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.