Tuesday, April 28, 2015

The long road

I still remember it like yesterday. March 2012..got woken up by a phone call from our Trusts communication team. I had to,as the Clinical Director, put in a media appearance...Diabetes UK had broken a news that showed Portsmouth were one of the worst as regards diabetes foot amputations. The local and national news outlet had run stories- and I had to make a public appearance.
I taped it that day- and still have it in my collection. Defending bad news is never nice but whats the point in being a leader if you can't stand up to be counted when the chips are down? It's not just about the award ceremonies...but I remember that vividly..remember my ears burning when the interviewer pressed. my whole being screamed out to say I couldn't be responsible on my own...but that day, I aged many years- and learnt much.

I learnt also much about colleagues whose glee were only too faintly hidden..after all, we were the upstarts who had dared to change how diabetes care was delivered and the thinly veiled taunts stung. You see no one sees the hurt, the times when you sit down..they only see the public glitzy persona, the trophies, the shine...but a learning experience none the less. And I learnt one more thing..the essence of where I worked, the friends who I worked with- across Trusts, across professions who had a steely determination to improve things. When we analysed things, it was apparent, there were gaps everywhere through the service..1 foot MDT / week, little structured access to vascular or orthopaedics, lack of education in primary care, enough access...you name it, we didn't quite have it.

Today about 3 years later...today marked a special day. a day when finally the final jigsaw regards the service fell in place. a progression to a clear pathway, a 5 day foot MDT, better access to orthotics, orthopaedics and vascular surgery, an education package for primary care specifically on feet- and finally green light for an inpatient podiatrist to help on the vascular wards. Some might say, they already have this...you know what..we didn't..and now we have- and the struggle we have all gone through to get here would fill a book inits own right. But we are here and collectively that pride is something I would love to share.

So much has happened and certainly not the time to rehash the disappointments but only to think of the highs. Whether it be Consultant colleagues all pitching in to do the clinics, whether it be our podiatry colleagues determination to improve things in the community or our CCGs steadfast support to make it happen- and of course support from our own Division..there are many many things to look back and be proud of.

So to Darryl Meeking, our foot lead or Sharon, Emily, Mandy,Susanne et al from Solent NHS Trust..or our friendly Commissioners such as Sarah Malcolm, thank you for all the steadfast determination to get there. It's now time to deliver- and hopefully we can- with early signs being pretty positive. A word also for Diabetes UK for also being a fantastic voice of support- that has been a magical extra source of support.

So we are here..lessons for others? What do you need? Time. Determination. The ability to get up and try again. And mostly? A sense of camaraderie - whoever you work for.

Finally, for those who "enjoyed" our amputation rates..I never forget- and haven't. Good on you for being awesome and frankly, if i didn't have the spur, maybe we wouldn't have got here. If you have amazing outcomes, I applaud that and do come and tell us all how you did it.  Till then, let me take a moment and say frankly how much of a privilege it is to work with such amazing colleagues in Portsmouth. I was born lucky...my choice of work place was no exception either.

Saturday, April 18, 2015

Choice..the ultimate myth?

Patient choice. Feedback. Opinions. Patient power. How much do we actually mean it? How much of it is actually possible? How much of it is ticking boxes; appeasing some and little else?

The answer uncomfortably is overall, we have just about moved past lip service. And it's tricky...to assume patient always knows best is a bit debate provoking...as you always worry how much information the use of a particular ask is based on..is it media driven? Is it due to some ill thought out national campaign? Is it due to industry influence? To make matters even more difficult, we are in an era of what appears to be a power struggle...personally I have found it baffling, but when anything related to care is denied, then not all conversations post that denial is sensible or rational. 
Every one, quite rightly, looks at their care and wants the best..any prioritising by health care professional based on even evidence is then seen as denial and this builds the power struggle.

Some HCPs try to have explanatory conversations which always have the potential to end amicably but again, in a system where health has been converted to widgets, time is one thing most people don't have...cue further debates. Easier to shut the patient out and carry on regardless, right? 
And then there is the fundamental of the NHS..GPs as the vanguards- understandably too- for any further escalation to specialist care. How does that exactly square with patient choice? Let me give you an example..a patient develops type 1 diabetes. Now if I or any of my family developed that, I am crystal clear what I would want. To be seen by a specialist who has trained in type 1 diabetes..let me emphasise..not all specialists have that either in buckets...so I would want to research a bit, use my knowledge of the system and see someone reputed or good in their work. I will be honest, if I lived in London,I would like to be seen by Pratik Chaudhury..not because he is my mate and we share a common love for whiskey..but because I KNOW he is good. Would I see him privately...no...I would talk to my Gp and basically make sure my care in the NHS was overseen by the best..I would use my position and knowledge of the NHS system to get what's best for me.

