A Child of the NHS...

I was born in 1955. I am a child of the NHS through and through. My father worked as a hospital manager i was born in St Georges Hospital Hyde Park Corner in London ( it is now a posh hotel!). I have worked in the NHS for my whole working life. Am immensely proud of it and of the amazing things it does everyday. I have absolutely loved my career and have been so privileged to work with fantastic people. We are united by vocation and a deep and fundamental belief in the underpinning values of what we are doing. We are here to serve.




We don't get it right all the time. Remember reading the first report on mid staffs and was moved to tears by the stories of the suffering. How could this happen in our beloved NHS? I am fortunate never to have seen that kind of neglect and wrong doing. What I know for sure is that most of the nhs which is a huge and complex organisation is not that. My patients tell me of great care, high standards, kind people. Not every time. But most of the time. People going beyond what they have to do because it is the right thing to do.



Recently I was told about a young man who is having lots of problems and was admitted to a young people's mental health facility over 200 miles away for assessment. His family were not happy and brought him home. The local team provided round the clock care for him at home until a more local and acceptable place could be found for him. Some of that meant being there with his family keeping him safe through the night. They were not paid extra. They didn't do on call normally they did it because it was the right thing to do. I heard about it by the by.. They didn't do it for glory or thanks they did it without hesitation because they care.



The NHS is facing challenges much greater than those it has faced before. The future feels more uncertain now than at any time I can remember. We need, I think on this 65th anniversary to pause and remember why we are all here. I have been at a meeting of people like me, GPs who have chosen to take on the leadership of their local NHS from across England and what struck me about everyone spoke to was that they were motivated by wanting to make it better, wanting to sort out the difficult ,the complex, the things that have been left undone and unresolved by others because they are motivated to make a difference. As a group we don't have all the answers but we are determined. The word bravery was used a lot And I think we will have to be brave. Brave and open and honest with our public however challenging that may feel at times. W can't offer them everything they might want but hopefully we might each of us can find a way to make our little bit of England better and over time that should add to something better.



I think it is easy to forget the miracle that is modern medicine. My mother, who I have written about recently is 93. Until very recently she was living independently. She would describe herself as fit and hasn’t seen herself as a major user of the NHS. She has had both her cataracts done, a hip replaced and wears a hearing aid. She couldn't afford to do any of that privately. Without the NHS she would be lame, blind and deaf. Shut off from the world. She would probably be dead by now. All of those things are routine, un-dramatic but they make huge differences to our lives. I have close friends who have survived breast cancer.



I could go on. I often think that when we plan change we forget to include those fundamental aspects of the issue that we take for granted and sometimes that means we lose them before we consciously even know they were at risk. Yes the NHS needs to change but can we all please remember why is was created in the first place. My sister lives in the states and has insurance but her care does not in any way measure up to the care she would get if she lived here. I spent a while in France recently and my experience of care there was that general practice was very primitive and there is a complete lack of any domiciliary care for frail or palliative patients and people die in distant impersonal hospitals because there is no alternative. But that is another story. We must not fall into the trap of believing everything is better everywhere else.



Aneurin Bevin is quoted as saying:



THE NHS will last as long as there are folk left with the faith to fight for it



As a child of the NHS I want to fight for it survival. We may not know how now to solve every problem but we can be united by a collective will to find those solutions whilst hanging on to the principles that underpin it. Will you join me?

We need to talk about urgent care..

I told my family about my blog…. They said I should write about our recent experience of urgent care , with my Mum. I mentioned it briefly in my last blog… The urgent care experience we had really underlines all the issues that face us collectively as a system…




It was Bank Holiday Monday ( it always seems to be..) my Mother, who is 93 and frail, felt dizzy. She didn’t feel well enough to stay alone at home. She was afraid she would fall, she has done several times before. She has carers who come in three times a day. They work for an agency. They don’t get paid for travel between clients. They tell me their only training is a DVD given to them when they start. They are always in a rush. Sometimes in a week she can have 15 different carers, and the turnover is huge. My Mum has dementia and new people make her anxious. So staying at home with the care she has wasn’t an option. Mum has been failing for the past few weeks and we had had several conversations with Social care that she needed a different place to live. Extra care probably, somewhere with resident care, but it hadn’t moved fast enough and following 2 previous hospital admissions in 3 weeks we were once again in a mess. My brother called GP OOH, or at least NHS111. What followed was a wearisome 50 minutes of repetitive questioning.. and holding…. Different people reading computerised questions.. did she have chest pain? weakness? Finally we spoke to someone who offered us a GP visit… I was an out of hours GP until very recently. I could triage a phone call safely in 8 minutes max.. although I usually had a good idea what was going on within the first minute. Is it surprising more of us are simply giving up and going to A&E

