Friday, February 20, 2015

#Medicinegetsbetter

It's actually Helgi's fault. Yep, pure and simple- a chap otherwise known as @traumagasdoc on twitter. He got me started when we discussed whether things got better in Medicine- and to be honest,reminiscing...would I do it again..yep, without a doubt- and Helgi as ever, eloquently put his thoughts down

So here's my tuppence worth. I was a House officer, then a Senior House Officer for nearly 3 years then became a Specialist Registrar for 5 years- with 2 years added on doing research- and you know what? It's been quite a ride. I am not going to get sucked into those puerile debates about "in my days"- I interact with juniors enough to know that the fire of dedication, the urge to work hard and do good is exactly in the same proportion as we had in "our days". It's not their fault if hours have changed,training have shortened- within those limitations, all junior docs are as hard working as ever or at least the proportion in't any different. Do they moan more? Well- its more public now- why? Because we have social media- on twitter, in 140 characters, you can offload your angst, grief, frustration - which to many may seem like moaning. To the bystanders, I was no different. We used to do it in a pub, among friends, complain about the system- the opportunity for it being public simply wasn't there. If there was, would it be any different from now? Probably not.

So many folks I worked with- whether it be Azman when I was a clinical observer, John when I was a House Officer, Aparna,Kate,Ros, Matt,Paul,Jeremy,James when I was an SHO...they were all good fun- hard working, dedicated folks who have now become GPs, Consultants- and are the same folks I knew that many years back. Life was tough, pay was..heck..that certainly wasn't great - (anyone remember those Additional Duty Hours??) but I suspect we all knew where we were heading to. Being a Registrar was tough- and none more so than being the Medical Registrar on call. Consultant coverage was a rare beast, you were pretty much the last vanguard- whether it be the wards or on calls- it was tough, referrals were rubbish, but you worked, you had fun, sometimes lost your cool- but in general, worked your time. The pay was better- while the world kept changing. We probably weren't as politically aware as the present generation is...you started to hear vague terms such as PCTs- what was noticeable was the contract changing,

And life was fun- there was a sort of a trench mentality I suppose due to the hours etc- but most of all, the concept of a team was ingrained. There was friendly banter between specialists but heck those were the days before everyone cherry picked their thing. Cardiology had just started their campaign to prove how special they were- and as thrombolysis improved, we watched with bated breath as Medicine evolved.

Then I became a Consultant- and what can I say? It gets better since your junior days. You hear that pay could be better- I don't know- I feel its actually pretty good. If in doubt, use this tool..go on, check it yourself- maybe get some perspective when compared to the UK. If you fancy a small flutter of your socialist heart, see where you stand with respect to the world. Interesting, isn't it? Working hours are good- am on a 11.5 PA contract for my trust- thats 46 hours- ok so I work more than that- but heck, clocking in and clocking out isnt why I took this profession up.

I can't speak for others. I am not a GP, I am not a Acute physician, I am a Diabetologist- because that's what I chose to be. The pension is good- and in fact most finance advisers would, still, advise you to stick in spite of all changes made. The weekends are few and far between. I go to work, have amazing colleagues in the department- of course there are ups and downs- that's life. The NHS is under pressure- I would expect to be put under pressure too but if I take a step back, sorry- I can't pretend life is bad or even life is ok. Life is actually quite nice...I do the job I love, the job I wanted and while doing that, I try to smile and give the patients the expertise I have been taught. I know others will disagree and tell you how rubbish life can be- but having worked in other health systems? No- its not bad at all.

So guys and gals, its actually ok. Yes, there's a lot of negativity and no I am not saying being a Consultant is about skipping over a rainbow chilling on top of a unicorn either. All I am saying is that I appreciate you all put in a lot of hard work and effort. Stick to it- and if it means anything, Medicine does get better. There are ups and downs, there are frustrations but in the main? It ain't bad. Don't leave as for starters we all need you and more importantly? You would have missed out on the best time which you have worked so hard for.