Let's now take the example of John Smith. He however has to go to see his GP and even though his choice is to see a specialist, he is now at the point where a GP can decide whether he sees a specialist or not. There is a huge degree of variability around this particular scenario. Some would be aware of their limitations and simply do the needful, while I have also seen many who would refuse. Grounds? Twofold..first politics...not nice to be criticised for referrals to the hospital...don't you know we need to keep referrals down..so John gets caught up in that stream. 
Second? A degree of ignorance as well…isn’t type 2 the same as type 1 diabetes? If one can be managed, surely the other can?  Well actually it isn't. But away from the science of it all, hands up how many GPs have actually trained in type 1 diabetes care.Pop quiz question..how many GPs or Practice nurses are aware what's the eligibility criteria for pumps? Even if they are, do their local team have the service..or even training?
Once John crosses that hurdle, then comes the question how does he know what level of care each specialist centre provides? Any tool or common portal to have a look and make that decision? You must be kidding...so you go to the local specialist centre...and you take what you get. Do you know whether the local team has someone specifically trained in pumps, technology or even type 1...Nope, surely the specialist knows it, right?

So there lies a fantastic dichotomy of patient choice. Driven by a combination of measuring GPs on referrals made and a degree of ignorance, in the world of type 1 diabetes, choice is an anathema. Should all patients with type 1 diabetes care be under specialists? Possibly. Should they all have access to specialists? Most certainly. Why? Beyond the ego, beyond the efficiency drive of saving PbR costs per referrals, look at outcome measures for type 1 diabetes. Awful is a polite way of putting it..variability is high.

Here's a genuine question to ponder as someone put it on Twitter...does choice and free healthcare actually go together? If patient choice is paramount, then can or should a GP deny referral to a specialist based on cost savings? Does denial of so bring the patient back more frequently creating more stretch on an already stretched primary care system? And more importantly does such barriers end up in patient care being compromised?
When we talk about systems that are efficient, in relevance to a long term condition, we have to talk long term...poor care in type 1 diabetes today results in poor outcomes down the line..look at the money being spent on complications...but yet we worry more about saving referrals on a widget based system today. 

We need to be bold enough to have these discussions openly with patients and fellow professionals. Not pay lip service by asking patient leaders to come along for free and give a talk. Not tick a box, not say we have patient involvement when we are not discussing the genuine elephants in the room. 


As ever, these are my personal opinions and of course is from the angle of a niched population such as type 1 diabetes. Our ultimate responsibility is towards patient outcomes and it is certainly important to maintain relations across the sector...it is by the same token, our responsibility to be responsive to patient needs and challenge accordingly the system which makes a mockery of patient choice. Things are improving..slowly...but we need to specify whether it's possible to have unlimited choice in a system where finances are under such a massive crunch..or we have healthcare based on widgets..not quite on relations.

Saturday, April 11, 2015

The efficiency cocktail

I am not easily impressed but I must say I am now. Simon Stevens, the NHS boss has indeed achieved something few have. I have liked the 5 year forward view thoughts from a clinical perspective - as if you see it from the prism of my specialty, it lends itself well plus has looked like a genuine roll of the dice to see if integration can be done by changing the structures...not to mention it was a nifty bypass of the Lansley act. So clinically I was interested and then having seen Samantha Jones take up the helm in guiding the Vanguards and a brief chat later, yep, clinically I certainly see it having legs...if..and that is a big if...if there is genuine appetite amongst all the stakeholders to commit to the process.

However I have been more impressed as to how with elections looming, the "give us 8 billion" has become something all are either being forced to commit to...or having to find ways of doing so. It's amazing as before the 5YFV, no one actually knew what was needed, apart from "give me more"... And then suddenly we had a figure. Hidden beneath that is the rest 22 billion needed in efficiency which I will come to later..but at least, we are starting to get finite numbers promised by politicians towards the NHS..a different debate whether it will be delivered,how etc

The obvious flip to that is if that 8 billion does arrive, does the onus for delivering the rest 22 billion fall on the NHS? We ( and I know many will claim Stevens doesn't speak for them..but as with any organisation, the man is our CEO and that document was probably one of the most lithe and sensible ones I have read in a long time) asked for a certain sum of money and said we would find the rest in efficiency. Would the politicians be emboldened enough to say "ok then..here's your 8..now if you can't find 22...sorry..your fault, not mine"? Fascinating in its own right but I must applaud the fact that Stevens has at least managed to get the politicians to commit to something finite..it's a start compared to "just give us more"

Then comes the 22 billion...some believe it's possible, a lot believe it's easier to actually discover life on Mars. We shall see..I have my doubts as anyone else..for starters, if I was a hospital trust finance director I would be pretty worried. Better get cracking quickly to be a PACS..or its gonna be time to poach others work. In the mix is 7 day services...oh such a heady cocktail...factor in shrinking tariff and you can see where the efficiency drive will be aimed. To complicate things, comes the signs of provider revolt..already due to have a bearing on repeat admission tariffs..what a sumptuous cocktail we indeed have!
Did anyone say we should have less managers? Well, it's probably time to stop churning that nice sound byte. We need some good managers..and never more if we are to get anywhere near those efficiency numbers. Not to mention the fact that even if you take away all those nasty managers, it will still give us a decimal fraction of the 22 billion

And let's also see what comprised a significant chunk of efficient savings last time..ah yes..pay freezes...more to come? Consultant contract negotiations...now there's another battle ground..thought to be fair that's probably aimed at the 7 day services and see whether it can be delivered without a huge rise in cost. Isn't that cocktail tasting marvellous? GPs according to a survey have said they don't want 7 day services with all other pressures, we keep looking for Narnia for those GPs sitting around...the pressure cooker is building.

