Thursday, July 30, 2015

Harsh reality?

Florida. Atlanta. New York. 3 cities with a difference..3 cities where 2 weeks whizzed by..away from the hustle and bustle of work. Not quite away from the NHS though...Twitter provided a harsh reminder of the emotions and issues always there at the tip of the fingers. The last few weeks have witnessed a storm of opinions, thoughts, blogs, open letters...the views of the medical profession has been there for many to see. Angry, hurt, disappointed...some say out of touch with the public, to some that bit being immaterial.

Taking a pause, how actually does it affect Consultants if the NHS ceases to exist or moves to a 2 tier system.a system let's say which say has an NHS NHS you can access only via co-payments or top ups. The very concept makes many froth at the mouth, their heart churn but anyone worth their salt, deep in their hearts knows, financially at the very least, we are in a situation which is nearly irrecoverable. The money doesn't stack up anymore. Yes, you may not agree with that but there is also the minor issue of the electorate mandate.

The evangelism of a few, however right at the present, will ironically, perhaps supply the ammunition to break the back of the NHS will history judge them? Time will tell. Today's patient safety advocates have opted to go for the issues of patient safety first, ask for resources later. Todays news as regards NICE U turn should come as no surprise- the money simply doesnt stack up.
Tomorrows ones - hopefully- will be at least bolder - at least raise the issue of prioritization and resources first. Only then maybe, just maybe, we would avoid the issue of better-staffed wards but financial balances in the red. Did you say money shouldn't matter when patient safety is at hand? Ah but it does...ask any Trust or CCGS finance directors. To fund X, they have to cut Y. To YOU patient safety maybe paramount, to someone else, having psychology support for their diabetes maybe of a higher priority. In footballing terms, to aspire to win the Champions league is laudable- maybe you need to have the resources (and talent) like Barcelona to do it. Pure talent or will rarely cuts it- in any sphere of life.

So how would it affect those recent pantomime villains called the doctors? In a business called health, in a world where we are worried about our future, worried about dying, worried about growing old....I will allow you to make your own conclusion to that. Free from the "trappings" of a public funded structure or the "dreaded efficiency", only one thing for all irrespective of ability to pay. Thus, it is with a incredible dose of irony one notes doctors trying to resist the slide of the NHS..spun today as the pantomime villains trying to protect their salaries and could also be about the strongest force trying to raise a united voice against the inexorable slide at hand.

The doctors with their entrepreneurial sides will in fact, most of them already an open market, their skills or whatever you want to call it, will be unbounded, unfettered...would you bother about who was suffering due to inability to pay or would you worry about how much you can earn? If that sounds like blasphemy, do pay a visit to other countries where concept of "free health" is met with raised eyebrows and genuine surprise. Some will struggle in isolation, opting to stay true to their ethos of "help others at all costs" while the majority will fall in line with the 2 tier NHS...that's called life, that's called making sure your own family is provided for, that's called reality. Sounds harsh? Maybe YOU wont do itbelieve memany will. Do patients needs come before your own families needs? Think about that

That's exactly what has happened or is happening in other countries...UK will be no different. I also do appreciate many believing that morally it would be wrong - however when I did raise that argument to Mexican chap a few days back, his response was curt, waspish but perhaps true too."A country which has spent centuries plundering other countries maybe shouldn't lecture others on morality". All about your viewpoint, isnt it?

So why do I write this particular blog? Simply to ask one more time for some semblance of unity- amongst doctors for starters. Too many divisions exists- on lines of what we do, what CEA awards we have, whether we do private practice or not...maybe it's time to try and get a united voice. Then it's a bigger gathering of like minded voices...and that's everyone who firmly wants the NHS to survive as it is.

Let your passion to improve the present not destroy the future, let your own prejudices towards your colleagues not hamper a united voice...for tomorrow if the system changes, it's not the doctors who will will be many more who will.folks not born with the fortune or luck fate has provided them with. It's a very simple question you believe enough in it? And if so, are you willing to forget your differences?

Choose well.

Thursday, July 23, 2015

Opt in; Opt out

Before I proceed with this blog, let me lay down a few cards, especially regarding what gives me at least some mileage to pass an opinion. 

I am a Consultant in Diabetes who has so far:
Been a Consultant in an acute Trust contributing to diabetes and general medicine
Been a Consultant working within 2 community Trusts 
Been a clinical manager for an acute Trust as well as a community Trust
Work on a CCG Board
Work/involved with think tank such as the Kings Fund
Worked with quangoes eg:NHS Institute of Innovation& Improvement- renamed as NHSIQ later

Happy with that? Ok goes.

It's time now for this 7/7 debate to have some pure facts...facts based on experience of working within different formats/organisations, facts away from the raw emotions understandably generated recently. So let's get to the nub.

