Wednesday, July 30, 2014

Gosport Gathering

It was a nice pleasant evening, perhaps a tad muggy as I walked into the seminar room at Gosport War Memorial. A patient engagement event laid out to discuss openly with the people in the community about their diabetes care and it was nice to see people spare their time to come out and simply..chat.

The fabulous community nurses - Jane and Julia were there outlining the educational role they have for primary care before some open Q&A from the audience and it was nice to see a lot of interaction from the attendees. And there were a few..frustrations about lack of communication between different sectors of the NHS, frustration regards access, queries about local amputation rates,the essential healthcare checks, the need for healthy food, the practical difficulties regards exercise...but amongst them, there were also those who were simply happy with their care.

An evening which I must say I really enjoyed as I genuinely believe that patient engagement continues to be nothing but a mirage, a tokenism most adhere to. Case in point? You can simply close your eyes and say what the main frustrations with diabetes care is...yet, we spend hours in meetings, drawing up pretty pictures, heck..even perhaps adding a name tag to something...while the patient issues? Exactly the same as it was a few years ago.We discussed finances, briefly ventured into politics, exhorted patients to be constructive critics, not join the media maelstrom...and was nice to see most still have faith in the care they receive. This was an audience primarily with people who have type 2 diabetes and this was an opportunity to show that healthcare professionals too are only but human. An intense desire to improve things but still as susceptible to coruscating criticism as anyone else. 

And it also made me realise how difficult it is to have an actual debate about finances, the inability to make ends meet- some due to intransigence of some to change their way of working, some due to inability amongst separate organisations to work together as the bottom line at the end of March is still King...and the constant appeal that more finances will sort the mess out. It may to a certain extent, it certainly won't go the whole hog.

But amidst that, are the patients, still wondering how to exactly be seen by someone who knows what they are doing, someone who can simply see them on time. Social media and use of internet..simply the bastion of the young? Don't fool yourselves based on some half baked stats...the elderly gentleman in the front row had a twinkle in his eyes when he asked why in this era of skype and emails, communication wasn't better. Why indeed? Why is it that Newham can do it but Gosport can't? Both still have the same umbrella logo..NHS...so why isn't it a governance issue somewhere and is somewhere else? 

So thank you to Liz, Dan, Gethin et al for laying out this event- and gladly look forward to helping out with more of such events. Makes much more sense to hear directly from the patients rather than send a 27 question loaded form to fill out. Ask and you shall hear what you need to hear...the question is whether you genuinely believe you can make the changes. As a diabetes department, we would be the first to acknowledge that everything isn't sorted but would also say that we are keen to improve things as we take advice from patients on board- our transitional service, 7 day working bear proof of that.

Patience and time...give the healthcare professionals that...mix that with the dollop of passion they bring and sprinkle on some charm...I promise you...a heady brew can't be that far away.

Friday, July 18, 2014

The Servant God

How many times have you heard that one? The old stereotype built in by years of media, bluster and self-aggrandisation...the all-powerful doctor who knew it all, blew everyone away with their knowledge, their skills, their arrogance...whisper it softly perhaps even God like in their ability and demeanour...healers weren't they? They told the patients what to do...and they did. They told the nurses what to do...and it happened. A paternalistic model doesn't develop overnight, does it?

But then times changed...the world changed...patients, quite rightly, found their voice, became more inquisitive about their care, tried to know more about why their care may have faltered.and then found their Gods, self-styled or otherwise, wanting. And as sure as what happens when you see your hero or deity slip, obeisance changed to disappointment, disappointment then moved to anger. How dare they? How dare they fail their duties? The disappointment in seeing these God like creatures be fallible, be prone to the same errors as others, with the same foibles hurt...the angst was palpable. But slowly but surely the tide has started to change...even the media has started to move on. Yes, most of the Consultants are still ridiculously charming, handsome, sweeping folks off their feet, but the George Clooneys and Patrick Dempseys were also fallible, with emotions, making mistakes.perception is key, isn't it? How big a role the media plays in the depiction of anything...all you need to look is at the public perception of success of CPRs and the disproportionate attachment to reality.

The bigger question is who wanted the God like status...perhaps it was society in those ages, perhaps it was the desire of some, perhaps it was the wish of many..who knows. What I do know is that in  a modern era, that's not a title most young guns who have become Consultants want...(though recently a vascular trainee did do his best to change my romantic view on that) and to be honest, unless we shed such ridiculous artificial notions, you can forget about any level of patient or staff engagement.

Lets make it crystal clear what doctors areHuman beings, trained to do a specific job, at the cost of the taxpayer. Human beings with exactly the same amount of foibles as anyone elsePossessing the same level of angst, empathy, indifference, passion, tiredness as anyone else. Lets not elevate them to the level of Gods as I can guarantee you it will, as it already has, end in disappointment.  