#medicinegetsbetter

Sunday, February 15, 2015

Radically different

It's easy to say when you don't have any consequences to bear. Easy to ask someone to "rock the boat", easy to ask people to "change". Let me be very clear at the very outset. To the many who have joined different campaigns, there is no doubting your willingness and intention to change. Yes, as I have said before, an ever increasing question is what it has ACTUALLY delivered as well as whether some of it is nothing more than tokenism. I have said before and I will say so again...it shows nothing but the stress of the system, the situation we are in that we have to pledge to smile at someone, be kind, answer a telephone or be polite. It's not necessarily something we should be proud of but if anything a bit worried that in a healthcare system, we need a pledge to keep patients safe. However if that works as something to reinforce the basics, so be it.

Time has also taught me that most of these individuals who I hear about seem genuinely interested, passionately care and want to make a difference. I respect that and appreciate your desire to help, humbled by your dedication too. The problem is the NHS  needs not just those basics to happen but something much more fundamental. It needs changes in way we work, changes in how we deliver care in the modern century but a tripod of old school thinking, perverse tariffs and misplaced allegiance all combine to dissuade many a would-be a rebel or radical.

Let's take the case of the whistleblowers. If we believe what happened to them as documented, then what exactly has happened to those who were involved in shutting them up, destroyed their careers? The doesn't seem to have been anyone named, prosecuted or anything..so what's the message then? If we are saying the biggest radical of them was pinned to the cross for others to learn from and be dissuaded from raising the voice, where exactly does the slogan of "be a radical" fit in? Or is that we don't believe the whistleblowers and it was all just a personal vendetta we all just disagree with?

There's an oft used quote- rock the boat but don't sink it...I struggle to understand what that means. Go so far but no further? Be a radical but with limits? Ask the diabetes world, you will not come across a bigger rebel, radical, maverick than me, ask any organisation linked with diabetes- be it Diabetes UK, ABCD, YDEF...coin whatever term you want...and I bear the scars. The only thing that has helped me survive has been my colleagues, my family and the security zone of going back into that clinic, interacting with my patients and enjoying the day job. It's tough, it's hard, it's sometimes depressing and sometimes it doesn't feel worth it.Its easier to get your head down, do the day job- and go home. The salary stays pretty much the same, so why bother?

The million dollar question is..after seeing everything and reading the Francis report, ask yourself the question...would you whistle blow? If you are in in organisation like Wigan, as per what Umesh Prabhu says, you raise an issue, be a radical and you will be listened to. But let's face it...isn't that a rarity? I personally have been fortunate enough to work with different Executives locally and I have always had a willing ear, someone who has listened to needs of patients and helped....but does the story of the whistleblowers fill you with hope or dread? 

I will tell you what will make you think twice. It's called life. It's called everyone around you. It's called your career. On the ground, unless you can change THAT,unless you radicalise that, all sorts of movements will always be objects of derision a for some. There will only be a handful few who would put their whole life at risk for sake of the patient...the change needs to be much higher up...the change needs to be in the openness of the system. If you work in a quango (for want of a better word), then exhortations to join the radicals will always be looked upon with one question....what's the consequence of leading people to change when that individuals suffering or consequences don't affect you? How many of the self professed radicals have come out and stood publicly with the whistleblowers? We all or at least Roy Lilley certainly does question the appropriateness of use of public money when CQC and Monitor is questioned. Quite rightly too. As should I be for the amount of taxpayers money spent in training me and now paying me.

So shall we also question the use of public money for all the various networks, organisations which seem to have sprouted over the last 4 -5 years? When money is tight and believe you me it is when I am battling for a few thousands to justify improved care..at what point do we question what these quangoes have achieved? Not in a derisory way but a genuine open discussion...is that even possible or as soon as you do that, you are a troublemaker, not a rebel? To paraphrase, one mans rebel is another mans troublemaker...all about your point of view, isn't it?

I am not a sceptic, if I was, all that has been achieved locally wouldn't have happened. I am a born optimist while time has taught me to be pragmatic. I will be the first person to ask a junior doctor to think radically but I would also be honest about the consequences, also be the first to be there for them if the evangelism of radicalism burns them. Those who advise must tred with caution, must appreciate the impact on lives, must appreciate why there is derision from some quarters.talk, as ever, is cheap.

