Friday, November 29, 2013

Gamechanger V: Training....where's the patient?

It's simply astounding how disconnected NHS structures can be, how poor future workforce planning can be, how out of sync training can be with modern healthcare demands...there seems to be a lag period..and by the time training curriculums catches up, the NHS and its healthcare needs have moved on, the priorities have changed, the needs of the patients have change.
Lets start with this new fangled love all policy makers now's called "Long term conditions".No longer is it about single disease such as diabetes, COPD, heart failure but no, as the patient has multiple comorbidities, we need to have multiple disease specialists. As a plan? Fabulous. Execution? Not surprisingly....slow. Why? because immaterial of how you brand it, that "multiple disease specialist" a few years back used to be called the general physician. I still recall doing general medicine clinics...all disbanded gradually as we needed to champion specialism. Who used to come to those clinics? Yep, you guessed it, patients with multiple problems, and a GP asking you to join the dots together, get a few disease processes sorted in 1 go. Now as time has phased, and finances squeeze, sending the same patient to a diabetes clinic, then a heart failure clinic and finally a COPD appointment doesn't look right, either from a patient experience or a financial one.

So where do we find these "long term conditions experts?" I can assure you they are a rare breed in the hospital, in fact as lots of junior doctors will testify, early mornings are spent trying to cherry pick specialists patients and wondering who to hand to or grumbling about the "general medicine patients" on the list.
So where are these specialists? Have we now managed to narrow them down only to elderly medicine physicians, the only ones who still look at the patient as a whole? But we only have so many of them..and the demand for them grows exponentially every day. Is it then the GP who does this role? Then again, the pressure on time for them is well documented too. Thus as evident,we have problem with the present...but a bigger problem brews with the future.

We are planning these models but training still is delivered in specialist silos. Long term conditions? Don't be silly. It's only about diabetes, only about heart failure.General Medicine training? You learn what you do on the wards, attend a few conferences, try your best to get to a few regional training days but always takes second preference to your own specialty..not always due to choice of the juniors but also pressure from their own Consultants. It maybe the priority of the Policymakers and even the patients, certainly not in the training cycle though.
Another example? End of Life care.  I read about Elin Roddys passionate plea to improve this area and with an ageing population, multiple morbidities, increased malignancies..he need to have the skills or even the mental inclination to spend those extra minutes with the family and patient is paramount. what about training though? Is it responsive to the needs of the patients? Is it adapting to the changing population?

So what can be done? Forget the present for a minute and invest some time in the future. There is little point in talking about models for which we are not training our juniors. The Royal college of physicians talks about how they want to bring general medicine suggestion would be to stop talking in waffle and actually get something robust in place. We have specialties who duck out of any general medicine commitment as they don't have   General medicine accreditation. cardiology is a prime example..and Gastroenterology is  trying their utmost to follow suit. I know so as the local college tutor as the cardiology trainees don't attend sessions on end of life care, COPD "there isn't a training requirement". Not their fault, just pressures of time make them choose appropriately. The sadness of that is compounded by the fact that in my training years, some of the best general physicians I met were actually cardiologists. Up and down he country, those who have been left to pick up the baton of patients with multiple problems ( cue Respiratory physicians, elderly medicine physicians etc) feel the heat of this, day in, day out and ask for all to share the load but unfortunately training continues inexorably targeting a single specialty disease process.

So want to change the game? Then tackle training NOW. Do we need more single disease specialists? Debatable. Do we need more up skilled GPs, do we need better trained practice nurses, pharmacists...well..that question is on the same level of is the Pope a catholic? If you want better general physicians or multiple disease specialists in the hospital, then make it mandatory part of training and job plans, not an option. Stop waffling about with polices and do it. And if you don't have the muscle or know how then come to the conclusion that we need more elderly care physicians as long term conditions specialists, up skill GPs and give them quick, fast access to single disease specialists.

Maybe we need to accept that we need to invest a lot of education money into upskilling GPs, use the fourth year of training for targeted LTC training rather than continuing as is...maybe its time to invest in training of specialists to be educators, develop the importance of being there for primary care as a many trainees are specifically taught about teaching skills? Accept elderly medicine physicians are turning into the last bastions of general medicine..and train appropriately rather than force folks to do something they don't.

Either way, a fundamental change needs to happen NOW. No more time for endless meetings of educational gurus mulling over nuances of the curriculum, we don't have the time left for things to happen 5 years later...while the patient needs have changed now.