So the GP came… he wasn’t local and didn’t know much about local services. He didn’t think she was “acute” but clearly wasn’t well enough to stay at home. The Acute Trust refused to see her. The GP had no idea about intermediate care ( although the Acute Trust- who also manage community care say there is 24/7 access on their website) The only phone number the GP had for district nursing went to ansaphone. So now what? After 2 hours the GP phoned 999 for an ambulance and my Mum went to A&E. WE were advised NOT to go with her because if we did they might just send her home…

We were left feeling we probably should have phoned 999 straight away but we knew she didn’t need that really.

The next day I went to the acute medical ward at 9am. I knew the doctors would be there then I was informed, a little brusquely that is wasn’t visiting time and everyone was busy. I pointed out that my Mum has dementia and therefore is both confused and frightened so I would like to sit with her for the ward round…using some medical terminology and the Dr title helped I think as I was allowed to stay. We agreed my Mum wasn’t acutely ill but needed to be in a more supportive home environment. A social services assessment was arranged. I went to work… an hour away. I was then phoned to say the assessment would take place in 45 minutes on the ward. As luck would have it my daughter has a week off uni, lives in the same town and was free to go to be with her. My daughter then witnessed a row between the staff nurse and the social worker about how long it would take to organise a placement for my Mum, which only stopped when my daughter interrupted and asked them not to talk about her grandma like a piece of smelly baggage no one really wanted. The outcome: a short term nursing home placement and a long term change or residence hopefully to an extra care flat, if being in the nursing home didn’t lead to too much loss of independence and confidence whilst we waited. Her discharge was delayed ,even then, because the Doctor in change of her care decided at the last minute an echo might help… after 3 more days, an increasingly confusion and no echo and with the help of a very enlightened Sister, I all but kidnapped my Mum and took her to the nursing home…

We talk about the problems in urgent care. Lots of people have tried to look for who to blame. The problems like most in the health service as complex, wicked…. If they were simple we would have got it right be now. The evidence tells us older, increasingly frail people attend A&E with complex problems. In our own area we didn’t see much of an increase in numbers of admissions in November, December and January, and yet the hospital was really busy. The people in hospital were older and more frail and took longer to be sent home. So urgent care is linked inextricably to care for older people. Stopping them going into hospital in the first place and getting them home as soon as possible….Get that right and the A&E issues will diminish…ignore it and focus only on more A&E services and nothing will change… treating the increase in minor problems and the worried well is relatively simple…

And how long will it take us to realise the ONLY way to make NHS111 work for patients and the system is to have highly qualified people at the front end.. doing triage straight away. More expensive in terms of labour costs- YES but system wide it will save by reducing unnecessary blue light trips to overcrowded A&Es and most importantly will make the service better for patients.

And can all of us remember every day and every time that patients are just people in nighties and pyjamas, but they still need to be treated with respect and kindness.

Flowers for my Mother

Everyone is talking about leadership…. There are courses, books (one of the best have found is one called Intelligent Kindness by Ballatt and Campling which I really like) and conferences everywhere I turn. It is apparently the answer to IT all. Although I am not quite sure what the IT is. When is leadership something different from management? Is there really a difference between clinical and managerial leadership? It seems that clinical leadership is now the in thing…and I am glad about that because it has given me the chance to take on this role rather than be left to sit on the side-lines as I have done in various PCT roles in the past and people actually listen to what I have to say now which is novel! but what do we really mean by leadership anyway…



