Thursday, April 20, 2017

The Dubya Philosophy

Remember Dubya? 43rd President of the United States of America. George W Bush- man at the helm when the September 11 atrocities happened. A man who always divided opinion- and roundly mocked as well as admired for his macho lines of "Either you are with us- or you are against us".
To be fair to the man, this wasn't his creation- you can scour the textbooks of history and find plenty of examples...Mussolini, Lenin- heck, if you look into the Bible, even Jesus is attributed to have said..""Whoever is not with me is against me, and whoever does not gather with me scatters" (Matthew 12:30). My Bible knowledge is a bit rusty, its been some time since I was in school- so my apologies if I got that one wrong- but you get the idea..the principle isn't new.

So its actually shouldn't come as a big surprise when in our world, the same thing plays out again and again. I must admit to me now having to change my views on some things- especially that its possible for all simply to get together, have a mature respectful debate at all times. Its not. I think we probably have to best do with trying our own best- and accept there will be variations on what Dubya said- from different quarters.

I will give you a few personal examples. Lets start with the discussion about "Low carbs"- I will- someday write a blog about my own personal views on it and the evidence- but for now, I will limit it to the Dubya philosophy. I understand the passion- and also do admire the inherent belief that this is the answer to improving health. No issues with that- and as regards passion? Excellent too. I am happy to engage, debate and even ask relevant bodies to review the evidence. However, when that suddenly takes a quantam leap to direct abuse- you have to stop and think...is that right? Do I ignore or do I try to reason? How do you reason with a racist? Or do you accept thats a part of society- a darker part- which is just an inherent side of life? I suspect that cuts both ways- if the "lowcarb lobby" can go overboard with their passion, the flip side isn't to mock them, deride their understanding of science and call them quacks either. But then again, "with or without me" seems to be a part of our lives- so maybe all sides just need to take that into stride...maybe...I don't know.

Here's another one- I recently tweeted that the actual long term condition experts -beyond the patients- are GPs- and there isn't a need to create another specialty. A generally rational discussion ensued but in between there were some suggestions of me being blinkered, short sighted, assumptions I worked only in acute trust...all these from folks who have never met me, not heard me speak and be clear in public meetings that nurses are the backbone of diabetes care. However,nurses help in delivery of care- if you had to follow a clear line of expertise or uniform evidence of training- its the GPs. (I am not aware of a standardised programme for nurses to do before they deliver diabetes care at the moment- with huge variations as to how this is done- so here sits an opportunity perhaps)
Now that's a personal view- so of course it can be challenged...why that has to translate to me being labelled as being disrespectful to nurses...I will never know. That too from folks who probably don't know that my present Clinical Director is a nurse- and am very proud of it too. It's as if there are no middle ground- you either love X (substitute X with doctors, nurses, managers) or you hate them. Fascinating.

But then again, there's hope too. A recent discussion on CT scans and acute abdomens was actually good fun. Humorous yet with plenty of good debate from all corners- so who knows- maybe there is hope. As was a discussion on a recent trial in Insulin Pumps. However, to be honest, I think the realisation sits that passion, 140 characters and instant snap judgements will never allow a utopia of calm, tranquil, mature debates...so be it. I suspect my appeal is not to go personal...play the ball, not the person-as it takes away from areas of good debate and a lot of fun which human interactions bring. I also know from the experiences of Brexit and with GE2017 around the corner, its a naive, perhaps even foolish ask- but there you go. As for me, go personal- and I mute or block you- the loss-to be perfectly honest- isn't mine.

Debate is fun- sometimes you make a statement to provoke that and make people think. Thats what human interactions should be about- and the reach of Twitter, the flat hierarachy offers huge potential. A little less of the Dubya philosophy may serve us even better.
As the kids like to say.... #JustSaying

Thursday, April 13, 2017

The Berkenheim Project



Let's say you have diabetes. Or someone you care about or look after has diabetes. How do you know the person looking after you is trained in it? To be more accurate, if you are referred to a hospital team, how do you know they are any good? Assume? Accept that it's the only place around to go to? Challenge your GP? Go online to find out? And to think about it, is there any data or information out there at all?

