Monday, January 23, 2017

On the horizon...

Lets try something positive in this blog, shall we? Its a tough ask- and when you relate to the NHS, its doubly tough. If I criticise something within the NHS nowadays, I get "how could you do that as an NHS England bod?"- whilst lauded by some for being "transparent"…while the same folks turn on you for being positive- "how could you say its not all bad when the NHS is on the verge of utter obliteration?' In the cold light of day, Trump did actually win- simply by eliminating from our lives balance or a rational debate.

Anyway, let's try to write something positive- something related to the job I do with NHS England.
When I started off on this journey regards diabetes, I wrote about the top three priorities and to an extent, all of them are nicely on track. However you cut it, diabetes -for sure- has had an uplift of funding and at least in my experience, many seem to be talking from the same page. Whatever be the organisation, diabetes is up there- after spending years lying on the scrap heap. Whatever be the reason behind it, its certainly a priority and that is not a bad thing.

Around August, I gave a sort of update as to where things were at - and in the new Year, here's the next instalment! Read if you are interested in diabetes care-here's what the diabetes team at NHS England have been up to.

1. Transformation Funds: The forms for the bids (all 43 million£ of it) were finally released- and considering the extent of the work, money involved, short time spans etc etc…it has been an absolute joy and pleasure to see the number of bids from across the country. Final figures are to be confirmed but they are in excess of 200 and the work put in by all involved is simply fantastic. Much kudos to all for taking the time-and yes, much beyond working hours- to do all the work- whatever be the outcomes- this can only result in improving diabetes care across the country. A gauntlet was laid down- and for sure, the community has responded.

2. Diabetes care pathway/ model of care: This has been something CCGs have grappled for with ages- finally we are getting a pathway from NHS England- which should hopefully help CCGs/ Vanguards/STPs to get all parties to work towards it. Some clarity about different types of diabetes -especially while commissioning- will be welcome- as the nonsense of "all diabetes needs similar treatment" needs to stop if we are to improve care.

3. Digital Strategy: Plans are being formalised- and the scale of ambition is high- with a phased approach towards it. It is time for educational modules to be available online- and plans are on track- albeit admittedly it could all happen much quicker. One to keep an eye on- but a Type 1 portal with options of downloads, interactivity are all in the mix…the question is of feasibility rather than simply finance. If all goes to plan, it could be something quite exciting indeed.

4. Access to technology- continues to be high up the agenda. Ongoing conversations with Abbott re Libre, discussions with companies regards CGM/Pump access- all are happening…all I can say is that progress is there- yet its not all down to either CCGs or indeed the companies…a large part of it is education or even willingness on all quarters to adapt technology. What is the point of opening up technology to all…if the diabetes community doesn't wholeheartedly believe in it yet…or indeed have evidence of training in them? However, there is no doubting the desire on all to make it happen.

Other relevant bits have been exploring nurse education with the diabetes nurse organisation, TREND, discussing options with the Trainees via the YDEF, conversations with the BMA-GP group regards QoF- revisiting areas such as targets in frailty….many strands indeed- it's a question of which bits land- at the least. Conversations with ABPI on outcome based commissioning for pharmaceutical companies are yet another strand…it's been a busy few months indeed.

Around the corner, sits something exciting…the chance to visit all specialist centres, use data to discuss gaps, highlight good practice, have discussions with executive teams about diabetes care (remember the impossible tour? )…all in all, lots of ideas, thoughts…all to hopefully help in improving diabetes care. Will all the ideas work? Unlikely- but even if some do, that would be progress.

Its been a pleasure to work with some dedicated folks within the team…but has all of this been a doddle? Not in the slightest….want to know more about the obstacles, challenges and hiccups? Next week it is then…about "patient leaders", "structures", "interference" , "email/Twitter abuse" and much more. It's not been a picnic for sure- but progress regards diabetes care certainly seems to be in the right direction.

Time will tell whether all of this was worth the time. Or not. Till then, its all been a fabulous learning experience, if nothing else.

