Saturday, April 29, 2017

Brave enough?

How bold are we? How much do system leaders actually mean when they talk about having clinically led systems? It's like a moment in time when the sheer rhetoric of all that chit chat starts to grate so much that most folks lose interest. More to the point, how much do politicians or for that matter, even managers trust clinicians to deliver what's needed? The intriguing answer to that - after all my years of management at different levels? Absolutely no idea.

Clinically led organisations do goes the saying...yet how many organisations are actually clinically led is a matter of dispute. But on the flip side, there is no better time than now to perhaps road test much are managers actually ready to cease control or do they genuinely see themselves as part of a team with their job to deliver the clinical priorities as outlined by clinical teams? I am keen to test the theory so over the course of time will indeed share the experience. The problem is the more clinicians feel rebuffed when their plans or suggestions are rejected or ignored -the more you disengage how do you square that circle? How do you get the prodigals to return? Even with my role in NHS England, I am bemused by how many non clinicians I sometimes have to spend time explaining why Type 1 diabetes needs focussing on. The evidence is there, the need is there...yet..somewhere the trust isn't in a clinician.

Let's take diabetes. Many separate pots of money...let's make it simple. How about we forget all the nonsense of widget based system for a long term condition, add in all the present expenses in acute and community providers whether it be outpatient based activity on a payment-by-result for an acute Trust OR block contract to as community provider)  and look at a 10 year contract to deliver for the region some basic priorities? Let's say you give that system 10 years to improve amputation rates, improve safety, improve education, improve pregnancy outcomes....well tested principles which has benefit for patients and economic return for investment.
Stop micromanaging, give the clinicians the onus and responsibility and the task to live within that budget. Doable? Give them the onus to improve those simple markers, not blue print every single detail as to how to do it.
Get it done, learn from others...your area, your money- deliver the outcomes - engage with primary care...prove your salt as a clinician- and make sure you have a fantastic manager and financial person to help you do it.
I can guarantee you that most clinicians would relish that challenge...that is the essence of why doctors went to medical school- to improve outcomes...not to lessen referrals on a spreadsheet. Stop going for surrogate markets, let's give a timeline, a budget and the markers. Everything focussed on those markers, networks helps to amalgamate good ideas...stop branching off and doing some vanity focus only on a few key priorities.

Brave enough? And more importantly, do the system leaders trust enough? If you are a manager...go on...ask you? Are you brave enough? Does this excite you? It works on guarantees, it works on many assumptions but it does energise the clinician to deliver.

You want to change care? You want to improve outcomes? Time to be bold, time to change funding structures, concentrate on outcomes that matter. We from NHS England can certainly outline the priorities and support in delivery....but no amount of power points, articles or lectures can deliver or excite clinicians enough till you have the faith in them to deliver. Bold enough? All of these structures...vanguards, STPs etc etc give you all the structures you need. If you want to cease the moment, then as system leaders, the time is now. I can assure you there are plenty of clinical leaders in diabetes who would pick up that gauntlet.

Is the system?

Thursday, April 20, 2017

The Dubya Philosophy

Remember Dubya? 43rd President of the United States of America. George W Bush- man at the helm when the September 11 atrocities happened. A man who always divided opinion- and roundly mocked as well as admired for his macho lines of "Either you are with us- or you are against us".
To be fair to the man, this wasn't his creation- you can scour the textbooks of history and find plenty of examples...Mussolini, Lenin- heck, if you look into the Bible, even Jesus is attributed to have said..""Whoever is not with me is against me, and whoever does not gather with me scatters" (Matthew 12:30). My Bible knowledge is a bit rusty, its been some time since I was in school- so my apologies if I got that one wrong- but you get the idea..the principle isn't new.

So its actually shouldn't come as a big surprise when in our world, the same thing plays out again and again. I must admit to me now having to change my views on some things- especially that its possible for all simply to get together, have a mature respectful debate at all times. Its not. I think we probably have to best do with trying our own best- and accept there will be variations on what Dubya said- from different quarters.

I will give you a few personal examples. Lets start with the discussion about "Low carbs"- I will- someday write a blog about my own personal views on it and the evidence- but for now, I will limit it to the Dubya philosophy. I understand the passion- and also do admire the inherent belief that this is the answer to improving health. No issues with that- and as regards passion? Excellent too. I am happy to engage, debate and even ask relevant bodies to review the evidence. However, when that suddenly takes a quantam leap to direct abuse- you have to stop and that right? Do I ignore or do I try to reason? How do you reason with a racist? Or do you accept thats a part of society- a darker part- which is just an inherent side of life? I suspect that cuts both ways- if the "lowcarb lobby" can go overboard with their passion, the flip side isn't to mock them, deride their understanding of science and call them quacks either. But then again, "with or without me" seems to be a part of our lives- so maybe all sides just need to take that into stride...maybe...I don't know.

