentlemen..without you, it simply wouldn't have happened. I have been the public face of it, the spokesperson, the person to showcase it..little else..the credit for this belongs to many others.

Firstly my amazing colleagues..for years my Consultants...then folks who believed in my vision, never unhappy with me taking the spotlight, allowing me to show boat, drive the changes and keeping implicit faith. Darryl, Mike and Iain..its has and is been nothing but a privilege...my colleagues, my mates, folks I intrinsically trust with anything...gentlemen..thank you.
Then what about our nurses? What can I say...I can't repeat myself enough..they ARE the lynchpins of what we do...amazing women who do a job I can only stand back and admire...ladies, a group hug from me..you all have been just simply ..wow...folks who have shown it can be done.
I must acknowledge my primary care colleagues who have received us with open arms- across 83 GP surgeries. everyday has been a learning experience..simply being stunned by the workload...and silently making a note the care being provided. Thank you guys...it has and is fun...great to work with you indeed  :-)

At this point, I must say I tire of the managerial bashing I continuously hear. Let me make this crystal clear..without some good managers to work with me, none of this would have happened. Firstly Melissa Way, then Sarah Malcolm..if you want to ever know why we need managers, go and see what they have done for us. Local CCG leads have been great...people always ask how we have done what we have..well..without such forward thinking ones like Jim Hogan, Andy Douglas, Paul Howden et al,..it would have stayed confined to a powerpoint presentation - for sure

Finally, our patients...I have observed, learnt, taken feedback, accepted the challenges thrown and been my driver to implement what we have done. We haven't solved everything but are always open to being challenged, always open to change and improving things further. The above may indeed read like an Oscar acceptance speech but I don't know of any other forum to thank you so many who have made all this come true.

Ladies and gentlemen, genuinely, from the heart...for once taking off the aura of arrogance, letting the ego rest for a bit...just wanted to say thank you to all. I wouldn't have even dreamt of getting where we are when I started my job in 2008..and wouldn't have without you all. Partha Kar...today....says thank you. From the heart. xx


Thursday, October 23, 2014

The Fantastic Four

Sometimes it's worth taking a pause in the hustle bustle of life, politics, work to perhaps stand back and simply say..thank you. This blog certainly aims to do that...thank you to four special ladies with whom I have had or continue to have the utmost privilege of working with. Why am I writing about them? Simply because they are the unsung heroes similar to the thousands within the NHS who are self effacing, humble, absolute super- professionals but never recognised in the fast modern world of self aggrandisation and publicity. I have said this publicly, in forums as well as blogs...I have one specific task..it isn't job planned but I do it. It's publicising the work of the department of Diabetes & Endocrinology of Portsmouth.Love it or hate it, call it the marmite effect, whether it be via blogs, twitter, public campaigns or articles, I do indeed try my best to highlight the stupendous work some of my colleagues do...sometimes it's branded as my ego, to some it's cockiness..to me, it's giving these individuals the rightful place they deserve when they don't have the time or inclination to self publicise like so many do on public forums ( but feign mock horror when someone suggest so!) or social media. Looking after our team is my job too..and yes, it does involve going out and showcasing some amazing work that happens day in and day out.

So lets start with Sharon Allard. I have known her for nearly 12 years now- and recently we went out and celebrated her 25 years of being a part of the diabetes department. Always humble, always the quiet one, she has been a pillar of strength for anyone who has done research within our department. An amazing individual, her patient focus has been second to none and indeed someone who patients love unequivocally...there is something special about Sharon...if you know her,it is impossible to have not been touched by her kindness. An archetype nurse specialist..someone who embodies what nursing should be about..and tongue in cheek? She has been doing the 6 Cs much much before it became a hashtag campaign.

Next is Jane Cansfield..another nurse specialist who celebrated her 25 years with us..again someone who I have known for more than 10 years. One thing about Jane? She knows someone who knows someone...master organiser, lynchpin of social events within the centre..everyone within our department loves Jane..without Jane, there never has been any organisation of travelling together to conferences. Her knowledge about retinal screening puts many a specialist to shame..hang on..let me change that..actually, I know very few specialists who know more about retinal changes than her. Jane' s our go-to person..always helping, always accommodating..someone who has and is always there whenever there is a problem.
Testament to how much both these ladies are appreciated? We organised a 25 year party..bar a couple, we had a full house turn out including legendary figures of the Portsmouth team from the past such as Ken Shaw and Sue Craddock.

Next up is Jean Munday...and I cannot describe in words what Jean means for our department. Jean breathed the word "retirement in another 5-7 years"..and the sheer look of panic amongst all of us said it all. Without Jean, our endocrine service doesn't exist anymore..it collapses. A legendary figure in our department..someone who commands respect and admiration from all irrespective of their status or grade, Jean is someone I would encourage any nurse to learn from and try and perhaps achieve even 25% of what she has achieved. It is our pride that she has been shortlisted for Nurse of the Year..whether she wins or not, if we had an award along those lines in our department, Jean would have walked away with it perhaps every year.Her intrinsic knowledge about endocrinology will put most to shame but more than that, her calmness, friendly manner has made her so special...best of luck at the awards, Jean!

