Saturday, May 25, 2013

Not me, guv.

Its actually now getting quite tedious. First it was all a bit of "fun", then it became the usual staple of black humour and now it just downright seems silly. We seem to be falling over each other to blame someone for the A&E crisis. GPs, risk averse junior doctors, social services..what have I forgot..ah yes, work shy specialists, throw in a few lazy nurses and of course throw in some of those naughty patients - and it's everybody's fault..except that I rarely hear anyone say.."actually, haven't got my own house in total can I blame someone after my house is tip-top?" Oh no, it's the standard line.."Not me, guv..its actually the fault of those.."...feel free to fill in the blank with whoever s name you want to.

I have now read reams of paper on what needs to happen..heck..even attended a few courses for the sake of it. Interestingly..everyone has the answer...on a power point or a flip chart. And I have been seeing the same "blocks", same "solutions"..since 2008. I am pretty sure they have been around since before that...but I continue to be bemused. Bemused at the fallacy that no one seems to actually be able to implement all the sagely advice.

So, you know what...a young Consultant who does significant amount of general medicine, works intrinsically with acute medicine, apart from his speciality has some tips to offer. Bear in mind, this is only for acute Trusts and their Commissioners- not for primary care or OOH. I am not a GP- so have absolutely nothing to offer as regards advice for GPs. So from the creator of the Super Six Diabetes model, here are some Super Six tips. Feel free to ignore- but is a collection of views from like minded Consultants...views shared in that high arena of cerebral debate- a pub.

1. Policy-makers:  Stop being risk averse. You will never get the perfect mix. Sometimes you have to take a leap of faith to make things happen. Cut down on the endless meetings and debates and start somewhere. You think you have heard about the perfect model from the Kings Fund / Nuffield / Faculty of Leadership...hurrah...put it in place. See what happens. Allegedly it can't get any worse.

2. Leaders: Stop lecturing others. If you are a specialist, don't lecture a GP how to run primary care.You don't do their job and possibly think the world revolves around your speciality  so give it a break. Vice versa too please by the way.

3. Leaders: Stop trying to please everyone. It doesn't work. This isn't the X factor, so there is no prize at stake by winning the popular vote. If you feel that every patient needs review everyday by a senior, either physically or at the very least a discussion with juniors and nurses, then implement it. If job plans say they should be doing it and are not, then haul to account. If not job planned  then see what will need to give or invest appropriately.Doing structured regular morning ward rounds isn't rocket maybe "boring for some", but structured job planning can put this in place.

4. Physicians: If you work in a DGH and are a physician, stop behaving like a super specialist. You are a general physician with skills in another particular speciality..well done you...and do please fulfil your specialist responsibility but AFTER you have done your generalist role for the hospital, working with your acute medical colleagues, if not for them. Don't ask the Diabetologist or Respiratory Physician or Elderly care physician to pick up your patient with cellulitis. You went to medical school, its not that complex. They are as busy as you with their outpatient work, so give it a rest. Honest. And oh yeah, also stop making ridiculously banal comments about GPs on ward rounds. You don't do their job- so chill out dude.

5. Commissioners: If you think something needs to happen, commission it boldly. A provider should deliver what is commissioned, so if you feel regular early reviews are essential, put it in the commissioning document. Heck, even CQUIN it for a laugh.If not done, hold provider to account.

6. Commissioners: You want to create integrated care as regards unscheduled care- how about going for 1 provider rather than Tom, Dick and Harry all trying to create a business margin off the poor patient? If people prefer to go to A&E, fair enough, equip it to deal with the higher pressure. Stop using phones, mobiles, telehealth or whatever else to try and create "another" avenue. I have tried it when my daughter was ill- it confused the bejeesus out of me.Hey, how about even considering using the acute Trust as the one provider organisation?

Will this work? Who knows..but you know what? If at least the acute trust delivers all of that, then at least you can't say the acute Trust isn't engaged. I have one simple mantra in life- you can point fingers at others when your own house is in order. In my training period, have seen immense variability as to how acute Trusts want to blame social care and GPs? Go ahead- but AFTER own house in tip top condition.

So do please go and try. We all now have established what the problem is and I am sure there are gazillions of powerpoint slides with solutions over it. How about trying to implement it? If then it doesn't work, then hey, maybe, just maybe, the catchphrase "Not me guv" will be taken seriously. Yes, we know the impact of social care and the rest of it...but when there are so many issues to tackle, it would make any analysis easier once one part of the system is delivering everything they ought to. Till then, otherwise, the finger pointing will continue.

