Sunday, June 22, 2014

Scot-free?

It's a thought which came into my mind while having a discussion with some trainees. Going through the e-portfolio, you have to admit it's a chore and there are numerous seniors out there secretly grateful they didn't have to do anything as onerous as this..however beyond that, whatever be the motivation of educationalists (and there are some debates about that) there's no denying the numerous and rigorous testing of ones competence junior docs have gone through. "Have you done enough procedures?" / "Have you got proof of that?" / "What do YOU self assess yourself as regards competence in that procedure?" / What does your supervisor think about your competence in that supervisor?"...endless..all in an effort to root out the Shipmans of this world. 
A person who was a psychopath first, a doctor second- but came to be the harbinger of all that's evil about doctors..those uncaring fiends which had to be rooted out. ..the irony probably being that Shipman would possibly fly though an e-portfolio- eyes closed, undetected. Anyhow, I digress.

If you look at Consultants, yes, it maybe flawed, yes, it could be used better..but performance management is a buzzword which has stuck in the NHS and raises different levels of hackles. "Have you started your clinics on time? / Have you finished your theatre list too early? / What's your LOS?"..I won't discuss how blunt those tools are in this blog sometimes...here's an example..recently a manager asked me what time I started and finished clinic..he opined it was less than the 4 hours of a PA. I pointed out that I also had 20 adhoc slots through the week- which equated to not just an hour but more than that..put in place to help adolescent patients who couldn't attend at times of my choosing but would rather at their choosing. Patient choice anyone? He understood but felt it would be easier for him to collect his data if I didn't do these adhocs...I am older now..so a polite smile and a firm no is what he got. 
Did try to point out that whether I am good or bad as a doctor also had to be measured by what patients thought about me (both paper and on-line link available to view); what my colleagues thought about me (360 appraisal available), what outcome measures such as admission to hospital for the adolescent patients were (again, publicly available)..Ah but I digress again.

So to the basic initial question...how do you measure the competence or lack of a non clinical manager? I tried on twitter, lots of ethereal answers, lots of intuitive thoughts, lots of well respected and leaders with their thoughts..the end product? Actually very little.The question has to be however why that is the case. Does this continue to engender the feeling of "them" and "us"? Is it blasphemy to suggest that the managers, who perhaps rightly or wrongly see themselves as the guardians of public tax money which the nefarious, wine swilling, lazy Consultants are frittering away are scot free of any scrutiny themselves? Or is that there is something robust out there which I am not aware in which case I profoundly apologise publicly to all managers for the frivolous nature of the comment above?

I have seen plenty of managers in my time as a clinical manager- some "good", some "ordinary", some "awful"..aha...I hear you ask...how did you know what they were? One characteristic stood out...listening. Listening with one thing in mind..improving patient care..and I am afraid not all do. For some its about meeting a target, a number...and if that's what they are judged on, then I understand the reasons why. When your job is on the line- whatever your profession, patient care related evangelism seems to drop down the agenda- nothing wrong with that- as its easy to criticise from the outside when YOU are not in the same position...but it again suggests that the markers to judge the manager, if indeed they do exist, is wrong.

So, as I laze on a Sunday afternoon, I ask all the leaders, all the bodies, NHS Confederation, NHS Graduate Management scheme..to come up with something which could be useful. Something which ties in with what the clinicians are trying to do- and makes all sing from same hymn sheet. Something radical like perhaps measuring the TEAM- consisting of the clinician and manager- on patient outcomes, feedback etc...you win accolades and awards together, you also take the criticism and fallout together.

Till that day, till you have something unified, till the day we have clinicians being measured on targets they haven't helped design- and the right or wrong impression that managers are running scot-free..it doesn't matter how many courses you run on teamwork or group hugging, the NHS will always be divided into "them" and "us". If the driver for different members of the teams are different, then there is no chance of those teams pulling in the same direction. 

So..who wants to work on that with some clinicians? I am game...anyone interested or rather just be scot-free?