(With thanks to Jonathan, Matt and Jeff for tolerating me for the last 9 months or so! )

Thursday, January 19, 2017

Lost in a maze

Do you have days when you wonder whether you are lost? Days when you look at the latest email and wonder who the senders are? I do not know what is going on in the NHS but I do know there are so many organisations. bodies, people that I am utterly confused. And frustrated- as it seems they have now become barriers or yet another body- who needs to be involved- and whether unwittingly or otherwise, are now halting progress. They all seem to mean well- yet…

My recent experiences are not unique- every clinician I have asked say the same thing. Wrapped in a tinge of self importance, a title of some relevance, the many many layers of structure are simply annoying- and to the patient- they mean nothing. I am pretty sure this blog won't make me popular- but I frankly am at a stage of my career, where I am now in a "don't-care" mode. My job is not to make everyone happy, it isn't to win a popularity contest- it is to try and improve care for patients who responsibility sits with me.

Lets take Vanguards- in a politically toxic environment, where every single initiative and venture is seen with suspicion - we forgot what its role was supposed to be. At the core of it , it was pretty simple- to try and get people together. Do something basic- like work together. Vanguards were the structure established- come to think of it- what does it say about us that we aren't capable as adults to do that ourselves- that we need permission, we need a structure- to exhort us to think beyond our titles, beyond our affiliation. Many moons ago- a manager sternly pointed out to me that my allegiance rested with the acute Trust- as they employed me. My response that day- stands to this day- I am employed by the NHS- the Trust was simply a means to pay my salary- my responsibility sat with the system.
I always make jokes about the Super six model being the fore-bearer of Vanguards- we did one simple thing- we didn't wait for permission- we treated our primary care colleagues with respect- thats pretty much it- and oh yes, fought tooth and nail with every layer of management to get the plans approved. I do smile when I see the very people who blocked all attempts of this model now go around talking about it- or even "try to spread good practice"

Too many bodies, too many layers….trust your clinicians, whether you be part of a network, Vanguard, STP…think of it…all you are is a structure or an attempt to get people together- which in my book- can be done in a pub, in the drawing room of my house or even over a meal at the local curry house. Trust yourselves- and believe me, you don't need any permission from any structure or body. If you belong to a new fangled organisation, don't obstruct- think of whether you are now just yet another layer which is doing yet another meeting to discuss yet more plans.

CCG, Vanguards, STP, local providers, Strategic networks, Academic networks…what chance is there of any progress if all of them want to do more meetings? Stop talking, planning- go do something. Do anything- even go and fail- but just do something. Trying to fill in local transformation diabetes bids have been simply mind boggling- let along use of words such as mystifying- while trying to understand who the heck some people are- or their roles are. The irony has been stark when some of these folks have taken time to read documents written by me- back to me….stop this Monty Python circus- and let the clinicians do some work.

Final note- all these roles are on public tax payers money- at a time when we are crying out for staff at all quarters. Its time to see what the return of investment is on some of these quangos- and if there isn't, get rid of them. Because frankly, now some of them are now standing in the way of delivering patient care.

Saturday, January 14, 2017


I think its' s about time we did a collective sorry to our GP colleagues. I am tired, annoyed, angry and simply aghast at how many roads now end up at a GPs doorstep as the "reason".
I am a Consultant- and no one in my family is a GP- and I have no vested interest so lets be crystal clear- we really need to stand together as a community and more importantly, stand next to our GP colleagues. And to be honest, this is no political parties singular fault- we all are partly responsible for where we stand now. Those barbed comments about GPs, those ward chats about "GP, eh, as a specialty?", those "Huh, they deal wth coughs and colds"….at some point, it was inevitable it would cascade down to policymakers- and we have finally got there.

And I must admit, I have been in that brigade too- when does a joke stop being a joke? The last 6 years of my career has been eye-opening as regards learning what GPs do, recalibrating the understanding of the complexity they deal with- and if we as colleagues cant get past the thin layer of disdain we "specialists" do, then what chance politicians or others who don't deal with GPs day in, day out? I can actually sense the fight draining out of GPs, I hear good colleagues saying "I am done"…and this is not right. As a fellow clinician to another clinician, if it makes any difference to you, then as  Consultant, I will be categorical- there are many things we could all do better but the present NHS crisis is not down to GPs. And I am sorry it has come to this.