Finally, a mention about Gwen Hall. I have known Gwen personally for about an year or more but have known of her for a number of years due to her national profile and work in diabetes education. A strong character, we head hunted her to helm the Portsmouth community team fully aware that she would step down after 1 year or so but boy hasn't that been a recruitment master stroke. She has helped put down the basics for primary care leading on education and support for our local GP surgeries and I suspect the Portsmouth of the future will always thank her for her time, efforts and undisputed passion to improve diabetes care. On behalf of the team and the wider community, thank you Gwen for your time and help to develop diabetes services in Pompey.

All in all, it has been nothing but a privilege and an honour to work with such amazing individuals. There are many such more with whom I work within our department but at this moment of time, these fabulous four and their contribution to making our department stronger and improving patient care must be applauded and recognised. I have always maintained that there perhaps are better departments than Portsmouth but I doubt there are better places to work in...it has always been and continues to be individuals such as the fantastic four who have made it so.

So ladies and gentlemen a moment to pause and say thank you to our Fantastic Four. a moment perhaps for the wider community to also look at where you work and go tomorrow and say thank you to those who are the unsung heroes.
Such individuals exist in every department in the NHS and it is time we have them their just due.Go find them,make them perhaps a cuppa and just say "thank you"

Tuesday, October 7, 2014

Wrong tack?

So shall I dip my toe into this water? Challenge the RCGP and thereby the GPs..or are they a separate entity?  Let me set my stall out at the very outset..don't know about politics but amongst the mates I have grown up with, those who are GPs, I see less of, they arrive late for the football games, look a bit more knackered, so this isn't a debate about who works hardest. Let me be perfectly honest, most GPs, I know work harder than me and unlikely to have as good a work-life or as Mark Cheetham likes..work-family balance.Thats not a condescending sop to balance for what I write below, but as I see it day in, day out.

Nope this isn't about that...this is more about the pathway or tack adapted by the RCGP akaThe Royal College of General Practitioners... it's made me wonder...is the RCGP more of a collegiate institution or a trade union? I say so without prejudice but mostly from point of view of my own college which has tended to adapt a "hands off" approach to political changes,for good or bad..though in all fairness, their engagement as regards the future hospital has been laudable to say the least.

But the RCGP in recent times has slightly baffled me as quote unquote one of my GP colleagues "it just says more GPs". Which in itself is an interesting position in my book, as the ethos behind that seems to believe that more GPs will solve the problem while on the ground, if given a choice,for right or wrong,I would probably have more practice nurses, more community DSNs...whatever be the case, certainly more primary care staff, not necessarily "just GPs"

It is at this point I can already hear murmurs saying what qualifies me to speak about such an issue? The answer is probably not much but am giving a perception, from the outside if you may, that the position sounds too siloed. Put patients first...absolutely 100% with you....But not by saying lets just have more GPs. Not by saying "give money from hospitals"...believe you me, hospitals aren't running in rosy balance sheets either. I appreciate I offer perhaps a narrow siloed view but diabetes care isn't going to be resolved or improved with more GPs...more primary care staff...absolutely 100%.
As an analogy, you will never find me go out and say we should have more and more diabetes consultants...not certainly when we still haven't evolved enough to work differently and learn to help primary care more, rather than do our clinics in the traditional way,still ducking behind the spectre of information governance and shying way from patient access.More on that chestnut later.

Which brings me to the next point...on one hand, the clamour is for more GPs..on the other hand, posts can't be filled, people are leaving,social media is abuzz with burnouts, GPs themselves encouraging others to leave,tough working life..all this publicly played out...impact? I teach medical students and the proportion of folks considering becoming a GP continues to dwindle. Recently I asked on twitter what makes a GPs job attractive and there were some wonderful stuff,absolutely inspiring..heck...if I had my time again, may have gone for it myself. So why the lack of balance? Yes jobs are busier but to say working conditions haven't improved from say, 20 years ago, isn't right either, is it? You can't attract generation next by being negative...careful you don't end up being the reason why no one wants to do primary  care anymore. Those who work with me know that without being condescending, I am very public and open about my admiration for GPs but a bit of balance is needed.

I can only offer tips from history...recruitment in our specialty a few years back was low, with poor job prospects...there is a session at the Annual conference in diabetes UK called the Consultant/SpR session which happens every year. And year after year, as an SpR, I went there and heard people just moan, talk about how life was bad, negative..and a bunch of us sat in the audience and vowed to change that. The SpRs had a 10 minute slot and we decided to showcase the positives in front of everyone...give it a bit of balance and energetic people like Emma Coull, Pratik Choudhury, Marc Atkin went up on stage and said "No" to the negativity..and people started walking way from that session feeling all was not lost, positives were the too. It's our job to inspire generation next, not to push them away. Yes, of course realism, not shying away from the toughness but a bit more balance too, right? It's great to say we will "make" people do more generalists, "make" more GPs....one fundamental flaw? You can't make anyone do anything they don't want.


