Saturday, January 26, 2013

The Super Six Diabetes model

Leicester. Gateshead. Bristol. Hackney. Harrogate.Barnet. Just among the areas who have asked about the local model of diabetes care..expressed an interest, wanting to know more about this, perhaps a consequence of it winning awards, perhaps a reflection of it being published in journals...whatever be the reason, its been a pleasant surprise to be contacted by CCG leads, fellow professionals enquiring about this, asking about the financial modelling and what has stood out has been the warm compliments and the realisation that all areas face the same basic challenge while trying to integrate do you define what needs to be sitting inside an acute Trust and what in the community? And for that in the community, how do you address the challenge of not asking simply the GP to take on more work, address the variability, challenge the naysayers etc?

Our journey possibly started with the first article written on this topic- where the concept of "let's define what needs to be in the hospital" was fleshed out. In simple terms, the question to be answered was this "Would the patient benefit from coming to the hospital?" OR as I always ask my trainees when they review patients "Can you do something HERE within the hospital that can't be done elsewhere?" Thereby, the "Super Six" was born. In short, either it was the expertise of the diabetes Consultant concerned eg: insulin pumps etc or the multidisciplinary nature of the clinic whereby the presence of multiple professionals together was easier and financially more viable to achieve within the hospital eg: antenatal diabetes care. I am not going to spend time discussing the multiple negotiations, discussions that had to be put in place- not only with Commissioners from PCTs at that stage, newly emerging GP leads for CCGs- but also with the acute Trust- along with the Community Providers. Suffice to say it took some time, lots of coffee, explaination etc but as a testimony to what can be done when you have people willing to listen and the basic intention to change...the model was put in place. 
At this stage, let me do some myth busting. To those who say that doctors are the only ones who understand patient care, that's not my own experience. I have met plenty of doctors who refuse to see the bigger picture and are more concerned about what will happen to their job plans, think of their own convenience (leave the hospital grounds!! Blasphemy I say!!!) rather than the basic question.." Would the patient benefit from coming to you in your hospital clinic?" Some of the biggest players concerned in making this model work have indeed been managers (thank you Melissa, Lesley and Gethin!) as well as GP colleagues (Tim, Jim, Koyih and Barbara- do take a bow), nurses (Jane, Debbie...ever grateful) and Trust Executives- and for that I will always be grateful. Beyond all, as always said, am just darned lucky to have 3 awesome colleagues - who although senior, have put nothing but utmost faith in the new kid on the block. D'Artagnan had arrived.

What about the community? Well, little point in doing clinics out there...that has been tried and all that has been achieved is shifting of clinic rooms from the confines of a Trust to somewhere else. How do you tackle the issue of education and support for primary care? So we changed it. Lots of meetings and opinion seeking from patients,GP colleagues and practice nurses want a designated hotline at the end of day? Got it. You want an email address with guaranteed 24 hour response time? Done. You want visits to surgeries to discuss patients, go through audits, have a general chat, build relations with each GP surgery in region? Done. Want to know how its been all going? Pulse and Primary Care & Diabetes journals kindly accepted our on!
Did we do anything amazing? No- in fact all these plans have been there before. They just haven't been implemented either due to the intransigence of a few or a failure to convince of its worth. Perhaps a case of being in the right place at the right time...either way, we are where we are. A happy position- without threat from within the Trust or from CCGs. Time then to deliver.

In short, we,as a community, are working to get this right. I am tired and fed up about the word "impossible". We live in Portsmouth- and wouldn't say we have solved everything- but improved relationships and working together we most definitely are doing. I also hear the issue of multiple providers and how it can fragment care- and no doubt there are multiple examples of this. But you know what? In our region, we have 3 providers in the main- Portsmouth Hospitals NHS Trust, Southern Health Foundation Trust and Solent NHS Trust. As far as diabetes goes however in the South East Hampshire and Portsmouth CCG, there is one model of care- which all 3 organisations have signed up to and work together to deliver. Utopia? Unbelievable? Come down and see us- any time you choose.