My mother was admitted to hospital three times in the last three weeks. She is 93 years old and has dementia. Up to this point she has lived quite successfully in a small flat with a day time warden and a life line service but clearly things are getting more difficult. As a family we experienced the wonders that are the fragmented, patchy, variable services for older people. I am sure our experiences will not be that different from everyone else’s across the country. Where my mother lives is an average sort of place with an average sort of trust and an average GP. Nothing extraordinary but okay. As we navigated through out of hours services, acute medical wards, wards for older people, community hospitals, social service teams , care homes, what became obvious to me is the huge variability of attitude, approach and energy within one small location. The worst experience by far was trying to get help initially and the tortuous map of repeat questioning( does the system have dementia?) and changing personnel that is NHS111….. 50 minutes to get to speak to someone who could maybe do something… To the best… a small community hospital with the attitude that it will make the right thing happen and that each person is important and valuable..



What made the difference? Dare I use the word? Leadership…. visible leadership… in the community hospital the matron is brilliant, she leads by example. She cares, she bothers, nothing is too much trouble… and everyone in that hospital is infected with a sense of purpose and achievement. It feels good to be there. The staff smile, they stop and greet you when you walk in. They don’t rush by with their eyes to the floor.. looking busy and hassled….My Mum was happy there, I was relieved and happy she was there. She made progress. But why the variation? It cant be right can it that each little building block of the NHS is so dependent on the individual in charge. It makes it far too fragile… So within a huge organisation made up of so many tiny parts how do we drive up quality everywhere? It feels like an impossible task. How do we get 100% excellent CCGS doing great commissioning and all trusts and All GPS caring for patients to the highest of standards? Because that is what we want for our mothers, our children, ourselves.. what is acceptable variation? We know that 50% of anything is below average, just by the definition of the word , but we have to reduce the distance from worst to best so that the variation isn’t big enough to feel from a patient perspective. The only answer I can come up with is something about the leadership of the whole system, not of each hospital or CCG but of the whole NHS. It needs to be different, palpable, with core values that are lived by everyone in the work they do every day.. Where leading can be kind. Not soft or sloppy, but intelligent, and caring. So each part of the NHS, each layer each organisation can look up and se those values everywhere. No bullying, no intimidation, no weasel words to avoid answers. AS NHS staff, managers, clinicians, support - senior or junior we have to treat each other with the same values we expect and value as patients. WE must never forget that we are all potential patients in the system we design…. my guiding principle as a GP has always been ..would this be good enough for me.. my family… if not then it isn’t acceptable for anyone….



The new NHS is an experiment… it allows a whole garden of flowers to bloom…it is a risky plan especially in such a cold and cloudy time…as a new flower ourselves I applaud that but it relies on a gardener who understands how to get the best from each variety, and how the species interact with each other. She needs to be present, visible, dealing decisively with the weeds and with those bits that overgrow, or aren’t healthy… watering, feeding, nurturing, and providing the environment that will support healthy development whilst being clear about the overall direction and shape… gardening a system requires patience , vision, permissive bravery and the wisdom to act decisively but kindly when necessary.



My mother was bewildered by the labyrinth of services she encountered….. do we have the collective will and the imagination between us and together to work with the system we have and make it work for her?

What a difference a day makes

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It hasn’t been a particularly good couple of weeks in the land of CCGS.. nothing big really but lots of hassle that makes doing the job difficult and  increases stress… no amount of zumba can take away the stresses of not being able to get on with the job because we don’t have phones or emails  and it is amazing how much time you can lose trying to retrieve lost diaries…

But.. then we had Tuesday and an “open  space” event… about care for older people.. I have never been to one of these before and  it was new to most of us and a bit daunting… no sitting  quietly in the back of the meeting planning quietly what you are going to cook for tea.. no this was all about full on participation .. listening and contributing…It was part of a piece of public engagement we are running called “fit 4 the future” and  involved all our local stakeholders.. public.. private ..voluntary… it was great . 70 people came and there was so much energy and  positivity in the room. And I thought that I wish our  public could see this.. see how passionate the people  who work in our many services are. How much they want to make things better, that despite cut backs  and staff shortages and  so much negative coverage in the media about older peoples services these people really care.

