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)