In 2010/2011, I ran the emergency stream in Portsmouth- and the target we achieved locally was 97.4%. Just 5 years ago. Since then we have poured resources into more and more staff, focussed relentlessly on emergency care- while the target has gone the other way- no lack of effort, no lack of process- while external after external folks have come around and tinkered with marginals- never stood up and tackled the one area which would make the biggest difference- social care funding. We have good managers, good clinicians- for whom the sole existence has become about sending someone home- or just knowing whether they can be outlied to some distant ward…we have to step back and think what exactly have we done to ourselves? This is NOT why I went to medical school- I don't want to know how many discharges I made in the 1st 2 hours of my ward round- I want to know whether the patient I discharged was safely done and didn't come back within 24-48 hours.

Process gurus may not agree with me- but frankly I don't care- because the only person in front of the family or indeed the GMC for a wrongful discharge will be me and my team- no one else. Whatever be the reason, whether it be families, structures, support, ageing population etc etc….this country needs more social care funding. Without that, this system is bust- to deny that is a bid to join the Trump administration to be perfectly honest

However possible, whether it be cross party agreement or whatever be the case, politicians of all colours, get your act together please.. the NHS boss, Simon Stevens- has come out and said so publicly- listen to what he is saying. And get social care funding sorted

In the meanwhile, to a GP colleague- wherever you are, a virtual hug, coffee or beer…for what its worth- thank you for all the work you do. 

Sunday, January 1, 2017

Compromising costs

The concept of compromising fascinates me. Totally. Especially in the realm of leadership roles. Many a leadership course/document will ask to you about consensus, the need to find the middle ground…the broader question always has been what ends up getting compromised in the end? Especially if one takes the example of health- who actually gets compromised? The management? The clinicians? Or is it the third party- about whom the debate rages- the patients? The ability to find the middle ground is always an art- but its always a fascinating thing to wonder-who actually gets compromised?

Lets take an example- lets say general medicine and the perennial debate as to "who does it?" I have and will always maintain that the wedge of fraction was sowed in medicine when someone somewhere decided to give one specialty the privilege of being that extra bit special- whether it be cardiology or anyone else. So we have now come a predictable full circle where the bulk of general medicine is the hot potato…who does it? Can we get all back- so the debate rages on…net outcome when we enter the arena of compromise is that we end up getting something half-baked where everyone gets something but somebody somewhere suffers. Some clever Cardiologist once told me "We have too many cardiac issues to resolve"- the compromise being that the others would have to absorb the extra work..the cost? The diabetes or respiratory patients whose outpatient attendances dwindle, community work suffers…we compromised, we went for a middle ground- somebody, somewhere in the health system suffered as a consequence of that.

How does leadership in health square with compromise? Is a rigid style one to follow? Is ones steadfast belief the way ahead? Well, look how that panned out regards 7 day services. A starting point where perhaps compromise could have opened up the gates to a wider debate- has now descended into utter farce. An uncompromising bullish style has resulted in even trained healthcare professionals wondering whether actually anything needs to change on a weekday. On this occasion, the suffering of the professionals and the resultant angst made no patient safer- so who actually lost or won with that style either?

For what its worth, perhaps it boils down to winning the hearts and minds- because beyond all the aggro, all the posturing, I still believe, in the most, doctors will respond to needs of patient care. There is perhaps a reason why mortality doesn't vary on weekends…to me, its perhaps down to the near super-human extra effort put in by the many clinicians battling with different staff ratios-compared to a weekday. That's good will- and no science or research can factor that in their calculations. If we want to improve anything or change a system- whether that be in hospital or specialists working in community, its about the message- and the NHS seems to have lost it in a swirl of money and politics. 

3 things are pretty important in any discussion about change- the ability to convince that it will genuinely help patients, the ability to assure remuneration of pay and the relevance of work-life balance. The junior doctor issue failed us on all 3 issues- and we are where we are. If you want to learn anything from that in an era when "woking differently" is the buzz-word- have a think how you hit the 3 points made…it may help to avoid a compromise. Compromises tend to work well for the players involved- except for the ones whose care is being debated- and that, ladies and gentlemen, isn't why we do what we do.

Just some food for thought (and some personal mulling!) for when we get back to work in the new Year. 
Want to change care? Compromise isn't necessarily the way…because compromise costs. At the end, it always does for someone, somewhere...