Sunday, May 19, 2013

Great Expectations

There comes a point when it will have to be said. Duck it as much as you want, avoid the issue as much as you want, try and twist the media as much as you like, there will come a point when some one has to put their hand up and dash the great expectations of the public. The great expectation that as things stand the NHS will continue to provide everything and more; the great expectation that errors will cease, the expectation that communities will be equipped to keep people at home away from the cold corridors of emergency departments, the expectations that GPs can do more, junior doctors can work harder, specialists will do one point, someone will have to let the cat out of the bag. That there is no more money to give everything to everybody at the highest quality possible.
And it doesn't matter how many conferences you attend about "working together"; how many meetings you be a part of exhorting the "servant-leadership model", how many flyers you read about integration of health and social care. At the end of it all, any economist worth their salt will tell you this..unless there is more investment, it simply, is not do-able any more.

The latest drive within hospitals? 7 day service. Any dispute it needs to be done? None whatsover. Skeleton staff over weekends compared to weekdays have been known to harm patient care. So have no doubt that 7 day cover is a must. But we have forgotten one simple does one move to 7 day service when even the 5 day service isn't sometimes good enough? We want Consultant reviews over 7 days a week...but a great idea only when they do so 5 days a week. Many a places this doesn't happen- either because they are busy with their other scheduled work or are doing something not quite within their job plans. their respective managers know that to move to a 5 day service review, something will have to give, something will have to stop. We decide not to...ergo we can't do 5 day cover in a uniform basis...but we are having conferences on 7 day cover. We are looking at workforce implications...we are talking loudly as to how we are about to universally embrace 7 day working...but no one has any answer whether it will get blocked at the financial stage or does something else stop. A good example? I can do 7 day cover but that would mean me also taking time off to compensate for my week day work..which means cancelling my type 1 diabetes clinic. Something suffers, something gives.

All this while the expectations keep getting fuelled. Politicians of any colour or even commissioners need to be honest, need to be bold to engage with the public to say we have no more money left to pour in. Funding has flat lined ..and yet we keep talking about how we are going to make it happen. The thing with visionaries is that they rarely do the implementation- and the NHS is now in a bind. Nurses have kept on saying they are short on the wards..but its evidently all about working differently, cutting waste or some other speak which sounds clever but increasingly means little to departments and staff who have no other "waste" to cut or cannot work any more differently.

So please- some honest conversations please with the paying public. As a Consultant, I get paid to spend 46 hours per week at my work, my average runs at about 70. And I am not unique either. yes, there are the bad apples but the majority of staff whether they be GP or nurse or specialist are exactly doing that...working far and beyond what the pay package is...trying to bridge that gap, trying a bit harder to meet the great expectations.

A good jockey knows how far to push a one point, the whip ceases to work..and the race is lost. I am a born optimist and our department fizzles with pride, passion and the desire to make a difference. Not so unfortunately everywhere. Most places have folks over worked, over stretched, resorting to black humour to fend off the tide of media diatribe against the whole profession...and still we don't do much to calm the levels of expectations fuelled. Instead we jump from one bandwagon to another. I am passionate about making a difference to people's lives but let us, please, be realistic. In an era where cost cutting is such a huge drive, in a era where every department has to show examples where they have to meet a Cost Improvement programme target every year...please..lets be realistic, start to have honest conversations about what's achievable and what's not.

I will finish with the words of JFK.." The great enemy of the truth is very often not the lie, deliberate, contrived and dishonest but the myth, persistent, persuasive and unrealistic".

Sunday, May 12, 2013

Phase 2

Was just an idea, nothing more..floated by our departmental dietetic colleague, Sue Beaden while we had one of our Type 1 diabetes team meetings about "improving the service". And then it developed...the rest got involved, I did what I do best...the publicity, the showcasing...and as if in a blur, the day arrived. An event where patients could meet with all concerned, the specialist team, the community team, psychologist, podiatrist and in the new NHS the GP commissioner and his team. No lectures but a genuine chance to interact..listen..learn..develop.Sounds like fantasy? Sounds like something those umpteen conferences and leadership course exhort us to do but without any concrete examples? Well, it did actually happen. I am not going to spend time here saying what it was for patients with type 1 diabetes...simply because I don't have type 1 diabetes. If you want to hear their thoughts or even the thoughts of a parent of child with type 1 diabetes, read here and here.

My blog is about one from the professionals point of view. Firstly, as the team lead, you had to stand back and pay respect to the team who had given up a Saturday morning to be there. Voluntarily. Without any remuneration. Coasting, did you say? Some of the sound byte generators needed to be at St James Hospital on the 11th May. So at the risk of repeating myself, it is nothing but a privilege to be allowed to lead such a team. Is there a better job out there? Perhaps. Is there a better team out there? No chance.

Then came the event itself..the feedback received has been excellent...but from my own perspective, it was a pleasure to see Laura stand up and speak. Clearly a source of inspiration for many- an example of what can be done if one wants to. Our team's job as with Laura is the same for everyone with type 1 diabetes.."we are here when you are ready; we are here when you need us". As part of the speed dating exercise I hopped around 7 tables..8 minutes felt so little...but so much was learnt. the need for 24/7 cover prompted by errors in spite of all educational tools thrown at other areas of hospital, the need for supporting primary care better, the need for avoiding reduplication of results, the need for better information exchange with primary care, the need to explain to primary care that Type 1 and Type 2 are different pathologies...this wasn't our national "leaders" telling us, this was patients, for whom we do this job, telling us to make it a bit easier. In between them, there was some glowing feedback about the service, other members of the team..I already knew Iain Cranston was one of the most patient focussed doctors I have ever met..hearing that from one of his patients made it even more concrete. In one word, simply put...humbled.

