Saturday, January 31, 2015

Time to learn's done. And heck, it's been a long goodbye. July 9th was when I asked to be relieved of my position of Clinical Director of Diabetes- but as ever, man proposes and the NHS 6 months and a bit later, its finally done.

It's been a fantastic ride- highs, lows but more importantly a superb learning curve- not a single experience, good or bad has been wasted. Much has been achieved and I have spent much time on my blogs eulogising the team I have been a part of, our local commissioners who have helped, our executive team who have supported- so I won't rehash that.When I started as the CD in August 2009, I was told one thing by my senior colleague- and to this day, I have followed it which has helped us no end. He said "As CD, you are the departmental ambassador- to management, Executive team- and the sole patient advocate in meetings when daft suggestions are made from non-experts. You have one job- keep the patients at the forefront- and to do that, you do what you need to do".

I don't think I have had any better advice and you know what, I have never veered from that- the feelings of others have taken a backseat when the question of patient care has come to the fore- but as ever, the job wasn't to win a popularity contest, the job was to try and design a service which would be supportive to primary care needs, show that specialists are not just ones who sit in clinics, a service which kept patient care at the fore, was responsive to the need to have 7 day service- and one which was immensely proud of what it had achieved over the last 5-6 years.
In the history of the Portsmouth diabetes team , there have been many eras in the past- the one shaped by Partha Kar ends- hopefully history and more importantly patients locally will view it positively- warts and all.

It has given me time to reflect- the last 6 months and think about what i need to learn more about the NHS and its system. To this end, twitter has been an amazing educational media. Too often, I see everyone having an opinion about others- without actually having experience of what the "others" job involves. To me, thats an anathema nowadays- especially since I myself have been guilty of that fault in my yesteryears. I am supremely confident about my abilities- time and experience has allowed me to realise that doesn't actually extend to knowing the ins and outs of challenges others in the system may have.

So having a look through my own career- so far, I have been a provider within an acute Trust, a provider within a community Trust, a manager within an acute and a community Trust, have a role within a prestigious think tank (Kings Fund) why not broaden the horizon a bit? As ever in my book, nothing gained till have indeed taken the plunge!
Have recently joined a CCG board (Ascott & Bracknell) - and been to one of their meetings- which simply for me, has been nothing but an absolute experiential joy...felt like a kid walking into  his local comic book much to see and read, so much to..enjoy! Early days but I intend to enjoy this role- it's easy to criticise CCG boards or anyone who does commissioning- would love to be in a better informed place rather than simply criticise

The other body which everyone seems to have an opinion on is the CQC- I do see diabetes errors as a regular thing- reflected in the National Diabetes inpatient audit- a year on year exercise without a huge improvement noticeable...I would love to be able to understand how things work within the Diabetes seen as an important patient safety issue, is enough done to challenge Trusts, is enough done to protect patients, what about 7 day service etc much to learn, perhaps even advice the CQC about where to look...I hear those who say CQC isn't sensitive enough, not robust enough..well internal processes haven't really helped to reduce simple insulin errors - so why not see whether this national body can help improve the care of patients with diabetes? So join it is!

In between all that, the clinical work continues- just for reassurance- as at the end of the day, thats what the taxpayer did pay for to train thats my work, thats my love, thats what is my day job.
Exciting times indeed ahead- new arenas to explore and learn about- this isn't a year to do something special - this is just the time to learn.

Wednesday, January 21, 2015

Seven. I did a quick headcount as I sat down. There were seven GPs in the room. The there were GP trainees, the practice nurses, the practice manager, the community diabetes specialist nurse and finally me. It was the regulation biannual visit to one of our local surgeries..Swan surgery in Petersfield to be part of our diabetes model of care. And tell you what? A few hours whizzed by.

It was actually fun..and those hours had everything, chat about patients in whom everything else had been tried, discussion about evidence of new drugs, chatter about the condition of pre-diabetes, review of an audit, talk about the difference between type 1 and type 2 diabetes, suitability for an insulin pump, the services available...and you know what? I go back to again the same was actually fun. There was light hearted banter amongst all, there was a GP amongst them who worked for the local CCG who took a few jokes on the chin, we joked about how who was the busiest..and we did so over lunch..we talked about patients, we talked about improving care, we talked about the next steps...and in case you missed it...Yep, it was fun.