More things to come- some just started such as the "Hypo Hotline" for paramedics, some in the pipeline such as a structured Diabetes education programme for all professionals in region...and beyond the patients, its based on 1 thing and 1 thing only. Respect for each other. I can't do what a specialist nurse can do, can't do what a manager can do or a GP can do and am open and honest about it. And when I say I respect and understand what GPs are going through, that's not me being condescending. I work with them. They are my friends who I go out for drinks with. And I know and respect that. And all my trainees are very well aware of my response when any one publicly or privately denigrates a fellow colleague. Spend time with them- and then make your judgement. In return, I suspect the diabetes specialist community wants the same. Respect. For the CCG leads who now have to decide about diabetes care, perhaps spend some time with your local diabetes specialists and see first hand their challenge too. 

So my tips after setting this all up with support of friends, colleagues etc, my tuppence to all involved in diabetes care? 3 simple words. Respect. Engage. Change. 

And oh yeah, leave the word "impossible" out. You know whose dictionaries they belong to.
Now go break a leg.

Friday, January 18, 2013

The pace of change...

7th March 2012...still remember that day pretty well. The evening before had had a relatively busy night, meeting up with friends and colleagues in Glasgow at the Annual conference of Diabetes a late start was warranted..till I got rudely interrupted by my phone. It was someone important from our local health economy and the "hello" sounded tense, a bit gruff. Cagily I asked the reason- and it seemed a story had broken in the press about amputation rates and Portsmouth had taken a beating. We were the second worst or thereabouts....this was bad, this didn't make the local health economy look good...and then the bombshell, I had to go on TV to do a press briefing. Tried all sorts of excuses to wriggle out of that one, but nope, it had to be me. And so it was done- hastily borrowing a shirt from a colleague, asking the cameraman not to include the jeans in the frame, it was done...Admittedly a bit wrong footed as the year before had been spent on trying to solve the diabetes conundrum...where doe it sit..primary care or secondary care? Contracts had been signed..the Super Six model was just off the ground...and then this hit. Since then, much water has flowed under the bridge...public meetings to raise profile, to discuss issues at hand, the usual cynicism, the usual culture of shifting never was anyone's fault....and finally it triangulated to 2 key areas. The lack of enough multidisciplinary clinics to look after patients with ulcers and the timely referral of foot problems to podiatrists. 

And for me the whole journey till this point has been an educational trip. Diabetes UK were a big ally- doing road shows  chasing Commissioners, chasing the Trust, highlighting the poor care..NHS Diabetes helped...everybody pitched in. Locally the Commissioners engaged in negotiations, different Trusts housing different professions ergo podiatrists under one Trust and Consultants under another managed to come up with a in with the newly founded Community provider..all of this happened. Vascular and Orthopaedics pitched in. Easy, wasn't it? Who said fragmented systems couldn't come together, data sets "meant nothing" was all so simple, wasn't it?

The problem is all of the above on paper sounds very simple. Attend any course, any event organised by lets say the Kings Fund or NHS Institute..and they make it sound quite easy to achieve. The other day I watched an episode of "The Thick of It" and by god, it reminded me of an event I had attended in the not too distant past. That was an attempt to get 3 Trusts to get together and "think differently"...facilitated by folks who didn't have the foggiest idea as to what diabetes care meant, the challenges it threw up for a primary care physician, the frustrations of a specialist or the befuddlement of the patient with the multiple providers. 3 events later, none the wiser, I asked the other attendees what they thought they had learnt. The consensus? Diddly squat.

Sorry I digress...but for us as a locality, we have finally managed to get the multidisciplinary clinics going, as of last week and agreement to roll out an educational portfolio for practice nurses et al led by podiatrists, hopefully within a very short time. The question I have is that why does it take 9 months to do that? A senior colleague with whom I shared my frustration suggested that in NHS timelines, this was like moving in supersonic pace...but thats not good enough for me. Just because things are not right, we accept that? I would like to challenge that notion to the hilt...and my observations of this whole process has been twofold. Firstly, there is no shortage of people who want to do the right name it, managers, podiatrists, commissioners, contracts team, doctors,,everyone wanted to help. Secondly, there are just too many cooks in the whole process.  We are very quick to criticise and go into ultra panic mode when the dreaded word "privatisation" is mentioned but how much time do we spend on streamlining  the system we have at present? Too many chiefs, too few Indians does come to mind..but the last time I used that adage, people looked at me strangely...before the penny dropped. They thought I was genuinely touting for more "folks like me" (Indians, geddit?) to be involved. Duh.