Consultant opt outs part 1:  Let's be crystal clear on this..emergency work has no opt outs. The NHS needs 7/7 emergency cover and that's something any manager worth his or her salt, with backing from clinical leaders, should and must deliver. There is NO contract obstruction to that. the question thus is...of people are struggling to implement what is already IN the contract, what good will a contract change actually achieve? Get better skilled managers, clinical or otherwise, not contract changes.

Opt outs part 2: There indeed are opt outs in Consultant contracts. They are for elective work. So let's see why many want to have this removed. 

The one for all principle: if no one else has it, why should Consultants? A fair point. No one is special indeed...but let's look at those who have no opt outs. Specialist Nurses, many elective clinics are run by them? Very few..some due to lack of resource, some due to lack of need, some due to lack of will. So..if we can't even implement elective work for those who have the opt in..what good would a contract change do without the investment? 

Financial: weekend elective work is indeed done- at a cost. Consultants and others involved are thus paid higher rates, as negotiated locally. This costs more and thus is an issue. But it's an issue because the Trusts are running out of money and need more elective work, thereby money..while they get beaten over a rack when the targets get missed. Why are targets getting missed? Because the surgical beds are filled with medical patients who can't go home due to lack of funding in social services etc. Cue last minute surgical lists cancelled, cue targets being missed, cue waiting list initiatives. How vicious do you want a cycle to be?

Political: negotiation tactics always involves decrying the other side( especially when it's tough) and painting Consultants as the pantomime villains plays to the classic view of decrying the higher paid individual. I have no issues with that but that's slightly underestimating the faith and belief other colleagues within the NHS have towards Consultants too. Anyway, it's politics to try and force the other side to the table..weakened by public pressure...the problem is you need the Consultant to deliver the force or contract battles, you can achieve only so much. An engaged Consultant or for that matter anyone will deliver far more productivity..and accusing medics of not doing something they have been doing for years, has somehow brought many warring factions together.
I am also aware that there are patients who fall between emergency and elective. That indeed is the case..and that is about access, about using resources differently..and no, you don't need contract changes for that. Example? Let's say neurology. Does everywhere have a 7/7 service? the responsibility for that falls on the physician on call. Sometimes it care beyond their expertise..but rather than input resources into 1 specific specialty, that's where networks come into play...for that you need organisations to think beyond their silos, think beyond their own bottom lines...that's got little to do with contracts.

Finally, to the BMA...apart from the message from last week ( I repeat, do NOT put the next generation on the line and protect the present) here's something to mull over.."You will not get what you deserve, you will get what you negotiate". Is there money already in the overall contract? Is there a place to consider the Clinical Excellence awards and making them ALL time bound? is there a place to reconsider automatic increments? Is there money there to help fund elective work where it is needed and make the savings needed which is otherwise being burnt via WLIs?

As Consultants, we have always taken pride in leading change in our services and for once, it is good to show unity. Here lies a perfect opportunity once the angst has died down and the point is make some suggestions and overtures....if not to do something which many have  struggled so turn this debate into one simple issue of "Show me the money, we are here to do what is needed". Politicians come with a mandate and are sometimes also let down by advisors, advisors who have left the coal face long ago, high on the ambition and intention scale, low on keeping pace with developments at the grassroots  Don't also forget this will also compete with safe nursing staffing as well as primary care investment. 

Finally? If indeed there is no or limited money...then we talk about prioritisation. If safe staffing on wards is indeed of the highest priority, then maybe elective work on weekends isn't. In which case, the debate about "opt outs" is just a fallacy, nothing more..and nothing less. Or shiver me timbers..are we talking about electives on weekends which a public taxation can't afford at present funding...are we now heading towards asking the public to pay for an upgraded service? 

We shall indeed see. Now THAT would be a whole different debate regards opt in and opt out.

Saturday, July 18, 2015

Its all a bit odd

Florida. A wet, muggy afternoon. Am on holidays in Disneyland...sitting by the pool as I write this. Don't worry, I am relaxed..enjoying my time off..but while the rest of the family takes an afternoon nap after yet another scorching day at the Park, this seemed like a perfect moment to pen some thoughts.

It's been amusing to see the #IaminJeremy take wings on social media...and it's always the humorous ones which make you chuckle the most..and enough already has been said about whether Consultants work 7 days or not, so won't waste my breath on it.The hard fact is that Consultants, in the main, do emergency weekend work, the contract doesn't allow you to duck out of it. Non emergency however isn't. The debate of course is what constitutes what and whether Consultants should have the right to do so or not.

As a clinician, and as a manager, this has left me scratching my head a bit. Beyond the humour and the daily mail headlines, it's all a bit weird. As a manager, take this catch 22. Hospitals are jammed to the gills, social services are bust, departments are judged based on how many discharges have happened per understandably with all hands on deck, elective procedures get cancelled. The waiting lists bulge and to ease that target, with Consultants  having power to opt out, the only way to bring back parity, waiting list initiatives come into play- and whether we like it or not, it's a headache for many in management, not to mention the financial consequence. So if only, that leverage could be broken, then it's another way forward or simply put, another part of the system creaking..another finger in the dam.