The worry I suspect is that as trainees we saw this coming 8-9 years ago when specialists started to pull out citing their super specialist skills...the rot had set inside the hospitals..and now its cascaded to the wider community. You reap what you sow...and in case you do want to tackle the future and the multi morbidities conundrum ( which incidentally I see as a success of the NHS way of working) then the time to act is now....Royal College of Physicians/ Health Education England..are you listening closely enough..and more importantly are you ready to tackle the issues head on?
I am sure there are a lot of physicians with a wry smile looking at this attempted resurrection of the general physician in a new garb. The circle of life is nearly complete.

Wednesday, November 27, 2013

The perception of reality

A break from the Game-changer series to reflect on something from last night.Twitter can be so amazing minute you are debating whether the NHS deserves an ideological shift, the other moment you are talking about the importance of early diagnosis of cerebral haemorrhages followed by in depth analysis of the latest slant on the eponymous Spider-Man storyline. And then again sometimes, you just be a voyeur and read some tweet threads.

Recently I sat through a fascinating thread where a few general practitioners debated the importance of public relations. I suspect on twitter we do have a self selected group who may not necessarily represent the vast majority but then again it does offer a sneak peek. Differences of opinions on this thread line were evident followed by one concluding that we shouldn't waste our time on such issues.
And even though I didn't jump in, I had to disagree. In the world we live in, like it or not, perception is key. A shrill continuous banging of drums opposing policies gets you pretty much no where. Let me give you some examples...for starters the Liverpool Care Pathway. We had twitter in an absolute meltdown and all of us who deal with End of life care felt this would not be beneficial. But instead of countering media versions, lots of folks went on the rhetoric, made very valid points...but in the end? the LCP doesn't exist any more. Recently a ward round drove home to me what we had lost...or more importantly what the patients had lost. As a profession we should have done better,we should have opposed the media with charm, our own public relations offensive..we didn't...we decided to depend on the rhetoric,pour out our emotions...end result? No one lost out except the patients and their families who deserved it.

Now let me give you the opposite fact two of them...where good publicity, branding has helped to emphasise something which is so basic but yet so important. For starters, the 6C campaign...I will admit I was among the few who rolled my eyes at it. "Compassion"?? "Care"?? Why would you need to emphasise that? Surely that was fundamental to what nurses do? But over time, it has caught the imagination, it has focused the mind on something basic yet so important...and as the Julie Baileys of this world to ensure  will attest to, somewhere down the line, the basics were if it needs a catchy name to reclaim the ground, so be it. If thats what's needed to make a nurse stop for a second and get that glass of water closer to the elderly lady, then 3 cheers to branding, publicity and a charm offensive.  

Another one? Kate Grangers "Hello my name is....." campaign.Simple yet effective. Now I have had corridor conversations with colleagues who have found this campaign odd.."why is this even a campaign?", juniors who have felt this to be a stunt ( till they read and learn a bit more about Kate) but there is no denying its impact. It's the basic tenet of a healthcare professional, shows the ability to interact, be compassionate...and again, this campaign for sure has focused the mind on something inherent which somehow has been forgotten,somewhere in the mix lots have indeed forgotten the basics of human interaction..introducing yourself with a smile. Impact of branding and perception? Absolutely amazing.

So back to the concept of perception. Beating the shrill rhetoric of "hard working GPs", "there is no money", "we only live for the patient" maybe indeed your own personal preference and admirable practice but thats not representative of everyone. For every ten amazing GPs, there is also one who has the bottom line of his finances in his mind, who makes pride in the business and profits he runs..I have met them, shared a beer with them. Are they less caring? Not necessarily but neither are they on twitter saying they like their profit margins too.
So..suggestion? Be open, launch perhaps a charm offensive, maybe even come up with something catchy..explain to the public what pressures GP surgeries work to, why it is different , if at all, from a private enterprise..step away from words such as internal markets, qualified demand and talk in plains simple language that patients can understand.
It's a lot to do with perception...a specialist is as much Dr House as much as a GP is Doc Martin. Be proud of what you do, yes, excellence is and must be an everyday thing, it also is something that should be championed and highlighted with pride...dare I say the stiff British upper lip which holds back self praise could be resulting in losing the battle against a savvy media with its own agendas?

