Saturday, February 25, 2017

Changing Landscape?

Have you tried doing any talks on "NHS structures'? It's an absolute nightmare. Apart from the gazillions of bodies, there is the other small matter of having to change your slides every few years. Or depending on your experience of the NHS, maybe simply using some of your old slides!
Either way, it is no picnic at all- with the added problem being that no one quite knows whether the latest iteration is indeed the "final piece of the puzzle" or indeed adding one more layer of complexity.

Lets take a step back- and just use Diabetes as an example- just to avoid the usual dingbat response such as "what do you know about dementia, huh". So, we have NHS England, then we have 4 regional teams, we also now have 44 STPs and 50 Vanguards. Lets then add into the pot 15 Academic Health networks, 12 strategic Clinical networks. Then let's now factor in 209 (or whatever they are now) CCGs, 150 odd acute providers, who knows how many community providers and many many GP surgeries. My apologies to all those who forgot. 
Trying to have a unified policy- to tackle variation? Well, thank the Lord that the 12 labours of Hercules didn't involve sorting out care within the NHS- thats all I would say!

My personal view- (before tweets appear that NHS England says so-its good to clarify these things!)- is that in all those organisations, there are many, many individuals who are trying to do, in the main, the right thing. There isn't some massive conspiracy afoot from folks involved in them- they are trying to do the best they can- with the financial boundaries set, the challenges put forward- while trying to balance the needs of the population. The money- is a political thing- and all these bodies can only do what they are given with- as simple as that. If you want to direct your fire at anyone, these bodies are probably the wrong focus- yes, sometimes, the crunch of finances make people do things they wouldn't do to their loved ones- but thats where the lack of joined up system fails us all- the lack of appropriate checks etc.

So here's some crystal ball gazing. I see the commissioner-provider split melting away- as that has probably created more angst and variation than a lot of other things. I have worked with some fabulous clinicians who have been good Commissioners such as William Tong or Jim Hogan- but in the main, after doing this on many levels, we should leave commissioning and its structures with those who understand the nuances and are trained in it. Managers. 
Clinicians are trained to provide- and in times of need, gaps and locum crunch, please do so first.
Lets give you an example, if a GP spends lots of his or her time trying to shape services around the region while their own surgery is struggling with patients or data suggests about 7 in 10 people don't get their basic diabetes checks…then suggest you get your own house in order or help your colleagues at the ranch first. 

I see providers- acute and community fusing into bigger ones- and  gives primary care the chance to deal with one organisation rather than multiple- with multiple IT systems, personnels, lanyard colours or even fax numbers. Can primary care do it as a pack? It seems to be edging that way- and I see commissioners starting to focus on a few things-as identified by the Right Care work - universally- rather than each area having their own priorities and increasing variation. Vanguards were the kick start to look at new models of care- and they are here to stay. Lets be honest- if we believe nothing needs to change as regards models of care, and all can continue as is, then thats blatantly wrong. Don' like the Portsmouth Super six model? Well, go build your own- but don't tell me the system is perfect as it is with diabetologists working in isolation in the community.

Final bit? About STPS- and haven't they had a bad press. The ire about their "plans" does raise a wry smile- and I wonder how many have actually read financial plans of their own Trusts over the years- the projected cuts etc to make the balance sheet correct. Don't forget in the end, many of these executives also breach these very plans- as they realise the importance of patients & their safety- and rather take the heat on finances rather than safety. Its a generalisation- I admit- but isn't that far from the truth either. 
STPs- have some good ideas in them- a principle of "please work together as one body". Yes, there are flaws but then which NHS plan doesn't? Its for us to engage, try and shape the landscape in my view. The issue of money is key- and much kudos to those who raise the issue and keep the pressure on- but that should not, stop the work thats also needed to try and see whether we can join the silos of the NHS we work in.

Interesting times ahead- and those are my predictions- the biggest one of them? Let managers do what they are best at; let clinicians do what they are best at. 
Work together- we may get somewhere. Just.


Sunday, February 19, 2017

Good Ole Days

Last week was a bit of a throwback. You know…the one we doctors love referring to. The Good Ole Days. Away from the hustle bustle of NHS England, the politics or even the clinics I do for diabetes and endocrinology, this was a week on the wards.
I had been asked as part of the changing landscapes to help on short stay unit- once upon a time, I thought it worked well when we had one team throughout the journey of the patient- but all the leaders and great minds have decided that more silos are better…so fair enough. Help I will provide- though how that helps…ah well… thats maybe for another day.
Anyway, so a week on the wards it was. And I really enjoyed myself- a lot. We had about 4- 5 "junior" doctors- of different grades- and it was simply a pleasure. Forgive me for saying blasphemous things- but I didn't feel burnt out, we had time for breaks - we also had time for teaching. You don't have to believe me- you can ask the juniors who were there- I am sure they would be happy to go through how the week went.