Let's take it as a clinician..let me give you an example of my specialty. Foot clinic...a requirement via NICE is any new diabetes foot ulcers should be referred within 24 hours. Most hospitals don't have even a 5 day service, let alone a 7 day service. Now if someone asks me should I do a Saturday foot clinic..the answer is "Yes..with a but". The 2 buts, at least in my case, what else do you want me to stop doing? I work on a 1:7 weekend helping to evidence patients on wards as well as ensure a 7 day urgent diabetes service is in place. Do I drop that...or would there be investment? Even if we get past that hassle, to run a foot clinic, there needs to be a podiatrist, not to mention urgent access to vascular, orthopaedics, radiology...ergo everything running like a Tuesday. Do-able? If you say yes, come to the table, I say.

What baffles me however is the stance. Politicians are rarely someone who take steps without advice and the key of negotiations are always simple...keep something up your sleeves to make sure the other party never walks away. The tone of war/battle makes it all sound very heroic but at the end of the day, the people you need are the ones you are trying to alienate. Healthcare is an oddity in the sense that without the personnel engaged, you simply can't deliver. To say in 1 hand, the days of the god-like Consultant is over and then also say that it's due to absence of a Consultant,mortality can go up is all a bit odd.

A bit of honesty from both parties..yes, the BMA would be welcome too.Or let me rephrase..perhaps a bit of better clarity. From the politicians point of view, it would, perhaps sound, much better if there was acceptance the majority of Consultants do work emergency services BUT there is now a need to discuss elective work on its all now tied in with how the non elective side works. From the BMA side, perhaps a bit more honesty too...who are you standing up for? All the Consultants or is this just about the new ones? Or is this again about sacrificing the incoming ones to keep individual bits ok? It honestly gets a bit Pythonseque when you see a Professor lecture about 7 day working, when as a junior, you have seen them appear 1-2 times a week on the wards, leaving everything else for the juniors...

So perhaps, just perhaps, all the posturing needs to ease off. It's pretty pointless to be honest- as without the finances this won't stack up. As someone who enjoys negotiations, I also understand classic negotiation posturing on both sides and the end point, as we all know, will be somewhere in the middle. To politicians, let us do our jobs..we aren't too bad at most statistics will say. Yes, there are things to improve..and to be honest, if we didn't we would be living in utopia. To the BMA, for sake of us all, negotiate and negotiate with some chutzpah and panache, not like petulant kids. ..and whatever you do don't sacrifice the incoming ones at the altar of bargaining.

Best of luck and have fun...for me? It's time for me to meet Buzz Lightyear. To infinity..and beyond! 

Sunday, July 12, 2015

What gives?

The plates are shifting...slowly and surely, they once again are moving to a head. Some sterling work by Shaun Lintern has shown that NICE are ready to publish nursing safe staffing levels -which undoubtedly will put pressure on NHS England to either adapt or reject. A political hot potato- this will indeed be a difficult one to juggle as one either runs the risk of ignoring NICE..or there has to be pretty good reason to ignore it- at a time when mid Staffs etc have highlighted the importance of safe staffing and the impact on patient safety otherwise.

So it comes to a head..and before progressing any further with this blog- let me make a clear statement- this is NOT about debating whether safe staffing is important- it is. Simple as that- no debate. Patient safety is paramount and safe staffing to achieve that isn't one to be debated. HOWEVER the question is if we have 1 pot and an efficiency drive to achieve, what gives to achieve that? The finance directors around the country have shifted uneasily with the safe staffing issue- not because any of them have any issues with patient safety- but because they appreciate the financial impact of it. Commissioners -for sure- have felt that uneasy feeling for its them who now have to decide what gives.

If we want to tackle the area of safe staffing- whether it be via NICE guidleines or whatever means- that requires front end investment OR robbing Peter to pay Paul. Did I hear someone mention about the 10 billion extra? I won't rehash the argument made eloquently by many others- but thats something that primary care needs and is about using that money innovatively. So if we use that pot, does primary care take the hit or do innovations stall? I have said many a times- this is the era of prioritisation-and the quicker we start having that discussion, the better for us all.

So let's say that safe staffing as per designated ratio is paramount- the fundamental what isn't? Is it about perspective? Is it about evangelism? Is it about personal experiences? Julie Bailey has been nothing short of admirable (ok tenacious if you aren't a fan) at her drive towards making this a national priority..what would happen if we had someone as driven, as focussed , as media savvy pursuing the agenda of let's say, health education? Would that be of a higher priority? Would that be a fundamental core- or would it be in the second rungs while safe staffing is the core issue? Its magnificently tricky.

