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 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, - 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. 

Monday, January 23, 2017

On the horizon...

Lets try something positive in this blog, shall we? Its a tough ask- and when you relate to the NHS, its doubly tough. If I criticise something within the NHS nowadays, I get "how could you do that as an NHS England bod?"- whilst lauded by some for being "transparent"…while the same folks turn on you for being positive- "how could you say its not all bad when the NHS is on the verge of utter obliteration?' In the cold light of day, Trump did actually win- simply by eliminating from our lives balance or a rational debate.

Anyway, let's try to write something positive- something related to the job I do with NHS England.
When I started off on this journey regards diabetes, I wrote about the top three priorities and to an extent, all of them are nicely on track. However you cut it, diabetes -for sure- has had an uplift of funding and at least in my experience, many seem to be talking from the same page. Whatever be the organisation, diabetes is up there- after spending years lying on the scrap heap. Whatever be the reason behind it, its certainly a priority and that is not a bad thing.

Around August, I gave a sort of update as to where things were at - and in the new Year, here's the next instalment! Read if you are interested in diabetes care-here's what the diabetes team at NHS England have been up to.

1. Transformation Funds: The forms for the bids (all 43 million£ of it) were finally released- and considering the extent of the work, money involved, short time spans etc etc…it has been an absolute joy and pleasure to see the number of bids from across the country. Final figures are to be confirmed but they are in excess of 200 and the work put in by all involved is simply fantastic. Much kudos to all for taking the time-and yes, much beyond working hours- to do all the work- whatever be the outcomes- this can only result in improving diabetes care across the country. A gauntlet was laid down- and for sure, the community has responded.

2. Diabetes care pathway/ model of care: This has been something CCGs have grappled for with ages- finally we are getting a pathway from NHS England- which should hopefully help CCGs/ Vanguards/STPs to get all parties to work towards it. Some clarity about different types of diabetes -especially while commissioning- will be welcome- as the nonsense of "all diabetes needs similar treatment" needs to stop if we are to improve care.

3. Digital Strategy: Plans are being formalised- and the scale of ambition is high- with a phased approach towards it. It is time for educational modules to be available online- and plans are on track- albeit admittedly it could all happen much quicker. One to keep an eye on- but a Type 1 portal with options of downloads, interactivity are all in the mix…the question is of feasibility rather than simply finance. If all goes to plan, it could be something quite exciting indeed.

4. Access to technology- continues to be high up the agenda. Ongoing conversations with Abbott re Libre, discussions with companies regards CGM/Pump access- all are happening…all I can say is that progress is there- yet its not all down to either CCGs or indeed the companies…a large part of it is education or even willingness on all quarters to adapt technology. What is the point of opening up technology to all…if the diabetes community doesn't wholeheartedly believe in it yet…or indeed have evidence of training in them? However, there is no doubting the desire on all to make it happen.

Other relevant bits have been exploring nurse education with the diabetes nurse organisation, TREND, discussing options with the Trainees via the YDEF, conversations with the BMA-GP group regards QoF- revisiting areas such as targets in frailty….many strands indeed- it's a question of which bits land- at the least. Conversations with ABPI on outcome based commissioning for pharmaceutical companies are yet another strand…it's been a busy few months indeed.

Around the corner, sits something exciting…the chance to visit all specialist centres, use data to discuss gaps, highlight good practice, have discussions with executive teams about diabetes care (remember the impossible tour? )…all in all, lots of ideas, thoughts…all to hopefully help in improving diabetes care. Will all the ideas work? Unlikely- but even if some do, that would be progress.

Its been a pleasure to work with some dedicated folks within the team…but has all of this been a doddle? Not in the slightest….want to know more about the obstacles, challenges and hiccups? Next week it is then…about "patient leaders", "structures", "interference" , "email/Twitter abuse" and much more. It's not been a picnic for sure- but progress regards diabetes care certainly seems to be in the right direction.

Time will tell whether all of this was worth the time. Or not. Till then, its all been a fabulous learning experience, if nothing else.

(With thanks to Jonathan, Matt and Jeff for tolerating me for the last 9 months or so! )

Thursday, January 19, 2017

Lost in a maze

Do you have days when you wonder whether you are lost? Days when you look at the latest email and wonder who the senders are? I do not know what is going on in the NHS but I do know there are so many organisations. bodies, people that I am utterly confused. And frustrated- as it seems they have now become barriers or yet another body- who needs to be involved- and whether unwittingly or otherwise, are now halting progress. They all seem to mean well- yet…

My recent experiences are not unique- every clinician I have asked say the same thing. Wrapped in a tinge of self importance, a title of some relevance, the many many layers of structure are simply annoying- and to the patient- they mean nothing. I am pretty sure this blog won't make me popular- but I frankly am at a stage of my career, where I am now in a "don't-care" mode. My job is not to make everyone happy, it isn't to win a popularity contest- it is to try and improve care for patients who responsibility sits with me.

