Thursday, June 27, 2013

Chicago musings

Chicago. Having spent the last few days in the Windy City, attending the American Diabetes Association conference, it has been nothing but an eclectic experience.The city itself was fascinating, a dreamy, relaxed version of New York. Amidst the high rises, life seemed to have a gentle pace. Amidst the down-town traffic, some amazing Jazz clubs rolling out some absorbing Blues tunes.It was hard not to fall in love...easily one of the better American cities I have had the pleasure of visiting.

And as ever, an experience to enrich the mind and recharge the batteries. Bumped into old friends greeted by warm embraces, similarly passionate minded individuals who are keen to make a difference...cynicism wasn't the buzz word, it was more of realism. Got to know some others a bit better, beyond their normal work veneer, the witty, humorous or perhaps more human side. Making decisions about life, family and work. And perhaps also sure signs of getting old, or does one call it maturity? Walked up to build back some bridges, time would always the greatest healer,Niru Goenka was right, wasn't he? Struggled to do late nights....I blamed it on the jet lag..inwardly knew perhaps it wasn't the case. Encountered some mild ribbing too.."left your A game behind, Dr Kar?", Dr Kar, away from the incessant adrenaline driven hubbub of the NHS, just wanted to relax. Sometimes you never know how much it all takes a toll. And amidst the relaxation, there as always the reminder when one opened the hospital emails of the state of play. Emails copied into showing the tired, angry exchanges generated by pressures of the system...who has time for morale building in the NHS when the incessant drive is to get the numbers correct right now?

But it was fun. Some staggering findings about the amount of financial burden poor diabetes care is leaving worldwide, a stronger realisation across the globe that primary and secondary physicians do need to get their act together, see alternative providers such as pharmacists and nurses as adjuncts to helping improve healthcare, rather than challengers and of course, some good academic findings (a possible vaccine for Type 1? ; a possible use of type 2 diabetes drugs in Type 1 diabetes?) which shows promise for the future.
Sitting down with young energetic bright research minds like Pratik Chaudhury and Dinesh Selvarajah..discussing CGM findings, exploring options for type 1 diabetes patients..ahh..such a refreshing exercise for the mind...pure science, no NHS politics..what was not to love?

I have never believed that the US system has nothing positive to teach us, I mentioned so after my visit to Seattle...indeed there are bits which we can learn from..never catered to the blinkered socialist view that nothing is there to be emulated. Simply put, that's ideological beliefs blinding one to the possibility of emulating good practice.
But there is the darker underbelly which one met too. The scenario where one person faces the grim possibility of their immunosuppressive drugs post kidney transplant not being renewed after 3 years due to insurance issues....people in the NHS...surely complain about the failings, but also recognise the system you have....continue to bash it..and a fundamental change will leave us all in a place of deep divide and discomfort. And of course, areas where the NHS is streets ahead of the game. I sat through sessions smiling, appreciating the work in hospitals being miles ahead of where the Yanks I always say, never be shy of good quality work...but hey, doesn't sell those newsreels does it?

As ever, I realised the amount of collective goodwill around amongst the UK delegates to make a difference to patients..and I return with recharged batteries and energised that this battle isn't a lonely one. Passionate people abound, whether they come from Bath, Medway, Derby or Leicester. Optimism bristled irrespective of their profession..Doctor, nurse or pharmacist....and you know what? The parts will add up to the sum, I promise you it will.And I may have something else to hopefully offer to the world of interesting meeting with a passionate John Sjolund...who knows what may come of that...we shall see...but something I have always wanted to do.

And finally, after 5 days, it was time to leave...leave the Windy City behind...leave the city of the BlackHawks..a city which rejoiced after winning the Stanley Cup sparking some amazing scenes on the streets. Thank you Nicky, Gary, Lisa, Dani et al for making the whole time so enjoyable.

So...back to the grind again. Recharged batteries, some new things learnt, some deals in mind, some old friendships renewed, some friendships strengthened, some new friends has been worth its weight in gold.