Then we talk about evidence and investment or even opportunity costs. Lets take NICE...depends, again, on your experience and perspective. Type 2 diabetes guidelines- 2 drafts- a significant amount of money invested- as a diabetes specialist, the first draft was simply a group of individuals making a fantastic pigs ear of the data. Cometh the protest from the whole community..a fast turnaround and we are getting somewhere. Trust the organisation to look at data properly without prejudice or cost being the issue? What was that about sacred cows and our need to challenge them?

So the time is now. If safe staffing is the priority as per whatever evidence base, then lets start discussing at community and hospital level, what isn't the priority? There is 1 pot- in which there is only X amount of money. To make 1 side of that investment go up, another side will dip...what is that? Community care less important? Funding 7 day GP service less important? We need to discuss this rather than giving our views that our own area of focus is the most important.

In my eyes- type 1 diabetes care is optimal, can be improved and shame on you if you say you can't afford all. But there is also a realisation that something has to give to achieve that...which is exactly the conversations we have started with our local folks. Think what you wish for- and if you get your wish for- also spare a thought for those who haven't had their wish granted or who haven't been able to make their case eloquently enough.

We all aspire to world class care.The fundamental question in a world of finite budgets is simply....what gives? Or can you convince the powers that be to invest rather than divert.

Sunday, July 5, 2015

Happy birthday my lovely

67..depends on your view really whether it is close to retirement age or not. Has it served its time - has it got life yet in it..again, a perspective or which prism you want to view it from. On this day, the birthday of the NHS, let me be honest- I have never been in the tub thumping camp that the NHS is the best thing humanity has ever produced, nor pandered to the shroud waving camp that anarchy is around the corner and zombies are about to inherit the earth. Mostly because its pretty nigh impossible to have any sensible conversations with folk from those camps- eyes bulged, muscles straining, each camp tries to outshine each other- leaving us all wondering what exactly needs to happen to make things evolve.

Some have been let down by the NHS and mostly their anger and frustration has been fuelled by the duplicity, the effort to hide, the need to keep the truth away..some have used that as a force for good (step up Mr Titcombe), some have been bitter, angry...understandably too as the NHS has failed to appreciate the angst the loss of a dear one left behind. On the flip side, I have seen some absolutely stunning care, compassionate, way beyond the call of duty which makes one believe the old lady maybe still has life in her. Anecdotes shape our view, personal experiences mould our thoughts.

I was born in the NHS and I had the fortune to come back and meet the midwife and Consultant who delivered me.My parents always talk about the amazing care they received. Since then, I have been trained by the NHS, I have worked as an acute provider, community provider, done management roles, leadership roles, been part of quangoes, think name it, I have dipped my toe in everything the NHS can offer..and on its 67th birthday, all I can say is that it is neither awesome, nor awful.
It is good, with its warts, with places to improve...caught in a financial crunch..perhaps in an idealogical maelstrom..struggling to keep up with all the challenges thrown at it....this wasn't what she was built for but over the years, has adapted, depended on its workforce to deliver. And it still will. Will the NHS continue to exist? Yes. Will it deliver everything for everybody? No- and perhaps rightly too. We all want the best for our patients and as a patient, I want the best for the pathology I have. I am a diabetes specialist and I want the best care for every single diabetes patient I have or anywhere. Is it possible..the answer is no as I also do appreciate it competes with the care of frail elderly, mental health,social's now about priorities.

So on its 67th birthday, if we all want the NHS to adapt, then it's perhaps a time to reboot, time to perhaps think outside our own ladies and gentlemen, there is only 1 pot. When you want to generate revenue off the back of something, it will only come at the expense of someone else's need. So think- and be honest. We all had an understandable fit of apoplexy at the thought of charging many of us would go to work and stop the 1 DNA  is instantaneous discharge rule. We know why we do it...financially a repeat referral generates more pot as I said. And also spare a thought for the patient whose letter had gone to the wrong address or the GP who has to do the referral again in times of crunch. There is no point in making pledges or being energised by conferences if you can't bring back that compassionate or even system wide view to work. None whatsoever.

So on her 67th birthday, just think that to keep her going, the pot of money is one. The need to be honest is high..whether it being open to patients about what is possible or it to colleagues as to what needs to stop. Let me give you one example...another squillion GPs or Consultants won't do anything for type 2 diabetes care..but upskilled HCAs, better supported Practice Nurses and unshackling pharmacists? One budget across providers? Now, you are talking.

The million dollar question however sits with one basic you believe the NHS is worth it? We can blame all politicians for years to come...but let's never forget our own egos, our own views and vested interests also stop us from doing what's needed. Brave enough...or simply aiding the NHS down to a 2 tier system? History will judge the politicians in their own will also ask what we as professionals did too.

Happy birthday, my lovely x