So let me begin with an acknowledgement to a gentleman called Jens Berkenheim. A mountain of a man but with the most pleasant personality ever- with a grin forever etched on his face. I can't quite recall how we met but I haven't forgotten his sheer energy and desire to improve type 1 diabetes care. He simply wanted to know the questions I put above. And he tried...I could only support him in those days as a clinician from Portsmouth verbally and there has always been a lingering frustration that I couldn't do more. And frankly, Jens met many a closed door- who wants to share their data with a member of the public? Blasphemy.

Many an hour of mine I have spent listening to old wise heads muttering about the care in primary care in diabetes...perhaps the biggest irony sits in the fact that if you want, you can find out a whole lot about GP surgeries and their diabetes care. You can criticise them as much as you want, but at least the data is there...transparent. On the other hand, we specialists in diabetes have....hold your breath..ah yes..not much. Is that because it's presumed we are just good? Or are we not sure enough of our data to be transparent enough?

Now I know a lot of diabetes outcomes are all about "working together" and most issues are of the "system". If someone has an amputation, the pendulum swings from "GPs don't check feet" to "hospitals don't have clinics"....but you know what? There are actually a few things which hospitals are accountable for- solely. So why not measure it? Is it because it could become a beating stick or could it be a chance to improve variation, learn from other areas etc?
Let me also digress slightly at this stage and say that my other specialty endocrinology isn't free from this either. Here's a simple example- most hospitals see pituitary patients...do you have any idea of cure rates for acromegaly based on hospital? You could and you should but...you don't. Patient choice is such a beautifully crafted word indeed

Anyway, back to diabetes. Let's take inpatient diabetes care. Should a patient with diabetes know how safe or not their hospital is? Data is there...yet not public. Why not? If I had type 1 diabetes, I would like to know what are my chances of getting my insulin when I am ill and not well enough to self administer.About 1 in 25 patients with Type 1 diabetes go into DKA while in hospitals, you bet I would want to know how my local hospital is doing. And if that data is public, would it drive the hospital to ensure it is doing all it is can to reduce it- or even get to mean if it's an outlier?

Then there is the issue of pumps and technology. Again, if I had type 1 diabetes and wanted a pump, I would like to know whether my hospital provides it and if they do, whether there are trained people there. Wouldn't you? I wouldn't want anyone experimenting on me- neither would I want anyone who has done a weekend course in Kings or Bournemouth doing it as part of their 5 year training.....so why not make that transparent too?

2 simple examples...but you can see why the time is right for diabetes centres to be "benchmarked". Whether it be the simple issue of patient choice, transparency, reducing variation or even to get to par with our primary care colleagues, the need is there. The key however is to ensure its seen as a tool for improvement not as something to wave a stick at. It's part of modern medicine that we should be brave enough as diabetes specialists to back ourselves, our training and be open enough to acknowledge poor care and work to improve it.

So with a thank you to Jens, the question to my diabetes Consultant colleagues  is....are you ready for it?

Sunday, April 2, 2017

Astute or Risky?

Half glass full? Or half glass empty? It's sort of like a perennial question to anything that sits in front of us? Born optimist? Cynic? Or a pragmatist? I suspect a lot of this runs through our lives- with the pessimists viewing the optimists as skippy,happy people without any sense of realism while the optimists see the pessimists as harbingers of doom, mood-hoovers who simply obstruct progress. A pragmatist is rare to find...and certainly difficult in the white hot emotionally driven atmosphere when it comes to that ethereal religion, the NHS.

Which brings us to the latest report from Le Beard, Simon Stevens. Now you may or may not like Roy Lilley for his views but in one of his blogs, he absolutely nails it when he says that you need to make your own mind up about the report and not be guided by others prisms- whether it be of politics, deep seated dislike of anything from private sector or indeed the basic need to suck up to the head honcho of the NHS- due to a desire to get in his "good books".
So here's my personal take- and let me remind you once again of the word "personal". It's not policy, it's not a "you have to follow my view"...it's simply a personal view after reading the document.