The event itself could not have been better timed either as events reflected in my last blog emphasises  Lots of kind words, emails and texts have been sent to me, expressing support, some theorising about conspiracy theories, some stating it's time to look after only one person- myself. Which does need clarification...there has been no skulduggery, high end Machiavellian politics, prejudice which has resulted in me losing out.Even if there was, I have no desire to know more either. To suggest so is to demean the person who has got the job. On the day, the better person won. End of story.

Its time to move on and make this the best diabetes service in the business, one based on patient thoughts, ideas and one which shows good outcomes.My flirtation with management outside diabetes is over, and has helped me to focus back on an area which clearly needs much more to be done, locally and nationally. In this new era of the NHS where boundaries are being blurred, if we can develop a service of pride, why be limited to only Portsmouth and Hampshire? Why can't we lead the change and cascade the ideas to everywhere else? Why indeed can't we get to the level of say Bournemouth, Leicester or Sheffield everywhere?

The BMJ Awards night suggested we were one of the top 4 teams in the country both in diabetes and Leadership. I took time to speak to the winners- and what stood out were their outcomes. So the next step is indeed about just that. The patient conference was the first step...this is Phase 2 of my Portsmouth Diabetes team project.

We will, indeed, one day, be the best. With a team like that behind me, there is no way that won't happen. I absolutely promise you that.

Wednesday, May 8, 2013


This blog is personal. More than 25000 reads in total on previous entries but this one was for my own reflection, a time to use the blog for a bit of personal catharsis. An evening when I had come back from work with mixed feelings and as I took a sip from my glass of Talisker swirling around the ice cubes, its was good to pause. And write.

Been Clinical Director, Diabetes for nearly 4 years now, plenty of awards, innovative model in place, appreciation from patients...thought the time was right to make a move to something different. Yes, there were still challenges in diabetes but just felt I could do more for patients within the community and hospital if I went for a bigger role. And relished the idea of taking on a bigger challenge...armed with one motto...if patient care was to be compromised, then no doctor, manager or nurse was big enough or had a reputation fearsome enough who I couldn't take on. But alas, not to be. Maybe the passion was too much, maybe it was the age, maybe I was too outspoken, maybe it was politics, maybe I simply got stitched up (how could I possibly lose out?)...lots of thoughts swirled through my head as the disappointment sank in. 

But to be perfectly honest, I ended up losing out to a top bloke, a respiratory Consultant who breathes patient care at all times, believes in the ethos of general physicians...simply put, very similar to me, just a better candidate on the day. I won't lie...its all very "cool" to say "its fine" or"never wanted it anyway" and keep rocking the banner of nonchalance...but the fact is I was disappointed, bitterly disappointed. Not because I lost out, but because I genuinely wanted to help, make a difference. I remember trudging back to my office with all sorts of reactionary thoughts in my head and within the next few hours, 2 things happened.

To begin with, one of my colleagues who has known me since I was his Registrar and then subsequently his research registrar,came into my room with a cup of coffee. He sat down with me, and he said exactly the things he knew needed to be said. A gentle pat on the shoulder and 10 minutes later, I smiled...and in one flash I was reminded why this department has always been so dear to me. As the news gently spread around the department, one by one, the nurses, HCA, admin staff came in, some armed with black humour, some with a hug...some simply with "their loss, our gain"- and it was just...lovely.They cared- this was my family away from home.
Then I opened my emails and 3 things sprung out. 2 emails- one from Dorset CCG and another from Brighton CCG asking advice about our model of care and another one from a private healthcare company looking for a chance to discuss "options". In one word, opportunities were there...mine to choose and pick from. 

As they say, one door shuts and another one opens. Maybe its a sign- maybe my job within diabetes isn't done- maybe I need to take the department to the next level; maybe I am destined to stay within a chronic disease such as diabetes...maybe in this world of CCGs etc the potential of diabetes care- cutting across boundaries is endless. Either way, not what I had planned or hoped but then again 39 is perhaps just too early to be Chief of Medicine, if ever at all, for me. Its uncharted territory but so it was when I took over as the lead for diabetes. 

Mourinho has always been an idol for me...cocky, self assured, winner, reviled by many, respected by his team...but on the day arguably the greatest manager in the football world retired, perhaps destiny says I am less suited to winning trophies with different clubs...but rather go for multiple awards with one particular one. Time will tell- for now, Dr. Mark Roland, new Chief of Medicine, Respiratory Physician - best of luck with the new challenge. Rest assured, the diabetes department will deliver their side of patient care needed..and more.