Monday, August 31, 2015

Not quite NICE enough

It's an interesting conundrum...do you set the principles first before attempting to achieve it? Now normally that seems to be the perfect approach- how do you know where to go if you haven't set your destination first? That clearly makes sense in a normal world but unless we have all been living under a rock, you may have noticed the NHS isn't quite in normal times...so back to the question...is it the principle that needs to be set first- or more a question as to what is affordable/needs investment/needs working differently...take your pick depending on your inherent belief

The problem also is that as soon as you raise a question...its because you are against it. Well, not quite- sometimes questions are asked to raise the validity of what can be achieved, not necessarily questioning the principle. Let me give you an example- recently, lots of media attention was drawn towards how lack of senior cover was compromising patient safety on weekends- beyond even the debate about the accuracy, when I raised the question whether what is being asked is achievable, many a patient safety advocate felt I was against it. Well, not quite - just want to know how those extra bits are going to be funded. Leaders of all hues have a responsibility- to aspire to quality care- but also to be realistic and more importantly stop raising false hopes- as for those who have pinned their hopes based on promises made...not achieving it causes angst, hurt and frustration.

Let me give you another example- whats new in town? Ah yes, the latest NICE type 1 diabetes guidelines. Now before the world and its dog descends on me after reading this- let me make2 things crystal clear. Firstly, I am one of the biggest supporters for high quality care for type 1 diabetes patients and secondly, the committee who have come up with the guideline are comprised of folks I genuinely respect. It's led by Stephanie Ariel, one of the few folks in the whole world to whom I would bow anyway based on her prowess- not to mention some others on the list. For a change, its a committee comprised of folks who garner respect- which is light years away from what the type 2 guidelines committee are- making a pigs ear of a guideline, wasting valuable tax payers money...but that's a different story altogether.

So back to the NICE guidelines- whats good about it? Well, pretty much most things- as something to aim to- simply fantastic- it has most things which all Type 1 diabetes patients should be able to have. There are new bits added to the 2004 guidelines and on face value, its not too far away from utopian type 1 diabetes care. Just one snag- it doesn't appear to be grounded in reality..or to put it politely, it seems like the principles are set- but without any wherewithal as to how to achieve it.
I know some will say its all about working differently, efficiently, using consultants differently...and without putting too much fine a point on it...you are speaking to the converted. Efficiency is what our care model is about- many an area spend many an hours trying to emulate what we do- so yes, I know. The problem...its just not stacking up anymore.

One small example- CGMS or Continuous Glucose monitoring system- approximately 4K. Flip it- thats about 40 outpatient appointments. OR care of 3 pregnant women. OR review of many a foot ulcer. Did we say priorities? Heres another one- blood glucose monitoring- it says 4 times/ day - if not 10/day. This in the face of an NHS where some type 1 patients have their strips rationed due to cost. Access to walk in clinics and phone contacts...at what tariff- built into job plans? Or not? So many questions, eh?
Do I think patients need what is said in the guidelines? Absolutely- do I, as a provider and a CCG board member think its achievable? No- it isn't- unless we have one of the 3 options:
a) An investment to create headroom- to allow new models to flourish, technology to ramp up- and thus give the savings in long term-as advocated by the think tanks
b) A debate about prioritisation- lets not broaden it too much- we could just start with diabetes as a whole
c) Increase investment overall in the NHS

I know its boring- I know its the same record...but on behalf of many a patient with type 1 diabetes, all I can say is that don't raise false hopes, unless there is a plan to implement. Otherwise discussions will be about patients, rightly expecting to have CGMS based on NICE guidelines...grinding to a halt with providers having to make business cases in a choked financial climate. Cue frustration and misunderstanding that the professional hasn't tried hard enough...the truth could be they did- and got turned down as something else took priority in the bigger NHS schemes. Here's something to ponder about. The last type 1 NICE guidelines from 2004...we achieved little of what was there- in times when finances were better- what gives us hope that 2015 will be different?

