Thursday, October 26, 2017

Going Digital

You know what…when I was in medical school, the word "digital" tended to be associated with "doing a digital examination"- so hope you excuse the Beavis/Butthead humour when i tend to have the urge to crack a smile whenever i hear the word the NHS is about to go…Digital. It never ceases to amuse me…sorry I know I am in my 40s…it shouldn't but it does. Anyway, beyond that, its all the fad nowadays, isn't it? We are all going digital- and that indeed is the next holy grail for us to chase.

But what does it actually mean? Does digital mean upgrading our fax referrals to emails or is it about using Artificial Intelligence, GoogleGlass etc to advance healthcare? Or is it a bit of both? I suspect this is where the NHS as ever comes unstuck. It has, suddenly- and quite rightly developed an urge to modernise with the times. It has all around it folks using Apps, WhatsApp, different communication strategies, use of cloud…heck, we all in our day to day lives have adapted technology as an ever present companion- yet come to work- and you wait..sipping your coffee, drumming your fingers…as the PC loads up- wakes up slowly but surely.
And this is where the struggle begins. On one end, we have the digital champions (No- I am NOT laughing) driving the uptake of innovation, trying to get the NHS up to the present century, while down in the basement, the fax machine whirrs into action yet another day. We have the most amazing dichotomy where any transfer of informatics have governance all over it like hawks- yet somehow sending letters through the post is ok. We have Skype frowned on as someone may hack the feed, yet its ok to discuss private matters on a ward with the curtain drawn- ah those amazing sound proof curtains. It feels as if the NHS is a vehicle let loose on a racing track- yet alas with still the engine of a Rover.

Amongst all that are 3 different levels of issues- firstly- the public and understandably an inherent sense of mistrust with continuous data flow and uptake. Care.Uk - and subsequently DeepMind have had their issues- and not unexpectedly, the public is not so keen to share their data with all- in some cloud. The conspiracy theories also don't help- but in the most, I suspect this one is a battle for hearts, minds and overall trust before we get informatics flowing seamlessly. The public has to trust the NHS to handle their data better- they seem to trust their banks more at the moment.
The second one is the myriad of providers, IT companies and their rules created. Let me cut through all the mumbo-jumbo and let me distill it down to simple english.
When I see a patient, why on earth, in 2017, can me and my GP colleague not share the same system to have notes? Not be able to entry our bits in the same system? I mean- thats just utterly bonkers, isn't it? Both professionals- caring for the same person- yet on different systems which don't talk to each other. What. The. Actual. Flip.
Finally, its that holy grail of "evidence". How on earth you do randomised controlled trials on digital technology -I have no idea. I mean, the pace at which technology moves, the NHS would have just completed RCTs on beta max by now- while we all were enjoying blue ray. The argument continues- let me give you one specific example. Structured education- ask any patient- they would welcome its presence. Do we have it yet? No. Why? Cos..evidence- or so says the professionals. Problem? As per national data- the uptake rate of the face to face ones- however amazing and evidence based it is? Well, its not very encouraging-lets just put it that way.

Fascinating, isn't it? The issue is whether the NHS can marry those 2 distant poles- one about faxing referrals, the other incorporating AI into insulin algorithms. I suspect the answer is yes- but it certainly needs both tackling, not just one. There is a need to modernise, there is also a need to keep pace.
Can we do it? Time will tell. The NHS has a blistering history with IT- of making a pigs ear of it. I could bore you with what we are up to in diabetes in NHS England- but won't for now- thats another story-for another day. But for now? Just let me and primary care be on one system- so that the patient in the middle isn't there wondering how amazingly amateurish we all are.

Convince me that's possible -seamlessly across the country- and who knows- we may boldly go where the NHS has never been before.

Thursday, October 12, 2017


What do you call a group of diabetes specialists? I don't know but whatever it is, "it" was there. Interspersed with people who had diabetes, fellow healthcare professionals, managers, colleagues from all parts of the diabetes world in this country, the annual Quality in Care awards in Guildford brought many together.

As I sat down in a corner, looking around, what struck me was the atmosphere..bustling with energy- amongst some old friends, there were many a new face some who I had heard of, some who I knew virtually via Twitter. I won't do a narrative run down of the event itself but the event had something about it. It was fabulous to see teams like the Liverpool team led by Reza Zaidi pick up a recognition. The drive to improve things has always shine through in Reza so it was great to see the recognition. Same for Paul Peters and his team from Durham,Jackie Eliott from Sheffield or May from Southport. The North West London team deserved every one they picked up as their drive, hunger and ambition to improve diabetes care has stood out like a beacon in recent times. And why not get the opportunity to shine and enjoy their moment in the sun? 

The Diabetes Research Wellness Foundation, led by Sarah Tutton, was deservedly recognised for all the local work they do- as was some fabulous individuals such as Sheila Smyth for their work. There were 3 personal reasons of satisfaction- the first two were related to projects I have been involved with- the Type 1 diabetes comic book and the information portal for Type 1 diabetes, T1resources. My only role in those were mostly to get the right people together but the credit for the comic book sits with Mayank, Danny, Joe, Jen, Andy and Laura. I know that sounds ridiculously self effacing but humility isn't my forte and on this one, credit where it's due. Same for the T1resources...the work done by Sophie, Mike and Kevin were astounding. Committed individuals working together to improve diabetes care- what else can one ask for?

I suspect the main joy for me was to establish an NHS England award recognising contribution above and beyond the call of duty. I do believe that our role cannot be simply to criticise or roll down diktats about the next target- but also to step in and laud good work where it's happening. A most deserved winner for Oliver Jelly- I would struggle to think of a more self effacing, unobtrusive person who has and continues to do so much to champion diabetes care. His expression was worth every single moment indeed!

