Saturday, June 17, 2017

Together- we can

So its landed. Money. Yup. New money. To improve diabetes care. No ifs and buts about it, no money moving around spreadsheets- simply new money- in excess of 40 million £. To be accurate, its exactly as below:
11.1 M to increase uptake of structured education
13.9 M to improve treatment targets
6.7 M to improve amputation rates
3.9 M to improve inpatient safety
A further 4 million for those areas whose bids weren't successful but needed improvement as datasets suggest needs while another 2 million to support improvement in areas with significant inequalities in diabetes outcomes
A total of 42 million £. For diabetes care.

Now? For the hard part. To those who say, money will solve everything, here you go. Time to deliver. I personally have never believed money is the end all and be all- BUT appreciably this may go a long distance. Let's see the outcomes and delivery. The aim is to monitor the outcomes and track results- so this isn't a money hand out to shore up services. Its to deliver clear outcomes- improve safety, improve amputation rates etc

Appreciably there will be some not happy, some feel more could be done, some who feel 42 million £ is very little- perhaps so- but look around you in the NHS and appreciate this money, if used well, could go a long way in present environment of financial crunch. Money will also be released in segments depending on outcomes, ability to recruit etc- so if you are an HCP in diabetes care, I wish you all the very best. The time is now, the time is to deliver.

In the background of this, sat a recent visit to San Diego- for there annual conference of the American Diabetes AssociationMuch learning and debate especially around the exciting prospects of classes of medications showing signs of cardiovascular outcomes, debate about their side effect profiles, while studies looking at impact of Metformin in Type 1 diabetes certainly caught the eye.


However 2 stand out events whetted the appetite if not simply to replicate what is happening in other countries. 
Firstly, went to an event - kindly invited to by an amazing patient advocate, Amy Tenderich and sat and took on board the concept of patient led innovation. Met Professor Eric Von Hippel from MIT whose research and work suggested the importance of giving patient led innovation space albeit in a non-profit environment. I was instantaneously told via Twitter we already had this- excuse my impertinence, but on the ground, in the NHS, at least from the diabetes point of view, I haven't seen any wide spread adaptation or even any national forum where patients have the opportunity to do so. Tech companies, absolutely yes; Clinicians, yes...patients or users? Not much I have seen. So you know what? Let's do something along those lines. 

A similarly fascinating session was one on language we use with patients. Indeed we have chatted much about it but in the world of diabetes the UK, I haven't seen a document or guidance present as to what are words to be avoided, and what's acceptable. To some, it will be PC nonsense- to me, it's not for me to judge when I don't have diabetes. If simple tips about better engagement results in better outcomes, it's worth it. It appears the Americans are due to pass a position statement on it, the Australians have done some amazing work on this- so we must follow suit. Without any hesitation, I have reached out to them and the response has been much heartening. We will do this in the UK- the question is who wants to join me in doing so.

So, new money, and a couple of new initiatives to drive patient engagement….in these hard times, it is appreciably, not easy to feel the world isn't collapsing around us. But we must try. We must believe. And we must keep doing the job we do. Use the money well, be prepared to have tough conversations about outcomes- and come help me do something more for patients. 

Together? We can. We absolutely can.

Friday, June 9, 2017

Limbo and Hope

How's that step into work feel for you today? Laced with a spring or laden with lead...or simply maybe a bit confused? It's tricky to try and interpret anything to do with politics today but we, as a nation, are now officially in limbo land. The country seems to have turned around and said we aren't giving you any winners....let's see whether you politicians can actually try and resolve it like adults- working together. As many know, I have always found Brexit odd especially in a world where isolationism is a relic of the past. Today, we are having a collective push from the nation which says...pause. And think please. You have to love democracy for that. There will be many permutations and combinations, many theories...but at the end, the politicians will have to show us the way. Show us the way to do something different - something a bit more measured.

The election campaigns have been frankly awful- whichever media you choose to see, whichever side of the debate you sit in and I suspect a vast majority of people, beyond the hard core folks have winced at the lies, half truths and blind belief in issues to suit the phenomenon of confirmation bias. And I am sure we will continue that again in the near future. But for now, it must be a time to pause and see what can be done together. All this talk of moral or Pyrrhic victory is only that...a bit like a hard fought draw. The bottom line is that democracy has said no extreme options as put forward by the main parties have been seen as acceptable enough to give them a majority- however one would like to paint that.
I like to look at things with a positive twist and this result is no different. Life never stops for anything but to wake up and contemplate the possibility of a second referendum on Europe, a softer Brexit and personally, a dismantling of the UKIP vote has been worth all the uncertainties of a hung parliament. 

What about the NHS? Perhaps not the best - as it could do with some sort of time for further planning. Could this be an opportunity to get the main parties to actually come up with something sensible together? Could we think of a different style of working? Or do we go to elections again for a clear winner? What happens if the public says "Sorry neither plans are good enough for us"?

The country as a whole has a big few issues in front of it- namely Brexit and from a personal point of view, of course, the NHS. I suspect the choice is ours whether we interpret the election results as one that's indecisive and needs repeating...or whether we take it as a mandate saying the electorate are fed up of the pettiness and would want our politicians to work together on such vital issues?

Who knows? For now, once the dust settles, limbo land is an odd place to be in. One way or another, we all need to know where we are heading and to me, it appears the voters have said to all our politicians..."Do it together" 
We all live in hope. In the interim, once purdah lifts, it's back to business on the diabetes front- and hopefully some good news to share....as I said, we all live in hope. We must.

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?