The NHS will struggle to exist, not because of political restructuring or any other reason, but simply will collapse if we don't have a robust primary care. The wizards have only a few spells in their magic box....if the gatekeepers stop to exist, the facade of sorcery may well be under threat. A campaign designed in the right spirit hopefully will not end up alienating the rest of the workforce...let alone the next generation. Politics is a part of what we all do...but in that game, hopefully the campaign doesn't t do more damage to the future of primary care. Have a think.

Saturday, October 4, 2014

Up to YOU

One of my colleagues recently mentioned that I had strayed away a bit from diabetes in my blogs...looking back, perhaps she does have a point...so let's get back to it this week- shall we? After all, politics and the NHS along with its challenges will always be there. Let's be honest and keep aside our political leanings for a moment...or if you are overtly optimistic, you may actually believe that the 8000 extra GPs that one party has promised from Narnia will help to provide the 7 day GP service the other party promises. Maybe they are actually working together, right? The elusive hunt for that wardrobe to Narnia is going to go on for a bit- so enough time to get back to that...for this week, let's get back to diabetes, shall we?

The National Diabetes Audit just got published -I am not going through the data - have a read….makes for sobering reading doesn't it? Yes, there are flaws with data, yes-there hasn't been enough data submitted...but cut it any way- if you had diabetes, you would be pretty worried 

Let's take the first one...we are talking about BASICS here. Nothing too complicated, nothing about evidence based medicine, nothing about evil Pharma promoting their drugs….these are basic checks that anyone with diabetes should have- as simple as that- and the national data around it is astoundingly poor. So what shall we say- primary care is poor? Let's take a reality check- shall we? Due to the evangelism of a few who are in committees, below is what primary care has now been asked to do regard diabetes care:

Screening / Diagnosis / Education / Early Intervention / Looking after co-morbidities / Seeing patient in home environment / Intensification /Complication Screening / Counseling / Appropriate referral / Keeping them out of hospital

Extrapolate that across all other disease areas- and the one thing that is crunched is...yes…..you guessed it….time. How much extra resource has moved to accommodate that sea-shift….very little to be honest. So you would have thought a golden opportunity for all national bodies to get together and look at working together- wouldn't you? Or do specialists take this an opportunity to suggest that they need more specialists....patients should never have been sent to the community? Do GPs say that they need more GPs and it would be fine? I will let you be the judge of that.

Let me be as honest as possible- Diabetes care in this country is in the hands of practice nurses- and if we want to improve care, then we need more educated and supported PNs, NOT GPs, NOT specialists. You don't need specialists to see everyone in hospital but need them to be as educators, guides to making sure the basic check is happening. Not that complicated, is it? It is however when national organizations work in silos, in isolation- all asking for more of their own. The National diabetes Audit has been running for a few years- responses from the national bodies such as ABCD (Association of British Clinical Diabetologists) have been tired, lazy, siloed…I predict a report as to how there is a plan to improve things…how long do you need to actually do so? The NDA hasn't shown much improvement over last few years....so what next? Another report? Where’s the public lobbying, where’s the setting up of educational events looking at addressing this basic issue? Why isn't this primary aim?

So to those who do diabetes as a speciality, let me say so clearly..it is YOUR responsibility to make it better- not anyone else. If you are waiting for national bodies to do it, you have waited, we have waited, I have waited…it’s not coming ..or if its coming, its not coming fast enough for the people who matter. YOU are the advocate for patients with diabetes, so engage with the Trust, work with colleagues, learn from others, go visit other places, find out what they do- and make the change that’s needed. YOU are the one who can work with patient organizations like Diabetes UK to help drive up basic care in the community, work with the practice nurses, build bridges with GPs, say you are there to help, not to judge. 

In the words of Martin Luther King.." Change does not roll in on the wheels of inevitability, but comes through continuous struggle". It's upto YOU as someone who does diabetes as a job to decide whether you want to lead that..or there is little point in doing audits, is there?


Saturday, September 27, 2014

Life without the NHS

So what exactly would happen if there was no NHS? And by that I don't mean the badge or the name because I suspect THAT will always stay..its the principle of "free at the point of access irrespective of social background etc etc". What would actually happen? Social media, newsprint is abuzz with the theories, primarily because it's becoming a battleground for the politicians and with elections coming closer, the noise has just got a bit more shriller.

And everyone has an opinion. People who have never worked anywhere else have an opinion, people have an opinion with wild fantasy laden, anecdote based remarks, people use study which suits them to make a point..and as ever, a practical based debate is impossible. Recently on twitter an event was held called "Without the NHS" and some of the tweets were quite interesting, fuelled with passion, laced with political beliefs, a few laced in reality but majority by those who believe it should stay as it is.

So, let me give you a perspective - having worked in a country where there is no such socialised medicine. Let's get some basic facts straight. The principle that because the NHS is free thereby ts the best medicine ever is frankly odd. The reason the care is such high quality is because of the staff and the care they provide. When folks say their relatives were saved because the NHS is here...believe you me, folks are saved by caring healthcare professionals all over the world, every day, with high quality care..irrespective of what the system is. So what would happen if the NHS became insurance based or the principle of free for all went? I will tell you what will happen. Overall care will not suffer..it will simply become 2 tiered. Consultants, GPs..their families will continue to get high quality care because they will be able to AFFORD the insurance. For a significant number, it will, simply put, become a care system where they will pay and recieve care to the extent they can afford.