Anyhow, but each bit has its silver linings and some folks irrespective of their employing organisation have simply been amazing,,so a big thank you to Melissa Way, Jim Hogan, Daryl Meeking, Sharon Tuck, Mike Quinn, among a few to make it happen...the irony is that one of them said,"just doing my job". And thereby lies the catch. Today, in the NHS when someone just "does their job", it is seen as being "dedicated", "outside the box"...while it should be the norm. Every little bit adds up...for every such thing whether it be something as "simple" as taking 9 months to get extra clinics going to the catastrophe of "Mid Staffs", we just provide fodder to those who would like to change the NHS one more time. When we as staff within the NHS do this, knowingly or unknowingly, it makes us look, simply put, foolish to say "Why mend something which isn't broken?" I would like to challenge all the powers that be to effect changes needed for patient care swiftly once recommendations are made, not sit and mull it, discuss it in multiple committees or worry about all the possible pitfalls.As Lincoln said.."Things may come to those who wait, but only the things left by those  who hustle".

So we begin a journey to try and amend the poor amputation dataset. This is going to take time, energy and patience..but I have full faith in the individuals around that they will do it. We now have to wait and see. Fingers crossed, we can.

Saturday, January 12, 2013

A new challenge

Questions. Raised eyebrows. Incredulity. Condescension. Sympathy...pretty much have had the whole gamut over the last few days. Have had an offer sitting with me for some time..would I step into the hubbub of unscheduled care? The chaos, organised or otherwise, that is a patients journey from their attendance to an Emergency department till they are discharged from hospital. 
And I mulled over it. The person who has based his life on instantaneous calls, based on gut reactions...sat down and mulled. Maybe its because I am close to my 40th birthday. Maybe a bit more maturity has set in. Maybe the "resolutions for 2013" list still hasn't got covered by other paperwork in my office. And point number 5 stared back at me.."No more new roles". Factor in the time I now want to spend with my family...the odds were not quite adding up. So I kept on deflecting the requests from personnel I trusted, I had done something along these lines back in 2009. 6 months of that..and it was soul destroying. Achieved a few things, but lots of frazzled relationships, burnt egos of senior colleagues...and I recall at the height of those times..turning around to see very few there to support...all those who promised to be"right behind me"..had chosen simply to be there..or slip away into the shadows. So why again...why indeed?

And then something flicked the switch. Patient confidentiality does not allow me to say why..but I saw something which put a lump in my throat. I am known for my hard negotiation skills, being a renegade, rough edged...but that day I saw something which made me flinch. And instantaneously my mind was made up. My experience of diabetes care has taught me something...stop criticising the system and others, if you are not willing to do something about it yourself. So I have taken the plunge. Thankfully this time, there is support and the line up of folks around to help is quite impressive indeed. Doctors, nurses, enviable collection of folks from different walks or specialities have pooled together...folks I know look beyond the narrowness of their speciality and are willing to help. So we try together and I walk back into it...maybe some things cannot be sorted out by one person, sometimes it needs a group. In my usual comic book analogy, if Iron Man could win all the battles on his own, why the heck would he need the Avengers? 

Don't know why..but this time around, it feels different. On the commissioning side, there are folks who I have grown to trust due to the work I have done with them as regards diabetes. On the provider side, ditto..there isn't anyone in that mix who isn't you have to look forward with hope. A temporary remit- but one which maybe worth its weight in gold as regards experience. Myths swirl in hospitals- and the more systems are under pressure, professionals blame each other. Doctors blame managers, managers blame nurses, medics blame surgeons, surgeons blame pharmacists...the list is endless. Been there, done that, got the T shirt with diabetes amputation rates. As a community of healthcare professionals inclusive of doctors, nurses and podiatrists we are in the process of rising above the question is can that same approach be brought to this one?

The one thing we perhaps need to change is the excuses. I am not willing to see any emails or have any conversation which has the following words in it.." Patient care is important BUT.." Sorry guys and, nurse, manager...after "patient care is important"...there is no "But". Yes there are resources issues but being kind to the patient in front of you, taking responsibility for them does not need a million excuses- as simple as that. 

So it role to ensure patients are getting what they need in a timely fashion on the wards, reviewed on time, transferred to the right ward, right speciality  being reviewed daily, having their treatment and investigations on time.. and when being discharged, having coherent instructions being sent to their primary care physician. Yes, its about improving the "flow" of patients...but its with patient care in mind- and while trying to deliver a good quality care, if "flow" does improve (which I genuinely believe it will) that can only be a good thing.