I can't preach to anyone, neither do I intend to but there are many ways of attaining what needs to be done for patient care, and I don't think rhetoric is the way ahead. A local example lies in the Super 6 diabetes model. The concept? "Specialists do only a few things in hospitals, rest is by education, virtual and face to face". Sounds like anything amazing? No it actually isn''s something we as trainees always chatted about over beers.
All we did was label it, package it, wrote some articles, won some prizes and boom Partha Kar was a "thought leader". No actually he isn't. He is still the brash chap he was, still making mistakes, still trying to do the best but lucky with an amazing team....doing stuff that others are trying...only difference? The perception of what we do...the showcasing of what we do..proudly. No longer in Portsmouth is a Diabetologist the mild mannered person who accepts anything thrown at them, but now it's a team which knows when to launch a charm offensive and when to snarl when patient needs are paramount..irrespective of whether the person at the other end is a Board member, fellow colleague or manager. We are not here to satisfy others egos or do their jobs, we are here to do the best for the patients.

We are here to do best for the patient,so to achieve that you use whatever tools you have in your armoury..and perception is paramount. Andre Agassi once said.."Image is everything"...maybe that's a stretch too far...but a combination of talent and passion , which the NHS has in abundance..combined with a better image...can and will be an electric one.

Primary care is the bedrock of the NHS and rather than the rhetoric, my suggestion would be to seize the initiative and be at the forefront...Gerada set the tone in her inimitable style....who's next to pick up the baton? Who's the one to launch the charm offensive to explain what being a GP means? And if you don't believe that its not needed, then look outside the window...the NHS is slipping if primary care cant save it, then I can assure you, no one can.

Sunday, November 24, 2013

Game changer IV: Bring the public in

I was thinking of this post being one on general medicine within hospitals, that area of pitched battleground for most...but that will have to wait till the next one. As for this one, I am going to touch upon that most interesting of subjects...patients. We keep on hearing about putting "patients in charge"- I will leave all politicians out of this to avoid an idealogical debate (as most things nowadays descend to) so lets concentrate on the professional leaders who keep saying they mean to. Throw in the mix the conversations from patients as to how they would like to be more involved and you have a heady cocktail. There's always been the assumption that doctors, managers, nurses ergo folks who run or are part of the NHS know best and its always interesting to see whether that is actually true. Indeed there are attempts to involve the patient in pathway developments but lets try and extend that theory. How about we really try and let go? Would it work? Too dangerous? Well, lets theorise and see, shall we?

How many patients actually know what a referral to the hospital costs? How many know how much their follow up costs? Could we open all that up? There has been talk of individualised budget- a minefield to decide how to actually cost it and set it up but even if you give an individual a budget, what happens when that is spent? Can we let the patient decide? Are we bold enough? My type 1 patients could ask why the NHS doesn't fund all to have CGMS (Continuous Glucose Monitoring System)..well I could but it means I will have to stop delivering something else to balance the costs. Who decides that? The patients as a group? What would my pituitary patients then say? What in fact would my Type 2 patients on a dialysis machine say? Lets talk about some numbers. A new patient appointment gets my department £239 while each follow up about £ amount which is not constant as that rate is going down year after year- while the staff costs are same if not more. Add in the pressure from Commissioners to reduce costs each year and you have a shrinking pot to play with. 
So yes of course I would want to have 7 day service, psychological support for all, CGMS for all...but without any money available to invest, I can deliver those by only one way...drop something else. In the world of diabetes, the other choices are, or at least for my team...pregnancy service, kidney dialysis service, foot diabetes service...what do we do...go Big Brother style..put it up to the public vote and say "You decide"..?

The other question is does each patient approach it from their point of view? When I had the problems with my back, I instantaneously felt that this had to be most important issue that needed to be sorted. I suspect its the same for anyone who has themselves or has relatives with mental health, long term conditions, neuropathic pain or a pituitary tumour...which explains all the patient charities jostling for space and attention. Does he who shout loudest get the biggest slice of the pie or is about which celebrity you have to back your cause? Stephen Fry beats Amelia Lilly hands down any day...does that make mental health more important than Type 1 interesting conundrum indeed.

So how about we actually throw open the gates indeed as regards tariff? Not talk to patients in sanctimonious terms as to how we "all should work together", how "its about the process", how " we all need to come together"..and actually showcase the financial problem we are in? The master plan that we, as doctors, managers can manage finances has clearly not worked, so why not open the books to patients...perhaps they may come up with suggestions we haven't thought about? I certainly have no clues and I can assure you nor does the majority of leaders in the NHS. 