Finally, thank you to Sanofi for hosting it and especially Becky Reeves who I have known as a friend for a long time. It was a fabulous evening- and for me, in a policy role or as someone who has snapped and barked while trying to raise the profile of diabetes care...yesterday evening felt like my job is nearly done on this front. The room was full of individuals who understood the pressure of the NHS but hadn't dampened their spirit or drive to improve diabetes care - and they stood together with patients in an effort to do so. Much more needs to happen but the will is there, it feels the morale isn't broken...and that to me, is the main thing which will improve care- not the money or a stick about "who isn't doing well" . Thank you to all who were there- thank you for all the work you do and the passion to improve care.

It is much appreciated. X

Friday, October 6, 2017


Tenacity. How far do you take it before you know what...this isn't worth it? The NHS tests you, doesn't it? The groups, the bodies, the approval process, the multiple committees...its enough to make your eyes water. At one point, you are just happy to do your day job, pick up your salary- and go home. And therein lies a lot of the inertia in the system. Its not simply the lack of trying from individuals, its the incredibly byzantine process that sometimes makes you go..."Ah well".

Let me give you an example- recent release of diabetes transformation funds (41 million £ across the country for 2017-2018)- and its been absolutely fascinating to see it from two polar opposites. One- from the central team- giving the money out- and hoping /expecting folks to get on with using the money to improve diabetes care...(after all, we keep getting told, if we only had some money to "transform" the system, all would be better- so surely, the system is now adult enough to use the money when it arrives?)- and secondly from a local level. I don't hold any management roles anymore in diabetes at a local level- but the intrigue of the process made me decide to get involved- perhaps also to get a feel of "how IS it going on the ground?" When clinicians voice their frustration, are they actually meaning it..or making excuses?

And you know what? It has been one of the most fascinating, character building, frustrating as well as eye opening things I have ever done. Without going into too much details (you have to save something for your book after all) below is a list of organisations I have had to contact, seek approval from, inform, cajole, send snappy emails to, chat with to get the money moving to actually deliver care:

Local Sustainability & Transformation Plan Board
Local CCG X 3
Acute Trust
2 community provider trusts 
Podiatry department
Orthotic department
5 GP leads with interest in diabetes
NHS England South team
Clinical Network
Accountable Care System

I suspect I have missed out a fair few- but at last count, to free up the money which we from NHS England allocated- it has taken me 187 emails, 17 meetings, countless conversations and many many hours spent doing something I am not even paid to do- apart from that tenet of "we are here for the patients".Towards the end, I was doing it simply to find out how far this trail would go, how convoluted can we make the process, perhaps even just for my own entertainment...and in a nutshell, why even money can't solve the problems the NHS has. It's given me insight and perhaps food for thought as to how we should use money in future, if at all.

All the fault of Lansley and his creation of the maze or just a convenient excuse to absolve us of our roles too? I suspect there is a mixture of both. I recall negotiating in the Pre-Lansley era too. Multiple PCTs, Trusts firmly entrenched in their bottom lines, GP discussions at individual surgery levels, if you ever want to know how easy or difficult it was to ensure there was one diabetes team across 3 providers in 2010? Buy me a beer was perhaps just a tad less folks to negotiate and barter with- but the atmosphere was as much stifling....the financial crunch at present has perhaps forced previous siloed players to come a little bit more out of their entrenched views-but that's about it. Lansley didn't help but it wasn't a land of honey and manna either before the Health & Social care Act.

The NHS and the varying roles I do keeps teaching me valuable lessons...and one of them very simply is that it's easy to slip into a zone of thinking "why aren't they doing their job?"- whether it be from an NHSE perspective..or from a clinician on the ground. This maze and byzantine process needs to stop if we are to have any hope of progressing care- let's put it this way, if I accepted all the meeting requests sent to me, I would have zero time to do the work I am actually supposed to do- look after patients. 
The even greater irony is that none of those bodies are actually deliberately trying to stymie care or filled with villainous characters....they are doing their job, as asked by the system, following a process set up by ourselves over the years- though there probably as ever is a jostling for position. Whenever a new structure or body emerges, the previous ones perhaps feel a bit threatened, want to justify their presence, make their authority felt. Whatever it may be, it doesn't help those for whom the NHS has been set. Of that 41 million £ earmarked directly for patients with diabetes, how much will actually end up directly helping them? I wish I could give you a confident answer at the moment- from my experience of local devolution, the variability seen etc? Let's see.

So where to next? I suspect some of the legal issues come in the way...but some, if not a lot of these bodies need to go if we are to entangle the mess we are in. We can dislike STPs, rail against  ACS because they come from the land of the free...but whatever it is, we must and have to stop this merry go round with multiple organisations before anything can happen. Clinicians don't have the time, energy to "keep at it" all the time..its soul destroying, disheartening and not something that helps any of us. What I find fascinating is the number of conferences and meetings say exactly this very thing, attended by these very folks...and yet- when it comes down to it? The process goes through its churn- it's as if the NHS cannot unlearn something it has been accustomed to do.

You would think this blog is written in frustration- it actually isn't. The end product of all that has been that "we have finally got there". Its written to showcase the challenges we have created for ourselves. This one particularly is to exhort anyone who reads to think how their role in any management body actually helps, what sort of "power" one must cede to allow patient care to flourish and think beyond the narrow tramlines of "process". We must do better than this..we must have the ability to sit around a table, streamline organisations and be quick, nimble and get to the actual business of delivering patient care quicker. We need to make our way out of this maze. And quick. 

Otherwise, all the money in the world won't improve care- it will simply be more of the same. Here's to  a good weekend but please, do take a moment to think. How actually does the maze help any of us? Or the population for whom we are the appointed vanguards of using taxpayers money. Have a think, won't you?