Friday, June 21, 2013

The bubble

I have come to a finite conclusion. I live in a bubble. A bubble full of weirdos, unnatural people, a bubble where utopia is only but a stones throw away. A bubble where things aren't all in meltdown, a bubble where people are..happy, proud to be doing their job, come to work with a smile. and this world is magical where everyday brings new challenges, challenges to which answers are actively sought, resolve one and move on to the next.

Magical, isn't it? Did I also hear you say unbelievable? Did I hear you even mutter something about this state only possibly being induced by pharmacological intervention? Heck I have even heard about folks doubting those who shy away from the cynicism, that they cannot be taken seriously, they have no sense of realism. And perhaps all that is true, perhaps I DO wear rose tinted glasses but everyday I walk into work and do enter into that the diabetes department. I have wondered for long why that has been the case. many theories, many conjectures...all the PowerPoint bullet points about an effective happy team followed to the T..maybe it's that...but there's something else.

Recently I went to a national meeting..where a significant amount was dedicated to bashing the previous managers within the PCTs and now in the Clinical Support Units. They evidently "knew nothing". It was laced with comments about the CCG leads too..why didn't the GPs go back and look after their patients rather than try and devise pathways?On the train back, I went on twitter and saw how "CCG leads etc were clueless" and as is the wont armchair critics continue to have a field day. Anyone to actually step up and do the job rather than criticise? much easier to criticise Rooney for missing a free kick while munching on a pasty, isn't it?

Let me now take you back to this amazing bubble. In this bubble, I have met umpteen managers and clinicians for whom I have nothing but respect for at least stepping up to the plate in the most challenging times the NHS has faced. In this bubble, they have been fabulously supportive, been with me, the model of care outlined,all along the way. GPs who haven't pretended to know everything, but have listened,reasoned and helped deliver a care pathway which we inherently believed would help patients, was the future, was the way ahead..specialists supporting primary care, not isolated in silos. Majority of the country still talk about integration, attend meetings, take notes....South East Hampshire and Portsmouth CCGs went ahead and did it. and what about the managers? Those dastardly lot we doctors love to hate..the ones who once sacked will solve the financial crisis of the NHS, the ones who are the soft targets of the politicians. Firstly I have news for you..without good managers, you cannot deliver a good clinical service. If you think you can, that's naivety and disrespect for individuals whose job pressures you do not understand. Secondly, come back to my bubble for some news.

In this bubble, these managers have been as much committed to making things happen, helping deliver clinical care..and this week reinforced that. Any clinician worth his or her salt will tell you how many obstacles are there or put in your path to deliver good clinical care..and this week, I needed the commissioners to help. And you know what? They did..bang on the money. I have stayed away from saying this previously but beyond the clinical engagement of the GP Commissioners ( without whom the bubble wouldn't have existed), a significant credit goes to the managers for thank you Melissa, Sarah, Lyn et al. Thank you for keeping the bubble alive.

 I know some will read this and feel me possibly having a "plan" and thus talking up the local commissioners. the reality is that I don't I have got what I have asked for at every juncture. In the NHS, we don't say thank you enough and that's what perhaps sucks the morale of all, up against daily challenges. And I am tired of  smart asses criticising especially when neither have they shown a willingness or strength Rostand up and do it themselves. You may disagree with the Health Act, you may disagree with the politics but you must at the very least say thank you to those who have shown the strength of character to at least attempt to steer the system rather than it descend into total anarchy. In my romantic comic book fuelled analogy driven world, what would Batman ever do without a Commissioner Gordon to help him?

So that probably answers a part of the bubble issue. Why does it exist? Why are people happy in the diabetes department? Because every single staff can deliver what they want without fearing about politics, resources, jobs....that bit I handle..and deliver due to some fabulous folks in the local CCG and CSU. I hear all the cynicism, all the chest those who tire of it, come spend a day with us, with the nurses, administration staff and medics of the Portsmouth diabetes team...I promise will like the bubble.