Here's another one- I recently tweeted that the actual long term condition experts -beyond the patients- are GPs- and there isn't a need to create another specialty. A generally rational discussion ensued but in between there were some suggestions of me being blinkered, short sighted, assumptions I worked only in acute trust...all these from folks who have never met me, not heard me speak and be clear in public meetings that nurses are the backbone of diabetes care. However,nurses help in delivery of care- if you had to follow a clear line of expertise or uniform evidence of training- its the GPs. (I am not aware of a standardised programme for nurses to do before they deliver diabetes care at the moment- with huge variations as to how this is done- so here sits an opportunity perhaps)
Now that's a personal view- so of course it can be challenged...why that has to translate to me being labelled as being disrespectful to nurses...I will never know. That too from folks who probably don't know that my present Clinical Director is a nurse- and am very proud of it too. It's as if there are no middle ground- you either love X (substitute X with doctors, nurses, managers) or you hate them. Fascinating.

But then again, there's hope too. A recent discussion on CT scans and acute abdomens was actually good fun. Humorous yet with plenty of good debate from all corners- so who knows- maybe there is hope. As was a discussion on a recent trial in Insulin Pumps. However, to be honest, I think the realisation sits that passion, 140 characters and instant snap judgements will never allow a utopia of calm, tranquil, mature be it. I suspect my appeal is not to go the ball, not the person-as it takes away from areas of good debate and a lot of fun which human interactions bring. I also know from the experiences of Brexit and with GE2017 around the corner, its a naive, perhaps even foolish ask- but there you go. As for me, go personal- and I mute or block you- the loss-to be perfectly honest- isn't mine.

Debate is fun- sometimes you make a statement to provoke that and make people think. Thats what human interactions should be about- and the reach of Twitter, the flat hierarachy offers huge potential. A little less of the Dubya philosophy may serve us even better.
As the kids like to say.... #JustSaying

Thursday, April 13, 2017

The Berkenheim Project

Let's say you have diabetes. Or someone you care about or look after has diabetes. How do you know the person looking after you is trained in it? To be more accurate, if you are referred to a hospital team, how do you know they are any good? Assume? Accept that it's the only place around to go to? Challenge your GP? Go online to find out? And to think about it, is there any data or information out there at all?

So let me begin with an acknowledgement to a gentleman called Jens Berkenheim. A mountain of a man but with the most pleasant personality ever- with a grin forever etched on his face. I can't quite recall how we met but I haven't forgotten his sheer energy and desire to improve type 1 diabetes care. He simply wanted to know the questions I put above. And he tried...I could only support him in those days as a clinician from Portsmouth verbally and there has always been a lingering frustration that I couldn't do more. And frankly, Jens met many a closed door- who wants to share their data with a member of the public? Blasphemy.

Many an hour of mine I have spent listening to old wise heads muttering about the care in primary care in diabetes...perhaps the biggest irony sits in the fact that if you want, you can find out a whole lot about GP surgeries and their diabetes care. You can criticise them as much as you want, but at least the data is there...transparent. On the other hand, we specialists in diabetes have....hold your breath..ah yes..not much. Is that because it's presumed we are just good? Or are we not sure enough of our data to be transparent enough?

Now I know a lot of diabetes outcomes are all about "working together" and most issues are of the "system". If someone has an amputation, the pendulum swings from "GPs don't check feet" to "hospitals don't have clinics"....but you know what? There are actually a few things which hospitals are accountable for- solely. So why not measure it? Is it because it could become a beating stick or could it be a chance to improve variation, learn from other areas etc?
Let me also digress slightly at this stage and say that my other specialty endocrinology isn't free from this either. Here's a simple example- most hospitals see pituitary you have any idea of cure rates for acromegaly based on hospital? You could and you should don't. Patient choice is such a beautifully crafted word indeed

Anyway, back to diabetes. Let's take inpatient diabetes care. Should a patient with diabetes know how safe or not their hospital is? Data is there...yet not public. Why not? If I had type 1 diabetes, I would like to know what are my chances of getting my insulin when I am ill and not well enough to self administer.About 1 in 25 patients with Type 1 diabetes go into DKA while in hospitals, you bet I would want to know how my local hospital is doing. And if that data is public, would it drive the hospital to ensure it is doing all it is can to reduce it- or even get to mean if it's an outlier?

Then there is the issue of pumps and technology. Again, if I had type 1 diabetes and wanted a pump, I would like to know whether my hospital provides it and if they do, whether there are trained people there. Wouldn't you? I wouldn't want anyone experimenting on me- neither would I want anyone who has done a weekend course in Kings or Bournemouth doing it as part of their 5 year why not make that transparent too?