However, I will finish on a positive note. The NICE guidelines is achievable- to do that, it needs some big bold steps, steps that will upset some, steps that will not be palatable for many, steps that will need some serious leadership.The billion dollar question? If the present lot haven't been able to deliver over the last 10 years, in times of need, what faith do I have that a NICE guideline will impact much?
To end- my final view of the NICE Type 1 guidelines? Good but not bold enough. Positive but not revolutionary enough. In a delicious twist of irony...a bit more boldness could have opened up the way to achieve much in there. Have a think what that could be..won't you?


Sunday, August 23, 2015

I don't know

I don't know..I honestly don't know the answer to many a things- and those who are sure they do..are simply either putting on a  face of sheer bravado or..I don't know what they know or believe..but its either not grounded in reality of life and politics..or they are aware of something I am not privy to. I won't say today I have seen enough, won't bore you with all my "achievements" in life, all my exploits..the honest truth? I don't know.
Do you know what I am talking about? Its the NHS and the direction of travel. There is a lot of things I don't know or believe views are too polarised in- all of which stops and continues to obstruct any meaningful discussion

For starters, there is a question whether the NHS needs more money...again..I don't know for sure whats the answer is- I really don't. I look at diabetes care- and I don't even know how much money is where, who is spending it, how the counter productive tariffs are supposed to help..so how can I honestly ask, hand on heart, the public to give more? I look at the lack of finances needed for say, structured education..I also see the sheer wastage that inappropriate treatment of the elderly brings, the vested interest to which many acute Trust works, the Best Practice Tariffs which disappears into bottom lines...and I don't know whether there is enough money. Or not. I don't know but I would someone independent to tell me.

I don't know whether privatisation is the all encompassing evil beast some say it is. Is it because I do private work in my own time? No, its because I also am aware of many a state arenas providing poor care. No- did you say? Maybe so- but again, I don't know - I want someone more clever to make that call..someone independent,someone across political lines- I really don't mind who I work for, where I work for- as long as it serves patients and provides high quality care- thats my position. Blasphemous- did you say- maybe so in the tight chambers of twitter- not so much in the entire world maybe. Again, I maybe wrong, but I don't know- I honestly don't know.

Many dislike the market, would like the return of monopoly. Is that the right thing? I don't know. We have organisations like the CQC because we couldn't do the job what we were supposed to do. Would a monopoly help that? I don't know- I don't have the experience- but I would like someone independent to tell me.
Finally, to the name that seems to make all professionals bristle. Hunt. Do I know whether he is out to destroy the NHS? No- do I think so? I don't know but playing the man, having an angst against one man is no solution when we need to debate the policy as a whole. The point, in my opinion, has been made about what was said regards weekend working- it was aimed at the BMA and misfired..but it is time for us to ask the above questions- and if the answer is only from polarised views, then its time to ask for someone independent. Don't forget many also see the same man as someone who has set a clear agenda for patient safety...you may have a view that it is a politicians smoke screen- me? I don't know

I am tired of polarised views- and that includes those against political views. There is a certain quality about being in the tent in my view. There are many who hate the Tories, hate the fact they are the ruling party- but whether you like it or not, thats who are in the government- for another 4 years- if not longer. If we care for the NHS, then it makes sense to have that dialogue with those that are in the seats of power- a desire to improve /save the NHS should over ride all else. perhaps for some, thats too far a bridge but thats the scenario we have now- but I am more willing to try.  I apologise to all who may find my views offensive, wrong, out of order...but I have spent much time doing many things- and I must put my hand up..I don't know anymore. And I want someone independent to tell me.