For one day, we promise you a day of smiles,optimism and positivity. Take some of it away and infuse it somewhere else. The NHS needs a bit of sunshine, like never before.

Sunday, June 16, 2013


How far can you stretch a rubber-band? How far can you take it before it snaps? It's always one of those million dollar questions in an every day life of a Consultant nowadays. The question that I always face, while doing job plans is how far does one absorb before it snaps? Or does it ever snap at all?

Even more to the point, would it ever get to the point where a Consultant refuses to see a patient because its beyond their contract? Would there be anybody who would have said "that's enough"? Intriguing questions as the demand increases, politicians fuel the more for less demand and everyone is asked to go that extra mile.
On one hand, there is the contract itself- in some eyes, its generous- especially the Supporting Professional Activity bit. In a 40 hours job, about 10 hours per week is supposed to be devoted to this. For revalidation, for appraisal, for teaching...some say its generous, some say its not enough. The problem is that it never takes into account individuals while applying a blanket rule. Not every one wants to teach or be an educational supervisor, so why should they be allocated time in their contract for this? On the other hand, there are some fabulous teachers- and the whole community is better served by allocating more time for teaching.
But perhaps there is a way- perhaps its worth considering the strengths of individuals within the department and annualising their job plans? Perhaps the allocation should be spread accordingly? Perhaps each is given a set time for revalidation (indeed Des Spence raises the question why we can't do so in our leave period like teachers)- and then see what can be allocated based on need of junior doctors, services? Why not use SPA time to create accessibility, create time for education and support for primary care, create time for governance issues or trust/local healthcare priorities?

But beyond the SPA itself, are we heading to a future where doctors would say "I have had enough"...would they turn away from a patient? To a lot, it would be unthinkable wouldn't it? A naive simplistic view would be that you get paid, and paid well to be a Consultant on a public sector, tax funded with it comes the issue that you have to do something extra, take a bit on the chin, knuckle down and do "a bit more". The opposite view would be that...isn't that what the old contract was about till we moved to a time based contract? The worry I have is to what extent the reliance on the benevolence on doctors will continue.

What if at some point doctors decide not to see patients as they are not paid for it? What if they down tools- behave like a trade union? The analogy could be that if this was a car industry (and we know how much we love giving examples of the airline and car industry in the NHS...!!) and the workers down tools, the theory is that production stops, car sales go down, the management suffers losses and they come to the table to negotiate. Problem is in that example, no one really suffers harm except the bottom line of the management...try that in a healthcare sector and there's a real life human being who suffers, the patient...due to no fault of theirs. On one hand, immediately the doctors are "greedy" while the reality maybe that they may have been stretched to breaking point and can do no more...while on the other hand, downing tools in a healthcare sector is nothing short of a nuclear option, making all of us deeply uncomfortable,entering into a challenge with our conscience...a deeply disturbing territory- and part of the reason why the pensions strike achieved such poor turnout.

And it makes me worry- that as a system we may not be too far from it. I see colleagues exhausted, on the verge of burn out...and I am not sure how far they can be far that rubber-band can be stretched. And I also know they are colleagues who are not mercenary minded, who are not driven by money..and how much it pains them to think of the unthinkable. I am a born optimist but I see a worrying trend developing. It's not about the money earned...its about how much you use the benevolence of clinicians and how you use it. I keep on hearing about "wastage"...but I hear very little about how much the NHS is fuelled by goodwill...the ability of doctors and nurses to do "that little extra bit".

Let's all be a bit careful how far we stretch that rubber-band...the day it snaps completely, I can guarantee you the NHS will end. And it will be nothing to do with structures of the NHS. It would be to do with burning out one of the most valuable and non-measured qualities,that particular trait you can't quite quantify in a job plan, the oxygen on which this system runs in spite of all the toxic's called..goodwill.
To colleagues who contemplate that option, there must and must be an option out there which does not involve compromising patients. The frustration I understand, the pain I appreciate but never went to medical school to walk away from a patient..and I exhort you, nay plead with you, not to go down that road. Once that is done, an irreparable harm will be done to the reputation of a physician- otherwise known as a healer.We must find a way around that. Must.