Why do I share this with you? Simply to also give you a perspective that not all GPs are entrenched and want "more GPs", not all simply say "it's too much"...there is a huge carder of them who actually are very VERY open minded about working..differently..appreciate the help specialists can give..stay away from the sarcasm laced comments about "you can't do my job" and actually are bending over backwards to work with different quarters of the system to make care better, looking at different ways of delivering care.
To those who form an opinion about primary care based on social media or the general media ( or even the generation next who aren't sure about taking this profession up) , let me offer you a counterbalance. There are two extreme opinions in the is that they are lazy fat cats who earn in the most six figure salaries and form the top 4% of the earning population and don't do weekends or out of hours. The other is that they work day in, day out, and are drained to the hilt, on the verge of quitting and work in a battle zone . The reality is that both those extremes do exist but the majority sit away, as with any debate, from the extremes.
Where do I base that opinion from?Locally I have had now nearly 5 years experience of working with 83 GP surgeries along with travelling up and down the country discussing with primary care and meeting GPs everywhere you can name.  I don't know whether its just by coincidence that I meet nice people or we are just blessed with good primary care colleagues but I have yet to meet the snappy ones who offer judgements or opinions in 140 characters and will not brook any further debate or care to stick to the archaic terms of "primary care" and "secondary care". Hospitals are part of the community..lets get that fact straight. Not separate.

Just to emphasise that Swan Surgery wasn't an outlier, this week I also visited Denmead surgery...again, 4 GPs in attendance, practice nurses, practice managers, discussion over lunch, reference to studies, discussion of Yudkins controversial talk on pre diabetes ( check it on's fascinating), chat about clearing up the confusion for type 1 diabetes patients as to where they should have their essential health checks done if under hospital care...what can I say? It was fun, it was enjoyable, it was a privilege to be out there amongst such fantastic GPs. Did we jest about those letters from secondary care? Of course we did..but not in anger, not with was more with a need to ensure we do get the process right. The best decision we ever made as a diabetes team was to decide, apart from the super specialised bit, not to do clinics in isolation in the community. It has been an amazing experience working with can never discount the human touch, the education provided by face to face ..and that's a 2 way education..respect doesn't come from reading documents and stamping your foot harder, it comes from talking to a fellow professional and understanding that all at on the same side, just with different skills.

So, you know what? Try it, try going to GP surgeries and vice versa..make your OWN opinion about GPs after meeting with them. I promise you one will be fun. It has been for us over the last 4-5 years and to the question what has the super six model of care done? Outcomes are come slowly...but it has done one fundamental has shown us the value of GPs and specialists working colleagues...while having some fun along the way.


Tuesday, January 6, 2015

To clarify

You must have noticed it, haven't you? The words that were uttered in black humour, with a wink and a dash, words which were said in closed quarters at the end of a busy day, words which came forth over the nth's all quite openly spoken now. It's the patient..or rather the fault of them. Their fault they waste doctors time, nurses time, ED time..inappropriate, awful, wastage of precious time of healthcare professionals. Trivial issues brought dare they ask for help.

And it opens a Pandora's box, doesn't it? We have all seen the patients we deem are unsuitable, the drunks we have encountered in ED queues, the ones who forgot their prescriptions and needed better planning- but in a system which treats millions- the question has to be what proportion of that are what we term as "time wasters". We ask, no, demand that the public should look after their health better and bother us less, yet how many times have we followed the mantra of regular exercise and the healthy diet we are so quick to profess? As a Diabetologist, I look at HCPs everywhere and can only say this...practicing what you preach ain't easy, so why be so quick with the judgements? Some of the recent Twitter exchanges have been uncomfortable..challenge is good but with respect too, right?

It's a difficult argument and there are many fold reasons why the system is creaking but from my own perspective, blaming patients ain't gonna quite help. Making people feel guilty about coming to see a healthcare professional ain't the way ahead in my book. I have recently been to ED and yes, I have seen folks who perhaps could have gone "elsewhere" but how is it their fault that we have so many avenues to access when ill? How is it their fault if 111 follows an algorithm and goes down the risk averse route to send them to to ED? How is it their fault that the out of hours GP is too swamped and has a waiting time of 6 hours to see them? Blame anyone, blame ourselves for not being adult enough to work together, blame leaders for never quite getting out of their silos, blame politicians for not being honest with the overall situation, blame anyone but don't make people feel guilty about seeing us.

I write this with a bit of sadness after recently seeing an elderly lady who tried to stay away from GPs and hospitals while trying to manage her COPD. She said she didn't want to bother her overworked doctors, she said she had read a blog which said patients needed to self manage better. You know what? The message maybe the right one, but that is not the patient we are trying to educate, this is the wrong message gone to the wrong person. What do we call her now? Stupid for not understanding the message of the article? Or kind for trying her best to help out her poor doctor?

I urge all to be careful with the rhetoric. It's easy to shift the blame, easy to blame all...let's leave the patient out of this one, shall we? Today, categorically, via my blog, let me be crystal clear. As a Consultant in Diabetes and Endocrinology who works across organisations, any patient who is under my care, I do NOT want you to feel guilty about contacting me. I do NOT want you to feel you are disturbing my peace by asking me a question which may keep you safe. I do NOT want you to go without your insulin if you have lost your pen and then worry about disturbing the overworked doctor. If you want help, email or text is easier to do rather than you being admitted in ketoacidosis. If it is within my power, I will help. I cannot speak for anyone else, I certainly can't speak for GPs who are far busier than me but I can certainly speak for myself. If you are stuck, call me, email me, leave a message with our administration staff, I will help to the best of my ability.