Monday, June 16, 2014

Hotel California

It's an ever shifting conundrum..what exactly does one attend international conferences for? I suspect it changes as your career and focus changes but in the main, at least for me, it has been about trying to learn something new, perhaps be excited by some innovation that can be brought back to where I work..and then again, there is the networking. Always an intangible concept it's something which is unparalleled in its richness..talking to peers, colleagues, absorbing ideas from each other..bouncing ideas off each other...and as my annual sojourn to the American Diabetes Association comes to an end, it's ticked pretty much every box. In short, it's been absorbing, fascinating,rejuvenating and dare one say, sometimes even eye opening.

Lets face it...a few days in San Francisco is no punishment and as the plane touched down on the sun-kissed tarmac, away from the incessant lurching from one crisis to another in our beloved NHS, a smile crossed my lips. Sure the killer jet lag reminded me acutely of those days left behind when jet lag was beatable with one more glass of whiskey...now the bed seemed more appealing a surrounding rather than yet another round at the bar....but I was ready to do some learning.

And boy, there was some..and then some more. Learning about engagement with adolescents, listening about self management tools, shared decision making...so much the NHS could adapt..actually let me correct that..so much we in Portsmouth could adapt. I have never belonged to the camp that we have nothing to learn from the Yanks...the healthcare system maybe different, may not be to ones socialist liking...but the passion and desire of the healthcare professionals, the innovation desire are the same...and if we can take something back which may help our local patients, why the heck not try that?

A fascinating session on hypoglycaemia provided riveting insight into complicated studies..in fact left me confused a bit..but as ever, Dr Pratik Chaudhury with his Braniac level knowledge enlightened me while chomping on some bacon.Ah the beauty of networking! Social media came to the fore, was discussed though one got the feeling the UK may indeed be miles ahead of the game...only 1 poster illustrating its benefit in diabetes care was perhaps disappointing but at least it was being discussed, it was put there.

Sessions on retinopathy showed how amazing the NHS retinal screening service has been and much much kudos to those who had set it up..something that had helped tender diabetes as a cause for blindness down the charts...reinforcement that what you are doing is good is always an essential part of learning, isn't it?
A fascinating session discussing roles of a specialist ( Endocrinologist), primary care physician and a nurse practitioner was practically déjà vu.Here were some of the main challenges the PCP were facing in the NHS....overload of work, too much being thrown back from hospitals, multitude and explosion of drug classes,retirements and inability to fill posts....how does that sound, UK GPs? Models of care were rising up the agenda...but one major theme came out of the meeting...togetherness, talking to each other, relations, understanding the needs of the patients, a shrinking financial pot....no different challenges then.Fascinatingly eye opening

And then there was the meeting with so many...not just the people I knew ( bumping into David Kerr as ever a pleasure with his explosion of ideas and suggestions)..but folks from the Mayo clinic, Kaiser Permanente, folks from India, Chile, Holland, France ..not trying to ape their model of work but looking at clinical work, things that can be brought back...in meetings with these guys, felt like a sponge...projects building in my head..watch this space..I have some ideas which I want to bring to where I work...shared decision making tools, clamp studies, glucose monitoring...felt just like a kid in no candy shop. Some evangelists continue to believe that there is no better HCP than on the UK...I can assure you the passion and verve shown by so many from other countries were no less...we must be open minded enough to learn not be suckered into a jingoistic belief of British is best. The healthcare system maybe the best arguably but the professionals desire?Same everywhere.

So it's home time tomorrow..and simply put, I have loved it.Made some new delightful friends, sharing a drink or two with them in the evenings, joking about life and the rest..and all of it has been helped by the superb organisation shown by the ADA.Hats off to all involved for pulling off such a huge meeting with aplomb in such an amazing city....it has been much appreciated. Lisa and Gary...you know who you are...a sincere thank you

America...will be back next year in Boston..thank you for the hospitality. And as you like to say..Good night. and God Bless. X

Saturday, June 7, 2014

Scylla and Charibdes

Homer had described it perfectly...no, not the yellow loveable being from the Simpsons but the original Homer, the Ancient Greek who penned the Iliad and the Odyssey. In the Odyssey, he describes two irresistible and dangerous monsters called Scylla and Charibdes who sat in the Strait of Messina, a narrow stretch of water the hero,Odysseus had to cross..and thereby was born the oft used idiom "between Scylla and Charibdes". English literature was one of my favourite classes to attend in school, perhaps made even more appealing by an amazing teacher...and I still recall Mr. Peters closing the book with aplomb while explaining that idiom and with his deep baritone explaining how in life we would always be faced with these two monsters. Today we have it in the NHS.