It's probably one of the most astute document politically I have seen for a long time (and no, I don't need to get in his good books, I am ok on that front-thanks) In short, the NHS boss has said, with the money we have, we can't deliver everything. Something's got to give- and he has started a debate. Now you could turn around and say that's outrageous but it's probably an astute way to make a politician sit up. For long, I have wondered whether politics and NHS could be separated- the bottom line is in a tax funded system, that is simply not possible. We have to work with the politicians, we have to try and convince them of the need to invest public money- and in case you haven't noticed? Megaphone diplomacy doesn't work much. Let's be brutally honest- we don't have an opposition worth its salt - so I am glad someone - apart from the colleges etc are at least trying something different. If waiting times go up, if public satisfaction starts to waver, the politicians will think again-maybe...or so goes the theory.

You could turn around and say how could one use patients as pawns- there is that- but how many times have we said either we increase funding or we start having a debate as to what needs to be prioritised? We, as a clinical community, have baulked away from the prioritisation, so I for one, am glad that at least the debate will hopefully start in earnest.

Let's look at the other side- we have a clear prioritisation of emergency care, mental health, cancer- and I don't think there can be any arguments about that. Mental health has been ignored long enough for Cinderella herself to get a complex and it's about time, it was given the front loaded approach and priority it deserves. The message is clear- NHS England has a set sum of money and with that, there are some priority areas.
There is a clear message to continue support for Vanguards aka new models of care as is the desire to get systems working together whether it be in shape of an STP or Accountable Care system. For starters, that's good, as I am tired of folks demanding return on care models within 12 months. Let me be crystal clear- folks tout our local diabetes model as an example of "working together"- it took us 5 years to show benefit. 5 years, ladies and gentlemen...new systems take time especially when dealing with population based health...we need to get out of the premiership football club mentality of sacking the Chiefs if nothing is delivered in 12-18 months.

Finally? The 18 week target. Yes, it could potentially make folks wait longer. Yes, it could make private work go up- (just a pause too to reflect that in lots of cases, it will be NHS Consultants doing that private work, not someone from outer space) but could it also be the opportunity for specialist societies to step up to the mark? Will they be brave enough to prioritise procedures based on evidence base rather than some national whim or a charity backed public push? Do all procedures need to be done...many questions...but at least they are now open. Ask acute medicine colleagues around the country how many times they have heard that an "ology" colleague couldn't possibly help out -in spite of their general medicine accreditation- as they had an 18 week target to hit. Well, maybe time to assess which of those procedures are now a priority when your hospitals front door is creaking and some, nay, any help would go down a storm.

So, yes, risks indeed- and Stevens is putting himself central at it- while making it clear to the politicians that this will have quite possibly a public bearing too. With the money there is, we either provide an average service on everything or we prioritise and provide a brilliant service on some- while putting pressure on the purse bearers to fund the bits which are slipping. To me? It's a brave call with lots at stake- and for that, credit where deserved. It could be a defining moment for the NHS depending on the response it brings from politicians in next few funding cycles. In the end, the ones who cry foul maybe right- it may also open the door for co-payments- it indeed is a high stake call- but something has to give. It is not in the NHS executive teams gift to increase taxes- that sits with the government


And to be honest? If you don't like the path taken, try and see whether you can try and galvanise a political opposition to challenge. Because that's supposed to be their job, not the role of the Chief Executive of the NHS.

As the saying goes…"We live in interesting times".

Friday, March 31, 2017

Taking stock

31st March 2017.
That pretty much brings it up to 12 months of doing this national role. Title has a nice ring to it...Associate National Clinical Director of Diabetes, NHS England. Don't know what that title means to you...but it means a lot to my mum- and that's what it's about, isn't it? Always mummy's boy- so it always gives me huge joy when I see her face light up or indeed my dads obvious pride. I remember what they did for me...the sacrifices made...so that's all good

Beyond that, however, it's also a post funded by public money and the question in my mind with these roles are whether as leaders we justify them or not. I personally would like to. So 12 months is probably a nice point to take stock. To reflect and then weigh up whether to use public money or whether it's something that hasn't worked out and someone more capable (and there are plenty of them out there) needs to do this.