Finally, I am a Consultant, reasonably entrepreneurial, street-smart and whether the NHS survives or not, there will always be a way for me. I do however believe in health being a fundamental right of any human beings- and so I would like to...no...not fight..but engage with those who want to discuss it. I don't want to fight- I want to help..I want to try- and to those who want to, I extend my hand. If you want to take the offered hand, then join in.
You know what I am talking  about- its the group I am a part of and very proud of. It has a gathering of a group of individuals with different views and beliefs (and not all of the above views are shared by all either)- but all with a willingness to engage. We will stutter, we will stumble,we are not politically savvy...but we will acknowledge a mistake when we make it. And we will try. Any successful team always brought together a group of individuals with different beliefs...but the key lay in the ultimate goal...the ethos of NHS Survival is no different

In my life, I have never waited for anyone- forged my own way- so if you want to help, then help..you can be of any political leaning, any belief- but if you think an independent opinion is the way  ahead, then do so. If you feel it isn't your forum, I wish you all the best in whatever forum you try and develop the NHS further.

Will it work? I don't know. But it most certainly is worth a try..and if not anything else, would have made some good friends for life. To those who are my friends, those who know me, know about what I stand for...help if you can..if you believe in me. If you can't, thank you for considering.


Friday, August 14, 2015

Fine balance

Recently something happened...without going too much into details, I saw a bright young healthcare professional upset...and I mean genuinely upset. There had been a post on social media- directly against the care given...and I saw it...caustic, bitter,angry. Patient confidentiality stops anything else but I knew it wasn't accurate...and yes, I know enough about social media to know everything isn't accurate and in someone who lives with a chronic disease, its isn't right to judge either- as quite rightly those who don't have it, do not live their lives, do not live their frustrations.

But what about the carer? Compassion is a 2 way street too- and the number of amazing examples of healthcare always far outweigh the minority of poor care. Indeed there are some examples which can never be condoned. professionals who don't care enough but that minority is no different to any group of individuals- a mixture of extremes makes us all the human race we are. So I asked the question on twitter whether there were any blogs which actually spent time appreciating the care they receive. I always see blogs which suggest what could improve, I also read highly critical blogs..there also seems to be a dissociation of the reality the NHS finds itself in. Any carer in the NHS will tell you one thing- the expectation, the pressure is high but more importantly the financial numbers are simply not adding up. Under pressure,under constant squeeze of time, compassion gets eroded - one step at a time....someone said compassion needs nothing extra...wrong..compassion and caring needs one thing we don't have nowadays- time.

If I am honest, locally, we have our own Ninjabetic whose previous blogs have been of constructive criticism as wells laced with appreciation (examples: here , here and here)where it has been due..however I have been keen not to highlight those- as it once again goes back to what I myself have been guilty of..."Look at us, aren't we amazing?" Time has taught me it does tend to rub people up the wrong way- and its perhaps time to share- but with more care, more humility and less bravado. 

So I asked for examples beyond our local patch- and I must admit to being very pleasantly humbled at not only the beautiful tweets I received but also the sparkly examples of what they care they felt they had received. 

Want to read? Have a go here and here and here and here . Beyond diabetes, a great read sits here It does make you feel nice and warm.

I have never done guest blogs but via twitter someone kindly said she would put down a few thoughts...have a read below..from Emma Stahly ..in her own words...



My daughter was born at 36 weeks gestation, weighing 5lb 5oz. Against the odds, my induction had been successful and 8 hours after my waters were broken I gave birth. I felt on top of the world, empowered, proud - and grateful.

As soon as I called my diabetes specialist nurse (DSN) when I got a positive pregnancy test, I was booked straight into the diabetic antenatal clinic for a scan, blood tests and a chat with my consultant about my blood sugars. From then on I saw my team every other week, and e-mailed my consultant almost every other day. I did all the hard work, but I never felt alone doing it. I felt listened to, and that I was working on my diabetes in partnership with my healthcare team. My control was excellent, and I believe it was in part because I was so well supported.

