Sunday, November 27, 2016

Heart of hearts

I don't know how many of you do ward rounds but I swear you should. Just for the heck of it. Just to experience what Bill Murray went through in Ground Hog Day. Beyond my niched world of diabetes, I do what is colloquially called "Unselected work". In simple definition, its known as seeing anyone who comes to the ward- none of the "No Sir, its not quite the level of heart failure needing Cardiology opinion"..nor the "Ooh, old but not quite old-as it doesn't fit the latest criteria". Nope- anyone- heck, even the fractures. I jest of course but you get the drift..its all a world of specialism while we dance around on egg shells trying to fit round pegs into square holes.

Then there is the fascination of this ethereal thing called 4 hour target. How in the blinking blue hell is a target for which the acute Trust only is liable when the problem is with the system of ANY use…beats me- but hey, what would I know? Evidently its a marker of system pressure- well if thats the case, then open the newspapers- plenty of indicators there- don't need a target to drive everyone up the wall when no one in their right mind actually believes this is achievable without adequate social care.

When discharge targets and achievements take precedence over all else, the world of healthcare has taken a turn into another arena where teaching, healing, pastoral roles- are all footnotes of history. An assumption that professionals keep patients back on hospital beds, or refer them just for the lark drives us into unknown realms of mutual mistrust and finger pointing. The facts never bear out- its all about anecdotes, its all about that stray incident. Sensible plans would be to focus on the biggest area which could unblock the log jam (yet to understand why everything in hospital is so focussed on toilet analogies!) but nope, its about the small things. Someone obviously took the tagline of ASDA a bit too seriously (Every little bit helps)..the amount of time we theorise what quicker discharge summaries would do…and we wonder why our junior doctor colleagues wonder what exactly their role is on ward rounds anymore.

I said this about 3 years ago- and I will say this again. The 4 hour target is irreparable- its no longer about the process-its now about capacity. We can spend as much time as we wish blaming each other (ah if only we all did GIM / ah if only we had more radiology scans / ah if only patients didn't turn up) they are all- bar none- tinkering with the small margins. Every little bit helps- but when you are rejoicing at scoring one, but already eight down, even the most optimistic Liverpool supporters from Istanbul will tell you- there is a limit to ones dreams. At some point, they roll into fantasy.

In the middle of all this, I admire the dedication of all those who do this day in, day out- whether they be nurses, physios or there "flow"-managers…I have no idea how you do it- and keep sanity. What I would ask however is perhaps all to realise that there really isn't anyone who's working less than you. When a radiologist says 'don't send unnecessary requests"- I can promise you- I don't. I do so when its needed. I don't get paid more for an extra scan, neither do I like to irradiate people just because I like the Incredible Hulk storyline.

The system needs to understand mutual shots do so little- and if you haven't done someone else's job, you really have absolutely no right to criticise another, Junior doctors do jobs nowadays I would simply hate to do- ticking boxes has never been my thing, you see. 

By all means, rail against the system, rail against the lack of social care which is buckling hospitals, the lack of community beds, the lack of adequate primary care provision….but go easy on each other. The 4 hour target is a relic from an age- which doesn't exist anymore. Maybe its time for one across the system- I don't know what it is- but this much I do know, without social care funding, the emergency stream is all about how pretty you can make your powerpoint slides. 

In your heart of hearts, you know that too. Don't you? 



Sunday, November 20, 2016

Post-Truth

Post truth. That's the word nowadays. The Oxford dictionary has said so- and we are where we are. 

Defined by the dictionary as an adjective “relating to or denoting circumstances in which objective facts are less influential in shaping public opinion than appeals to emotion and personal belief”- in other words, simply put "all bets are off". The days of evidence, the days of rational debate lies in tatters- its now about emotions, its about beliefs, its about "taking sides", its about "with us or against us"….the divides are sharp, the discussions are bruising and nothing, simply nothing is any more "unacceptable". In a notable diversion from usual business, both sides of the Atlantic chose the same word this time- the world of "post-truth"

In a world fed up by establishment let-downs, the sheer impact of political correctness, we have the rise of the personalities, the world of the outrageous…the signs were there- when Z-grade "celebrities" were feted by the media compared to genuine artistes…who needs a Dylan when you have a Kardashian…we now have moved to the full blown culture of outrageousness- where its politically correct or a liberal to say "sexism or racism is not acceptable"…the cult of publicity hungry figures- the utterances of Katie Hopkins & Piers Morgan occupies more time than Aleppo. We are numbed to brutalities, numbed to yet another dead child…we are more fascinated by what Trump will tweet next. The US elections played out like Brexit 2.0 - a fixed social media bubble that the "righteous" would win, while millions just got tired and fed up of the rhetoric and just wanted "change"- however outrageous it may be. 

