Saturday, January 27, 2018

Murky




This week- no surprise- a blog to reflect upon the Bawa Garba case. This isn't one to discuss the intricacies of the case (its been already played out widely in the media -general or social) or the "closing of ranks" -as some have suggested- but a personal viewpoint from someone who has been in the NHS for 20 years now.

To begin with, my views as a parent. Whatever the rights & wrongs of this case, a father & mother lost their child- and nothing in the world can equate to that sorrow- unless one has faced that sort of tragic circumstances. My blood turns cold at the very thought of even the slightest harm to my children- and simply put, there is no words to comfort them enough for their grief. However much time maybe a healer, the scar will remain- as will the fact that errors contributed to a child passing away.
It also makes me wonder whether, we as a system, have contributed to the whole murky saga too. Past examples of patient harm- have never quite ended up anywhere much- beyond "We will learn- and move on". For the individual who has lost a loved one, its perhaps all vey good for someone else to say "we are looking to learn"- but the physicality of seeing an individual who you believe has caused the ending of life to your loved one, continue working…sucks. Its not unnatural to say "accountability needs to lie at the doorstep of someone- not the ethereal system" . I suspect those of us who- fortunately- haven't faced anything of that magnitude may not realise that sometimes in the cold light of day- the passion is likely to be ignited more when the harm is your "own".

Then comes the reaction of some professionals towards those who raise issues. I will give you the example of James Titcombe- some of the vitriol he takes is pretty..well…special. Comments such as "using his child death to make a point" angers me, annoys me- and belittles us many folds over. Cue? Entrenched camps where strong patient voices- driven by personal hurt- clash incessantly with many- strengthening the confirmation bias that professionals are just out to cover their own backs- losing out attempts at rational discussion. For many, there has been-frankly- no closure.

But none of these irk me- my views above are reflections of what I see- and part of me understands the angst. What irks me about this whole thing are a few other bits- and thats more about us, as the NHS, than anything else.

First- the factor of responsibility. However you want to couch it, this junior doctor was left high and dry by her Consultant. Period. The Consultant was aware of the pH and Lactate of the patient, wrote it in his notebook but decided not to review the patient as he expected her to "stress" the results.
I don't even know where to begin with this- but frankly? That irks me. I have always maintained that the Junior doctor strike/ contract issue was a reflection of something much bigger, a lack of support, many instances of seniors not standing by their juniors- and here we have the tip of the spear. Its little things you know, annual leaves, unjustified demands from management, making sure they are safe….and then the culture gets further worse- and there we have it.
Then there is the issue of corporate responsibility- how does any of this not reflect on the Trust and Execs/Managers at that time who allowed such conditions to appear- well, another bit which makes me shake my head. Basically, when it came down to it- and the system needed a "head", it was the junior doctor- someone who could be sacrificed as collateral damage.

Second- the issue of race & colour- that uncomfortable fact. Many many papers etc have been written about GMC convictions and how things are judged- and the perceived bias. Would this case have been looked at differently if the said person was locally trained & white? Its an uncomfortable question which the system needs to be keep asking- but my belief is Yes- it would have been.
Lets give you a simplistic example- a liver surgeon has a bit of lark, plays God- and brands his initials on a liver- gets a 12 month community order and a fine of 10K. Different case- but I can bet you if that surgeon was non-white, he would be doing a bit more than that. I say that from personal experience- the system struggles with anyone who doesn't fit the mould, the judgement of "success" or " failure" is different- however many powerpoint presentations or committees you create to make yourself feel a bit better.

Third- the long term implications. I have always debated here the issue about whether being a medic is a vocation or a job. If its the former, how far does that take you? How far would you cover- how far is that rubber band of safety? How far do you keep trying as "otherwise who will help the patients?" This ruling will challenge that more- and frankly? We are poorer for that. I may smile at their vocational drive- but privately I admire them- and appreciate them for that extra they do.
The impact on personal reflection has been well rehearsed already- and that irks me. A bugbear of mine is improving insulin safety in hospitals…this drives a spear through that endeavour…with a big part of this taking away reflective practice in a safe environment. It drives defensive medicine further up- the system is already creaking with the unnecessary tests we do- "just because" or "what if". This now changes that fact…lets be honest, you would rather organise a CT scan- rather than face the possibility of missing something which could compromise your career, yup?

A murky place indeed- much of our own doing- and some of it the GMC bid to appear muscular- when in the past, they and the NHS have been accused of being far too lenient to medical staff in the face of patient errors- its a crying shame that the pendulum swing has taken us to this place. It irks me especially when there is a such a strong commitment to improve safety for #diabetes patients within hospitals from our end.

If there is any silver lining to this cloud, it perhaps also bares some uncomfortable truths to us as a system- the role of seniors, the issue of race- and the culture of safety we love talking in aviation terms.
Ask any aviation expert, someone would certainly be accountable- its unlikely it would be the first officer flying the plane. The NHS just got a bit more murky.