Towards the end I started to suffer more hypos and the expected insulin resistance didn't happen. My obstetric consultant became concerned about placental failure. I was booked into the maternity ward every other day for cardiotocography (CTG) monitoring. Each time I sat there with my belly strapped up, clicking every time I felt a kick, my consultant endocrinologist showed up to have a look at my blood glucose diary and see how I was doing. Finally she became concerned enough to call the obstetrician, who arrived at the ward immediately. He decided to admit me to receive steroid injections to help the baby's lungs, and that I'd be induced 48 hours later.

My daughter was small for her gestation, and I was told my placenta was too. I believe had I been allowed to carry much further my baby would have been at significant risk. I am certain that my consultant team spotted the danger and made the call at just the right time to deliver early. They are paid to see patients and make these decisions daily - but the pay in itself would by no means guarantee positive outcomes. They are committed to their patients, to healthcare, and to making lives better. They may well have saved my daughter's life, and I will forever be in their debt.

Beautiful, isn't it? I will be honest- i don't want false praise- a sentiment which will be echoed by thousands of professionals everywhere. But I don't want to be told off always either..I took this job to help- and in the circumstances, I am trying the best I possibly can. Patients and professionals have to work together- there should be no "you" and "us"- if the system is such that this decide is created, then we must- I repeat, must join hands together to ask whether the system is sustainable, ask ALL political parties to accept a review of where we are heading. The NHS is struggling and this is not the time to have divisions- this is the time for the public and the professionals to unite for better,safer care.

Shine a light where needed..but with care...just as the professional doesn't know what you are going through with your needs...similarly you, perhaps don't know what the professional is going through every day in their work. Let's have that balance- it indeed is a fine balance- but one we must work together to keep.

To the professionals, read some of the links too...its not all bad either. In the heat..it perhaps feels so but it isn't the case always. The fact is..we all need to look out for each other a bit more.

Tuesday, August 11, 2015

Soft touch; hard evidence


Much has been said about the role of the Care Quality Commission in recent times- a murmur has gathered pace with the Professional Standards authority questioning the role of regulation. 211 million pounds is the figure mentioned spent behind CQC and maybe its time for some sense checks, as well as for the CQC to consider the next phase of its development.

For starters, let’s be honest- nobody likes to be examined or regulated. We, hopefully, all go to work believing to be able to do the best for our patients- so any external regulation raises the question whether we are or not. Sadly, past events have suggested there probably is a need for this- and the question is whether CQC needed to exist whether all Trusts and staff had done enough with their internal processes. That’s what, perhaps, CQC needs to tackle..a step away from the criticism and be more of a guide. Shine a light but also make robust suggestions, share examples from their travels where its better. There is little point in saying “you are not good” if you can’t be a support to improve or indeed give suggestions as to how to do so within present financial constraints.
Interrogate success, not failure- that possibly needs to be how CQC functions

Secondly, I have seen CQC appear in a few Trusts- and to be fair, it has opened doors to fight the corner of patients in some cases. The name CQC has made managers sit up and listen when previous business cases, please, data has failed to do so, failed against the wall of financial imbalance. One may say that’s a culture of fear but it’s a sad indictment of internal processes where the name CQC is needed to make changes. In an irony, perhaps it makes the case more for its existence. To many, the message thus is..sort your own internal bits out..if you do, then the CQC doesn’t need to exist

Thirdly, the money involved. 211 million sounds a lot but its also about context- especially when you think that the whole NHS budget is about 110 billion. Our local 3 CCGs has a combined budget of about 800 million- so in a national context, that money released would be about 1 million/ CCG..something that would be swallowed by CIP budgets in a blink of an eye

Finally, its also about CQC learning from experience. More soft touch, less marching in. But most importantly? The need for data. Quite rightly the return of investment is asked for- as with every sector of the NHS and this is where CQC has floundered. Let me give you a simple example- CQC has examined X number of steps- as a diabetes specialist, I would like to know what diabetes specific changes have happened in hospitals to keep patients safe? Gillian Astbury was one of the deaths due to lack of insulin in Midstaffs. Has CQC inspection improved that? Anecdotally, the answer is No. Prove the doubters wrong- show that insulin prescription has improved, show that errors are less, never events are less..think of metrics, markers, maybe even simply checking whether the recommendations given in Trust Z has been implemented or not.