What was observable was a few things which probably suggested where some of the future lies. I am sorry, but holding roundtables or even hands will make ruddy no difference- especially with an organisation which has been pushing for imposition of the contract in the first place. Thats a bit like Trump imposing the Muslim ban- then deciding to have a discussion with Muslims to discuss how it could be enforced properly. I am not mincing my words on this- its a waste of time. It may help tick some boxes for some folks- but just like the last attempt by HSJ, this will gather dust in some corner soon. You want to do something of relevance- do it properly with open and transparent engagement- or else, don't bother. Bar a twitter storm, it makes no dent in anything per se.

It was interesting to hear from the juniors their views of the senior workforce. A toxic cocktail of work pressure, lack of support or indeed belief that this ship has sailed has now percolated into many seniors. The enthusiasm isn't there- not my words- and that percolates into the juniors. When a "whoever" asks you to do something, the first thing a senior has to ask "how does this help the patient?" We are scientists- our job is to ask why. We are leaders of the wards- our job is to look after our juniors, our job is to make sure they are protected from banality….do we do enough?
The culture of acceptance seems to have seeped though- do we need to revisit our noble aim of vocation and the professionalism of a job? Forget everyone else. Do WE find time to thank our juniors, do WE find time to smile enough? I don't think we do. I repeat- there is NO junior contract amendment which will help morale- till we play our parts too. We have much to do…how much do all the Execs actually believe in the pastoral role- how many Trust CEOS would support the time needed for Consultants to do that- how many MDs would….or would they rather have yet another roundtable to consider all this?

I do diabetes. I do endocrinology. I do general medicine too. If there is a part of me which would do things out of "vocation"- that would be to find time for the juniors. Why? Because when I was one, I will never forget the role folks like David Jenkins or Tony Zalin played in my life. That is what made me who I am- learning to smile, see the positive side of things. I am not a complete idiot- I can see the pressures the NHS is under- and the optimism takes a beating every day. I also know that without looking after our future workforce, this game is over. It doesn't matter even if Bill Gates did a multi billion donation to the NHS tomorrow- there is no amount of money which can account for a junior feeling looked after. In my opinion- and I know many will disagree- we, as seniors, have to stand up and challenge things being asked of our juniors- which doesnt help patients. Medicine was, is and never will be a tickbox- however much anyone tries. 

So..the Good Ole Days? A lot - still- sits in our hands. Why wait till its impossible to turn this around?


Sunday, February 12, 2017

Vocation or Job?

It's probably best to start this one with a caveat. This-as ever-is a personal view- and perhaps more of a reflection of my personality- rather than a critique of larger mankind- especially in the world of healthcare. But it's always been a source of intrigue for me-as to how doctors see themselves- and where they feel they fit in the paradigm of life.

Is being a doctor a vocation? A higher calling? Some form of vision appeared to drive me to be a doctor? No- I will be very blunt- I grew up in a family of doctors- in the heart of Kolkata-when the economic boom had yet to hit- and my choice was made for me pretty much by my parents. I can't think of a time when I didn't want to be a doctor or indeed thought of a life as something different. In the hub-bub of Kolkata, the job came with prestige, respect and was important for my parents. Plus I grew up seeing my parents do what they do- working 7 days a week- long hours- yet always finding time for me and my sister, holidays etc.
So for me, it was never a vocation- it was something which was -maybe- natural? Times have changed and I don't see either my son or daughter doing it as "natural"- they will do in life what they want to do- explore opportunities (once non-existent in my times) but there certainly is no expectation per se.

So to me- its a job- I trained for it- worked hard, had lots of fun along the way, did long hours- and today, I try to do it to the best of my ability. There are lots of things I will get wrong, as any human beings would- and have exactly the same foibles as a nurse, a teacher or a pilot. All trained individuals, doing their job to the best of their ability- and trying their hardest to minimise errors due to human factors. Nothing more, nothing less.

Thus, to me, a job comes with its limits as to what can or cannot be done. I do try to help out beyond my contracted hours or indeed get involved in areas beyond what my designated roles are- but thats my choice- and not done due to a feeling that I have to do this. Thereby if I am tired, the fault lies no where else but me- as I CHOSE to do beyond what my job is. It's not a vocation, it's a job- and the ethos of that percolates through the team I work with. I hope no patients can say we don't try harder as anyone else- but on the other hand, it makes for a team which sits and has lunch together, laughs at each others inane jokes, finds time for trips to Nice to watch football....its a job, not a vocation where I have signed my life away endlessly to the system.

Maybe thats where a rethink is needed. When you say its a vocation, we are special...is there much surprise when people then expect you to work more for nothing..its a vocation, right? You signed up to help others- no matter your personal consequences, right? Surely as an ethereal being, a bit more helping others isn't a big deal, right?

Maybe time to think whether to be treated as professionals, you need to see it as a job- not a vocation. Jobs come with rights, regulations, rules....vocations don't. And I appreciate thats maybe a difficult conversation for many- to actually think that we are not answering a higher calling. As I said at the beginning, its a personal perspective...and I certainly am not doing this just for love. I am a professional trying to do my job to the best of my ability- and its a job which I love doing everyday.