I suspect the question then becomes "hasn't worked out for whom?"  Personally, I have enjoyed it, I like the buzz and the experience of mingling and understanding the ethos of the movers and shakers of the NHS has been fascinating. At the end? They are all humans- with the same foibles as any, prone to errors as any but mostly, with an innate sense to improve care. So, personally, no issues and frankly, bar a few skirmishes here and there? Working within NHS England has been fun and enjoyable. Let's put it this way...no personal calls from Bruce Keogh or Simon Stevens for a "talking-to" and that whilst they being very aware of what I have been up to. Come to think of it, not even a "calm down" from NHS England communications Czar, Mr Enright either. Just knowing smiles.

What about the clinical community? Those who know me well will know others opinions have rarely fussed me when patient care is put to the test.Ask our local economy...for sake of better care of diabetes patients, I have rarely, if ever, shied away from a confrontation - whether they be a Chief Executive, Medical Director, Chief of Medicine,middle manager or a Cardiology colleague. As I always say, when as the spokesperson for those with diabetes within the system, I compromise...the only people who are compromised are the patients with diabetes,not me. That has been the fundamental as to how we created the Super Six model, expanded inpatient diabetes nurses or foot clinics.
Nationally I didn't expect it to be different but a pleasant surprise has been the support received from most quarters. Winning recognition in eyes of others is never a drive....even notoriety gives you that. For me, I am here to do a job- improve diabetes care...if I wanted to win a popularity contest, the X factor comes around every year.
(Don't forget..my comic book heroes are Batman and Wolverine, not Superman or Captain America)
I have recently asked the question "Should I continue" to a few of the most respected diabetes doyens I know- and the emails I have received back have been humbling- and indeed, for someone whose middle name could easily be "Brash"...it indeed has been poignant and worth reflecting on.

So I suspect it brings us to the most important group who matters. Lets distill this down..I get paid 4 hours per week to do this role, 4 hours of YOUR money, to improve diabetes care. Have I justified it so far? My remit was to help Jonathan, the present National Director, inject energy, belief while drive on some areas such as collaboration with multiple stake holders etc.
One may say 12 months isn't enough...in my opinion, it's enough to allow people to have an idea whether the work is on right track or not. And frankly? I would like to know too. There are many other avenues by which I can earn that money- so money isn't an issue...feedback however is. So...please...do let me know...and all constructive criticism very welcome. What's been good? What not? What could have been better?

So taking stock time it is. To all I have worked with so far, thank you. Who knows what exists around the corner....but from my own perspective? I wouldn't change a thing about the last 12 months. Whether I continue or not, the memories are something I will always cherish and will be etched in my life history as one of the most enjoyable 12 months I have had. It is my personal belief that there is a sense of belief in the diabetes community, sparkling with some dynamic patient and HCP
leaders....there appears to be a momentum to improve care- and if that in itself is true (and not a figment of my rich imagination), at least I would have left some contribution to diabetes care.



  

Friday, March 17, 2017

The number game

Numbers. Audits. Results....how do you interpret them? With views of evangelism? Rose tinted spectacles? Shades of Doom? How much does our confirmation bias affect us? These sort of things do swirl in my mind whenever I am sent an audit to review.
I suppose it depends...if you genuinely believe that all fault is due to politicians, then it's natural to look for the gaps and blame it on them...that's the confirmation bias in full swing. On the flip side, if you want to be positive and believe in the fact that the NHS is unparalleled and will not tolerate a bad word about it, then the good news shine through.