By the same token, don't say they are servants either. That implies lesser rights than others, a person at the whim of others, a person who must serve their masters, come day, night or otherwise. Let me repeat again...they are human beings with same needs, same desire to sit down with their families at end of day, same need to enjoy the latest Marvel movie and talk silly with their kids, same interest to go out with their friends and enjoy a drink or two.  I know there are many who like to label themselves as servants, public servants, servant leaderswrong terminology, wrong perception- and by your evangelism, you tar the majority who are struggling to battle the everyday pressures while balancing their own lives. Use that tag...you can kiss engagement goodbye too. They/We are paid by the tax payers...do please hold us to account but don't give us tags that create an illusion.   

The system, as I say, with any topic of discussion, is always like a pendulum.swinging from one extreme to another. Yesterdays God needs to be todays servant is the chant- the reality is that patient engagement or staff engagement, as always, is a 2 way street. Treat patients with respect, they engage.doctors are no different either. I am pretty sure I echo many when I say I am no God, neither am I anyones servant. Just a professional trying to do his job, with passion and desire to improve patient care. On the way, mistakes will be made and all one can promise is to learn from that and make things better.

Treat me as a God.absolute power in the end corrupts absolutelytreat me as a servantin the words of Charles De Gaulle..In order to be come the master, the politician poses as the servant.

I have no desire for that either. Have a great weekend x

Friday, July 11, 2014

Era of the nurses

All good things must come to an end,as the saying goes. And after 5 years, it's certainly time. 2010 July I was asked to become the Clinical director of the Diabetes department in Portsmouth Hospitals NHS Trust and no, it actually doesn't feel like "just yesterday". Time has moved at its own pace and 5 years later,you just feel its time for someone new..one thing I picked up in a leadership event was the ability to know when to move on..and the time is now.It just feels right.

For many years, the job has indeed come first,be at work by 630/7 am, working on the emails, spending evenings away negotiating with GPs, Commissioners, stakeholders, travelling, learning from others...it's been a long road. A long road but worthwhile every single bit of it and as I look back, it is with a great sense of pride at the legacy being left behind. A model of care which is viewed by many as a pioneer, many accolades, improving outcome measures, raising the profile of diabetes within and outside the Trust,..I have enjoyed every single bit of it. Of particular pride has been the fact that in spite of all the focus on clinical delivery, research and innovation has blossomed and feedback from trainees have suggested the department to be one where they feel they are looked after with ample educational opportunities.A department where morale appears good, low sickness and staff turnover rates suggests a happy work force while patient feedback has improved consistently as testified by low complaint rates..while hopefully we have paid more than just lip service to patient engagement via our Sweet Meet, our launching of a 7 day diabetes service, etc

People always ask me the catalyst behind our success...there are 2 strokes of luck which I don't know how to ask anyone else to replicate. Firstly, the ability to work with a dream team, with not colleagues, but friends, friends who are passionate and have delivered care with a smile..making work..fun! Secondly, an incredible alignment of the stars where we had a fortuitous combination of clinicians, Commissioners, Managers...all ready to make the changes needed, changes which attempts to redefine how diabetes is delivered within acute Trusts. There have been many to whom the success can be attributed to but Portsmouth hospitals CEO, local CCG commissioners, managers such as Sarah  Malcolm, Melissa Way, Lesley Munroe,Clinical managers such as Richard Jones, Simon Holmes ...I can only thank you for the support shown over the years.There has been treacle which people above have helped cut past...all of which have improved care enormously..so thank you.

So to the inevitable question...who next? For years, I have heard debates and discussions as to how nurses are the lynchpin of diabetes care...but always been a bit bemused by the lack of them or paucity of them shaping diabetes care. So, in a last bold "outside-the-box" move, as a department, we have suggested that Lisa Skinner, our existing nurse lead take over the role of the departmental lead. Hand in hand,I am also stepping down from diabetes lead roles in the community and asking Jane Egerton to take over lead role in Hampshire with Alison Tier in Portsmouth. Thus, a creation of a fantastic nurse triumvirate who can shape and run diabetes services across the community and acute services.We talk about nurse leaders...my suggestion is lets stop talking and do some walking in diabetes care.I firmly believe that these are exciting times for local patient care and with Lisa, Jane and Ali in charge, the local community care will be served amazingly.

