Thursday, February 12, 2015

The perennial question....

You work for the NHS. Sure? You work for the patients. Sure? You work for whoever employs you. Is that better? A perennial bone of frustration for many who would like variability to lessen..the debate as ever is who do you actually owe your allegiance to? The public would say "us"..we pay taxes, we pay your salaries, surely you owe your allegiance to us. Or is it the NHS? We always balk at the suggestion of something like Tesco but we partly marvel at its consistency whether the store is in Stoke or Southampton while also wonder about the monotonous nature of all the stores. Is variety the spice of life?

In an ideal world, you would think we would all be employed by the NHS and thus work to a standard. Anyone who has been in the system will tell you that's pretty much a fantasy...we do a lot of things well in the NHS , consistency isn't one of them. If ever in doubt, beyond the tub thumping evangelists, ask junior doctors. An under used resource, they,at least to me, have always known the real truth..very few work in so many organisations, very few will vouch that the level of care was equivalent everywhere they worked. Why is that? Is that simply due to variability of staff? Is that simply because of lack of leadership? Partly yes, but partly because we live in a world of competing interests, a world of different targets to hit, different financial drivers...the issue is lack of honesty about that basic thing.

Let me give you a simple example. A patient with type 2 diabetes goes to their GP, has been on 3 medications for his diabetes, the marker for control still shows no signs of shifting. What could the GP or practice nurse do? Well, in a modern world, they could, in theory, pick up their phone and ask a local specialist, who they maybe friends with,about what the next step should be. The specialist theoretically could say Stop X, try Y and get back to me if that doesn't work. From a patient perspective, that sounds cool, doesn't it?Quick, fast, efficient. From a GPs point of view, again, quick and fast as well as a bit of education on the job..and knowledge what to do when the next case with similar problem comes through.

What does happen or has happened is they get referred via a letter, gets seen perhaps by the specialists after a variable amount of time (insert anything between 4-18 weeks) ,gets a letter back saying Stop X, try Y and patient will be seen again in 3-6 months. A letter follows after (again, insert anything between 1 week - 3 months) posted by Royal Mail or whoever (Governance, who's that?) the GP or practice nurse in between trying to do everything, tries desperately to see what he or she needs to do, if nothing, file away.

Payment by Tariff pays £239 as per this years tariff ( mind: an ever shrinking number since whenever) along with £99 for the follow up. CCG coughs up..then the financial screws tighten, it dawns on someone that that's too costly, so they suggest a community service.
The community clinic does pretty much the same thing (Stop X, try Y) but this time the cost is cheaper as its on a block contract, so send as many as you want...the activity builds, the screws turn, staff get exhausted and the cycle continues.

On the flip side, if we did go for the modern option of phone, chat etc, that would have stopped the local trust getting that money, which is their life blood to survive..that drops,income drops, staff start getting off laid...the cycle is set.Of course, we would/could have a phone tariff but as any finance person knows, it amounts to tiddlywinks compared to the real deal.

So, for a change, let's be honest. There is no point in asking people to be kind, change or anything else unless the drivers change. We all, at the end of the day, work for our organisations who pay our salaries and thus will do what naturally keeps our organisation ticking..whether it's a GP surgery or an acute trust or a community provider. An acute Trust gets spanked by 4 hour target while it should be a marker for the system..we all know the reasons why the 4 hour target is failing, yet Trusts are consumed by the desire to improve their 4 hour target...while it rarely becomes a beating tool for OOH, 111, community providers et al.

The question is whether the powers that be are adult enough to actually be honest about the whole picture as things stand. Grandstanding or campaigns will become objects of derision while the basics are not addressed. Rarely if ever, I have met a manager or a nurse or a doctor who isn't trying or keen on change but if you want to impact change, then the drivers need to change first. How many managers would go to their superiors and say we don't need the activity as it can be done much easier/would be better for patients/help education but the flip side is that the organisation would lose revenue? In fact, how many clinicians would?

Time to be honest, time to be transparent, time for all to understand what pressures the "other side" is under, what targets are being asked..whether the basic question is being asked. In public forums, plenty will say it's to patients, no one else, it's to the ethos of the NHS...when it comes to the nub, the majority will always swear it to the organisation.
Today, pause, think and answer this question...."who do you ACTUALLY owe your allegiance to?" The organisation who employs you, the NHS or the patients? In your heart of hearts, you and only you will know the answer to that.

(Next week: Why radical leadership and boat rocking advice is flawed)


  1. This is a really good blog, thanks. As a patient, the bit that really resonates with me is "consistency". All the rigmarole that goes on in the background of any business is irrelevant to the customer as long as they get the service they need. I know in the Portsmouth Endocrinology department, I will get a very good service and that department works closely with other departments in Portsmouth as well as other departments in other trusts (Neurosurgery in Southampton for instance). But from patient stories I have seen on the web, patients who have very similar conditions to me, certainly have vastly different outcomes to me. Patients waiting weeks to see their Endocrinologist, not knowing how to contact the consultants, disconnect between consultants and other departments etc. Lets say I moved house to Birmingham and had to go to a different Endocrinologist in 'Birmingham Hospital', I would expect the same level of service and departmental connections as I get now. But it seems this is far from guaranteed.

    Fix this and I'd be a more reassured patient.

    1. Easier said than done of course but a level of consistency as well as information about quality of care should be available if we really believe in patient information and choice. Lets see!

  2. Every patient who walks into Tescos - hundreds/thousands of them- have exactly the same consistent experience. They have minimal interaction with staff... and less and less as time goes on. If all that was needed in the NHS was that people turned up to a building and wandered round it and left again then I'm sure we would be providing a consistent experience. But it isn't like that. Good care needs tinkering of the kind that you describe. We need to be flexible in how we do things. In fact consistency- as in everyone being treated in exactly the same way... have that app twice a year and that blood test x times etc ... is maybe going to decrease and that might be a good thing (as long as we make sure people don't slip between the cracks).

    Here's to working together... agiley!

    1. One size never fits all- the question is how keen are as a profession to show that flexibility. Time will tell for sure

  3. Wow - this is a fantastic piece and speaks to a variety of very real problems, not just in the NHS but in other publicly funded systems. Perhaps - if you asked "What is my purpose?" rather than "To who do I owe my allegiance?" some clarity would come as to what should be done. Thank-you.

  4. Thank you for your kind comments- we all work in too much silos at the moment- no doubt about that