So it is with similar swirls of thoughts that I looked at the National Diabetes Inpatient audit. What does it say? I suspect your interpretation will sit on how you want to see it. But let's take a step back and just take a time out for a second.
To begin with, this is categorically the most stand out data set as regards inpatient diabetes care across any country. 205 hospital sites contributed to it...this is no subset...this is an audit and a half. Much kudos to the energy and drive of many but especially Gerry Rayman from Ipswich who has helped us get to know what actually does go in hospitals- beyond the anecdotes, personal opinions etc

Let's look at some facts to cheer you up - and especially if you have diabetes and have to be admitted to a hospital for any reason whatsoever. More folks with diabetes are being seen by a specialist team- and hypoglycaemic rates in hospitals are down by about 20%. Foot ulcers picked up whilst in hospitals are also down- so to all the diabetes inpatient teams, especially the nurses who form the backbone of these teams...do, please, take a bow. A Herculean effort in present times and the diabetes community owes you all a collective thank you for that.

Now for the flip side...about a quarter of hospitals still don't have a diabetes inpatient team, 2 out of 5 diabetes drug-charts have errors in them while 1 in 25 patients with type 1 diabetes go into DKA as an inpatient- a mostly iatrogenic error where someone has forgot to give a type 1 diabetes patient their insulin. Take a pause and think of that. No insulin given in a hospital to a type 1 diabetes patient. In 2017. In a 1st world country. 
If you are a health care professional, that makes you wince a bit, no? And oh, yes, places which have e-prescribing have lesser errors. And lest we forget, patients aren't happy with content or timing of their meals in hospitals- though generally satisfied with care received.

So what next? We have done audits for about 5 years- we have seen some improvements, some haven't shifted...time to get cracking on those I reckon. Money is available specifically to help fund specialist nurses in the hope that this will drive those errors lower but it isn't just that. Simple initiatives such as policies of self management ( unbelievably those who live with diabetes seem to know more about their insulin needs and times than a fair few professionals...would you believe that....), learning from centres which do well, e-prescribing can make a difference too. Benchmarking is on its way too- and for sure, inpatient hospital safety for diabetes patients will figure very high on the list. At Diabetes UK conference, I heard some amazing examples from Southampton, Leicester and Derby while the work in areas such as Kings are well known too

It's time to get the negative bits right and we, as a diabetes community, have the levers in place, I reckon, to make it happen. Money, benchmarking and learning from areas of excellence are indeed nice but what gives me a ton of hope is the zeal of clinical leaders - whether it be from the nursing community via TREND or folks like Mayank Patel, Omar Mustafa, Kath Higgins etc. 
Lets look at this again- 2 out of 5 drug-charts have errors in them and 1 in 25 type 1 patients go into DKA while in hospital. 
So...Heres a challenge. Lets keep it simple....in 3 years, let's make that 1 out of 5 errors and get that DKA number to 1 in 100 and in 5, we aim for zero. 

Impossible, you say? Perhaps. But as the saying goes, if you aim high enough..even falling just short? Not too shabby. In my book, it's certainly within our gift to give it a try.

Tuesday, March 7, 2017

Hope…(And an Update)

Update from Diabetes UK….

Arrived on Tuesday in Manchester- as mentioned with hope…and wasn't it such a fabulous experience!! Meeting the trainees to begin with, a catch up with old compadres…it was as ever, fun. The next generation-as ever- never fails to energise me- and I saw plenty to fill me with that that twinkly word…hope.
The next 3 days went in a blur- keeping to ones promise to make NHS England accessible had to take its toll. Back to back meetings, explaining whats coming, plenty of handshakes, talks, taking questions, interviews….exhausting yet satisfying indeed. In an atmosphere of darkness, where lack of funding or morale within the NHS has been all pervading, it was lovely to see what a bit of extra injection of funds- along with ensuring your next generation feels valued can do. The conference bristled with positivity- apart from anticipation as the results of the transformation funds await to be announced over the next few weeks.

A big step forward was perhaps finally agreeing the priorities in diabetes as per the Right Care pathway- and hopefully the importance and recognition of Type 1 diabetes as a priority area for improving care. Again- due out shortly- but it felt good to close all the multiple discussions after months of discussions with many organisations and parties. Factor in the soon to be announced type 1 digital / self management platform that is being planned- and it feels we are finally making progress indeed. Or at least trying.