The financial grapple is something all Chief Executives and Finance Directors worry about- without any obvious solution in why not try something different? I for one, would be up for it..invite patients with diabetes and open the departmental budget up- show the challenges, ask for ideas and then perhaps we may have a way ahead. If not, at least we would have stopped fuelling expectations that we can deliver everything. If any patient organisations are up for this...lets try it out...could be an interesting 2 way experience. 

But continuing the way we are without actually explaining to patients the financial nitty gritty, simply spouting grey terms that financial problems will be overcome by "tackling inefficiencies" is wrong and will go nowhere to facing up to the challenge this country is about to face. You think you have a problem now? Forget the "spectre" of privatisation...there is a bigger problem at hand...simply put...the money is running any help from the users of the system should be grasped with two hands, if offered.

The question is...we talk about patient much do WE seriously believe in it?

Saturday, November 16, 2013

Game-changer III: Ward priority and transparency

So we all want to run a hospital smoothly as regards patient flow, don't we?Then as part of the Game-changer series, may I suggest to leaders to step out of the power points, step out of the meetings where they keep reading and listening about regular senior review of patients and actually make it happen?

We talk about regular senior presence, so why isn't that a core part of teams job description? Lets be bold, make it very simple...each team must have regular senior presence...lets start with 5 days, shall we? We want 7 day service in the NHS while we still haven't worked out how to produce regular 5 day senior doctor presence on wards, have we? Again, if the core business of the Trust is to ensure safe smooth flow of acutely ill patients, then it must be the core business of teams to have senior presence on wards each day. Consultant job plans are not that difficult, its just that most medical or otherwise managers struggle to actually get some to perform to agreed job plans, thus the need to revise the Consultant contract again. Not needed in my view, if you have the tools to be open and transparent about job plans and the requirement to be on the wards. What would the senior do? Make sure each new patient is seen after transfer from MAU, make sure all other patients under the teams care is either viewed or plan discussed with juniors..make time to meet patients relatives, and oh yes, be there for your juniors. For lots of physicians, it sounds like an alien concept, but ask our ITU colleagues, they have been doing so for ages.

In job plan terms, depending on acuity and number of patients, you need 3-6 hour per day on the Consultant contract language, that's 15-30 hours / week or 4-8 sessions/ week i.e. less than 1 Consultant dedicated to the wards to do what should be the primary reason you are affiliated with an acute hospital. Yes, I am oversimplifying it but there are teams who would rather prioritise their clinics and their procedures and leave the wards light..stick to 2 ward rounds / week.."It worked when I was a junior, surely it will now?"...cue over stretched juniors, cue no time for training, cue sick patients not having regular senior review, cue blockage in system and frustration from front door colleagues..who get frustrated at the lack of focus on flow of patients but rather on specialist work.

So, want to change the game...yes, of course primary care can do better, yes of course, community teams can pull patients quicker, yes of course, some patients who come to A&E could have another place to go to...but all those excuses a valid one AFTER all hospital teams make sure they prioritise their ward teams. Lets go one step further, make all job plans transparent..make it mandatory that all teams show commitment to the wards, show commitment to patient flow...of course it's much more attractive to go and do the specialty work such as a pump clinic or an endoscopy list...but then again, in a climate where we know regular senior presence is of such high importance on so many levels, that should not even be a debate. You do what needs to be done for patients and in a hospital, there is no bigger need than ensuring that sick patients are reviewed each day by a senior.

I am no preacher but only saying things what I have put in place for our team. A regular senior presence on the wards for our team is a non negotiable issue for all Consultants...whatever be the case, an 8 am presence is essential. Do I have other commitments...yes...a host of commissioned services within the Trust along with 2 community spare me when other specialists insist their elective activity is too much. What has that resulted in?  one of the quickest turn over of patients, a firm which consistently comes top on ratings by juniors as regards education, a team which stays within EWTD hours. Why the inconstancy all around the NHS then? Is it because we like to pamper to certain individuals or is it because we have traditionally designed systems based on what is our convenience rather than what suits the patients? Of course a physician likes to start at's because its convenient. We do so at 8 am..and has made our lives much more simpler..yes, on a social level, does involve juggling kids drop offs etc..but if you want to start the flow of patients in the hospital, you start early, not late..and certainly not when suits us.

For starters, lets do that.Make job plans open to all, make them transparent, make it mandatory that each team provides senior review each day on wards and if they are not, then do some genuine performance management...not one of those which sounds amazing, shows lots of revenue generated but doesn't take into account what the patients feel or what your juniors think of your inconsistent presence. And if individuals are not delivering whats in their job plans, then step up to the plate and find out/ challenge where  they are when they are getting paid by the taxpayers money. As regards departments who are facing increasing pressure regards elective work, my advise? Plan the wards first...and then if there is a shortfall for the wards, then try and build business cases..engage in workforce planning...but don't make the war your second choice.

