Sunday, October 27, 2013

The Game-changer part 1

We are in the throes of a Monty Pythonseque level of inanity at the moment. Ideas swirl around as to how to salvage the NHS, conspiracy theories lurk out of corners, the optimists try their best to paint a rosy outlook, the doom mongers scare the rest into a corner...its actually an incredibly interesting place to be in. In the midst of that, the money struggles to follow the patient. We talk..and debate..and mull..and conjecture..and we all then agree that the money needs to flow into the community..and then we all resoundingly fail to make it happen..why? 

Simply because there is no buffer...there is no investment to make in primary care with a gradual reduction in acute Trust capacity. The need for reduction in acute trust is NOW without the infrastructure in primary care being set up.The acute Trust then desperately tries to use the existing tariff system to make sure they don't suffer financially. Take the example of coding...for patient care, it should serve one and only one to build a data base of conditions, help to use to measure areas of improvement, help to measure outcomes..nothing else. What is it today? A tool to ensure the Trust gets paid for the work done. Cue suspicion from CCGs about gaming, cue mistrust why GP referred patients go to A&E..PbR works very well for procedural initiatives..but falls apart when trying to map the complex journey of a patient admitted with chest infection- who also happens to have diabetes and heart failure - and then also develops a urinary tract infection before being discharged.
Problem with the plan? You can bill the CCG as much as you want...once they even get past their suspicion, if they have to pay up, that money to you, Paul, will only have to come from Peter. There ain't no more money's a separate debate whether there is money in the "system" (yes I have read Jacky Davis book); but as things stand, the CCGs certainly don't have a magic pot to throw money at acute trusts.

And then we have another fundamental problem. Its called lack of respect or understanding of others work. We have leader after leader- and I do use that term loosely- who go up, claim to represent the masses and spout unachievable desires and options. Example? I have been involved in meetings where so called primary care leaders have stood up and said they don't need diabetologists. I will be brutally honest- that to me, at that time, smacked of disrespect, politics and arrogance. But I have now changed my opinion..3 years into our model of care, having been involved with 80 GP surgeries, I understand one thing..those leaders represent their own warped views maybe in order to cater to political sound bytes or their own careers. I have yet to meet a single GP colleague across the country who actually does the day to day job and treats diabetologists with such utter disdain. On the contrary, all visits to surgeries I am involved in nowadays are simply enjoyable- sitting and talking to like minded colleagues, colleagues who are swamped and just are grateful for some specialist help- on demand, when needed.
Problem? Those so called leaders are the ones who are involved in policy decisions which the majority don't agree with.

Exactly the same for specialists...seen plenty of diabetes Consultants who have treated and continue to treat GP colleagues with utter disdain ...their experience of working in GP care? Nil. Nada. Zilch. But still they lead organisations, still they continue to sit on policy boards, produce documents whilst their own patches ask for help from other areas. Did someone say national CEA awards? What's the blinking point of being a leader when you haven't even shown credibility where you work and all the junior doctors feel you are a laughing stock? 

So we have an interesting juxtaposition of a false economy plus leaders approaching system wide problems from a speciality angle, not to mention some with a distinct whiff of lack of credibility.Plenty of documents about how change can be brought but no ideas to implement. So you know what..I reckon either this will all drift along or there's one big game changer on it's way. Something fundamental will change because this is unlikely to drag on for ever. In the interim, lots have chosen to get their head down, do their job and go home and a handful few are trying their best to stay ahead of the curve.I personally have always enjoyed the daily debates, the politics that one needs to manoeuvre to improve clinical care but I also know that I am a bit weird too. The majority find it tiring, find it draining, find it insulting to explain to yet another external management dude that they are leaving their guts behind every day and not the stereotype painted by Lancelot Spratt. 

So we muddle on, the air gasping atmosphere of acute Trusts being sucked into a financial hole, the shrinking PbR tariff..all adding up to talented energetic people muddling on...trying to just do good for the patient in front rather than have time for the system. I am personally blessed to have a team around me who have an infectious amount of energy..another award to add to the collection on a national level...the only diabetes representation amongst the public, private and voluntary sector. But there's a growing realisation that without a major change, such innovation driven by teams will only be exceptions, not the norm. 

Muddling on is the default position till something fundamental happens....and maybe it's time to discuss those openly..question is are we ready for it? So...shall we start?

(To be continued......)

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