Sunday, December 30, 2012

The year that was....

So a crazy year comes to an end...and it's always good fun to look back, isn't it? You have highs, you have lows...but that's what makes the ride interesting. After all, if you don't have lows, how exactly do you feel the exhilaration of a high?

Within the diabetes world, the Portsmouth diabetes team continued to build it's reputation winning awards for a new model of care delivery..the principle being quite simple...the vast majority of patients with type 2 diabetes to be managed in the community with support from the the specialists the time to concentrate on areas such as Type 1 diabetes etc and hopefully, overall, improve diabetes care. Picking up recognition was great fun, and what was heart-warming was the recognition the fabulous nurses got from it. As ever, the unsung heroes...their joy was one to savour...and when local Commissioners and CCGs also won awards on the back of could let loose a wry smile. One could blog about it with a lot of in the knowledge that the hardest part to achieve within the NHS was done...making change. The rest was up to us now, as professionals to deliver. No excuses, no external factors...this was now ours to deliver.But then again, when you work with the folks I work with, you have nothing but confidence that this can- and will be- done.

On a personal level, the high had to be the recognition offered by patients, and specifically one motivated girl who felt I had contributed to her volte face as regards her battle with diabetes. To be honest, I wasn't..I just happened to be there when she was ready for it...but nonetheless, a moment of immense pride..and for that, thank you very much Ninjabetic. I recall the girl of a few years back...and see someone completely different nowadays..the drive, the passion to improve the care of herself and that can only be commended and admired. And the good news?...I meet young people like her nowadays more regularly...folks ready to make a job? Be and support when asked for- backed by a fabulous team of nurses and dietitians.And no, I don't do anything extraordinary...just something that used to be a norm for people who have inspired me over the years.

Social media exploded for me...and even though I have never met the Anne, Hannah, the Sjolunds etc of the world..I learnt so much. Realisation sank in that there was so much to do..but also the fact that this wasn't a single handed fight...the was no lack of patients who were willing to help, nor of fellow professionals like  Elin, Dean, Andy who wanted to make a difference. Beyond the world of type 1 diabetes, Roy Lilley in his usual coruscating ways highlighted what we could do better, twitter debates raged about whether the NHS needed to be privatised or whether the state backed system was one to be feted. As ever, the reality sat somewhere in between the polarised the NHS moved into choppy waters..unsure of it's future.I wrote a regular blog challenging the "super-specialisation" of hospital care which I reckon doesn't take into account multiple morbidities, challenging what a Diabetes Consultant actually does, questioning the deluge of guidelines...oh it was fun!

The lows were there of the brightest light of the diabetes world, Dr Niru Goenka, went out..too much potential, he had so much to give...but alas, it wasn't to be. The outpouring of grief was a reflection of the regard in which he was held but perhaps the biggest tribute we could pay to him, is perhaps getting diabetes care which he was so passionate about. 
Some personal relations, regrettably soured..some perhaps due to my forthrightness, some perhaps unintentional, some perhaps due to a desire to create an aura of mystery...keep the "real" me away,some perhaps because (ironically) I tried to step outside the "normal" Consultant mode of being a bit aloof. Who knows..but either way, to those who felt hurt, it wasn't intended...and I hope to bring a calmer, a more professional approach to the table next year. You learn as you go along, don't you?

So 2013 is around the corner. Resolutions? For sure...and giving a lie to the common myth, I have yet to default on new year resolutions in the past..and don't intend to change that. Some of them are personal and may have alluded to above..but professionally, the focus now shifts to people with type 1 diabetes. At the beginning of 2012, I had promised that at the turn of the year, the new model of care for diabetes care will be in place and people will know about it. I also remember in 2010 someone "important" telling me that changing traditional diabetes care was like taking on mission impossible. 
Now I am no Ethan Hunt but 2 years later, I think that question has been answered. Now to type 1 diabetes....can we change things? Can we make it better? Can we change the perception that this isn't about being overweight, it isn't something that can be prevented? I think so...but want an idea of the level of challenge? Here you go...
The Department of Health have advertised for a series of national posts across al specialities ..Cardiology, Stroke etc..and one among them is "Diabetes....And obesity". Diabetes. And. Obesity. One and the same...correlated, hand in hand. Is it the DHs fault or is it the diabetes organisations (and I include specialist, primary care and patient organisations in it) for failing to separate Type 1 and Type 2?
Perhaps I am being pedantic...but it does give an idea of he scale of the problem..but hey...what's life without a challenge? having the last few weeks of the year has been's been a nice little break...and I feel rejuvenated....ready for a new challenge.

Robert Stevenson once said.."We must accept life for what it actually is - a challenge to our quality without which we should never know of what stuff we are made, or grow to our full stature". Time to test it out...2013 is here....let's get ready for another year full of fun and pleasant surprises. The sky, after all, is the limit, isn't it?

Sunday, December 23, 2012

Do you believe enough in it?