In healthcare, what the patients say, what the patients need has to be paramount and for that, you make the changes that need to be done..not pander to egos, not make job plans as per individual likes.
So you want to sort patient flow within hospitals? Make some ground rules, be real leaders, step up to the plate.and deliver. That is what being a Game-changer is all about. we attend yet another meeting to hear about the more time or should we step up to the plate?

Saturday, November 2, 2013

Game-changer II : Redefining specialism?

So how bold are we willing to be? We talk about integration..a much vaunted and noble intention which perishes at the foot of tariff, multiple providers and the financial bottom line. But at least the discussions are it or hate it, you can't deny one thing, the restructuring of the NHS has brought to light some serious debate about roles, patient care...was everything ok before all this happened? Ask Francis, ask Berwick, ask Keogh...the changes have been long time forthcoming. You can disagree with the principles of no holds barred competition but the focus to give patients a voice, have safety high up on the agenda, challenging GPs and Consultants..nothing wrong with that, nothing at all. Anyone who feels these are non issues and had no need to be suggestion..don't let your political belief or ideology blur the need for some long over due debate about patient care in the NHS.

So in the Game-changer series, lets discuss acute Trusts first. Are we ready to seriously discuss the role of an acute hospital? It's an acute care hospital, so lets think about where all specialities should sit. 

I will give you an a crack football team, you have the divas, the high profile show ponies but without whom you won't actually win anything. So you look after them well and make sure they perform for the team. In NHS speak, would that be your interventional cardiologists, orthopaedic surgeons? Stop mucking around...look after them well and make them the jewels in the crown..make sure they only go and moonlight for another team when they have fulfilled their commitment to the team that pays for their salary.

Next comes the defence...the unsung heroes, the ones who actually deliver the game, each mistake NHS speak would that be the Acute Physicians, the ED folks? Again, recognise them for the hard work they put in, the long unsociable hours and make them feel wanted. 
The next thing a good team needs? Some good midfield generals...some folks who can run the show..make sure the attack and defence are connected, marshal the NHS speak, they are called Medical Managers. Train them properly, not just someone who puts their hand up, select those leaders and recognise their roles. Any successful team needs a fantastic back room staff...that would be the managers, HR, non allied health professionals. 
And the rest? You either have them on the sub bench or think whether they need to be in the team or not. Did you say a good team needed a good manager? That's the Executive team..who if good have the skills to make a good team a world beater.
Have a think...what's the purpose of an acute hospital? Its to deliver safe, efficient, kind and empathic care to someone who is acutely ill...isn't it?

So can acute Trusts have that boldness in them to open the discussion where some specialities should sit? Can we have a debate where chronic disease specialists should be? Why not in the community with acute trusts buying from them services that genuinely needs to be in an acute hospital? Would our GP colleagues develop a federated model and have LTC teams sit with them? A seamless organisation- integration not in name but in reality. Or even with community providers..a community based pathology needs to be based in the community- not in an acute Trust...that's what the refrain is- so are we bold enough to flip that model on its head? Or are acute Trusts bold enough to own the whole system and have an acute hub and a chronic disease hub?

Think of a future where bar a few genuinely acute specialities, everything sits in the community with acute trusts using services from this community hub as the patient needs. You want a mixture of specialties available as and when especially with patients living longer and with multiple you perverse "referral costs me money, so lets plod on". 
The thing that stops this is the survival of hospitals and the perverse irony is that they will possibly survive as an acute care centre if departmental budgets, job plans are all thrown into the mix and CCGs are bold enough to look at that future. Without that as long as the system have made Trusts slave to the financial margins and tariff, then they have no opportunity to innovate and we keep trying to force multiple providers march to the same beat..but in a game of competition, someone will lose as regards finances...and who wants to lose when the repercussions are so high?

So what about the unscheduled care or flow of the patient through hospital you say?....well..more on that next week..but for now...ponder that one....forget all the politics and money for a second...but where SHOULD your specialty sit..not for your convenience but what would be the right thing for the patient lost in the maze of multiple providers? In your know the answer. 

Till the next week where we throw some ideas regards an acute patients journey in a hospital...before we think what could be done with Clinical Excellence harm in dreaming, right? :-)