A difficult challenge? Well for this week, rather than mention any deep through provoking quote...its probably best to refer to a line Anthony Hopkins delivered with aplomb, albeit paraphrased..." Dr Kar, this isn't mission difficult, it's mission impossible. 'Difficult' should be a walk in the park for you". 

Let the fun...begin.

Sunday, January 6, 2013

Cynical Cacophony...

Social media is an interesting say the least. I spend time on twitter in the hope of learning and listening to patients and perhaps also to pick up pearls of wisdom from the great and the good. Examples of the former...numerous, a shining example of the latter? Sir Muir Grey..absolutely inspirational, someone who looks forward, eager to help us, the generation today, make the changes needed etc...but unfortunately they stand out as small oasis's in a sea of cynicism of anything new, mixed with excuses for any shortcomings of the healthcare system that have been highlighted.

Let's take some examples. Recently the DH launched the FFT or Friends and Family short, would YOU recommend the hospital, department or GP to your friend and family? Flaws? Of course...but as s starting point, why not indeed? I will give you a personal example..a few years ago, after a trip from Goa, I fell severely ill..and I had the most exemplary care ever possible from my GP. He didn't know my background but went out on a limb to help..simply..a patient. He reckoned I needed to be admitted, tried the local hospital and got...refused. I saw my GPs frustration...the medical registrars haughty tone to a senior colleague still rings in my I picked my phone up, phoned a colleague who was a Consultant in the hospital and he kindly arranged admission. diagnosis? Paratyphoid fever with liver dysfunction needing Intravenous antibiotics etc etc. Does my GP get my vote? Without a second thought. Would I want my family to be subject to the arrogance and ineptitude of the medical Registrar on call? No. I had to use my position to get admitted...why on earth is that right? Once admitted, again care was excellent...but that "refusal" jarred. So today when I see something like this, it sounds like a good thing...but oh no, the cynics are out in it's not scientifically validated, how it's a tick box exercise...maybe so..but at least it's a start isn't it? What exactly are we afraid of..someone actually saying.."No, the care provided wasn't good enough?"..are we that arrogant that we cannot possibly be wrong?

Lets look at the NHS Bill...issues not quite right with it? Plenty. The fear and bane of privatisation, the perhaps unnecessary complete overhaul...but for gods sake, don't patronise me by saying all was well before. We have the Mid Staffs sitting in front of our eyes...where care has been shown to be appalling. I always hear the cry of staff shortage and time issues...I have also, during my training period, seen staff plonk down a porridge bowl on front of a frail elderly patient...just out of her reach.. Requests to correct that has been met with a glare, a lecture about junior doctors and their "place" and even a caustic.."do it yourself". Kindness does not need excuses...there is no defence against what has happened...but hey go to social media and look at the reasons why it could happen. I am always told about the numerous examples of "kindness" and "good care" which overwhelms such blips...but the naive side of me thinks those 2 traits are why we chose to do this in the first place? So doing that should be the norm, isn't it? And those who don't should be held to account...or is that too simplistic a view?

Let's look at "leaders" of healthcare professionals.Their job, at least in my book, is to guide their membership to make patient care better. If however that time is spent in defending the members, then the distinction between them and their trade union blurs. I see leaders rise in indignation when any GP is challenged..evidently there is little to correct..all that is needed is more money.To quote my teenaged patients.."Whatever". 
Here's an example in my own speciality is pouring out that diabetes care could be better, we do worse than other countries...but I haven't seen any national diabetes body or leader come out and say "Sorry folks, we have failed you...our penchant to protect our own bastions ergo primary and specialists care has compromised care..and we will get it right this time around". Oh was someone else's fault..if not, it was the patients fault...those pesky type 1 patients deliberately not taking their insulin and not attending clinics ( how dare they?!) or the type 2 patients who just needed to "run more and eat less".... Who needs accountability when you have the twin towers of cynicism and excuses?

Thankfully on twitter there's a button called "Unfollow" you can stop listening to the constant cacophony...but what do you do in real life? My personal philosophy has been to simply...try. If each individual kept faith to their belief of kindness, then the sum total will and must add up. 

Naive? Maybe. But don't patronise me by saying I haven't seen enough. I have..and so far, the debate about public funded or privatisation is a moot one if the personnel involved can't find the time to get that porridge bowl closer to that patient. As the meerkat cheerfully says..."Simples".