Friday, May 19, 2017

This and That

Purdah and all that: Elections are coming and not surprisingly, social media has been hotting up. Folks with their political beliefs -whatever their working background- have taken to Twitter etc to highlight their views giving rise to an interesting conundrum for many. Quizzical looks abound along with head scratching to understand rules of purdah....what it is- depends on who you ask and how they interpret it. It's been fascinating to observe the wranglings, the debates...and what constitutes a breach and what doesn't. As I understand it, stay away from announcing anything new - some seem to have interpreted it as not doing anything new...but there you go! As an observer, my top tip for those working in the NHS? By all means, express your views- that indeed is your democratic right, just be aware of GMC regulations too about bringing colleagues into disrepute. It's a fine line to tread- and while others may enjoy or even use your opinion to further their cause, don't forget, the career, the worry etc as to impact of your opinion? It's only yours. So just be cautious, look after yourselves and if not sure, look up the GMC guidelines for social media.

The tent: Over the last year, if not more, as part of various roles I have done, I have had the privilege to meet many GP colleagues dotted around the country..and some I have been blown away by their passion, dedication and indeed zeal to improve care. Labelled quickly as the rebels, they have, in my view, appeared to have been placed "outside the tent". As someone who has always flirted with the edges of officialdom, yet try to be "part of the ordinary people", it fascinates me to see them. I can tell you what the NHS needs...Mavericks...and a whole lot of them. We all need the Goose in our lives but you can never beat a Maverick. They bring that X factor, the ability to inspire, the ability to make others believe...and we need a whole lot of them. You know who you are, help us out. To the question, will you be allowed in the tent...I have only one thing to say...I am here doing my job, aren't I? And if you believe we have done some good things for diabetes care, then think of what you can do for primary care.

Nothing changes: In a month, the elections will be over. Once upon a time, I was a big believer in divides getting healed post an issue. The Trump elections, Brexit has taught me that perhaps it's too big an ask. Our beliefs will be what they are, and will stay-whoever comes to power. The trillion dollar question is whether we, as HCPs, post the election can join forces to make some much needed changes. Perhaps it's wishful thinking but to me, in my life, in my role, I have one task: Improve diabetes care. 
Would that change if my preferred colour wasn't in government? Not in the slightest. Blue, Red, Yellow, Green...even Purple- it doesn't matter to me. My political beliefs may not match but that doesn't change my role- to advocate for patients with diabetes. Can we do that post GE2017? I don't know but I would welcome that- albeit in my siloed world of diabetes. I must also add that in my year in a bit, I haven't met anyone, who irrespective of their grade of "militancy" hasn't extended a hand of help, when asked. I would be much grateful if we could try to keep this going post the elections.


The last week - I have travelled a far bit, met Commissioners, network leads, Consultant colleagues,GPs, health psychologists, Practice nurses, Specialist nurses...and to everyone I have continued to say..you are doing a good job under the circumstances but let's see what we can try to get better. The next 3 weeks will be tough, and post that, one side will have to sit in opposition. 

For some in the NHS, it will be tough but post the dust settling, let's try and get back to what we genuinely love doing. Ladies and gentlemen, life's too short- and its not everyone who is given the opportunity to make a difference to someone else's lives. 

Saturday, May 6, 2017

Wards and being Special

7 days on the trot. On the wards- seeing any patients that were on the ward. One of those things called "unselected" medicine. A great bunch of junior doctors helped- and it was fun, enjoyable- and most importantly, educational for me too. The 7 days spanned a weekend and a bank holiday apart from normal working days- and thought it gave a perfect opportunity to put down some personal observations.

No change: Overall, nothing much has changed as regards attitude of junior doctors- it was the same level of enthusiasm, eagerness to learn and a desire to improve care as when I was one. I grow tired of the "in my days" nonsense. We don't draw comparisons between Chuck Berry and David Bowie- different eras, different styles, the sheer genius is indisputable- lets leave it at that. They are still the same eager folks- appreciative of good support from their seniors

Process: This has changed a lot- it had a feel of being more automated. Somewhere doctors seem to have lost their flair for independent thinking- it was more process driven, more protocol-based….board rounds at X, ward rounds at Y, standing on 1 leg at Z. Does it take the joy out of doing medicine- is it more about the workforce being the "same"? I don't know- but it certainly jarred. Maybe its just me- but if i was a junior doctor nowadays, I would question the point of doing some of the banal things they are asked to do. Where's the learning when you are seen by many as just someone to do discharge summaries?

Weekends and Bank Holiday: Lets get this factoid nailed. Without changing ways of working of support staff to deliver Sunday just like a Tuesday, tinkering with doctors work for weekend work is a bit silly. You can dance around that one as much as you want but the only constant I saw compared to a Tuesday were the nurses and the doctors- everyone else was a bit variable at best. Its not a uniform thing across the NHS. If YOUR hospital is doing it- shamazing…but it aint a universal thing. Period. 

