Thursday, July 27, 2017

Sweet Sixteen?

April 2016...took the step of joining the NHS England diabetes team. Here we are in July 2017...sitting by a seaside in Corsica perhaps offers the best chance to look back and reflect. Many had encouraged, some had warned about the dark side, some had been openly hostile, some had said its a treacle which will frustrate. So how has it been? 

To start with, I am going to say the positives. There are some people the world of diabetes won't see much or even be aware of...folks like Mathew Fagg, Jeff Featherstone,Ben McGough and Nin Pandit etc but in my experience and view, the world of diabetes will always owe them much. The shiny public relations and blustery side is easy..I have always revelled in that space, but without these guys working their magic in their quiet, non-obtrusive way, little would happen. To me, respect is always earned- and it doesn't matter what your title says, whether it be the Chief Executive of the NHS, a trust or indeed the HCA helping you run your clinic- and these folks have certainly earned mine. It has been a learning experience and surrounded by such folks just reinforces my eternal don't have to be perfect as a simply have to have folks around you who will complement you, look after your deficiencies. 
Which brings me to my compadre, Jonathan Valabhji. We didn't know each other much but over the course of time, it is my privilege to call him my friend. We have laughed and joked together, planned together ...and in parts, learnt how to work with each other. It's been simply an amazing experience. The external facade of me can do no wrong...internally, I know that throughout my career, I have always worked with others without whom I wouldn't have delivered anything.

Other folks within NHS England...the few times I have met Simon Stevens, I have never failed to be impressed with his vision and thoughts..I haven't always agreed but that's life- what has been fascinating to see is the respect towards colleagues and unquestionable desire to make changes. Bruce Keogh has always been a favourite, and although within a sphere, he will never be seen with respect, to me, he has always been a support who I will miss when he goes- as will the wider NHS. I appreciate this may not fit some folks narrative, but that's mine- as simple as that. 
Finally, it would be amiss not to mention Simon Enright...sparkly twinkly eyes, the Lord of communications- there's always that cool banter where he knows I am someone whose ego needs pandering to...and I know he is doing it too...effortlessly. The man knows what he is doing...and I respect that...he has enough experience of handling loose cannons- and respect to him for doing that...perhaps the only one who has done so with me with such élan. 

So, what about the other side? Well, bureaucracy is always an issue as is the vast maze of NHS England. Beyond the top tier, there has always been a thin veil of "who the heck are you?" laced with a generous dollop of patronising when you come with new ideas. There's always been that bit where you have to go and prove yourself again...sort of a repeat of what the career has been throughout my life- and NHS E has been no different...perhaps it's just ingrained in the NHS DNA. 
Beyond that work wise, the layers confuse me as do the multiple chains of process- which to me, does halt progress to an extent. Perhaps I am too harsh...the last 15-16 months have seen a fair few things delivered and maybe I am just a man in a hurry. Beyond NHSE, in general, the reception has been positive- amongst the clinical community, you have the usual mixture of admiration, support, jealousy, disdain...there's always someone who believe they know better- such is life I suppose. There has been a degree of academic arrogance - I suspect bound to happen when you challenge existing bastions- but in my mind, when you have strong support from Steph Amiel, Melanie Davis or Andrew Hattersley about "approach", the wannabes can be ignored. This isn't exactly a popularity contest....Big Brother has never been a programme I have watched.

So where next? Folks asked for money - the transformation funds were delivered; folks asked for clear national strategy - the right care pathway with its 7 priorities was released; folks wanted digital interventions- it's in the starts the delivery for all, not just us at NHS England. Benchmarking is the next big thing- more on that in future blogs- but in my last sixteen months, I have had a mixture of all sorts of emotions...mostly it's been one of satisfaction. NHS England hasn't felt like the dark side, more like a body trying its best within the financial rules set - and keen on improving care. I would encourage others to consider joining in whatever role to help things improve- if my experience has anything to say, it's certainly a roller-coaster worth getting on to.

Finally, I personally hope that some of the requests folks living with diabetes have made, are being listened to- whether it be in directed use of funds or indeed in strategies outlined. And I would ask you to keep the advice coming- because that's what matters, not some clinicians individual view or an academics notion of evidence. What matters is what makes a difference to YOU and is one of the reasons why I keep myself open to ideas whether it be on social media platforms or elsewhere. I don't know how much longer I will do this role- balancing out a full time job, while doing all this over half a day a week is not the easiest juggling act to do. But till I do, always willing to try- point out mistakes with respect and I will keep trying.

That's about all I can promise. Let's see what the future brings 

Saturday, July 15, 2017

Numero Uno?