Lets take Vanguards- in a politically toxic environment, where every single initiative and venture is seen with suspicion - we forgot what its role was supposed to be. At the core of it , it was pretty simple- to try and get people together. Do something basic- like work together. Vanguards were the structure established- come to think of it- what does it say about us that we aren't capable as adults to do that ourselves- that we need permission, we need a structure- to exhort us to think beyond our titles, beyond our affiliation. Many moons ago- a manager sternly pointed out to me that my allegiance rested with the acute Trust- as they employed me. My response that day- stands to this day- I am employed by the NHS- the Trust was simply a means to pay my salary- my responsibility sat with the system.
I always make jokes about the Super six model being the fore-bearer of Vanguards- we did one simple thing- we didn't wait for permission- we treated our primary care colleagues with respect- thats pretty much it- and oh yes, fought tooth and nail with every layer of management to get the plans approved. I do smile when I see the very people who blocked all attempts of this model now go around talking about it- or even "try to spread good practice"

Too many bodies, too many layers….trust your clinicians, whether you be part of a network, Vanguard, STP…think of it…all you are is a structure or an attempt to get people together- which in my book- can be done in a pub, in the drawing room of my house or even over a meal at the local curry house. Trust yourselves- and believe me, you don't need any permission from any structure or body. If you belong to a new fangled organisation, don't obstruct- think of whether you are now just yet another layer which is doing yet another meeting to discuss yet more plans.

CCG, Vanguards, STP, local providers, Strategic networks, Academic networks…what chance is there of any progress if all of them want to do more meetings? Stop talking, planning- go do something. Do anything- even go and fail- but just do something. Trying to fill in local transformation diabetes bids have been simply mind boggling- let along use of words such as mystifying- while trying to understand who the heck some people are- or their roles are. The irony has been stark when some of these folks have taken time to read documents written by me- back to me….stop this Monty Python circus- and let the clinicians do some work.

Final note- all these roles are on public tax payers money- at a time when we are crying out for staff at all quarters. Its time to see what the return of investment is on some of these quangos- and if there isn't, get rid of them. Because frankly, now some of them are now standing in the way of delivering patient care.

Saturday, January 14, 2017


I think its' s about time we did a collective sorry to our GP colleagues. I am tired, annoyed, angry and simply aghast at how many roads now end up at a GPs doorstep as the "reason".
I am a Consultant- and no one in my family is a GP- and I have no vested interest so lets be crystal clear- we really need to stand together as a community and more importantly, stand next to our GP colleagues. And to be honest, this is no political parties singular fault- we all are partly responsible for where we stand now. Those barbed comments about GPs, those ward chats about "GP, eh, as a specialty?", those "Huh, they deal wth coughs and colds"….at some point, it was inevitable it would cascade down to policymakers- and we have finally got there.

And I must admit, I have been in that brigade too- when does a joke stop being a joke? The last 6 years of my career has been eye-opening as regards learning what GPs do, recalibrating the understanding of the complexity they deal with- and if we as colleagues cant get past the thin layer of disdain we "specialists" do, then what chance politicians or others who don't deal with GPs day in, day out? I can actually sense the fight draining out of GPs, I hear good colleagues saying "I am done"…and this is not right. As a fellow clinician to another clinician, if it makes any difference to you, then as  Consultant, I will be categorical- there are many things we could all do better but the present NHS crisis is not down to GPs. And I am sorry it has come to this.

In 2010/2011, I ran the emergency stream in Portsmouth- and the target we achieved locally was 97.4%. Just 5 years ago. Since then we have poured resources into more and more staff, focussed relentlessly on emergency care- while the target has gone the other way- no lack of effort, no lack of process- while external after external folks have come around and tinkered with marginals- never stood up and tackled the one area which would make the biggest difference- social care funding. We have good managers, good clinicians- for whom the sole existence has become about sending someone home- or just knowing whether they can be outlied to some distant ward…we have to step back and think what exactly have we done to ourselves? This is NOT why I went to medical school- I don't want to know how many discharges I made in the 1st 2 hours of my ward round- I want to know whether the patient I discharged was safely done and didn't come back within 24-48 hours.

Process gurus may not agree with me- but frankly I don't care- because the only person in front of the family or indeed the GMC for a wrongful discharge will be me and my team- no one else. Whatever be the reason, whether it be families, structures, support, ageing population etc etc….this country needs more social care funding. Without that, this system is bust- to deny that is a bid to join the Trump administration to be perfectly honest

However possible, whether it be cross party agreement or whatever be the case, politicians of all colours, get your act together please.. the NHS boss, Simon Stevens- has come out and said so publicly- listen to what he is saying. And get social care funding sorted

In the meanwhile, to a GP colleague- wherever you are, a virtual hug, coffee or beer…for what its worth- thank you for all the work you do.