Campaigns: 2 new campaigns have hit the floor- as with many social media ones, for many on the ground who stay away from social media they came as a surprise. #Red2Green and #EndPJparalysis are the new ones. The first one makes me smile-as why a campaign to lessen the alert level of a hospital based on arbitrary criteria should make doctors (generally folks who believe in evidence base, NICE sort of thing) engage is beyond me- you may as well call it #Improve4hrperformance
Campaigns miss the point about the degree of cynicism doctors hold about such campaigns when they struggle to make one understand the clinical benefit of it….having said that, the #EndPjparalysis is one which has got legs- if its handled properly. 
The reasoning is sound, the clinical benefit seems good- but it must not slip into evangelism. Someone said that most of my patients would be on the golf course if they were not dressed in their PJs. Nope- if you know my style of doing ward work, they would be home wearing whatever they want- not be relaxing on an acute bed. The key is convince clinicians its a patient benefit initiative- not yet another hashtag designed to get people quicker to help a 4 hour target

Special: The "olden days" used to have general medicine clinics, general physicians..the ones who use to "specialise" in having the bigger picture, the ones who could join the dots, the ones who could come up with the clever diagnosis.
And then specialism happened..properly. We all became specialists..doing only a little niche, little else. The Cardiologists left general medicine, no longer were they dual accredited..they only looked at the heart. The dealt with heart failure but if it was due to a pulmonary embolism, it now had to be the Respiratory physicians issue. If by chance, the patient had a minor bleed secondary to the warfarin, they had to be seen by the Gastroenterologists, if, heaven forbid, their blood sugars were high, call the diabetologists....and if they had anything resembling silver hair, it would be a travesty if the elderly physicians weren't looking after them.So what the heck happened to us as physicians? I take my hats off to Medical Assessment Unit colleagues who still do and understand general medicine but are being reduced to triage doctors due to the incessant pressure of either discharging them or moving them to another speciality. But medicine isn't that easy...not everyone fits nicely into a category, a pre defined speciality, do they? 

So there you are- a 7 day trip of medicine- away from the specialty work. Its also a fact that perhaps I enjoy it as its not incessant- and comes at a frequency which is easy to manage- and keeps my interest levels high on both quarters. Perhaps also why everyone doing their bit would mean a lot- not create artificial categories of X being a specialty more special than Y. 
Maybe Chuck Palahniuk, author of novel Fight Club had the right idea..."We are not special. We are not crap or trash, either. We just are. We just are, and what happens just happens". 

Perhaps thats what we need- the ability to stop taking ourselves too seriously :-)

Saturday, April 29, 2017

Brave enough?

How bold are we? How much do system leaders actually mean when they talk about having clinically led systems? It's like a moment in time when the sheer rhetoric of all that chit chat starts to grate so much that most folks lose interest. More to the point, how much do politicians or for that matter, even managers trust clinicians to deliver what's needed? The intriguing answer to that - after all my years of management at different levels? Absolutely no idea.

Clinically led organisations do better....so goes the saying...yet how many organisations are actually clinically led is a matter of dispute. But on the flip side, there is no better time than now to perhaps road test it...how much are managers actually ready to cease control or do they genuinely see themselves as part of a team with their job to deliver the clinical priorities as outlined by clinical teams? I am keen to test the theory so over the course of time will indeed share the experience. The problem is the more clinicians feel rebuffed when their plans or suggestions are rejected or ignored -the more you disengage them...so how do you square that circle? How do you get the prodigals to return? Even with my role in NHS England, I am bemused by how many non clinicians I sometimes have to spend time explaining why Type 1 diabetes needs focussing on. The evidence is there, the need is there...yet..somewhere the trust isn't in a clinician.

Let's take diabetes. Many separate pots of money...let's make it simple. How about we forget all the nonsense of widget based system for a long term condition, add in all the present expenses in acute and community providers whether it be outpatient based activity on a payment-by-result for an acute Trust OR block contract to as community provider)  and look at a 10 year contract to deliver for the region some basic priorities? Let's say you give that system 10 years to improve amputation rates, improve safety, improve education, improve pregnancy outcomes....well tested principles which has benefit for patients and economic return for investment.
Stop micromanaging, give the clinicians the onus and responsibility and the task to live within that budget. Doable? Give them the onus to improve those simple markers, not blue print every single detail as to how to do it.
Get it done, learn from others...your area, your money- deliver the outcomes - engage with primary care...prove your salt as a clinician- and make sure you have a fantastic manager and financial person to help you do it.
I can guarantee you that most clinicians would relish that challenge...that is the essence of why doctors went to medical school- to improve outcomes...not to lessen referrals on a spreadsheet. Stop going for surrogate markets, let's give a timeline, a budget and the markers. Everything focussed on those markers, networks helps to amalgamate good ideas...stop branching off and doing some vanity project...you focus only on a few key priorities.

Brave enough? And more importantly, do the system leaders trust enough? If you are a manager...go on...ask yourself...do you? Are you brave enough? Does this excite you? It works on guarantees, it works on many assumptions but it does energise the clinician to deliver.

You want to change care? You want to improve outcomes? Time to be bold, time to change funding structures, concentrate on outcomes that matter. We from NHS England can certainly outline the priorities and support in delivery....but no amount of power points, articles or lectures can deliver or excite clinicians enough till you have the faith in them to deliver. Bold enough? All of these structures...vanguards, STPs etc etc give you all the structures you need. If you want to cease the moment, then as system leaders, the time is now. I can assure you there are plenty of clinical leaders in diabetes who would pick up that gauntlet.


Is the system?

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?