Highlights? The positivity was certainly one- as was meeting all the patients who had attended the event. It was good to hear their feedback too- and encouragement to carry on the work we are doing at the NHSE Diabetes team. Evening fun with the "home away from home" (Portsmouth diabetes team-of course!) as ever were special- as was hearing some of the positive findings from the national diabetes inpatient audit. It was heartwarming to see the drop in severe hypos in hospitals- even without much change in staffing levels.
However, a personal stand out moment was hearing some warm words from Prof Steph Amiel. Last year, we had a blistering discussion- and she challenged me to step up. It was nice to hear what she said one year later…a very personal moment indeed. If Steph thinks I am on the right track- it buries any other negativity pretty quickly -at least to me.

Downsides? 1 in 25 patients go into DKA while in hospitals (as per the audit)- a sobering fact-and we must change that…factor that in- and then think of rates when people are outside hospital. Let that sink in a bit in 2017. That must- and will- change.

Finally,a personal social experiment. I am well known to be dressed casually at most events- for this event, on day 1, I had a 3 piece suit; day 2 was a suit and day 3 was T-shirt & jeans. It was fascinating to see and hear peoples reactions- both from those who know me- and those who don't. Is it about personality, quality- and how much bearing has what you wear and the impression you create? A fascinating personal exercise for me- one to be continued more I reckon. How much in the era of showbiz do we actually live in? 



To finish, much kudos to the organising committee and Chris Askew for hosting such a great event. I enjoyed it- I enjoyed the atmosphere and fed off the belief too. 
Hope to be back next year- with further good news- but I also have a request for all those who came. Take that positivity away- and believe in what you can do. We are here to support, to help and do what we can. It is also down to you to have the belief to convince your local colleagues and take diabetes care forward. 

If stuck, you know how to get hold of us…till then x
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A week in Manchester- and to be honest, have been looking forward to this for some time. It's the annual conference for Diabetes UK where many colleagues mingle, share ideas, have a collective moan...and this year potentially bristles with the air of possibility. 

You don't need to be e recluse to know that the NHS is struggling. Any media outlet worth their salt is covering it and quite rightly too. You have to work in a hospital to know how "tough days" as regards the emergency pathway have become more of a norm, rather than a rarity. A "Black" status which even a few years back used to mean something is now on the verge of being normalised. It's not an unknown fact- we are struggling. Full stop. 

In the midst of that, there have been some good news for diabetes care. NHS England are on the verge of declaring which areas have won the transformation bids- about 40 million £ worth. Factor in the roll out of the National Diabetes Prevention programme and a few digital tools to help in education and self manahgement (on its way) and there just maybe something there for the diabetes community. The zeal is there amongst many organisations to work together...tough times have brought previously fractured parties together - and from the NHS England diabetes team, a willing desire to make use of the money- but with realisation that more of the same won't deliver much. The landscape of delivery is changing...if it passed you by, do take note of the 1st Consultant Pharmacist in Diabetes...Mr Phil Newland-Jones (Take a bow, laddie!!) 

The money is welcome and hopefully will help to improve basics such as safety in hospitals but this also does involve working...differently.

In the background is work with ABPI as well as all the technology companies to improve access, outcome based commissioning as well as a realisation that more needs to be done for populace at high risk such as South East Asian population. Watch this space...the game is indeed afoot. We are keen to focus on areas of high impact- while making sure primary care is squarely involved in any discussion regards QoF or indeed any models of care. Let's be categorical about this...asking primary care to take on more without resource, support or training is not something that works- it's time to stop that.

So I travel to Manchester with hope, optimism albeit,as ever, mixed with caution. I look forward to meeting our generation next, colleagues, patients as well as enjoying the evenings with my family away from home- the Portsmouth Diabetes team. If you have a question, come and ask. Yes, I work for NHS England, but I also do a full time job, am educational supervisor to many trainees- so always happy to take any queries- as long as done with a degree of respect. I don't think there has been any organisation involved with diabetes care we haven't tried to engage with- if there is, apologies- but come and say hello. I am always enthused to meet colleagues who are energetic, keen to make a difference - we need more of you indeed!

Let's see what this week brings. I travel with hope