Its that time again…the Commonwealth Fund has reported- comparing different health economies- and the verdict is pretty straight forward…the United kingdom Health service stands as Numero Uno.
You don't have to believe me- have a look:

Predictably it has drawn a variety of reactions- and depending on your level of confirmation bias, it has ranged fro "See, we are the best!" to "We are the best inspite of reduced funding-arent we glorious?". I say its predictable as in 2014, when a similar report came out, we did pretty much the same- we are the best, we don't have much to learn from anyone- all is well, happy days are here again. I suspect its an indictment of our times, when we as clinicians, born and brought up on the bread and butter of constructive critique have now been sucked into the realm of instantaneous judgements- all that matters are the headlines- little heed to the details below.

So lets dig a bit deeper, shall we? Lets start with the good news- have a look:
Makes you proud, doesn't it? Top of the tree- amongst many nations- the USA lagging behind- and maybe its time we stop actually looking at that- and perhaps closer to the continent. Anyway, I digress- this graph is sure to cheer many
But what about this one? Click on the bit called "Health outcomes"- and this appears:
Now thats not that good- so whats going on? We come trip of the tree in aggregate, yet when it comes to the actual nub of what matters, we just about pip the USA. So is this all a smoke screen- and statistical quirks or something we worry about?
I would suggest we all take our time and go through this- there is the worrying bits- when you look at say 5 year Colon cancer survival bit:
…yet when you look at 10 year decline in mortality, the results for the UK are sparklingly good
Finally, if you breakdown all of how all the different countries have actually performed, it makes for fascinating reading…
What does it tell us? Great at process, fabulous in equity (no question NHS tops everyone on that), good in administrative efficiency and access, yet poor in healthcare outcomes- albeit given the fact in certain areas chosen. We could debate this forever, but its not as clear cut as "we are the best" or "no, we really aren't". It does however create an amazing space for discussion. What does the report itself say? Read it- and draw your own conclusions

Then to the bit which gets everyone going…what about funding- again, draw your own conclusions from the graph below- but the picture it paints- considering everything is fascinating.
Overall, its a report which I hope provokes debate rather than siloed views. I have always maintained the NHS is a fabulous health system - conceptually- yet there are many areas we could improve on. To say that doesn't mean I don't "love the NHS" or want to "privatise it"- but simply that I am keen to improve things as they are. Outcomes is why I do what I do- I don't see my diabetes patients to improve their HbA1c, I do whatever I do in the hope i can prevent them from going blind, or lose their limb, have a happy life…as simple as that.

Finally, I will leave you with this to reflect on. Below is the last report summary- we all rejoiced in delight when we saw this- delighted that "The NHS was Numero Uno". What we missed was the detail. The report also said we were nearly the last in keeping people healthy. In short, we were great at looking after folks when they got ill…we just weren't good at keeping them healthy. And in a finite financial system? At some point, the burden of illness will crack it all apart.

This time, it would be good if we could debate this report- with some light, rather than simply heat. We all need to go back to having debate- allowing others to express their views- with respect and decency. We all need to do this- if we genuinely all want to make the NHS Numero Uno.

I live in hope.

Sunday, July 9, 2017

Full circle?

Lets start this blog with a simple request. If you are an Acute Physician, then you are welcome to respond as long as you don't take this personally. Its a blog where I ask a few questions with a general physician hat on. Its a question about a specialty from a fellow colleague- who is a bit torn between its function in the present NHS structures…anyway, here goes!

Acute Medicine is seen as a specialty- and in my mind, so far, it has been that too. A separate entity existing on a similar footing to my own specialty. However, as time has progressed, I have started having second thoughts- is it anything different from general medicine? Lets start from where we were- the days before any acute units happened. Admitting team saw patient from ED or GP-and they looked after them through their journey. Then came the era of specialism. Cardiology peeled off, followed by others. Acute medicine appeared- bound by the walls of their unit or hours post admission. Suddenly general medicine was no longer we all did. We had divided general medicine into small little convenient parts- the initial, acute bit (acute medicine), the single organ bits (specialism) and the rest which no one quite wanted to do. Elderly care physicians carried on regardless - while rest of medicine withdrew into their silos- leaving a few carrying on this ethereal beast called general medicine- stripped off its acute or specialist bits- a former pale shadow of its self.

As time progressed, the system realised that no one quite wanted to do general medicine- and the brakes started to apply-in a desperate bid to bring back generalism. The College has gone full tilt at it- creating a variety of opinions- and existing folks who left general medicine because of a variety of reasons (don't need to be at front door as acute physicians are here- OR - don't need to do general medicine on wards as specialist patients to look after) started to feel disgruntled at the fact of being asked to go back to the "olden days".