Sunday, January 21, 2018

Variation



Ever come across the often repeated sentence…"level the variation in the NHS?" I mean, you would probably have to be under a rock to ignore it- and frankly, there rarely is a conference or a meeting where this is not debated, slides presented, lots of policies made- and the barriers are well known. Plenty of work is being done, will continue to be done- and the drive continues to bring more to the "mean"- or at the very least bring the outliers a bit closer to the data pack. When you take that concept to innovation, then we walk into further complicated territories. The NHS, by nature, is cautious (you can't blame them - our fingers continue to be burnt by the latest fad out there); factor in many other issues such as finance, money etc- and its a cocktail of epic proportions

So- beyond the powerpoint and the glossy documents and the proposed solutions, how does it all work- or for that matter, not work? Thought I would share some personal experiences- my blog writes are becoming less- apart from time constraints, evidently whatever I say nowadays could be construed as NHS England…albeit it comprises less than 10% of my working time…so one has to be "careful". I suppose there's always a silver lining- someday I could write a book- ah the experiences I have collected is simply..well…lets just say you could run a season of W1A on it.

Anyway, I digress. So- back to innovation and adoption. One of the things I focussed on was getting technology to Type 1 diabetes patients- a bit more accessible. The Freestyle Libre was a case in point for me- I don't have any special love for it. I haven't got paid by Abbott, I don't have any shares in it- but I know a truck load of folks who could benefit from it- but can't as they don't have the finances. Plus for me, it was setting the tone, sort of a road test of the bigger challenges ahead- not just in Type 1 diabetes- but overall diabetes care. Could the community work together? What challenges would come along the way?

So- the first thing about innovation is "Its too costly". Thanks to the work done by DH and negotiations with Abbott, the company dropped their price by approximately 30%- a drop of £110/month to £70/month. I thought that was pretty good nifty negotiations by all concerned.
On top of that, we did a significant amount of financial work on this with the DH to ensure it wouldn't bust anyones budget- IF used in appropriate patients.
Next came-"Where's the guidance?"- so promptly came a national guidance- done by a group of folks comprising of CCGs, Pharmacy leads, Specialists, NICE, GPs etc etc
This was followed by "But NICE haven't approved it"- correct (Doing RCTs in technology takes time- and the world of tech doesn't quite stand static)- so we put tramlines as to who should get this device (NOT all)- and the company agreed to a national audit- data for which would be made transparent- and further inform NICE.
Then came "But this isn't Continuous Glucose Monitoring- so it can't replace it" - out came the International consensus statement suggesting it actually was exactly that- just a different type.

After all that, came the actual battle. Having to go through individual CCGs- its a bit like trench warfare. And THIS is where the variation REALLY kicks into gear.

Lets give you some good examples…Greater Manchester, Cumbria, Derby, Brighton…all agreed with the national guidance and said "Let's start". Then you have - let's say Somerset CCG who have said yes- but one of the mandatory criteria to getting a glucose monitoring device is to make sure your BP and Cholesterol is below "target". What glucose monitoring has to do with the other targets being on point…well…I have been left scratching my head a bit to be honest. The national guidance doesn't say that but the local one puts those stipulations in.
Then you have  Worcester who have said "No"- before the national guidance was published- but their next review will be in 2020. Why? Well, I don't know to be honest. Closer to home? Pan Hampshire- it looks good so far- final decisions due on 14 Feb. However, next to it sits Dorset who have said "No"- their documents doesn't even bother referring to the national guidance. So basically, if Hampshire says Yes, then if you drive up the A338 and take the M27 for about 45 minutes, you may get this innovative device if you fit the criteria. Same NHS…how intriguing is that? Or if you are a person with Type 1 diabetes, how shallow does the N in the NHS look at this point?

Finally, we have London- an absolute lynchpin to the process. Why? Because a huge amount of expertise sits there- as does the notion of this being a hotbed of technology. Hopes have been high due to the fantastic work done to get all working together regards the Transformation Funds. I have publicly said- and will repeat the laudable effort put in to work as a group.
However, at last check, as regards Libre it appears that there is no date to a decision- London evidently is so big and complicated it needs an "Implementation Guideline" which will come up with recommendations of "How to Implement" by April 2018. Factor in specialists themselves not agreeing where this device would sit- debating about changing the national guidance- and its a fascinating exercise in its whole self. Some may ask why make all the details public- well- I get emails/texts/twitter messages regularly from desperate parents or carers asking where things are- why people in Wales are getting it- and not England- so lets be transparent about all of this.

Personally, I am amused. I rarely get frustrated- (after all- I have enough fun in life not to get frustrated by such oddities)- and I also do know that just like the other areas going "live", so will London and other areas "happen" too. Some are taking more time, looking at others, perhaps will need more nudging- and to those who ask, No, we in NHS England can't and to be honest, shouldn't mandate this. It HAS to be up to local professionals to find the way, learn from other areas- thats the whole point of localism, rather than command and control!
But as a fore-runner, it also gives a sense of challenges ahead to any technology implementation- or indeed any work in variation. As a national body, we have negotiated the price, helped set up a transparent national audit as well as provided national guidance. Its not always the "national" team who can sort it- its also down to local economies to learn from each other- and not set out rules which makes variation worse.

