Saturday, August 23, 2014

Pied Pipers

Fancy a trip in a time machine? Why indeed not? If you ask around, then most agree the past was better, something about the present never seems right, the oft quoted phrase.."In my days"...so hop on..and let's zoom back to 2004.

The venue: Royal College of General Practitioners. Occasion? Discussion of diabetes care. In the audience- the who's who of diabetes care, discussing how to improve diabetes care. And times were good...there was money in the system and there was,evidently, big need to improve diabetes care. There was a recurrent theme- it was time to break the stranglehold on diabetes care of the hospitals, the Consultants. I was there, a junior Registrar- listening and trying to understand the politics of it all. And then it happened. A GP stood up, announced his title (quite impressive, more so perhaps he claimed or perhaps did have the ear to the "policy-makers") and said this.."I cannot see the point of having diabetes centres- all that resource should be in primary care". Lots of debate ensued but interestingly a lot of GPs in the room stayed silent....was silence a sign of acceptance? The revolution had begun.

Let's zoom forward...its 2009...one of my first public meeting with GPs in our local CCG...we intended to float a new way of working..Partha Kar was the new kid on the block- and it was part of an overall area wide strategy session. Loads of GPs in the room, lots and lots of important and grass-roots in there. I sat in the background- waiting for my session- and then my name was called out. I stood up- and recall having to walk the length of the room..and all I could hear was a murmur. Not many had met me then...and as I walked, you could hear the comments with little effort to hide them..."Another new plan eh?"; "Must be about protecting Consultant patch"," Who is this boy?"..a slight gritting of teeth as you walk up- the mantra in my head buzzing firmly..."Work with them, I must make them believe"...Got to the stage- and the GP leader turned around to the audience and said " Partha will now explain the point of having a diabetologist" with a smile, nay, a smirk. Disdain? Perhaps. Disrespect? Perhaps. Ignorance? Read on and I will let you decide.
My answer back was simple.." How's your skill at working with pregnant diabetes patients?" Pause..nothing much back.."Or for that matter Insulin pumps?". A moment of silence followed by.."Well, I will give you THAT". A murmur rose again in the room. We continued, we sparred, we debated and the birth of our model happened..but the majority stayed silent.

2010...an evening meeting with a group of GPs...explaining our model..and a lady introduced herself..again, another grandiose title, another leader..who opined that the new Health Act was finally the "time for GPs". The years of underfunding was now past...the time to strip hospitals bare was here now..to fund GPs. I smiled and wished her the best. The other 7 people in the room...stayed silent..looked uncomfortable...one mentioned something about the importance of a local hospital...but then concentrated on her drink. 

4 years later, its now pandemonium city. Leaders have tried their best to create pathways, create tramlines which restrict the type of patients who can go to hospital...they now need to go somewhere- so the GP surgery it is. The expected holy grail of money follows the patient remained an El Dorado..and suddenly the patients were there, the money wasn't. Diabetes was a prime example, perhaps even a forbearer...extrapolate that to all specialities and why is anyone surprised that GPs can't cope? Pathway to refer back also closes with clinics being disbanded, so where indeed does the patient or the GP go? 

5 years taught me a lot in management...what it also taught me how the silent majority are not part of decisions made. The fault lies with both- self styled leaders who dictate for others as well as the majority who chose to stay silent..perhaps even keeping the faith that resources would follow. Diabetes care has suffered as a result..there isn't even resources or time to do simple 9 care processes (just wait till the recent National Diabetes Audit comes out- makes for woeful reading)..let alone anything else. In the main, diabetes care is delivered by practice nurses- and by god, they are struggling. Struggling to even do basic stuff, let alone do professional development, keep pace with the changing times, new developments, evidence based medicine....

So to all leaders who ask for "more GPs"...that will solve little. There is need for increased resource in primary care, time for education- and perhaps even think of specialists in primary care. More importantly, it certainly is time to stop leading GPs off the cliff by agreeing to yet another pathway which is designed with only one intention..less patients for hospital. That has little or nothing to do with patient care but translates to more work for primary care with little added resource...if you don't understand that simple economics, then drop that title, stop attending the meetings and go help your colleagues in their day job. The rest? Stop being silent..otherwise that cliff edge now isn't too far away.

Next week: "The Leadership gravy train"

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