Hurts doesn't it? Tugs at your ethos of socialism? Let's flip this then...how do you feel when the UK to continue provide high quality care raids other countries in desperate need of nurses and doctors to fill up their own stocks..simply with the promise of a better life? Fair? Or does the principle of socialism stop at the UK boundaries? Or does the responsibility end with donating to Children In Need or something equivalent? Tough isnt it? I have worked in a system where I have seen people sell their utensils to buy medications, take huge loans to fund an MRI, get sucked into a world of corruption where the ones who could afford did and still does afford the best treatment money can buy..and though this may sound harsh...sometimes, even better care than what the NHS can sometimes provide.

I have seen the darker side of what "healthcare based on your worth" looks like and I cannot, simply CANNOT stress enough the importance of keeping the principle of the NHS intact...not the NHS, but the principle. Today its a political battleground and promises being made will only stop the slippery slope for a bit, not halt it. Primary care is crumbling, hospital Trusts are struggling...its decision time folks...NHS..free for need or free for want? And Life without the NHS or the principle? There are many and many on twitter and rest who will be fine without it...but there will be many out there who will struggle...big time. I will not regale you with my tales of working in an Emergency department in Calcutta...you won't want to know it, trust me. But when you have 2 folks gasping for breath, no nebulisers around you, 1 oxygen tank- and then you also work somewhere where most people are worried about the 4 hour target rather than a tubing of oxygen...let me tell you this...you don't want to lose the principle.

The NHS will always stay...but the slope has started..some procedures already banned, some products already being pushed by companies to "buy as its amazing"...been there, done that..and it wasn't nice wearing that T shirt either. Fight for the principle- its worth it.

In simple plain terms? You have no idea what you have got- or what you are heading towards. As a professional, I will always try to provide the best care- whoever employs me...but as regards the rest? Crunch time is here. 

Sunday, September 21, 2014

Lest we forget

I am all for innovation and working differently. In fact, the diabetes team where I work is well known for being at the cutting edge of working differently...check the articles, the awards, the feedback from local patients,primary care, CCGs...it is a fact that the diabetes team from Portsmouth are always up for trying new things, new ways of working within the existing financial constraints and envelopes....so the last thing you can accuse  me of being a cynic towards innovation.

But some things are now starting to grate...there's now been a few meetings I have attended, seeing a few twitter chats, a few workshops I have been to...where I think people are now being misled, deliberately or otherwise. How many times have you heard this..."working together is the way ahead"; "collaboration", "value based leadership"...aware of all of them, understand them all...but to indicate that will solve the problems of the NHS is simply put..misleading at best, irresponsible at worst. You create the impression that it's the intransigence of some which is preventing progression of healthcare and money isn't the key factor..when it is THE factor.

As part of my travels, I see projects all around the country, some fantastic ones, which all agree with, including CCGs..but can't move due to lack of start up funds. The are some fabulous 7 day working plans..again..jammed due to lack of start-up funds. For sure, there are inefficiencies in the system..use of technology could be better, interaction could be better...but to say money isn't an issue is blatantly false, It is THE issue...the question is whether any money invested is tied in specifically to transformational work or not. Last time, the cash injection came, it got squandered. The most recent one has been about meeting targets...where's the one needed to transform services?

For all those who speak about working together, if you are in a system when one provider has a profit, do you hand it over to primary care ( where it is needed) or put it into social care budgets or do you make sure your own bottom lines are flush to make yourself look good? If this is one system, surely the budget is also one...one that should be accessible to ALL parts of the system? But it isn't...and that's what grates when I hear folks talk about working together. Working together is not about having group hugs but actually helping each other with finances...got the chutzpah to do that or are we still stuck on eloquent words?  To say 7 day services can be achieved without investment or compromising on elective care is unrealistic and let me repeat myself, promoting to many the view that's it's down to a few HCPs unwilling to work on weekends. I work in Portsmouth Hospitals and on a weekend, at any given point of time, there are, just within Medicine, 8 Consultants on the floor. You want more, you either have to get more or make sure they have time off during the weekday, which compromises the clinic, lists they would otherwise do. Why?Because that person does actually have a life outside his work and may actually like some time off. Do I hear someone say "but weekdays are so much better to have time off"? That's also the time when the kids are at school and the Consultant may actually enjoy seeing his kids...to paraphrase someone...people get ill all the time, you are a father only once for your kids.

So, I ask all such vocal evangelists to maintain some perspective and responsibility.Hinting that if you don't do weekends, you are less patient centred is a desperate attempt to send many on a guilt trip, which is fundamentally wrong.

Let me end giving you 2 perspectives. As a clinical director, we have put in place fundamentally different ways of working in diabetes within acute and community trusts...with my natural sashay of arrogance, let me add that if you haven't heard about that,then suggest you do. We also have 7 day diabetes service in place..something most trusts don't have ( yes, including some of our leaders who talk about patient care being at forefront of everything)... And let me be categorical about this...this has been done by a combination of changing culture, working differently AND INVESTMENT. In case you missed it...the word is INVESTMENT.