If you break it down, very simply- there are basically 2 models of care. Hospitals run entirely by acute physicians and elderly care physicians with in reach from specialists OR everyone pitches in and helps out. Problem with model A? Not enough of acute physicians. Problem with model B? Not many want to do it- and when you don't want to do something, questions start to rise. What is it acute medicine is contributing if all of "us" are back where we started before acute medicine came into being?

Beyond that, there also arises a simple question- acute medicine - granted- is indeed a specialty with a skill mix. The question is what is it that differentiates it from what used to be called general medicine? Is it just the 1st few days of it or something entirely different? Is it something only trained folks can do- or is it that anyone can do? If anyone with GIM training can do, then that makes it GIM, doesn't it? Lets take that thinking further- when I see a patient, I ask for a specialist opinion when there is something i am not trained in to the extreme degree, beyond the initial assessment, resuscitation etc. I can think of many such examples in Cardiology or Gastroenterology. What is it in acute medicine? What will the patient have for which I will call an acute physician- something I cant do as a general physician? Its a tricky one- and frankly, I haven't found the answer yet.

At the moment, the call is for all to pitch in and help (model B-as above) but if I am doing the exact same work as a present acute physician does, what makes it different from my work as a general physician? I know for a fact that I wouldn't ask any one else to do an insulin pump clinic- what is the equivalent in acute medicine- or does it not exist? Is there a need for acute medicine to step forward and define their roles- or are we heading back to a full circle where we all do the together- and we are all called general physicians?

As said at the very beginning, this blog is an effort to raise debate and ask questions- not to cast doubt. I am open to being questioned about the role and existence of my own specialism- what is the equivalent in acute medicine?

Saturday, July 1, 2017

Insanity ...or not?

What changes the delivery of healthcare? Is it the structures? The breaking of financial silos? Or is it the quality of folks leading the latest organisational body? Healthcare has always fascinated me, nothing more than the approach we have towards success of leaders. To many, success is ethereal but surely legacy at the very least should be the ask post any leaders tenure.

What has always intrigued me has been the approach towards these structures- if you take a step back, the concept of whichever organisational design you look at is based on a simple principle..."working together". Take vanguards, STPs, ACO... you can criticise them, think it's all wrong but strip away the rhetoric , the political table tennis- and in its essence it's supposed to be about all healthcare professionals., organisations working as one big happy family. The problem invariably arises when the money is linked with a decreasing trajectory, not in line with a changing population --and in simple maths term, when that happens, someone has to lose- and folks retreat back into their organisational boundaries.  The thing the NHS does is to move to another structural redesign in the blind hope it will help yet forgetting perhaps simple human factors.

In my experience, for what it's worth, any redesign, model of care etc is worth not even the value of the paper it's printed on if you don't have someone who can deliver it- whether that be by sheer determination, charm, clinical nous or whatever. It hardly matters what system design leaders come up with..if you haven't got your  clinicians convinced, it's dead in the water. Think of a football team..the coach has a vision, wants to force it through, the players don't believe in it....that team invariably falters....simply because you didn't get the players to believe. It's a fundamental principle we seem to ignore time and again in the NHS. To labour the point, let me give you an example of diabetes. 90-95% is delivered by primary care- with GPs being key to process. It doesn't matter a dime if you create a model - however signed up the specialists are- if the core workforce doesn't believe in it. You discuss the model first, get sign up...and the you do it....we, in the NHS, specialise in doing so the other way around. And then we wonder why project X never worked.

This brings me back to the structures. Is there any point in changing structures if you have the same people leading them- just with a different title or lanyard? If they haven't delivered in their previous role and haven't got the workforce to believe in them, how can they deliver in this new role? What has changed? Just the structure....what hasn't changed is the individual, their ability to deliver or not..or indeed their reputation with the wider workforce. So why will anything change? 

Don't get me wrong, this isn't a call to ditch all existing leaders and start afresh but for sure we need to mix it up. I meet bundles of people bustling with idea but not allowed to get into those tiers where they should be. If you want to change the paradigm, you need fresh ideas, energy- that isn't necessarily an age thing, it's just perspective, it's about reputation, it's about legacy..and it's about trying a new approach. 

One of the best cliches ever used is the one about mentioned by that clever fella, Albert....."Insanity: doing the same thing over and over and expecting different results". 
New structures remind me of organisations will falter yet again, if you don't think about who is steering them. Having the same old folks, the old wine in new bottles saga is absolutely fine- as long as they have delivered something, anything and perhaps more importantly holds the respect of the workforce for their track record. 
Without that, we are just doing what Einstein mentioned.

Have a think about it and ask yourself this....if you want to change the status quo, do you think the existing folks can do it? Or could it be you?