Saturday, March 26, 2016


Its a tricky conversation to have. Can anyone else do your job? Doctors are always caught in a bind- in fact- even within medicine, people find it a tricky conversation to engage in.
Lets say you say "No, I don't think anyone can"- you run the risk of it being a comment laced with arrogance. If you say "Yes, I think they can" - you run the risk of being asked what exactly is the point of having "you". Factor in then the discussion about evidence of quality of care, the cheaper labour and suddenly as ever, a sane discussion loses its thread and becomes embroiled in idealogical discussions.
For a moment, I am going to ignore the uninformed ones who spout their views without any basic understanding of medicine. I don't grudge them that- whether they are journalists or just opinionated hacks, in a democratic country, they must and should have their right of opinion- however ill informed they maybe. I pass opinions on how Klopp should run Liverpool- that neither makes me someone with credence on that matter, nor someone to be taken seriously. Its an opinion- which is and should be open to debate- at least in my view

Lets focus on those who are in charge of NHS policy- and hopefully better informed. lets focus on health care professionals who are of the view that doctors and nurses roles can be done- partially or fully by the alternates- a different grade of professionals. The question is many fold- are they trained? Are they qualified? Will they deliver same quality of care? Or are they just lesser paid than us?
It's also a question of what history teaches us- or what we, in the NHS chooses to learn from it.

About 10 years or so ago, the cry was to move diabetes into the community- because it was "simple". Because "anyone could do it". Sorry- GP colleagues- but at that time, many GP leaders stood by that - wanted it to happen- the sheer volume arrived but as time went on, GP colleagues understood the sucker punch they got delivered. The patients arrived- the money didn't.Whatever be that policy merit, today 10-15 years later, a majority of diabetes patients don't get their basic checks done. Slice that data anyway you wish- but its not really that fabulous.

Would specialists have done any better? Maybe not.Should they have taken the initiative at that stage and engaged with primary care better? Perhaps- and many ifs and buts- but the sole reason for that "Move into community/Anyone can do it" was down to one thing only- cost savings or cheaper labour. People who didn't necessarily have the required training or finances were asked deliver the impossible. Cue where we are today. Are primary care trained in Type 2 diabetes? Much better than the past and an ever improving feast. Are they trained at any stage about Type 1 diabetes? No- categorically not. But the drive to push patients into community/save money gave us variable care throughout the country. No one made any distinction even based on training of the professionals- it was all about "Move it out".

The fault for that? Didn't sit with the policy makers- in my opinion, it sat with us-as a community- where instead of playing our own siloed cards, we should have asked for assurances regards safety, primary care should have been clear about resources/support etc. We didn't- and we are here where we are.
So can others do our jobs? Of course- anyone can- with the appropriate training. Reducing cost indeed is an important plank- but not at the expense of quality or patient safety. The aim to reduce cost now could potentially translate into further costs down the line via errors, lesser quality care etc.

I will finish by a simple example- as a specialist, I do NOT see myself seeing every single patient with diabetes. I however do see the value of a specialists seeing patients such as antenatal diabetes, foot diabetes etc- as I don't want untrained people having a "crack at it".That's not arrogance- thats simply being clear about my skills. We talk a lot about airlines and their safety- I am pretty sure no pilot would be hesitant about making it crystal clear that the flight attendant may not have a go at it.As a specialist, beyond the specialism, I do have a role as an educator and support for 1 care- guiding others- but there will always be bits that no one else can and more importantly should do.

Can the alternates pave the way for the future? With the training. quality assurance -perhaps so. However, if money is the driving factor behind that-at the expense of compromising patient care, then as a healthcare professional, its not cockiness to raise a dissenting voice.

Its a thin line between confidence and the saying goes.."Arrogance is thinking you are above everyone else; Confidence is knowing no one is above you".

1 comment:

  1. Your first couple of sentences hit it on the head. Some of us are too protective of our specialty bubble to think that anyone else can do our role. Also that this probably is driven by limited resources and that frustrates us into thinking that quality will suffer.
    Saying that, the resources issue we just have to accept won't go away. It's up to us as specialists to manage this change in a way that quality is preserved and that we're only involved in the real speciality stuff.
    I know in my heart that a lot of my workload is routine and workaday and could be done safely by a junior or skilled AHP, this would free me up to do the nitty gritty as per my specialist training.
    From some of your tweets it seems like you'd be prepared to give up the (?fat, boring, lifestyle induced) type2 DM to primary care and retain the (young, intellectually challenging, possible future cure) type 1 DM within your secondary care ivory tower. I'd argue that most of each group, once diagnosed, established and planned could be managed by suitably trained people in primary care. Leaving you to deal with (if they still use this phrase) the brittle ones.
    The real question we should be asking is "if we're going to send all this out to primary care (from every specially) then how the devil can primary care cope when they're spending all their time shovelling cases in the secondary care direction?"
    The answer may lie in what have been termed mcps, multi spec community providers