The NHS is not perfect. In fact, let me be perfectly honest, it never will be. Even if the whole country's GDP was diverted to the NHS, it still won't be. Why? Because we are in the business of looking after humans, their illnesses, their sufferings...by humans with their fallibility and foibles. Anyone who promises you an error free health system is either naive, ignorant or lying. So not surprisingly the NHS has them..in fact quite a bit of it. In between the amazing wonders done each day, errors occur and there is a drive to get it better..and there always has been..will errors still happen inspite of all the guidelines, the check lists, the hashtags? Yes, it will.

The problem begins when people hide them, deny them, cover them up...step forward Bristol, step forward James Titcombe, step forward Francis...and the perception is built that the staff just want to hide errors, be content with mistakes..an imperfect system stands exposed,warts and all. The public looks on in horror as the prom queen is shown to be someone who also takes cocaine as a pastime. The religion that is the NHS takes a beating and the perception of  a secretive culture is built.....and there you have Scylla.
For anyone who may even have an iota of tainting the sacred cow of the NHS, it's like Christmas. Every single campaign raised, every single whistleblower who are absolutely and absolutely doing the right thing by highlighting mistakes that the NHS should learn from becomes a lightning beacon for those who want to show the warts of the prom queen. How did that Abba song go again..."The King has lost his crown"...

And then we have the national campaigns such as "Hellomynameis", "6Cs", "NHSchangeday"... Each and every single one of them admirable concepts but my unease towards them has always been known..not because of the ethos of them but because how it can be misrepresented.When I first heard about the campaign which Kate Granger has championed so well, I must admit to being a bit surprised. Why? Because when I gave my medical final exams, or my PLAB or my MRCP, introducing yourself to a patient was a non-negotiable, mandatory thing to do. In fact, I was told clearly that if I didn't introduce myself to a patient, I would fail. I then was a house officer, then a senior house officer and at every step saw my Consultant introduce himself or herself by name...surely it was normal standard practice? But then,as I grew up, it dawned it actually wasn't...so more strength to the campaign...but the unease persisted as again anyone with an iota of an agenda could potentially use it. 
And lo and behold, we now have the Daily mail and the Telegraph showcasing "how awful the healthcare professionals are..they don't even introduce ourselves...thus thank heavens we now have a campaign"..or words to those effect. Criticise  those papers as much as you want but they do have a readership..and whatever retractions you get, however many re-tweets you get on twitter, sadly, reputations are easy to tarnish, much difficult to regain . Think of this one for a headline.."Nurses need courses on compassion as  it has been felt they haven't any". I refer to the 6C campaign...a great initiative aimed at changing the culture but one headline with potential to destroy a lot of faith..anyone working as an HCP will know that headline is sensational..what about the populace at large? And there you have your Charibdes...any openness or desire to change  seized upon with ruthless efficiency by those who have papers to sell or an agenda to push.

So the NHS is caught, isn't it? All the whistle-blowing etc has exposed foibles which have been needed to learn from...but seized upon as failings. And any attempt to correct them are seen as more examples of..yes..you got it..failings.The PR battle is being lost every day...each days end brings a sign that the battle maybe slipping away ever so slightly. Finances are tight, patient expectations are through the roof, evidence based medicine lies in tatters...There are plenty of folks with the desire but each day the ones who are more keen to get their head down, finish the job and just go home to their family rises. 

I will finish with one little story..in that school classroom as Mr Peters explained the ferocity of Scylla and Charibdes..their monstrosity and desire for destruction, I recall someone saying that it was impossible to survive them...to which Mr Peters with his baritone boomed.."Never forget Odysseus survived them both".How will the NHS fare? Time will tell..it's ticking to some form of conclusion...someday the history books will look at these times and marvel at this fascinating passage of time.