Leadership is a fine art...the rats all thought the Pied Piper was a leader too. You want to change the NHS, you want radicals to take the fore? Show them that being a whistleblower doesn't need to end bad, show them the eventual outcome is good, stand by them and challenge the establishment. Or stand up and show us your own track record of being a rebel. A clever worded PR campaign can fool some, not all. I appreciate the value of PR, I am someone who has been to that school of arts...I also know credibility is built on results, not on empty words.


Prove me wrong.

Thursday, February 12, 2015

The perennial question....

You work for the NHS. Sure? You work for the patients. Sure? You work for whoever employs you. Is that better? A perennial bone of frustration for many who would like variability to lessen..the debate as ever is who do you actually owe your allegiance to? The public would say "us"..we pay taxes, we pay your salaries, surely you owe your allegiance to us. Or is it the NHS? We always balk at the suggestion of something like Tesco but we partly marvel at its consistency whether the store is in Stoke or Southampton while also wonder about the monotonous nature of all the stores. Is variety the spice of life?

In an ideal world, you would think we would all be employed by the NHS and thus work to a standard. Anyone who has been in the system will tell you that's pretty much a fantasy...we do a lot of things well in the NHS , consistency isn't one of them. If ever in doubt, beyond the tub thumping evangelists, ask junior doctors. An under used resource, they,at least to me, have always known the real truth..very few work in so many organisations, very few will vouch that the level of care was equivalent everywhere they worked. Why is that? Is that simply due to variability of staff? Is that simply because of lack of leadership? Partly yes, but partly because we live in a world of competing interests, a world of different targets to hit, different financial drivers...the issue is lack of honesty about that basic thing.

Let me give you a simple example. A patient with type 2 diabetes goes to their GP, has been on 3 medications for his diabetes, the marker for control still shows no signs of shifting. What could the GP or practice nurse do? Well, in a modern world, they could, in theory, pick up their phone and ask a local specialist, who they maybe friends with,about what the next step should be. The specialist theoretically could say Stop X, try Y and get back to me if that doesn't work. From a patient perspective, that sounds cool, doesn't it?Quick, fast, efficient. From a GPs point of view, again, quick and fast as well as a bit of education on the job..and knowledge what to do when the next case with similar problem comes through.

What does happen or has happened is they get referred via a letter, gets seen perhaps by the specialists after a variable amount of time (insert anything between 4-18 weeks) ,gets a letter back saying Stop X, try Y and patient will be seen again in 3-6 months. A letter follows after (again, insert anything between 1 week - 3 months) posted by Royal Mail or whoever (Governance, who's that?) the GP or practice nurse in between trying to do everything, tries desperately to see what he or she needs to do, if nothing, file away.

Payment by Tariff pays £239 as per this years tariff ( mind: an ever shrinking number since whenever) along with £99 for the follow up. CCG coughs up..then the financial screws tighten, it dawns on someone that that's too costly, so they suggest a community service.
The community clinic does pretty much the same thing (Stop X, try Y) but this time the cost is cheaper as its on a block contract, so send as many as you want...the activity builds, the screws turn, staff get exhausted and the cycle continues.

On the flip side, if we did go for the modern option of phone, chat etc, that would have stopped the local trust getting that money, which is their life blood to survive..that drops,income drops, staff start getting off laid...the cycle is set.Of course, we would/could have a phone tariff but as any finance person knows, it amounts to tiddlywinks compared to the real deal.

So, for a change, let's be honest. There is no point in asking people to be kind, change or anything else unless the drivers change. We all, at the end of the day, work for our organisations who pay our salaries and thus will do what naturally keeps our organisation ticking..whether it's a GP surgery or an acute trust or a community provider. An acute Trust gets spanked by 4 hour target while it should be a marker for the system..we all know the reasons why the 4 hour target is failing, yet Trusts are consumed by the desire to improve their 4 hour target...while it rarely becomes a beating tool for OOH, 111, community providers et al.

The question is whether the powers that be are adult enough to actually be honest about the whole picture as things stand. Grandstanding or campaigns will become objects of derision while the basics are not addressed. Rarely if ever, I have met a manager or a nurse or a doctor who isn't trying or keen on change but if you want to impact change, then the drivers need to change first. How many managers would go to their superiors and say we don't need the activity as it can be done much easier/would be better for patients/help education but the flip side is that the organisation would lose revenue? In fact, how many clinicians would?