As a person and a doctor, let me put this perspective. I love my job, love working in my department,have always done weekends, have a supportive Executive team who "get" diabetes...bar some usual work related politics, I am passionate about improving diabetes care and am most happy seeing patients. I also believe that my patients would hopefully testify to that too.But if I am asked to choose, my family will always, and always come first. If you think that makes me a less caring doctor, then shame on you for making many dedicated doctors and nurses feel that way.
We all have responsibilities as leaders...but however well intentioned, our own evangelistic passion and vision should not consume others in that flame. That would be something we should all bear in mind.

Next week:  Life without the NHS...beyond the scaremongering...

Tuesday, September 9, 2014

Picking cherries

It was always the thin end of the wedge. The day one specialty was allowed to have the option of opting out of general medicine because they were "special". Anyone worth their salt knew what was coming..and lo and behold...the leak on the dam gradually just kept getting bigger..and bigger..and inexorably we keep sliding, or even hurtling towards an inevitable conclusion.

History would suggest the cardiologists took the first plunge in spite of objections from others and that very day, whatever the reason, the camaraderie amongst physicians ended. One group was deigned to be more special than the others..they would have their own rota,their own service, their own cherry picked patients. Flip the coin and you actually see that also made sense for patients with cardiac problems, Up and down the country,many hospitals have swashbuckling cardiology units,swanky, efficient, slick..let me even use a management speak for a second..Lean. Financially it made even more sense...in a world of PbR where every single catheter gets costed and put on  a spreadsheet, the more stents you put in, the more profitable the unit became..the more the swagger of the cardiologists..they were the top dogs in town...and Frankenstein was born, the camaraderie was gone.the cherry pickers were in town.

Then one by one, they all left or are in the process of.....Rheumatologists, Dermatologists, Gastroenterologists...procedure was king, procedure meant money, procedure was sexy..a bit more IV zoledronic acid, a bit more bowel screening...Flip that coin again and you see patients have indeed benefitted from that..some absolutely remarkable departments. I personally have had amazing service from Rheumatology and can in fact see the benefits too...why spread yourself thin when you can do so much better in your specialised area? Why indeed do something else when your own specialised area lacks, you see patients suffer..because YOU are doing "something else"?

It's a tough one, isn't it? On one hand, you have the patients who don't fit into a niche, on the other hand, you want specialists doing 7 day service, helping out in the community, running their services slickly..something had to give, didn't it?And once you have precedence and indeed success, the thin end of the wedge was only just that. The success of Cardiology spawned the way for other specialists to adapt the same approach. Problem? Now we have an elderly population with multiple problems..single disease pathology doesn't exist anymore...how's that game of chess looking now?

It's also a vicious cycle..the ones who pulled out, left the others to carry the system of general medicine ..the smaller their pool became, the more disgruntled they got,torn between a desire to do the "right thing" of helping the patient without any label or triage...while mulling how to improve their specialists services.And no one is exempt from the habit of cherry picking.Acute physicians don't tend to look after patients more than 24-48 hours, rarely follow patients through on other wards...don't blame them..they have multiple fronts to fight. Some clever clog recently said at a meeting they weren't trained to look after general medicine, their training was special...the physician in me, the trainee in me who had worked through hospitals which didn't have acute units..cringed. Elderly medicine know they are getting or about to get swamped..as the age of the population increases, so everyone sets their own tramlines..age cut offs, greater than 1 morbidity,etc etc..again, no ones to blame..you are just trying to fight the tide with existing resources...make sure as the cherry pickers leave, they don't get swamped.

I have always maintained that we should have a simple rule..either all in..or all out. All in makes it equitable, all out makes it clear that we have to redefine how unscheduled care works. I have long held on to the romantic belief that the cherry pickers would be stopped and it has been lovely to see the College harbour that view...but one thing I have learnt in life...there are some battles which you need to learn to walk away from.In the battle between lets help all and lets make care for people with diabetes better, finally, specialism won.
For a system to say that a patient with a heart attack or a patient with an alcoholic liver disease is more precious or special than a patient with diabetes in ketosis is simply..wrong.  For a long time, it has been the issue of "he who shouts loudest"...but finally it is time for the white noise to stop. 20% of patients in hospital beds have diabetes..they deserve better, much better than what they are getting now..they suffer poor care partly because the specialists within the hospital have held onto an altruistic romantic notion while others have left and mock them for their naïveté. Swaths of areas in the community need better diabetes care...something which the specialists could and should support. Something had to give, didn't it?

Medicine is going one of two ways..either all will come back in and share their burden of general medicine..or hospitals will be run by acute medicine and elderly medicine, admittedly with resource- either transferred from other teams or perhaps even new investment..with specialist input along the pathway from all specialists. I suspect it's the latter...but would, be delighted to be proven wrong. Till then, we have a responsibility to improve care for people with diabetes..and I am more than happy to fight their corner every step of the way at any meeting or forum.