So here we are..Christmas is around the corner...the time for festivity, cheer and high spirits and for a few days, the politics rest, the battles are ceased and its time for the family. Spent the weekend introducing my daughter to Tolkein, my son to the story of Spiderman...and their wide eyed amazement made it all worthwhile. Spent time watching Rise of the Guardians and the proud parents loved the wonder shown by their son at seeing the Tooth Fairy, the Easter Bunny and Santa..all there together...forces of good...fighting the Boogie-man. 

In the background, the world goes on...the same challenges of emergency care continues, my type 1 patients still drop me texts and emails asking for help, the hospital managers still sends out that last weary email asking for "one more push" goes on for all concerned. And we try...we keep trying to help. So to turn away, albeit for a bit, from the incessant battle, negativity of the whole system....just to take a deep breath is always welcome.

For those who live with Type 1 diabetes...I don't have T1D, I don't know what it is to live with- and I don't pretend to...but have never stopped admiring the resilience of those who do day in, day out. So far I have started on a journey to see what can be done and am feeling my way around the brutal politics and learned helplessness of the NHS. But not to worry...the quintessential rebel always has loved a challenge. A famous quote goes like this..."Just because something bears the aspect of the inevitable, one should not go willingly with it".Keep the faith ladies and gentlemen...just at the beginning of an interesting journey.

To my friends and like minded individuals who work within the NHS, take time with your loved ones and be proud of what we all do...because at the heart of it all, we want to make people better, we want to make the system better. If for a few days, we can forget all the divide of acute trusts, community trusts, specialists, GPs, nurses....then perhaps it just shows we can do something good altogether. Naive? Maybe. Realistic? Of course!

To all of you out there...a festive wishes- may Santa listen to your heartfelt wishes. 

"Agar Kisi Cheez Ko Tum Dil Se Chaho...Toh Poori Kaaynat Use Tumse Milane Ki Koshish Mein Lag Jaati Hain"...a famous dialogue from a Bollywood movie...loosely translated meant..."If you want something from the bottom of your heart , the whole universe will conspire to get it for you"

I have placed my wish...and I know its gonna come true. What's yours...and more you believe enough in it? 

Merry Christmas to all. 

Saturday, December 15, 2012

Shoots of spring?

Maybe its the time of the year...maybe its the smell of Christmas in the air...maybe that's what is making things look a bit rose-tinted..but you got to live in hope, right?

As part of one of the roles I hold, was asked recently asked to look at a Consultant job plan...and a pleasant surprise indeed. Easily one of the best constructed job plans I have seen in recent times, it actually had the same person doing both acute Trust work, as well as work in the community! Yep, no split or coining of that term called "Community Diabetologist". If I have ever seen a title which has been at the heart of creating confusion amongst the diabetes community, it was the creation of that particular term or role. Isn't the hospital part of the community? Doesn't the hospital Consultant have any responsibility in the community? Why this divide?!
So, to see a  job plan which actually recognised the role of a Consultant across boundaries  across the boundaries called primary and secondary care. Heck, there was even time for virtual clinics...recognition of modern technology as tools to improve patient had to let loose a wry but satisfied smile. 

And that's not only it...back in July in Philadelphia, I had loudly wondered amongst similar minded colleagues why all the numerous organisations couldn't get together to create something that all Clinical Commissioners could use as a template to redesign diabetes care...why couldn't we have a think tank involving EVERYONE? So, in December, when a draft document with all the right ethos and issues incorporated lands in your email inbox, you know things are happening. By design or accident or simply due to pressure from data or patient organisations..or perhaps even a degree of a need to self-protect...organisations have joined forces to create something. It may not be the end all and be all...but to have a document which had ALL the organisations stamp on it...a very satisfying moment. 

Throw in some further recent phone conversations I have had with several CCGs...and there is no denying that there is a distinct thaw in relations between all parties...there seems to be the recognition that specialists need GPs as much as GPs need specialists...and at the end of the day, bring them to a table..cut past the politics...the grumpiness, the demeanour of being a "hard-ass"....once it dissolves down....yep, they all do want to make things better, in spite of being weighed down by the finances, the politics of the NHS, the ever changing paradigm....managers, doctors, nurses....they all want to do the right thing. Is that a bit too much of the rose tinted glasses...perhaps so...but somehow it just feels a bit different. Maybe the last few years since the drive to change diabetes care has exhausted everyone ability to simply "posture", maybe between all the uncertainties of the NHS changes, people may simply have seen it as an opportunity to give it a try. Who knows the reason...frankly who long as the right thing happens!

I am someone who has criticised organisations for sitting back while patient care has suffered..but at the same time, always happy to laud those who do shake off the past and try afresh. And to that end, ABCD, NHS Diabetes, PCDS and Diabetes UK...well done all for making the right call. These are interesting times...and lets make no bones about it, as cheery as one wants to be, tougher times are to come. 

But at least something is being tried, something different. Last week, was part of an interactive meeting where people from different sides of the "divide" had to spend time together and come up with a "model of care". It was stage-managed, and yes, there was lots of mirth...but people actually talked to each other...without any prejudice or seemed  at least even for those few hours...they least....trying.

Simply too much optimism? Too much of the Christmas spirit? Or genuinely something different? Time will tell...but for now..I am happy to accept them as the first "shoots of spring".I know the pessimists will always say that it could all be nothing but a false dawn and one swallow doesn't show a spring etc etc..but hey, they saying goes...always...and always springs eternal.