Where in this world does the ethos of an NHS exactly sit anymore? The belief of everyone having care based on need, little else- the fantasy of liberal elements or the sign of a "modern" society? Or it is the definition of "modern" that has now changed forever? The NHS or its future seems to be playing out in a similar manner- a camp who predicts doom at all turns, pictures of people dying in the streets, professionals scrapping for day to day living, the only thing that would impact change being money, NHS England are the dark side..…countered by a world where its simply about working together, working differently, irked by the folks who scream blue murder at the mention of any changes, exhorting the erst to do more when theres little left in the tank. The divisions are sharp, the politics is dark- and many many folks watch this unfold with a depending sense of macabre predictability 

Having said that, there are always rays of hope…hope that out of all of this, something, maybe something will come out. As part of this blog, I wanted to mention 2 recent meetings I have had with my NHSE hat on- which gives me hope…hope that perhaps -somewhere along the sharp lines of divide, exists some hope. 
The first one has been the BMA and GP colleagues- a refreshing view to whats possible on many issues and the second one the junior doctors organisation in diabetes, the YDEF. I won't go into details but I have been touched, humbled and delighted to see the approach- built on one fundamental bit- to improve care for folks with diabetes. And to me, thats good enough.

We live in odd times but I have been, am and always will be an eternal optimist- and I believe in the basic essence of humanity to do good. So far, in my role, I have come across so many willing to try- that just maybe, in the post truth era, we may have a chance. 

Who knows- but when you ask a group of junior doctors to design a pathway for Type 1 diabetes- and they start with making the patient needs the primary aim…there's hope. 

Theres always hope. And till that is there, its always worth a try.Don't try and convince me otherwise- and please, don't dissuade anyone else from trying either.


Saturday, November 12, 2016

"Super 6 Diabetes": 5 years on



Outcomes…at the end of the day, thats what it must be all about. Has to be. Everything else in a healthcare setting is worth little, little more than waffle, colourful powerpoint slides, clever words, analogies- but sadly little else. Even the words of empowerment & empathy- words derided by some - is driven towards outcomes- whether they be happier patients or staff- they all lead to one thing- better outcomes. What exactly are we doing this job for?

I am yet to meet a single diabetes specialist who went to medical school to improve an HbA1c- and in a way, quite rightly, that same question is being raised, louder by the day- as to the medications and the outcomes. its never been about surrogate markers- but always about outcomes.
So to the Super Six diabetes model- and it is with significant pride we looked at and finally have published the 5 year data. Is it the ultimate model of care- not by a far stretch of imagination- and to be fair, we are in discussions about adapting to changing times, adapting to new structures…but the principle? Sound as much today as it was all those years.

The model was always very simple. Specialists use the hospitals for high end stuff- and the rest to be managed in primary care- but with one little tweak- be there in primary care too- visiting surgeries, physically seeing patients with GPs/Practice Nurses- as well us being accessible via phone/email etc
It cut across 80 odd GP surgeries; 3 provider Trusts, 1 ambulance service - and it held its own- bound by a very core strategy- the SAME group of specialists working in BOTH community & acute settings. It is my steadfast belief that the term "Community Diabetologist" is nothing but a tautology. The community has a hospital as PART of it- the hospital is not a separate entity and back in 2009/2010 when the word Vanguards and STPs did not exist- we ventured forward and tried to fuse all of primary and secondary care together.

Problems? Of course many- a lack of a unified IT, variation in degree of enthusiasm amongst primary care, community & acute providers with different financial drivers and targets to attain ("How many phone calls did you receive" - rather than "How many hypo admissions have we prevented") but then again, no one said it wouldn't be a challenge- and I love a challenge- so here we are.

I won't say more about the details of the results (have left relevant  links at the end of the blog) but this is more about being very grateful to so many who have taken this so far. I have never trained to be a leader, never declared myself as one either- and a leader is only as good as those standing next to him or her. Without my colleagues -whether they be in the department- or in GP surgeries- nothing would have happened. Why is integrated care so difficult- because its tough to get a collective view together cutting across so many providers- by effort, default, and a significant help of luck- we got there- and 5 years later, its been worth it

Whatever be the next versions- the model of care will change now- but 5 years of working differently has been really helpful-both for education as well as building relations with primary care. How DO you improve diabetes care- if you don't stand by; help; support and build relations with colleagues who look after 90-95% of those you purport to look after?

Today, it is with a lot of pride we see similar models coming up, being discussed and indeed versions being created. We,as a team, never had any monopoly on this- so if you want to know mores ever, just ask. 
And to so many across the South East Hampshire & Portsmouth area- Consultants; GPs, Nurses, Managers, Commissioners- thank you- its been worth every single moment.