In 5 years,I have tried, tried as much as possible and also fully appreciate the "Marmite" factor I bring to the table. The NHS is caught in a Hobson's choice...on one hand, changes need to happen quickly while the present structure of the NHS, management chains are not set up for innovation, quick,fast movements. To put grease on those wheels, relations have been bruised..but in my book, rightly or wrongly, relations can heal..what doesn't heal is the poor care we provide while we sit and mull and spend hours thinking how to ensure we don't hurt each other's feelings. In 5 years, our strength has been pace, the ability to make changes quickly, adapt to the times, be flexible and sadly, on occasions, it has needed more fire than charm. To all the NHS leaders who talk about change, medical engagement...look at the system where treacle frustrates and you will learn why engagement is so low down the scale..at a time when you need it more than ever before.

 Finally, as a clinician I continue to do my work and revert to my original passion...type 1 diabetes care..all across from adolescence to adult life. Lots of things to do locally and nationally..lots of ideas in my head...the world does look exciting with the potential! There are bits which I would have loved to resolve such as psychology support but discussions are at a good stage so I am hopeful we should be able to close that Achilles heel soon.
To Lisa, I wish you all the best and as with my colleagues, unflinching support to you as we all know how patient focussed you are and what you will bring to the table. Advice? The role of a clinical director in my book, is two..One, ambassador for the department and Two, the patient advocate in a management circles. Never back down from what you believe patients would benefit from, never accept a compromise which you know will compromise care of patients with diabetes. Stick to that..the rest?Falls in place.

An exciting future awaits us.The era of the nurses beckon..Lisa, Jane, Ali....May the Force be with you. Amen.

Wednesday, July 2, 2014

Simply the best?

Its bloody confusing. If aliens descended and started reviewing twitter, newspapers, blogs, media reports...they probably would just shake their heads and leave- simply confused by the lack of consistency in any news story about the NHS. A recent example of that was the recent Commonwealth Fund report which compared different countries and came up with the analysis that the NHS was the best in the world, maybe even the universe. Cue folks going absolutely bananas...twitter was agog with adulation, back slapping, joyous outpouring...none of which is surprising given the absolute shellacking its been taking recently.

As ever with the NHS, any sensible debate around the findings or even using it to plan for the future has been pretty impossible. We again break into silos...in general three..."Team Happy".. proclaiming that its all fine and its the fault of the government that a perfect system is being broken apart- and it absolutely was the land of milk and honey 5 years ago; "Team Angry".. who vociferously proclaim that there are evil healthcare professionals out there, uncaring, money driven, dark,dastardly souls , killing folks and must be stopped ...and finally "Team Sensible" the more rational or sane ones whose voices tend to get drowned a bit while idealogical battlegrounds are marked out, posturing is done, credit is claimed for the NHS being amazing..while a rational debate to actually debate where we go from here in a few years time...no sir..that's a tricky option, isn't it? 

The Tories say we must name and shame GPs in an environment where we can't recruit them for love or money, present GPs are fed up with everything thrown at them...then countered by Labour saying they will organise for patients to be seen within 48 hours.Even the RCGP joins in saying more money to primary care will solve the puzzle...while any sensible person will tell you its not just about the money, its about the morale. Why would you pick a job, whatever be the money, if you face such incessant pressure and public flagellation- especially when some specialities offer a better work life balance, less abuse? Stuff their faces with gold...give over..those days are long gone.

So let's look at the Commonwealth Fund report...those who want to improve don't rest on their laurels..they don't just say - ah well, we are the best, so why bother improve any more ..they look at areas where they can improve. So where is the UK NOT good...look down the table..its in one category..we come 10th out of 11 countries...the section? "Keeping people healthy"...and in a nutshell thereby encapsulates the impending crisis of the NHS. We are amazing, fabulous, awesome etc etc in looking after people who are sick - and lets make no bones about it- but we are rubbish at stopping people GETTING sick. Cue increased pressure, cue need for more resources...and when that doesn't happen? The bubble..for want of a better expression...bursts. So if you are genuinely trying to learn from the report, where exactly are the initiatives to keep people healthy...do remind me who are the sponsors for the World Cup or even the Olympics again? The penny drops.

So to Team Happy, I say, rejoice but also be humble enough to see that there's only way from number 1..that's down. Rather than blame it on specific governments, maybe we need to address the issues which will make us slip from that enviable pedestal- as a profession we need to challenge ALL politicians. To Team Angry, yes mistakes do happen but by god, we are trying our best every day with cramped resources to learn and move forward. Don't denigrate this amazing institution- work with Team Happy or even better let the folks from Team Sensible have a say.

The NHS..Simply the Best? Possibly yes..will it stay there? Not if we as a profession fight siloed corners and idealogical battles...the capacity or its strength to cope will wholly depend on the agenda of prevention. If we can't tackle that..then we are dead in the water...whether that health system is a private sector led one or a public sector one. And THAT is the bottom line..cos the Common wealth Fund report said so.