There will of course be some who don't agree...but it is indeed the direction of travel we all are heading towards...and much kudos to management for supporting the vision and looking ahead. As a team, we are immensely proud of the community set up we have and how that is seen by many as one for others to emulate. I have a feeling we may just done the same for working within hospitals....and could be a fundamental step to improving care for patients with diabetes admitted to hospital...for any reason..anytime of the day.  

Wednesday, September 3, 2014

All hail the leader

It's been fun recently..deliberately raising some provocative questions to see the responses but more importantly perhaps to showcase that there never is a black and white answer to anything..as ever..without any puns intended...they all are but shades of grey. However, one topic stood out..a topic which threw open all sorts of comments...the question was whether "Leadership" was now a cult,an industry and it's been fascinating to see not only the views but the folks who have contributed to it....the question has been in my head recently and it was intriguing to see so many agree.

I must admit to getting a bit confused nowadays...as everyone around me knows..I am a big fan of folks "stepping up to the plate" but recently..I genuinely can't understand any more some of the language used. Here are some terms..."Moving forward"; "Working in synergy";"distributed leadership";"empathetic vision"...and let's not forget "patient centred care". As someone commented on twitter...how many other types of care is there? Now before I get condemned to being someone who just needs to attend some courses on leadership, my question is what actually defines a leader. I have heard things like insight, determination,empathy..I have even heard that actually everyone is a leader. Well, here's a newsflash..I know plenty of professionals who actually don't want to be a leader...quote unquote.."just want to do my job well..and go home". Does that make them less of a person? Nope..I know them..and would have myself treated by them..eyes closed because they are grade A professionals. So what is leadership now? A tag? A title? Something which makes us all feel important? Is it about who shouts loudest? Or is it about someone who has shown outcomes which have improved patient care?

The explosion of social media has created a lot of keyboard leaders..a natural progression from the keyboard warriors..the ones who have an opinion about anything from Wenger's transfer policy to Obama's healthcare in 140 characters or less. And its interesting to hear them...because I don't understand some of the words used. I have been doing management for 5 years now- so the question is ..am I a leader? Well I am a member of FMLM..so am I? I work with the Kings Fund, does that make me a leader? Or is it because I have won awards and made a few lists...that makes me a leader? Or is it because I drop hints on twitter that I am bloody awesome? Or is it because as the lead of a team, we have something in place which is the envy of many? Either way, never done any leadership course or degree..so what does that make me..a freak? Someone who isn't part of the leadership cult..or does that disqualify me?

All interesting questions..but you know what? It rarely matters..as most of these leadership courses can teach you little..because most of the speakers have actually done little bar move from one post to another..with debatable improvements in patient care they have achieved. If you want to be a leader and make a difference, here's my tip..do good to the person in front of you. Start small...learn from folks, even outside the NHS, who have succeeded and see what they brought to work that made them and their team successful, delivered outcomes..and learn one simple thing about any leader you respect. They are all grey characters..persona with strengths and flaws..whether they be Churchill, Gandhi, Alex Ferguson or Shankley. Don't try to attend a course and be told to be perfect...that leaders must be pristine, have all the skills at the same time..No.if you do that, you put on a pretence which people see through. Rather find some others who complement you- and build your team. That, my friends, is what distributed leadership is about...it is about working as a jigsaw together and being accountable together.

So the next time a list comes out, look at it and think why they are there. As for me, I always ask one thing? If I am not on the list, is it because I upset someone by being forthright..as my ego and cockiness would just be surprised that  I am not there...OR if I am on the list, then is it because someone had to tick a box on ethnic backgrounds to make up the numbers and show how diverse they were? The sad bit? I am genuinely not sure any more.

Next week: The Cherry pickers of the NHS 

Saturday, August 23, 2014

Pied Pipers

Fancy a trip in a time machine? Why indeed not? If you ask around, then most agree the past was better, something about the present never seems right, the oft quoted phrase.."In my days"...so hop on..and let's zoom back to 2004.

The venue: Royal College of General Practitioners. Occasion? Discussion of diabetes care. In the audience- the who's who of diabetes care, discussing how to improve diabetes care. And times were good...there was money in the system and there was,evidently, big need to improve diabetes care. There was a recurrent theme- it was time to break the stranglehold on diabetes care of the hospitals, the Consultants. I was there, a junior Registrar- listening and trying to understand the politics of it all. And then it happened. A GP stood up, announced his title (quite impressive, more so perhaps he claimed or perhaps did have the ear to the "policy-makers") and said this.."I cannot see the point of having diabetes centres- all that resource should be in primary care". Lots of debate ensued but interestingly a lot of GPs in the room stayed silent....was silence a sign of acceptance? The revolution had begun.