Does that make me a lesser being to some? Perhaps- but then again, I am happy doing what I do- and wake up each morning genuinely looking forward to enjoying the job I do.
And that, ladies and gentlemen, is good enough for me.

Sunday, February 5, 2017

Wry smiles

In my last blog, I touched upon the last 8-9 months- the projects which have taken fruition, the ideas which have taken shape while doing the NHS England role- and its been fun…really good fun- while being an amazing experience to chalk up. But a query has been from a few quarters via emails etc- "what about any obstacles?"

And it brings to the fore the question- how open can one be while doing the role that I do? Well…if leadership is about openness and honesty, its worth a try- bearing also in mind sensitivities and bigger picture too …whats the point in saying some facts which may be a bit too close for comfort…you end up losing the job- and the opportunity to benefit many others. 

So…here goes…

Organisations: This has always been one of bemusement for me. We always talk about the importance of working together, criticise acute or community trusts and GPs not "working together"- yet in the world of diabetes, theres a separate organisation for specialists, primary care, nurses…all of whose views have to be taken into account- and rightly too. 
Then amongst specialists, theres one for adults and one for paediatrics….excuse me while I have a wry smile. I suspect this is where my co-conspirator Jonathan comes in- pretty amazing at trying to get everyone together…but I must admit to looking at this all with a degree of amazement….all for patients, right? So why the silos - I can only dream of- I suppose - of a united healthcare professional body championing the cause of diabetes. Some battles, you learn with age, to let pass…and perhaps uniting them is beyond ones power…but for sake of patients, it would be nice..No?

Are patient organisations any different? Well…theres Diabetes UK, JDRF, INPUT, Diabetes.co.uk - and I see nothing but amazing, motivated, passionate folks trying to improve care. Togetherness would be nice…yes, I know, naive…but a wry smile is all I can offer- while one tries to negotiate the myriads of patient needs

Patients: No- don't worry- I am not that brave to say anything ill-advised about patients. They are who I do this job for…but I do have an appeal for expert patients., or patient leaders. Don't forget that there are many who you may not represent…there is no absolute as regards  needs of patients. Be respectful of pressures and multiple pulls on the NHSE team too- and we are trying to work in extremely tough circumstances. So, yes, do engage, do put your views forward- but with respect. I do this job because it's something I want to do…but the job specs never said abuse would come with it. So- do allow me a wry smile, when an expert patients view has to be the "only one". No, it isn't- there are many others whose views we miss..and it is the silent majority whose lives we need to improve too..

Condescension:I suspect this always evokes the best wry smile of them all. Maybe its my age, maybe its me…but you pick up a degree of condescension which is pretty fascinating. I get it from some specialists - (Heres a comment: "what exactly does he know about Type 1 care- he wasn't trained in London, you know" Another? "I suppose we have to accept someone like you is developing diabetes plans")- and the thinly veiled mask of disdain sometimes slips. I suppose the position I hold makes it necessary for some to hold that mask- but its bemusing nonetheless. 
Perhaps time will change that perspective and for now, one can only offer a gallic shrug. Sometimes its just like being a Registrar again but then again, if I never felt I had to prove myself as a trainee, why would I start now? 
Beyond colleagues, it has also been seen in some NHSE/NHS quarters- while steeped in irony has been the respect shown by folks such as Simon, Bruce, Jane, Samantha et al. But among some quarters…"do you know enough, do you know what to say" has been an interesting if not slightly painful experience. Best example till date? Someone reading a document to me- which I had written,,,but really, it couldn't possibly be me, could it? So young….
The pressure to conform - blissfully unaware that I was asked to join because of my maverick self, not the ability to conform.

System: And finally, the system itself. I am still trying to understand what roles of some organisations are - bar actually- at least, in my view, possibly slow down progress. People always ask "what's the hurry?"…well, I have no idea whats around the corner for me, so I want to get things moving NOW, not sit and wait. So the time is now- not later. we talk about variation, yet all CCGs have their own way of doing diabetes, own pathways of treatment- why? I don't know. But I certainly intend to find out. So when I see yet another email from someone with a title I have no idea what that means, a wry smile passes ones lips for sure. And to be honest, its now started prompting emails such as "Sorry, can you clarify your role?" Bar those who live or care for diabetes- or indeed those who have an understanding of the pathophysiology…aren't the others simply to facilitate rather than obstruct?

So there you are….some issues- put as politely as feasible. Maybe someday if I write a book, I may say more- free of the complications of the role one holds.
Its not been plain sailing at all- and if there is one thing I could change- it would be the ability to quicken things up. Will it happen? I intend to try- and I can absolutely assure you that I indeed have the "license" to do exactly that.  Lots of wry smiles over last 8-9 months- as I said, its been a fascinating experience.

Lets see what the future brings..would I recommend it to someone else? Absolutely 100%. All things considered, I would do it all over again- and the team that I work with makes it all worth while indeed.