Monday, September 28, 2015

Reach for the Stars

Aspiration. A word that galvanises many to think of what we could do. It is however a fine line though. Take my own football club..Liverpool. Past glories abound and every year, the hope builds that maybe, just maybe, this would be the year. Aspirations are high but time has been a good builder of temperance. Now we talk about rebuilds, we talk about getting into the top 4...compare that to Barcelona...it's pretty simple...win everything you play in.

The NHS is in an interesting bind of its own. the pride of many who work in it is palpable, any suggestions that you may not be doing to the utmost level ( check any negative CQC report and responses) and we all bristle at the very whisper of it. Inwards, I suspect we all know we aren't doing as much as we can and different reasons are given for it whether it be vested interests, inability to work together, culture...the biggest one which does come through is of course finances.

This is where a dichotomy seems to have emerged with organisations within the NHS. Let's take NICE for example- a respectable body who looks at the evidence and makes recommendations. The problem is the aspiration doesn't quite match the resources or even the ability to deliver. Any think tank or health economists will tell you we are in a financial crunch and struggling to deliver what we have..so how would it be possible to deliver more? Therein lies a fundamental question.
Take for example the recent NICE Type 1 guidelines. One which would be a dream for anyone with type 1 diabetes...but to deliver it, something needs to stop or there needs to be some investments. I absolutely take the point that working to evidence base etc would help stop complications- but in the world of diabetes, that's about 10 years away...so where's the resource to invest to save?
When you ask NICE, their response is "It's not our job to give you the how". That makes it tricky because at the moment, no one quite does either. The problem is that NICE guideline manages to raise the expectation that those guidelines will be delivered- and when that doesn't happen..cue anger, angst..take it out against the HCPs who are the face of the NHS to many...drop in morale...the cycle continues. None of the policymakers, twitter champions etc actually face the patients...its the staff who are the face of the NHS.
CQC is another example. It sets the standards, then judges you based on that. However,when you ask them how with the financial crunch..their answer is pretty similar to NICE. "Not ours to give the how". It's an interesting position to take especially when all these bodies are funded by the NHS itself and not quite external per se.

So what would help the debate? Anything involving the public gets divided along political lines which as relevant as it maybe, hardly furthers the debate. Professionals raising their voice are sometimes branded as being of vested interest- so efforts continue at pace to try and get the public and professionals together. However think of this..how much would it add to the table if organisations such as Monitor, CQC, NICE all did their roles but with a caveat that these are aspirations which needs a financial review to deliver? It would certainly strengthen the focus as well as be fundamentally strong voices? All bodies with their respective roles but working together for a sustainable NHS. Too tricky?

I want Liverpool to win the Champions League...I want them to be Barcelona. But I also know that to do that, we need injection of finances to get the best players etc. and if that doesn't happen, I will learn to be satisfied with a trophy here and there and perhaps a top 4 finish. The question is where do our aspirations for the NHS sit and do we all have a responsibility to reach for the stars? If we do, then it's about time, all national bodies had a think..because if it comes down to the wire, they may not have much to inspect or create guidelines for. Or the crunch of money will shut them down too.


The choice isn't that tricky. If we believe in the NHS a and improving patient care- which is indeed the basic role of all those organisations too- then it's time to reach for the stars..together.

Saturday, September 19, 2015

Say it loudly..part 2

Lets do some maths, shall we? We know the NHS needs about 30 billion £ by 2020- not my figures- but as per health economists, think tanks etc. To help, Mr Hunt promised 8 billion of that and in fairness, thats what Mr Stevens asked for in the 5 year forward View. So he got what he wanted- the idea being that the rest 22 billion would come via efficiency savings, working differently etc etc

You with me so far? Ok. Good.. so that brought forth the Vanguards- a bit of extra cash to help them develop- never mind it came from Public Health (a 200 million spreadsheet shift)- all for the greater good- and if the Vanguards fly, maybe those efficiency savings would come. No problems there- big picture and all that. So we on track for what we need. All good. Innovation needs headroom - as the think tanks always talk about the much needed transformation fund

Problem..ah well.. a few here and there. For starters, 7 day working wasn't quite in the 5 year forward view calculations and its inherent bill...especially when folks started talking about elective work on weekends, that calculation started looking seriously awry. Thankfully better sense has prevailed and we are talking about non-elective care which actually is about patient safety. Still, a bit of a calculation upsetting curveball indeed

Then came the issue of efficiency- asking the NHS to achieve what it has never done- a level of efficiency never before seen. Even the most optimists don't see that happening- and with all thats possible, reckon, we would, at best, achieve about 10-15 billion of that needed 22 billion - hey-whats 5 billion here and there between friends? That would leave the NHS  gap of 7-10 billion, come 2020- early signs are there..have a look- the NHS is likely to declare- how much- around a deficit of 2 billion come end of financial year. Election time come..I predict a bit more injection depending on whether we have an opposition or whether NHS is polling as a major issue...and we will limp on a bit more.