To others reading it, my tip? Keep trying. Failure is normal- try again. And then try some more. Persist and keep focus. Build a team around you. And keep trying. Keep focus- keep at it and judge your efforts on outcomes. 
As the saying goes…"If Plan A doesn't work, there are 25 other alphabets. Stay cool"

Special thank you to:
  • Sarah Malcolm, Melissa Way, Lyn Darby(Commissioners/Managers)
  • Gwen Hall, Jane Egerton, Debbie Fishwick, Sarah Moutter, Ali Tier (Nurse specialists)
  • Jim Hogan, Paul Howden, Andy Douglas, Barbara Rushton (GPs)
  • Sue Harriman, Katriona Percy,Ursula Ward (CEOs)
  • Simon Holmes (Medical Director,Portsmouth Hospitals)
  • Bruce Keogh
  • And of course- the super-duper awesome legends /colleagues I work with everyday in Pompey
x


To read about the 5 year data:


To read more about Super Six Model of Diabetes Care: 

Sunday, November 6, 2016

Standards

It's a very weird world we live in... I suppose the whole Brexit thing and the bit about "not caring for expert opinions" perhaps should come as no surprise. I have always been fascinated by the NHS culture of how it looks at healthcare and who would be the most appropriate person to care for someone. It's a mind boggling cocktail…...fuelled by the issues of affordability, the system has always turned to someone else to provide that care. The views become starkly divided into "cheaper labour- how dare they" and "disrespect towards others profession...the sheer arrogance of elitists"...and all sensible debate stops.

Let's take the example of where we are at. A big issue is one of variation of care...how do you propose to improve that if everyone and anyone can have a go at it? I will stick to diabetes- if only to stop the barbs of "what do YOU know"...but it's simply amazing- at all levels. Consultants delivering pump services without formalised training; 1 care delivering high level diabetes care without a standard to aim against, nurses delivering care without any standard way of measuring quality...where does one stop? Is it all about money and do we deliver good care or service to the patient when we ourselves have no national set standards as to what "training" or "good" is?  I recently went to a meeting where a nurse specialist was clear that the care of the pump patients could be handled by a GP. How? Why? Is it because it's seen as simple? Or is it because we have no standards to say "No, X or Y shouldn't do this because they haven't trained?"

Or is it because we take a cavalier attitude to long-term conditions? Maybe the impact of that is not immediate, too long term for any of us to worry about it- compared to say the ability to put a cardiac catheter in? I don't know...this is me mulling loudly...but the more I do my national role, the more I am amazed at what is seen as acceptable. Why would you see something as acceptable, which you wouldn’t find the same if it, was your own family…or even yourself?

Empathy/Caring is a fundamental part of healthcare..but so is knowledge. There cannot be a system where any attempt to suggest the most appropriate person to deliver healthcare is seen as arrogance or protection of a profession. There cannot be any shame in saying "I can deliver X or Y better than anyone else- as I trained to a nationally set standard - on the taxpayers money". The world of health loses relevance when knowledge isn't a fundamental part of clinical care. In the midst of that, we somehow lose sight of that group of people who maybe, just maybe, may know more about the subject than us, if you haven't trained and feel like having a go, then at the minimal, listen to those who live with it.

Something needs to give. I can only speak for diabetes..and in the world of diabetes, the way to tackle variation does hinge on some basic facts and tenets of knowledge too, some standards of deliver, some standards of knowledge. If diabetes care was so easy, then we would have cracked the conundrum by now...getting everyone to have a crack at it doesn't work. Look at the results, look at the outcomes...we have much to do. Does training involve issues such as carbohydrates etc a any level regards Type 2 diabetes? Does it involve interpretation of blood glucose profiling for Type 1 diabetes? I am sorry to say..it doesn’t. Not as a standard that all must have.

So maybe the conversation needs to happen as to what a trained professional is, what the levels of knowledge should be, what a nurse should be doing or undergoing training to deliver care, what a Consultant or team delivering Type 1care should have in their repertoire...Tough? Maybe. But if you want to tackle variation, then it has to be linked with education, clear standards and maybe even part of that education delivered by those who live with it.

It's the 21st century. The plane analogy bores me nowadays when we can't even get basic standards in place. Let me make this clear….in that industry, a baggage handler is a critical part of the whole operation, a fundamental part of the whole travel experience. But whatever be the crisis or situation, under no circumstances would they be asked to fly a plane.


We have much to travel in diabetes care…technology is fantastic and we live in amazing times but so is the need for basic standards- at all levels. If we accept any else, then we compromise for the sake of money, ego, worry about hurting others feelings- but the only folks who suffer are the ones who we are supposed to be looking after. Take a moment….and think about that.