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.