Depressing? Not really- as the optimist also knows that it is possible to get good efficiency savings but the realist knows we are a fair bit away from it.
Why? Well- for starters, lets talk efficiency. In an industry dependant on soft touch approach, good will...to get efficiency, you need the goodwill of the workforce. Due to some mysterious reason, powers that be are trying their best to break that down. Which is exactly why as a Consultant, I look at this whole junior doctor thing with dismay. Forget the efficiency bit..we are struggling to get doctors to continue their careers and we are trying our best to make it worse. Odd...I always take pride as to what we do as a team- and what our juniors contribute..bottom line? Morale. Piss on it..and you can surely piss away your efficiency. Innovation? Technology...try and find someone more committed to it..and I can tell you without the presence of the person or the good will, those machines or technology are as good as cold machines. Newsflash- we haven't arrived at a dystopian future where machines do it all (and then take the world over either)

So, whoever you are, think about the generation next and the impact on patients. Our evangelist safety leaders are a bit quiet on this- perhaps out of embarrassment and realisation that championing patient safety without the resource or indeed, without a motivated workforce runs the risk of making things worse. As a Consultant, I am very clear that imposition of contracts is wrong and must be challenged. Whoever you are, whatever your title...have a think about why, for the NHS and patients, you do need to stand y our generation next. Say it loudly.

Next week, some suggestions as to where we could get some of the efficiency savings Mr Stevens alludes to...but till then...think of those glossy powerpoint you have made or seen umpteen times...think what they say about morale.

Then say it loudly.

Saturday, September 12, 2015

Whisper it softly...part 1



Take a moment. There..can you hear it? No? Try again...yes...there it is..the slowly dwindling voices. Voices of the few who have fervently championed the cause of "working differently"..championed the cause of doing so with scant regards to the "ask for resources". Eager to capture the eye, they wanted to make the case that finance wasn't the issue...today..their voices dwindle. The hard facts of balance sheets strike hard...the ethos of working differently sits in pockets...down to sheer charisma of a few individuals..not across the system the NHS desperately needs.

But why is it so? Is it about the money itself or could different working close the gap? Here are some of the fundamental chicken and eggs facing us today:

Staff costs: whichever way you cut it, staff cost is an issue and a pressure. Solutions could be to reduce the costs itself by cutting staff or reducing salaries. Cutting staff involves asking the existing ones to work differently ( ah yes), sometimes going beyond the call of duty..banking on vocation. Problem? By dropping the salaries or changing the dynamics of work life balance, the staff doesn't play ball..so it all comes to a head. What about hiring cheaper options? Divisive, inflammatory arguments rage about efficacy...debates rage about roles of others ..bang goes the thought of a team working together to deliver efficiency. Or even working differently. Oh and there's plenty on morale and its impact on safety, clinical delivery etc etc

Goalposts: it was a Herculean task to get the workforce to deliver what they were previously doing...now there are add-ons. 7 day services..an aspiration of excellence- but go back to point 1 and the pressure cooker builds even more. Think of being asked to serve 5 people omelettes but with 4 eggs..somehow we were whisking them all together and cutting the omelette up to make it look like 5 pieces...now suddenly 2 more folks have turned up. That's a challenge,No? The desperate hope that someone isn't that hungry...ah those tricky breakfast parties!

Patient power: The world is now a different place. Blogs, articles, social media, patient leaders, patient representatives ensure patients have a voice..and with that comes shifting of expectations. The dialogue of want and need gets blurred...do patient leaders speak for many or for a few? The debate continues but one thing is for for sure...a realisation starts to dawn that not everything is deliverable. It creates frustration, angst...cue clashes with clinicians. Cue morale issues, cue burn out.

Evangelism: Beyond patient power, there is evangelism. Guided by personal experiences, they have championed, quite rightly, the issues of poor care. But has it been too niched? Has it resulted in funds moving around from where the system needs? Nurse staffing on wards have been emotive...any Trust around the country will tell you the costs it brings. Is it important to recognise something else needs to stop? If it was that simple, we would have it everywhere...we don't due to combination of lack of staff and realisation that to do so, it will deprive someone else of something. Charities shout "outrageous" and tackle their own niched areas...the reactionary responses from policy makers help a few but does ti take money away from many? Cost isn't an issue when patients are concerned...a fair point...but then ask the source of the money flow...is that the question to be asked?