Time to be honest, time to be transparent, time for all to understand what pressures the "other side" is under, what targets are being asked..whether the basic question is being asked. In public forums, plenty will say it's to patients, no one else, it's to the ethos of the NHS...when it comes to the nub, the majority will always swear it to the organisation.
Today, pause, think and answer this question...."who do you ACTUALLY owe your allegiance to?" The organisation who employs you, the NHS or the patients? In your heart of hearts, you and only you will know the answer to that.

(Next week: Why radical leadership and boat rocking advice is flawed)

Sunday, February 8, 2015

Mind games

Her name was Sian. and at every single visit, all she did was cry. No noise..just tears poured down her cheeks. 7 visits later, she looked up and said,"I need some help. I can't live with this diabetes anymore. Can you help?" And for the first time in many a year, I winced. What help could I possibly give her? Send her to whom- re refer back to GP? Walk away from it? Send to a psychiatrist? Or a psychologist? I simply didn't know

Let me be honest, I have never been a believer when I finished my training- perhaps a flaw of our training that rarely if ever, one gets the chance to see a psychologist at work, understand the nuances, the support or even be given the training to understand what patients need. Too often, its about the number to hit, the complication to screen, the perfunctory chat about "how's everything?" before moving on to the next patient on the assembly line. But time is a fantastic thing..it gives you experience, teaches you things most books can't, most training programmes can't give you access to and certainly no lectures can educate you about.
In between is the issue of evidence based medicine- and as ever, in this country, we lose perspective when we debate evidence. You will have the EBM evangelists who will spare no one who strays from it, you will have the ones who experiment with anything- while juxtapositioned are the ones who appreciate EBM but also understand the need to stray from it - based on the person in front of you, based on the needs of the patient who just needs some help- and doesn't quite understand how big or small the standard deviations are on a research project. Someday I shall write a blog about EBM and its flaws, its tight constraints and the essential issue of not being able to replicate research in a financially constrained work environment- but that's for later. Let me put it to you simplistically, if we followed EBM to the tee as regards Type 2 diabetes, this would be quite a nihilistic world indeed.

Mental Health or simply put psychological support has always been a bit like modern NHS hashtag campaigns- always talked about but rarely implemented. Yes of course there are centres like Bournemouth, of course there are places like Kings who do amazing stuff- but the majority of places have little to no psychological support for patients with type 1 diabetes care. It's always been our achilles heel too..what's the point of having screening tools to assess someone if you don't know who or where to send them to? I see patients who sit in front of you, tears welling up, struggling to deal with the issue of having to inject themselves every day- and I have found myself helpless. I have tried but there's been a limit- and its rare for me to feel that way...spare a thought then for the patient who has to live it every day, eh?

So, it's been a minefield to try and set something up- different providers, different CCGs, different ways of working but this has always been something on my list to complete- and in one of patient engagement events, I had promised to deliver 7 day diabetes service and psychology service. Stepping down recently thus had come with this last twinge of regret- so it has been singularly satisfying to get this through. I must say the support from colleagues in partner organisations, the willingness to help and constant support from our commissioners have been nothing short of astounding- and without them, this wouldn't have been possible- so thank you so much.

There have been many things we have done, irrespective of what NHS structures have changed irrespective of who has won what contract, irrespective of number of providers, belief of other specialists- but this has been one of singular pleasure. It's because tomorrow if another Sian ask me that same question, I can at least smile and know what to do. i can at least get someone who is trained more than me to help Sian. For that, I thank you all..all of the who have flagged it to me, helped me to deliver and been there to support when needed. It has been much appreciated.

To colleagues around the country, you can use many many reasons why it can't happen..if its the HSCA today, it will be something else tomorrow. Try..and then try again. As specialists, we are the advocate of patients in meetings, forums etc where patients don't get access due to a multitude of reasons. If you believe in something that will hep your patients, let's not play mind games...let's not play hashtag hoola-hoops...lets deliver. From personal experience, there are plenty of like minded people- whether they be managers , nurses, fellow doctors- who are keen to join forces to make it happen. Go...give it a try.

(Real name of patient changed for purpose of blog)