Let's zoom forward...its 2009...one of my first public meeting with GPs in our local CCG...we intended to float a new way of working..Partha Kar was the new kid on the block- and it was part of an overall area wide strategy session. Loads of GPs in the room, lots and lots of important and grass-roots in there. I sat in the background- waiting for my session- and then my name was called out. I stood up- and recall having to walk the length of the room..and all I could hear was a murmur. Not many had met me then...and as I walked, you could hear the comments with little effort to hide them..."Another new plan eh?"; "Must be about protecting Consultant patch"," Who is this boy?"..a slight gritting of teeth as you walk up- the mantra in my head buzzing firmly..."Work with them, I must make them believe"...Got to the stage- and the GP leader turned around to the audience and said " Partha will now explain the point of having a diabetologist" with a smile, nay, a smirk. Disdain? Perhaps. Disrespect? Perhaps. Ignorance? Read on and I will let you decide.
My answer back was simple.." How's your skill at working with pregnant diabetes patients?" Pause..nothing much back.."Or for that matter Insulin pumps?". A moment of silence followed by.."Well, I will give you THAT". A murmur rose again in the room. We continued, we sparred, we debated and the birth of our model happened..but the majority stayed silent.

2010...an evening meeting with a group of GPs...explaining our model..and a lady introduced herself..again, another grandiose title, another leader..who opined that the new Health Act was finally the "time for GPs". The years of underfunding was now past...the time to strip hospitals bare was here now..to fund GPs. I smiled and wished her the best. The other 7 people in the room...stayed silent..looked uncomfortable...one mentioned something about the importance of a local hospital...but then concentrated on her drink. 

4 years later, its now pandemonium city. Leaders have tried their best to create pathways, create tramlines which restrict the type of patients who can go to hospital...they now need to go somewhere- so the GP surgery it is. The expected holy grail of money follows the patient remained an El Dorado..and suddenly the patients were there, the money wasn't. Diabetes was a prime example, perhaps even a forbearer...extrapolate that to all specialities and why is anyone surprised that GPs can't cope? Pathway to refer back also closes with clinics being disbanded, so where indeed does the patient or the GP go? 

5 years taught me a lot in management...what it also taught me how the silent majority are not part of decisions made. The fault lies with both- self styled leaders who dictate for others as well as the majority who chose to stay silent..perhaps even keeping the faith that resources would follow. Diabetes care has suffered as a result..there isn't even resources or time to do simple 9 care processes (just wait till the recent National Diabetes Audit comes out- makes for woeful reading)..let alone anything else. In the main, diabetes care is delivered by practice nurses- and by god, they are struggling. Struggling to even do basic stuff, let alone do professional development, keep pace with the changing times, new developments, evidence based medicine....

So to all leaders who ask for "more GPs"...that will solve little. There is need for increased resource in primary care, time for education- and perhaps even think of specialists in primary care. More importantly, it certainly is time to stop leading GPs off the cliff by agreeing to yet another pathway which is designed with only one intention..less patients for hospital. That has little or nothing to do with patient care but translates to more work for primary care with little added resource...if you don't understand that simple economics, then drop that title, stop attending the meetings and go help your colleagues in their day job. The rest? Stop being silent..otherwise that cliff edge now isn't too far away.

Next week: "The Leadership gravy train"

Friday, August 15, 2014

Eeny Meeny Miny Mo

I loved him in Good morning Vietnam...there was always something about the clown with a tinge of sadness in him..and it wasn't just comedy. If you wanted to know about his acting chops...watch one of the classic Chris Nolan movie..Insomnia..head to head with Al Pacino and Hillary Swank..simply an artist. So had to wince a bit when the news flashed about Robin Williams..another celebrity taken away due to mental health issues...and the issue got the focus it has always deserved, some good and measured; some downright awful and morbid..but it got the attention. More closer to home, Shaun Lintern who is not afraid of rocking the boat (Shaun, that Superman logo isn't you...try a Bat symbol...much more of a rabble rouser) published his investigative findings on mental health issue and it's provisions...and makes for grim reading.If you haven't read it, suggest you do..crisis? Nope it's close to apocalypse now. As a physician, I know so from ward rounds..Shaun's work just confirmed it.

The million dollar question however is what now? As I mentioned to a few colleagues, pick ANY service and you will see holes, some more than other, but holes none the less. And to every single person I have asked one question..but the answers have been ethereal, abstract, wrapped in buzz words, catch phrases...none, I repeat, none of which actually solves the problem.
So here is the question...we know mental health needs funding...in our cash strapped environ...where will you get it from? In the spirit of multiple choice questions, try this...

Option A: Raise taxes (Pros: will throw more money at system, according to some ONLY way out; Cons: Look at the wastage within the NHS ?..sure more money will solve it?)

Option B: Abolish competition, make it a monopoly (Pros: transaction cost saved,procurement issues lessened etc etc; Cons: lack of it may raise issues regards where the drive exists to improve..any attempts based on data is anyway neutralised by most poo-pooing them on basis that its either a cock up or a conspiracy)

Option C:  Prioritise services; accept that to provide high quality services, you may need to prioritise some above others (Pros: Gives opportunity to develop those services properly, not pay lip service Cons: who chooses the second tier services and based on what?)

Option D:  Do nothing and stick to camps based on ideology and have a shouting match.

Option A may happen..but where do you stop? Keep on raising it with demand and need growing exponentially? Option B: Perhaps gives you a release as a one off saving ..still not convinced how that drives quality..but then what? We do the cycle again?
I put in Option C simply because we already have that steadily, if not by stealth. Lots of areas have procedures not funded by the NHS or needing permission."Free at the point of delivery"? Or "Free at the point of delivery chosen?"