Sunday, June 9, 2013

A lesson from history

Let me say this at the very outset. As regards diabetes care, so called leaders of the GP world about 7-8 years ago  let down their colleagues.Massively. Misrepresented what the grass-roots wanted, misrepresented what was needed. Massively dealt their colleagues a poor hand..leaving them now, understaffed, under resourced to delver good quality diabetes care. I have no idea of other specialities so can't comment for certain but as regards diabetes care? Without a shadow of a doubt. you ask? Well, you know what...about 8-years ago, I still recall attending, nay sitting in a national meeting where diabetes care was being discussed. It was the time when "move in the community" became the clarion call and as usual, diabetes was picked as one of the disease areas to look into.  And I sat with utter bemusement to hear 3 senior GP leaders, one after another, stand up and explain why ALL diabetes care could move into the community, one even said there was no need for a diabetes base within a hospital, no need for diabetes specialists, quote unquote.."there is nothing a Consultant in diabetes does what a GP couldn't." I was bemused and dismayed at this...but those were the days when you listened, rather than piped up.The problem was that the Consultants in that meeting said little to counter, I even asked one of them why..their response..."ah don't bother responding to silly people".

Problem was those "silly people" had the ear of policy makers and a significant chunk of diabetes care moved to the community, without any planning. Problem? It didn't move with the resources necessarily...but hey, if all followed QoF targets, it would be fine, right? Many years later, the national diabetes audits show the folly of it...huge variation, some poor outcomes, admissions up....just asking the "GPs to take it over" doesn't work. Many reasons for that, including a non evidence based, blanket QoF but in the main, a policy shift driven by a few, but not supported by the many.

So here are some  tips to GP leaders (are they called CCG leads now?) from a specialist who worries other specialisms heading this way...with GP colleagues being asked to absorb the extra work

1. When you come up with ideas, please make sure it's not just your own prejudiced view, but that of the grass-roots. Please get a consensus view as that stops a lot of angst or resistance with the tag line "I never agreed to it". Maybe even borrow ideas from areas where primary and specialist care may ACTUALLY be working together.
2. Don't come out with statements like "we don't need specialists". That's a statement borne out of arrogance or a lack of respect. An example from the diabetes world? No you cannot do antenatal diabetes or pump diabetes. You haven't been trained for it, I have. Straight talking isn't arrogance- its stating the obvious which otherwise harms patients.Your level of patient care for those sort of groups of patients would be comparable to me providing GP care for a day, It's called "suboptimal". So try and define what bits is not appropriate for patients to be handled solely by primary care.
3. Think of the resource implications and also the impact on your practice nurse. Type 2 diabetes care, in the main, is delivered by practice nurses in this country...ask them whether the more complex patients is appropriate to be managed solely by primary care.
4.  If you want to have resources, then have a think whether simply increasing GPs or practice nurses will do. Do, please understand there are some areas in each speciality where you need a specialist opinion. They have been trained for that at the expense of the taxpayer...use them for that.There is a need for specialists to work differently too but it can only happen when there is acceptance they have a role, rather than none at all.
5. If you want to use Consultants, then see what educator role they can have. Asking them to do an intermediate clinic on their own serves little educational purpose. All that has been achieved is moving the patient from one building to another. You have dropped the revenue for the local hospital that year, but not allocated that money to the educational content which would help the GP to stop sending a similar patient for review.
6. There are some GPs who can "do it all" but in the main, most are stretched beyond breaking point. The one who shouts loudest that he can do all isn't necessarily representing the majority.

I could go on a bit more but in the main, the above ideas and views are not mine. They are grass roots GPs and practice nurses....collected after being part of a model whereby I and my colleagues have been part of each individual local GP surgery...visiting them twice a year discussing diabetes care, understanding the frustrations...and believe me, that frustration is widespread...the angst of more and more complex patients being sent out if hospital without any resource, point of contact etc.