Indeed, there are many arm length bodies that can be amalgamated and role looked at in times of financial strife- but on balance, the CQC probably still has a role as I am yet to be convinced that internal processes are robust enough and protects patients enough. But for that CQC also needs to adapt and be ready to answer critics with data- not with simple emotions. The need to improve care sits with all of us- the trick is to move away from the emotiveness and base it on data. Let’s see whether the powers that be are ready for that.

Wednesday, August 5, 2015

Ask the question

We must be able to do what we preach. No- really, we must. How many courses, events, conferences have we all attended where we talk about importance of being transparent? We must be able to- shouldn't we? We have an issue of patient safety- and quite rightly, it is top of the agenda. The CQC- for whom I actually don't possess negative feelings - (as frankly, seen enough occasions where the "fear" of CQC has worked far better than any data, any debate, any business cases to get appropriate staffing) - quite rightly tries to flag areas of poor care; poor staffing and asks the question of Trusts- and Trusts have to respond to that. 

What sticks in the throat of then Monitor turning around and saying- well.. actually staff appropriately. So we come back to a question. There actually isn't one question only. I know many want the question to be simply - where's the money- whether that be due to personal experience, whether that be due to political leanings, belief- so for many- that indeed could be the question. The efficiency evangelists say - there can't be more- which is also fair- in which case the question could be "Ok- so what isn't essential?" 
We could talk about value based interventions- but the interpretation of that is individual- who's bold enough to say "We think safe staffing on wards is most important, so we will stop providing pumps to type 1 patients"? Sorry- did that offend you? Is it by chance that you are someone or know someone with type 1 diabetes or does that not matter to you- as you are don't interact with people with type 1 diabetes? Ok- don't get angry- I will keep it- shall we then take away community rehab for heart failure? Outrageous did you say?

So what's the question? Well it could be many- the problem? All believers, evangelists are tainted by their own experiences, their own confirmation bias. I would like to ensure psychology services are available to all- that's because of my interaction with patients who would need that...would it matter to a Gastroenterologist..or a Radiologist? Maybe it would- but would it matter above their latest tech or whatever that would "improve patient care"? 
Let's take patient safety- the loudest supporters are the ones who have gone through pain personally or been at hearings listening to harrowing tales..their drive and passion is understandable but they didn't ask the question. They didn't ask one simple thing: Can we afford it? Or if we can't, what else is going to be sacrificed? Does it mean they care less about say the need for a pump in a type 1 patient? I don't think so- but question is would they rather sacrifice it to get better patient safety or improve patients they see everyday? 

It's tough, isn't it? I have been on the other side of the NHS  a few times  too- and before #hellomynameis became a movement, I never even felt the need for something like that. Why? Because every GP, Consultant, junior I met was polite , introduced themselves- and no, they didn't know I was a doctor. Kate's experience shaped her views but it still has been her views- which resonated with many...the difference? She knew the how...it didn't need the basic question answering- what else gives. This was a simple human interaction- nothing else had to give.

So we are now here. I do not know what is non essential staff. From my experience,a manager isn't, a dietitian isn't, an admin person isn't...so I don't know who is. But I would like to ask the question- Who is? I would like some to ask the question- what gives? I would like some to ask: How? If it isn't about money, what do you want me to stop?

If we are in a state where we can't do everything- maybe its time to do a few things of highest quality- and maybe top of the tree is nurse staffing. Then lets be adult and say we will stop other things. I am ready to have that conversation in the world of diabetes- with patients. Let me finish with a question...
Are you?