Here's a question...what's more important ..mental health services or diabetes?Cancer treatment or well funded primary care? Midwives or treatment of Psoriasis? Tough, isn't it? But the answer is simple...based on who you are asking. If you have debilitating rheumatoid arthritis, for you, that's the service of prime importance...it may not be maternity services.For the mum struggling with a 2 year old who has type 1 diabetes, it will, of course, be a fantastic type 1 paediatric service, it may not be a COPD outreach service or a dementia service. And then there are the charities..quite rightly driven by the prism of their own views.

So we come to an inevitable cross roads..and frankly I do not envy any policy maker, any politician who has to make those calls...it's always easy to criticise than to do...and will forever be. But time may it be too far away before society is called upon to play this game of MCQs..as tough as it will be. What started as a fantastic development of socialised medicine now comes to a crucial juncture.
The fundamental question is..will we make the decision based on sound facts, reason or are we going to be driven by emotions? Are we going to be able to make a tough decision which will not make all happy..or are we going to roll the dice and see what comes up?

Time stands for no one...and this question will keep coming back..again and again. So have a think..when you are asked the question..Choose wisely. Better that than a game of eeny meeny miny mo..right?

Next week: "GPs, vacuous leadership and inevitability of strife"

Thursday, August 7, 2014

You never forget

It's an emotive topic...the topic of colour...prejudice based on the colour of your skin and I recall listening to the experiences of my parents in the UK back in the 70s...people refusing to sit next to them on buses, bosses in the NHS being open that Indians shouldn't be in "high positions"...and then I look back at my journey and it's a darned difficult topic to discuss or talk about.Reports such as "Snowy white peaks of the NHS" are a reality check, a discomforting feature for many..an uncomfortable truth which grates with many, but a reality nonetheless.

And I will tell you why it's difficult for me to discuss this. One one hand, here I am, rabble rouser-in chief, made my reputation for good or worse in the world of diabetes, stepping down from a 5 year tenure as Clinical Director when most people begin...would I have been able to do this if there was a severe colour bias? On the other hand, is it not because I have some friends I work with, who have been comfortable with me being the lead albeit the youngest of us all,a group for whom colour has meant little?

I say so as throughout my career, there has always been instances...you never forget...my dad always used to say, and still does say to me..."don't aggravate people, it's not your country after all, colour bias will come through in the  end".. And I have for ever tried to rail against that...I was born here, I contribute to taxes, do everything any British citizen would need to do..this is my place too, right? But you never forget..you never forget a senior Consultant telling you while you are looking for a substantive registrar post that it was better to apply in the Midlands as that where "your type stood more chance". He/She of high fame..great endocrinologist, great doctor...slip of tongue, didn't mean what was said? Who knows...but you never forget,right?

For those who have never faced any race bias, being questioned on the basis of your colour, you will never understand the impact of it..you just won't.  Every single word uttered grates, makes your teeth grit, and depending on your personality, either creates a fire to consume all or a state of resigned depression and acceptance that colour is a bar and there isn't much point in railing against it.You never forget...I recall a conversation with a nurse specialist and a research registrar while at Diabetes UK, many years ago..during my tenure as a trainee..we were talking about job opportunities...2 educated women, high flying and in the course of time have become well established too...their collective view..why didn't I "bugger" off from where I came? Was it a joke? Was it tongue in cheek? Who knows...all I do know it stuck..you never forget,do you?

Patients are no dissimilar either...you think racism is associated with poor socioeconomic conditions and lack of education? Au contraire amigos, some of the most educated have said things in clinics, in ED,on the wards which have elicited mostly a witty response back...("You are a Chink,aren't you?" "No, actually I am Indian..the high cheekbones are just features of my dashing good looks"...keep it deadpan, Partha, keep it deadpan)...but they stick..you never forget. Beyond the veneer of polish and education, the nastiness of racism bubbles away.Society has made it more difficult to be explicit and open about your inner feelings but it bubbles away, ever present..it exists in a different garb..what did that report on the snowy white peaks say again?

To be honest however, for me, that has always acted as fuel. Fuel to prove that I belong, as much as anyone else. On the contrary, it makes me wryly smile to see any achievements which perhaps inwardly makes the covert racists wince. I see educated Consultants, holding positions of power and authority making fun of accents, the way people dress, the food they eat- and now ensure they dare not repeat it again- at least not in front of me. Don't demonise UKIP when the so-called educated ones harbour similar feeling albeit beneath the facade of  charm.
You never forget the barbs...you never forget who threw them..and you never forget as well that a few rotten apples don't make the barrel bad. The reality however,still is that you have to work that bit harder, that bit more differently to make a mark..everyday in the NHS. Some deal with it by battening down the hatches, some stop caring and some relish the challenge of the odds. Either way,as with anything, documents will do only so much, bold statements from Simon Stevens will only go that far...we shall see with time whether the NHS or for that matter society has it in them to narrow the divide.

Till then, you never forget.