Lack of headroom: Many clinicians will also agree that there is wastage in the system. To clear that, to get a fresh start, you need headroom. But there is none. Examples? To help deliver better flow in hospitals, you need better community support. Where do CCGs said get money for that when you are spending it on existing services, some non evidence based, fancy projects..but those that still continue? In the world of type 2 diabetes, to save money, you need to invest in prevention and structured education...where is the money for that when you are spending it on the tariff needed to pay for end organ complications such as heart attacks?  

So there we are...what was softly spoken hushed whispers are now starting to gain voice. Think tanks, health economists, politicians of all hues, managers...heck even the public as per recent polls are starting to query the feasibility and more importantly resources. It's also very easy to dismiss such blogs as the one I am penning as one of the "doom mongers". Au contraire, you will struggle to find a team which works more "differently"...and I am telling you this..the aspirations are not under challenge, the resource to achieve that however surely is. We did what we did..with resources.

So where do we go from here? The screws are tightening and there is an impending sense of everything building inexorably....hospitals are jammed in summer and autumn...frayed staff are everywhere to see. No amount of spin and cheery messages can drown them out anymore.

Next week....I will try to cobble some suggestions as to what could work...targeting exactly the points made....in the interim, have a think yourself and suggest some..I am all ears.

Saturday, September 5, 2015

Invest wisely

Its all very weird. Debate about 7 day NHS has started to walk into Pythonesque territory now. To start with, a 7 day NHS is absolutely what is needed...but somehow we need to get past the belief that the NHS exists only within a hospital. Talk about Safe staffing, talk about 7 day working..the debate is mostly centred around hospitals...which is a bit odd- given that the bulk of NHS is based in the community!
Look at it...Health economists are saying it; Think tanks are saying it...let's forget for a moment what the BMA is saying..(as that provokes various debates about vested interests)...but the message is loud and clear..in an era of cash strapped environment, the more cost effective way of doing things is to invest in the community.

Everyone, or at least most importantly, Mr Hunt, seems to have at least agreed that implementing a 7 day service will need significant amount of investment- but as a diabetes specialist, I am baffled. To begin with, I was told there was no money...fair enough...so we walked down the road of discussing tough choices, thinking of prioritisation...now I am being told, there is money but for ...what is it...elective work? Do you want me to do type 1 clinics on a Saturday? No problem..but unless you uplift my salary or give me another colleague etc, someone else will have to do the weekend rounds I already do. I have yet to have had any patient ask me for that- as they have adhoc slots, emails and phones to use regards their care anyway.

But let's not rehash all the old debates about other stuff etc...it appears that we have lost all sense of understanding as to what is actually emergency work. Evidently, me doing clinic on a Saturday will stop admissions...ok..as a diabetes specialist, let me say this, if you have money to burn..rather than increasing my salary further, how about you use that money to fund education for patients with diabetes, set up a help line, fund education of practice nurses...heck..even do something to prevent type 2 diabetes...now I can assure you THAT would certainly help save admissions, future cardiovascular events..you know..the sort that we all are doing this job for.

Let's be crystal clear- we are struggling for money- and for trusts strapped for cash, more money to do more elective work in present times will be like manna - will it help patients- the health economists say No. Should we use any available money in community care? Mental Health? Think tanks say Yes. Can't really accuse them of vested interests. Let's be serious- there is no extra money- its shifting lines on balance sheets...recently Public Health lost money, remind me how much did the Vanguards get to kickstart the brave new world? To get the money needed for 7/7 working, something else will have to give...will it be mental health? Community services? GP funding? Who knows

However,if this is all about making sure election promises are kept, little else, then please- do carry on. I will happily do some extra clinics on weekends- will it help anyone bar a bit of convenience for a few? No- it won't. We have made a savings of 1.8 million £ over 4 years based on outcomes saved in diabetes patients- NOT by doing more clinics but by providing support for primary care- but heck, are we doing evidence based anything anymore?

We must, absolutely must, think beyond our own silos- and consider we work for the NHS-as a whole- take a step back and see where the money is best used. In a climate of no restrictions, we can and must aspire for everything...otherwise we put resources where it makes the biggest difference for the population. It can't be that difficult..can it?