Let me end with a disclaimer too. This isn't a blog lecturing others, this isn't a swipe at those once-motivated individuals who feel so beaten by the system that they have now turned part of their ire against patients. This is to simply establish one thing publicly for patients under MY care. I don't want anyone admitted because they felt I needed a bit of respite. If it's an inappropriate request, I will point it out with humour and a smile. In 2015, I am trying my best to be more mellow and smile a bit more.
As the saying goes..everyone is going through something you don't know much about..and no one speaks on my behalf when they want you to "go away". Amen

Thursday, January 1, 2015

The mirror of Galadriel

1st January's that day of the year when you think of what's ahead, what could be, what may become. In the world of Tolkein, there existed such a device..a basin of water used in the Elven realm by Galadriel that could possibly show things that were, things that are and things that yet we dare to have a peak? Do we dare to have a look at a possible future and either batten down the hatches or do we step up to the plate and try and change what we see- beyond 140 characters, a vent in a blog or pledging on a wall? We shall see, won't we?

Let me have a peak though..let me see what I think may happen - if not over the next 12 months, but over many more..

1) Hospitals- unscheduled care will continue to swell, flow will become even more difficult, realisation will set in that all across the land the 4 hour target is unachievable. We shall all seek for the one who bears the ring- many pretenders will arise- alas, it won't change. It will no longer be about flow, it will be about acuity. ED staff, acute medical staff, ambulance crews will continue to buckle. they will step up to the plate one more time, one more day, hospital status alerts will stay at black mostly...the age of Sauron is upon us. Within hospitals, apart from those taking the heat, plenty will pay lip service, we will have a few stepping up to help, the rest will continue to do their specialist work. Social care or lack of it will be the critical reason why hospitals stagnate - the managers will look that bit more battered, a bit more frazzled- pushing the staff for a bit more while in their heart of hearts knowing there isn't much else to give.

2) General Practice - the pressure will ramp up- times are not going to change. They will ask for reinforcements but this time, the reinforcements may arrive to Helms Deep- perhaps a bit too late. The entrepreneurs will make hay- take over neighbouring surgeries, start employing Consultants, be innovative- the rest will get angry, distraught..go to work one more day- asking for one more effort. The natural instinct will be to lash out..hospitals, specialists, politicians, patients...the mood is dark, the forces are restless but there isn't much to stop the heat. A few rebellions will erupt- countered by the few entrepreneurs while the majority will go to work- one more day, one more effort to bring. One leader to unite them all, one Aragorn? Not quite visible in the mirror, yet.

3) Specialists - have been mostly quiet in the ensuing chaos but this maybe the start of them - either by choice or force, being asked to explore other avenues of work. Those who do private practice will CCGs cut off or restrict certain procedures, they will do more of those in the private sector. A few will rise to lead hospitals taking control of a system where primary care is rudderless and without will be the age of the Trusts..otherwise known as PACS. They may will become vital commodities- as entrepreneur GPs and Trusts battle for their services- whether doctors or nurses.

4) CCGs - Purse strings will will be all about relations with them. Payment by results will continue to drop and evaporate thus forcing Trusts to look at different ways of doing things- some silly, some fantastic. CCGs will become more powerful as they come into their own- look at working together with organisations like Public Health etc to form ideas..some silly, some will be up for grabs..entrepreneurs will flourish, Trusts will either join hands or take each other over. The time of the Entrepreneurs is here.

Finally, there will be an election...and irrespective of colour, hue or whatever, the above will stay the same. Next 5 months will be silly season, making promises which will be unachievable. We have rejoiced at Stevens ask for £8 billion...we have forgotten the £22 billion of efficiency savings we have been asked to make. No one has the answers, no one actually knows the way out of this...and no one has even breathed a word about increasing taxes...there is a tacit understanding that this efficiency savings will need to come..from us.Ladies and gentlemen, there is no white  wizard coming post May- there is no game-changer in the offing.

So...keeping to the Tolkein references, remember this..what Frodo saw in the mirror of Galadriel didn't come to pass in the end..we all know what he did to stop that happening. The key however was needed folks from different, elves, hobbits, dwarves to come together to make it happen. The question is whether we, as a whole, can come together, beyond the " I am special" argument and make it work. Singularly, all those visions in the mirror will come to pass. Together? We may just prevent it.

Time's ticking, ladies and gentlemen, Make any resolution you want..but better include the one to join hands with another beyond your own "clan". As Gandalf says.."The board is set.The pieces are moving.We come to it at last, the great battle of our times".

Have a lovely 2015, won't you?