So take it as an ode from a specialist. As regards diabetes locally, as mentioned before, we have been fortunate to have CCG leads who have listened and supported the above concepts, but the frustration in areas I visit is palpable. Forgetting even that, without an educational and support content for primary care, where specialists can have a big role,  there's very little help of us battling the ever increasing demand with a capped, maybe even reduced, finances.

This no longer is the time to score political points, it is genuinely time to work with specialists, understand their roles, respect they have plenty to offer (as it needs to happen the other way too) and hopefully, we can do some good for patients. Together. Side by side. Not jostling to see who is the big dog in the healthcare system.We keep talking about "working together", "care without walls" ....Let me quote you something from the "Tragedy of Hamlet"... "Suit the action to the word..and the word to the action". 

Saturday, June 1, 2013

The N word

Boldly emblazoned across all documents we handle within our workplace, flashed across our screens during the Olympics opening ceremony, maybe even one of the top things written in most political parties war rooms. It's the National Health Service...almost a religion for people in the UK, something not to be messed with, something which rouses emotions,fires debates, a symbol of pride for some, a failing beast in desperate need of modernisation ( whisper even the word privatisation softly ) for others..a behemoth where debates about safety becomes polarised into "how dare you touch our NHS" rather than "how can we get it better?"

And yet, the N in that NHS continues to be nothing but a misnomer. Yes, the concept remains the free at the point of delivery...but yet the variations of care simply astounding. And you wonder..if something works well somewhere...what stops it from being adapted somewhere else? For sure, local amendments need to be made...but somehow there seems to be a reluctance to adopt. There seems to be an industry now of folks who specialise in reinventing the wheel...going thro the same pains and tribulations a Trust/ PCT/CCG within even the same county, let alone in another part of the country has gone through. No intention to reach out, learn....get the process moving quicker.

So what is it? Pride? Arrogance? Reluctance to change...or simply if its not come from "my" head, not worth listening to? I attend meetings of peers, not to simply deliver or listen to lectures...but for me, the gold dust moments come in between..talking to them..listening to what they are doing, taking mental notes what I can adapt, what we could do better. I will give you an example..went to a meeting and over lunch started chatting to Dr Chris Walton, a Consultant Diabetologist from Hull. I kid you not when I say he is like Yoda. Calm, measured in his response, always with a smile when I launch yet another "plan"at him. Anyhow, he mentioned that in Hull, they had developed a pathway with their local ambulance trust for patients needing treatment for severe hypoglycaemia. My mind started racing..What a fantastic idea!!! Asked him for his permission to have a look at the pathway, brought it back, sat with our Commissioners, nurse team and ambulance trust, made some local amendments and within 3 months, we were live in action. 5 months in, it has been a fabulous project, ambulance crew happy, patients delighted, front door admissions down...and as a team, we will always be eternally grateful to Dr Walton for sharing his idea. 

 Last year while judging one of the categories in the HSJ Awards, the thought kept on coming in my mind...why on earth do we have such fantastic examples..yet localised in such silos? And it wasn't just diabetes, it was in every single sphere of healthcare, every single specialty within secondary care, innovations within primary care localised, not cascaded.

As ever, I cannot ask the old guard to change..I am too short in the tooth for some. But I can certainly ask my peers and juniors to embrace the idea of an NHS cutting across false boundaries. You want to improve diabetes care...believe it or not, no its not Portsmouth. Its Sheffield for their expertise, Derby for their model of care,St Thomas Hospital, Bournemouth & Poole for their Type 1 service....thats who we aspire to be.Every week, as Clinical Director, I have time set aside to overview all the sub services I run, look at the obvious weak points,try to improve and I can only encourage my peers to do the same. Drill down to the service you run and think what can I do better? Does anyone do it any better? Why can't I email them, phone them, see what they do? Why not visit them? If we all do it, it can only help in cascading good practice, help to lift the overall level of care. 

The N in the NHS will then actually stand for National, rather than, perhaps, notional. Don't be afraid to say the N word...just remember what it stands for.