Thursday, December 6, 2012

The perfect storm...

Sunday. And on call physician of the day. When I was in my training days, that meant an occasional call, once in a blue moon by the on call registrar to discuss an ill patient, little else. Not it's an occasion which causes trepidation....because you know the phone will ring...and on cue, it did. It was the duty manager, someone I knew, someone I knew to be a "good egg" when with a hint of desperation she said the was a queue formed outside the Emergency department and she could do with some help, what's the doctor of the year to do, eh? This wasn't the time to debate what I could do by going in, this wasn't the time to discuss about the geopolitics of the NHS, to debate whether out of hours services were not unto scratch...sometimes it's more simpler to shrug your shoulder and drive in. So I did.

What struck me were the staff. In the midst of the media blitz which details in gory details the ward sister who had mentioned that they were "immune to patients suffering", I met a bunch of nurses in that department. For the 4 hours, I spent with them, you had to stand back and admire what they were doing day in, day out. Many years ago, as the medical registrar on call, used to go to that department quite regularly and they remembered. There were the odd jokes about how my dress sense hadn't improved, the banter about whether I had come off the golf course...but to the patients in the queue or in the department, they were simply put, fantastic. Would I have any hesitation in having one of my own, god forbid, come to this department and be seen by one of the nurses? Not in the slightest.
Sure there was the disgruntled doctor, angry and cynical at the multiple changes to the system, the feeling of not being listened to, the frustration ....but nope they didn't flinch from reviewing that patient which needed to be seen. It was battle stations...a far cry from the world of chronic disease, a world of long term conditions. This was quick, fast and the pressure to meet targets was suffocating...a continuous feeling of trying to keep your nose above water. I met the duty hospital manager, trying to make patients flow quicker...looked tired, but still smiled...wanted to help...everyone seemed to want to do the right thing...and everyone had their own pressures to deal with.

And the instinct for anyone under pressure, especially when you know you are going flat out is to look for something else. Not just where I am..but everywhere in the NHS. I speak to colleagues elsewhere and the pressure isn't unique to us...its all pervasive, everywhere.

At the front door, it was about "inappropriate patients" being sent in by those pesky dare they opt out of out of hours? Truths and half truths make up our lives..and when you want to look for start believing in anything. You have patients who don't need to come in...sent in by NHS Direct to come to the hospital. For headache. Some clever algorithm had flagged "possible cerebrovascular event...while 3 questions from a trained doctor reveal she was under a lot of stress at home and it was related to tension.  You also see patients who come to the department because they didn't know what to do...and then you also see lots of patients who came to the hospital..because they are simply put...sick. There is no Telehealth, no community service, no slick mobile technology which would have prevented the elderly lady with drowsiness from a severe urinary tract infection from coming in.

Then you have the belief that no patients are being the myth machine says it's because Consultants aren't doing their reviews. The reality is that with social care funding under continuous pressure, the capacity to send patients home gets squeezed by the day. How do I as a Consultant look at the elderly lady in the eye and tell her to simply go home when I know that she is better suited in a different housing environment and isn't safe where she is? Do I simply say I have treated you for your chest infection and my job is done? If so, then I have failed to do what I promise to do every's not the numbers that's the person in front of you. I try to do that in my young diabetes patients...why would the patient on the ward be any different? And I worry everyday now about the risks taken...will she be safe, was that discharge too quick?

Don't get me wrong..the are ways we can improve..we can get our communication with primary care better, we can have more resources in the community, we can stop specialists from cherry picking their patients and ignoring that patients have multiple morbidities blissfully ignoring the days spent training in general medicine, we can tackle patient expectation more robustly, we can educate people why one should attend an emergency department..I am afraid that will only achieve a fraction of what we are all trying to do. It's no ones fault...the problem is we have an ageing population with multiple morbidities and a shrinking social care budget. We all keep hearing how community care needs to be bolstered, but with finances as tight as it has ever been, that can only happen at the expense of the acute trust.Factor in the perverse incentives of payment by results etc...and the need to have the locality hospital afloat to do even basic elective work and have an emergency department can't take the money out either. Throw in that all the increased admissions and reduced discharges encroaches on a trusts ability to deliver elective work, their lifeblood...and the vicious cycle crystallises into the incessant pressure all of us feel ourselves in.It just feels like playing chess..when you have just been "checked" for one more time...and inevitably leading towards that final "checkmate".

I am a born optimist..always have been, always will be...but on Sunday, I looked at all those tired faces of the doctors, nurses, managers..all trying...but with the fortitude of the boy on the burning deck. As a chronic disease specialist, I wished I could help in some way and we are trying by moving into the community etc...but the reality is gnawing. In spite of all the stories, and the half truths about doctors and nurses not being professional enough, my personal view is that the NHS has survived so long simply due to the extra bit most folks put in, day out. That extra 5 or 10 percent, spread over so many professionals have carried the NHS for a long time.

What do we do when that drops down to even 100%... what do we actually do? The "storm" is no longer "coming"'s well and truly, fact, it is nearly....the perfect storm.