To patients out there, I appreciate and feel your frustration- but this blog is to highlight the challenges we face too. I applaud all those areas who have worked together to help get this device to patients- as well as charities such as Diabetes UK and JDRF who have been tireless in their efforts. All I can say is we are trying- and with time, many more will come on board.
To the diabetes community:My genuine appeal? If we can't crack this simple bit, then the next phase of CGMs is far more challenging in present financial times. Think beyond your own centre, your own unit…we may- just- be able to do something good together.

Key to Map below:

Blue: Approved
Orange: Not Approved
Grey: To Decide

Link: (Courtesy of Diabetes UK):

https://www.diabetes.org.uk/get_involved/campaigning/flash-glucose-monitoring





Friday, January 12, 2018

Lost?

You can sense the despair in the air...you can literally reach out and perhaps even touch it. Enough has been documented about the sheer incessant pressure within hospitals, the ramp up of the noise in the media, the chatter on social media...you can't escape it. And with it has come a sense of inevitability about the cycle- yet perhaps a bit more tighter each year. The tough times brings forward a discussion of "how do we solve this problem?" along with the sharp divides of opinions, the same rhetoric of what may or may not work, the health care professionals saying "its the worst ever" and some sticking to smart alec comments about what should be done.

I mean...is it the worst ever? Or do we healthcare professionals harm our own cause by saying so each year- and we get to the "crying wolf" phase- where we get ignored when it actually is the worst ever? I don't know- but facebook posts from former years can be educational...it appears most winters, we struggled. Personally, how bad is it? Let me just say after a long, long time, I was reminded of my days in Kolkata...the sheer volume, the look of desperation in the poor doctors or nurse face...the annoyance that they couldn't do better. Heck, I even discovered places in the hospital I didn't even know existed- or at the very least, never expected to visit as a Consultant Physician. Problem is caught in the sheer white heat of social media, the message does get the counter of "here we go again"- albeit unfairly. Or at least it certainly feels so. It feels different for sure- something has to give soon.

Then there is the inevitability of the debate of "What next?". Take your pick. Hypothecated tax? Immediately appears a raft of idea why its a daft idea/scourge of the world/an evil plan to destroy Bevan's legacy. How about a cross-party commission? Well, that isn't good either- not all parties like it- because lets be honest, why get rid of a political football that has served many so well for so many years? Ok- lets ramp it up- how about a Royal Commission? Pfft, they say- it takes too long- long grass issue. Well, that's really funny and makes me smile. About 2 years and a bit ago, was part of a group which asked for it. Response then? Oh-it would take 2 years- and the NHS "doesn't have 2 years!!" Looking back, it seems we have had a lot of chat, a lot of political commentators have opined, but what has happened as regards funding the NHS question? Fanny Adams. I don't know- maybe, just maybe..if we had done something 2 years ago, we may have had something to discuss, implement, debate etc. But nope, heck, some tin foiled hat people even said we were pushing privatisation. Well, blow me over. 2 years later, welcome to GroundHog Day.

Then we have the debate about structures and funding. The main opposition-for example-to an Accountable Care System seems to vary between- oh its American- that's all evil OR we possibly can't integrate services as it opens the whole service to privatisation. So are we objecting to the structure, the concept or do we want to ban private companies from bidding? Who knows- but integration / working together sounded like a good thing. I have an idea- lets give it a different name...how about National Health Service?

Then we have the "appeal for funding". An ask which each year gets even more....well...peak bonkers. We all know where extra money "should" go- social care, primary care, better prevention health, better community support....where however it does go to? Acute Trusts bottom lines, PFI bills, locum bills, anything to do with improving "flow" with a few hand downs to the other areas which would be more useful longer term....total net effect of using the money? A big zero. A plaster- till next year- when "its the worst ever ever ever...so can we have some money please?" To make it peak W1A season, the ask is led by NHS Providers- the same organisation which was one of the few bodies to support imposing a contract on junior doctors. I may have missed their apology for getting that wrong- but all the money in the world is no good if you don't have the staff. The junior doctors issue was far more about money, it was about morale- it was about the future- it was about a workforce we could ill afford to lose.  It was about standing by your workforce, not disrespecting them...it was much bigger than a pay dispute.Combine that with Brexit, the uncertain economy, an opposition which is level in the opinion polls with the ruling party...and we are a bit...lost,aren't we?

Normally, I always like to say something upbeat, something positive. I am not sure I do about this whole mess. The narrative seems to be lost between - we need more money/ Corbyn will save us/We are the best in the world/Stop Privatisation/ACS is the Devils spawn...all of this means very little when you are standing in the middle of a Medical Assessment Unit and thinking..."This can't be right"- or looking at your duty hospital manager and thinking ..."Dude, you need a hug".

So please- all you clever people- try and come up with a coherent plan- because I am not aware of one- and neither can I see anyway out of this rut- unless we try and get our heads together- and perhaps, just perhaps be open to suggestions beyond our firmly entrenched position.
I don't care what system it is- but I would like to provide a better service than what we are starting to at the moment.

Till the next year.