So there we have it. 8 billion asked..and looks like we may get it...and if we do, then we won't necessarily be in a position to blame politicians...but that's only part of the picture with the bigger challenge of 20 billion to get.
We have pinned a lot of faith on the new models in 5YFV and fingers crossed, some of them come up. Not many have faith that the efficiency money asked for will happen...and indeed there are some who believe that the NHS is so big that money will come, from somewhere as "it always does". We shall see but it would be foolhardy to say this could be a helluva ride for quite a few of us. My view? Yes it's theoretically possible to get close to that but it needs massive changes on huge scale, changing mind sets etc but when I see how little we have achieved with 7 day service or integration due to conflicting interests etc, the reality worries me. A lot.

Do I envy any manager, clinical or otherwise, under pressure to deliver efficiency....Nope...but I will sit and sip on a cocktail and wish them all,the very best. From the bottom of my heart.    

Saturday, April 4, 2015

The last 5 years...

Elections are around the corner...and it's always great to listen to all how their working life has changed or not in the past parliament..and it made me think...what about us? The Portsmouth diabetes team.. and..what about me? How has it been in the last 5 years...shedding off all the views you hear, the angst...taking a step back..how has it been really?
What I will put down in this blog...can I PLEASE make a disclaimer? This is my view, my personal one, my personal experiences...untainted by my political leanings, beliefs or otherwise. This is what we as a team did over the last 5 years.

Individually, has the new "new" NHS affected me? The reality is no- it hasn't. My basic salary has stayed static but personally its not gone down- and I always appreciate how lucky I am to have a job which offers that. There have been enough activity for me within the hospital and community to keep me busy- apart from other local and national stuff- so personally, nothing much has changed. I am pretty sure I speak for my colleagues too on that one. Perhaps the fundamental reason for that has been is that neither am I a GP nor an ED/MAU physician who appear to have taken the brunt of the changes. Tell you what has changed..we have locally in Southsea been a pretty cohesive bunch amongst Consultants and GPs..all I can say is that its more difficult to have the GP colleagues out for a drink...they seem to either turn up in the second half of the football matches..or not at all- and look overall a bit more tired, a bit more browbeaten. I will be honest, I have had my tired moments but mostly due to individual choices to do more rather than the persistence of the day job.

As a clinical manager, I must admit to not being exposed much to the previous system- but I have found it beneficial to have GP colleagues with clout who have been willing to listen. I have heard in the past, PCTs being full of managers who didn't want to approve projects- but have met the same individuals who have been pretty instrumental in making things happen for us as a team- we have shared a camaraderie, had lots of jokes and doing business with them has been fun. We have overhauled how we do diabetes care, majorly built on our relations with GP colleagues, raised the profile of the department, expanded the workforce of the department  and slowly and steadily, the outcome measures for patients seem to be turning. Early days, but let's see.

The tendering has been challenging but been through that too- and worked with all potential providers and then the individual winner to keep the service going- it has been an experience, perhaps an inconvenience and in the world of long term conditions, would love tendering to be held fof for a certain period of time, the projects given enough time to breathe, settle and then deliver.What can you do with a 2 or 3 year contract in diabetes..well pretty much nothing! I look at the Derby model struggling to survive and again, appreciate the fortune we have had with local Commissioners etc

The confusing bits have been the myriads of new bodies- who seem to be willing to help but am still to be convinced that there isn't reduplication. We used to have the National Patient Safety Agency- in our world, was an important  body..that disappeared. NHS Diabetes was a good organisation- that disappeared..and now we have networks, clinical and academic, senates, NHS IQ, NHS leadership academy...they all seem to be tripping over each other a bit- in my opinion..a bit of streamlining would perhaps be helpful! I don't know about other regions- but as regards diabetes care in our region, none of them have contributed much in the last few years- sorry guys- just saying as I have seen it! Look forward to being corrected in the future but I do get the feeling that we have too many bodies who most people on the ground struggle to benefit from.

So in short, perhaps the old system wasn't all bad, most certainly needed a bit more clinician involvement- but perhaps bit too much of an overhaul was done. Baby with bathwater syndrome needs to be avoided in future .

In my next blog, I will put down my views what would be nice to see happen in the next 5 years but as a summary, personally its been a mixed few years. A lot achieved, a lot done- if we get some stability, I promise we could get much more done too! I can't look back and say that it's been awful or amazing...its been mixed but perhaps tilted towards the positive....maybe call it a B -

Reading and hearing much of what is going on in the wider world, perhaps that's something to look back at with pride. Here's to the next 5.