2 simple examples...but you can see why the time is right for diabetes centres to be "benchmarked". Whether it be the simple issue of patient choice, transparency, reducing variation or even to get to par with our primary care colleagues, the need is there. The key however is to ensure its seen as a tool for improvement not as something to wave a stick at. It's part of modern medicine that we should be brave enough as diabetes specialists to back ourselves, our training and be open enough to acknowledge poor care and work to improve it.

So with a thank you to Jens, the question to my diabetes Consultant colleagues  is....are you ready for it?

Sunday, April 2, 2017

Astute or Risky?

Half glass full? Or half glass empty? It's sort of like a perennial question to anything that sits in front of us? Born optimist? Cynic? Or a pragmatist? I suspect a lot of this runs through our lives- with the pessimists viewing the optimists as skippy,happy people without any sense of realism while the optimists see the pessimists as harbingers of doom, mood-hoovers who simply obstruct progress. A pragmatist is rare to find...and certainly difficult in the white hot emotionally driven atmosphere when it comes to that ethereal religion, the NHS.

Which brings us to the latest report from Le Beard, Simon Stevens. Now you may or may not like Roy Lilley for his views but in one of his blogs, he absolutely nails it when he says that you need to make your own mind up about the report and not be guided by others prisms- whether it be of politics, deep seated dislike of anything from private sector or indeed the basic need to suck up to the head honcho of the NHS- due to a desire to get in his "good books".
So here's my personal take- and let me remind you once again of the word "personal". It's not policy, it's not a "you have to follow my view"'s simply a personal view after reading the document.

It's probably one of the most astute document politically I have seen for a long time (and no, I don't need to get in his good books, I am ok on that front-thanks) In short, the NHS boss has said, with the money we have, we can't deliver everything. Something's got to give- and he has started a debate. Now you could turn around and say that's outrageous but it's probably an astute way to make a politician sit up. For long, I have wondered whether politics and NHS could be separated- the bottom line is in a tax funded system, that is simply not possible. We have to work with the politicians, we have to try and convince them of the need to invest public money- and in case you haven't noticed? Megaphone diplomacy doesn't work much. Let's be brutally honest- we don't have an opposition worth its salt - so I am glad someone - apart from the colleges etc are at least trying something different. If waiting times go up, if public satisfaction starts to waver, the politicians will think again-maybe...or so goes the theory.

You could turn around and say how could one use patients as pawns- there is that- but how many times have we said either we increase funding or we start having a debate as to what needs to be prioritised? We, as a clinical community, have baulked away from the prioritisation, so I for one, am glad that at least the debate will hopefully start in earnest.

Let's look at the other side- we have a clear prioritisation of emergency care, mental health, cancer- and I don't think there can be any arguments about that. Mental health has been ignored long enough for Cinderella herself to get a complex and it's about time, it was given the front loaded approach and priority it deserves. The message is clear- NHS England has a set sum of money and with that, there are some priority areas.
There is a clear message to continue support for Vanguards aka new models of care as is the desire to get systems working together whether it be in shape of an STP or Accountable Care system. For starters, that's good, as I am tired of folks demanding return on care models within 12 months. Let me be crystal clear- folks tout our local diabetes model as an example of "working together"- it took us 5 years to show benefit. 5 years, ladies and systems take time especially when dealing with population based health...we need to get out of the premiership football club mentality of sacking the Chiefs if nothing is delivered in 12-18 months.

Finally? The 18 week target. Yes, it could potentially make folks wait longer. Yes, it could make private work go up- (just a pause too to reflect that in lots of cases, it will be NHS Consultants doing that private work, not someone from outer space) but could it also be the opportunity for specialist societies to step up to the mark? Will they be brave enough to prioritise procedures based on evidence base rather than some national whim or a charity backed public push? Do all procedures need to be done...many questions...but at least they are now open. Ask acute medicine colleagues around the country how many times they have heard that an "ology" colleague couldn't possibly help out -in spite of their general medicine accreditation- as they had an 18 week target to hit. Well, maybe time to assess which of those procedures are now a priority when your hospitals front door is creaking and some, nay, any help would go down a storm.

So, yes, risks indeed- and Stevens is putting himself central at it- while making it clear to the politicians that this will have quite possibly a public bearing too. With the money there is, we either provide an average service on everything or we prioritise and provide a brilliant service on some- while putting pressure on the purse bearers to fund the bits which are slipping. To me? It's a brave call with lots at stake- and for that, credit where deserved. It could be a defining moment for the NHS depending on the response it brings from politicians in next few funding cycles. In the end, the ones who cry foul maybe right- it may also open the door for co-payments- it indeed is a high stake call- but something has to give. It is not in the NHS executive teams gift to increase taxes- that sits with the government

And to be honest? If you don't like the path taken, try and see whether you can try and galvanise a political opposition to challenge. Because that's supposed to be their job, not the role of the Chief Executive of the NHS.

As the saying goes…"We live in interesting times".