People had lots of ideas…some new…some a little off the wall…So much  of what we talked about was about how we work together  across the organisational boundaries that divide us to do the right things and make it better…accepting that there will always been boundaries somewhere and  it is easy to use these as excuses to do nothing…

And we talked about how many times we have all been here before.. said the same things before… can it really be different this time?

Well.. yes I hope so.. and I told my  story about the patient who came to see me for help giving up smoking.. they said sheepishly… well I have tried 4 times before and FAILED… and my reply was as it always is.. they were not failures they were rehearsals…. So lets hope that just like the smoker desperate to give up… we desperate to get it right this time can learn from all those many rehearsals we have all participated in before. .learn from why they didn’t work and  get it right ( or at least most of  it) this time…

So I went away from that day feeling tired but so much more positive.. buoyed by the commitment of so many people who just want to get it right and who despite everything care so much…

All Change!

So here we are… finally the real thing. Lots of people have asked  me “How does it feel?”…. Well the answer is for me personally .. not very different really in that we have been doing the job for the last 18 months or so.. but now I guess the buck stops here….with me, and that feels big!

What has been interesting though has been to watch the architecture of the commissioning ( buying services) part of  NHS  be taken apart and  rebuilt  gradually over the  last few  months picking up speed towards the deadline….and  how complex and difficult that has been. Now we have gone past the date when it all had to be rebuilt and ready for habitation… we have discovered  we need bits we cant find and  bits that we have that aren’t ours but don’t seem to fit anywhere else.... like one of those old jigsaw puzzles you find in a dusty cupboard … some pieces missing and some pieces that just don’t seem to fit anywhere…

Just to make life even more interesting many organisations have recently moved home ( we have moved from old PCT building to share  with our local authority) and along with that comes phone and IT chaos lasting weeks ( no landlines for 2 weeks, slow or absent internet access) …. And then .. just to top it all for some reason someone decided that Aprils Fools day would be a great day to migrate  all staff from one email system to a new one… with new addresses.. less functionality… marvellous!

And the day job has to go on.. despite lack of computers of telephones contracts must be signed, plans made, savings made.. the clock is ticking..

It has not just been us that have been confused… We  received a letter from a patient who was appealing against a decision made early this year by our PCT individual case funding panel and ,because of  reorganisations, her case is now being dealt with by a new and much more remote part of NHS England, involving a whole new set of people. And she is confused and I don’t blame her.

And I ask myself… surely we could have done this better…such big organisational change  means new jobs, new  roles, new colleagues, new challenges feels difficult.. painful.. confusing…uncertain… Surely the NHS -which does this so regularly-should be getting better at learning the lessons and at least do the structural bits efficiently and swiftly, which might lessen the pain.  Maybe the problem  is we lose so many good  people each  time we shake everything in the snow globe up again , and there are few  people left with the memory of the past and  those who are left worry about being seen to be  overly  negative..

It will get better, and in a whole this will seem like a distant memory we can laugh about…Lets hope there are enough of us left next time ……

A cultural revolution?

Much has happened in the past few weeks. Firstly and probably least importantly CCGs have been authorised as new organisations. We are now the real thing. I am no longer an interim, shadow or designate. I am in charge and that is both exciting and frightening. More importantly the Francis Report has thrown a public spot light on the cultural issues within the NHS was all know are there and have talked about in hushed conversations between friends. A bullying culture…top down pressure to make the money work.. jobs on the line..




How could we ever have thought that it was okay to accept that at the top of the NHS somehow believing it didn’t affect anything important, only mattered to those in receipt of the pressure, when of course we all knew somewhere inside ourselves that it affected everything..



And I wonder how to change it. I am now a senior leader. It is my job to play my part in making the NHS a better place to work and a better care giver for patients.



So much of it is SO good. There are so many who work really hard to give a fantastic service to patients, often unsung, unthanked they just get on with it because it is the right thing to do. In all of this soul searching it is important we remember that. It is about growing a culture that supports the good and challenges the less than good to be better, to aspire to the best rather than accepting poor standards.



Leadership is key. WE need compassionate leaders, who lead by example. It isn’t possible to have one culture of leadership at the top of the NHS and expect that not to filter right down to the front line. If we want compassion and caring for patients then we need a leadership style throughout the NHS that delivers that at every level. WE need to understand that being caring doesn’t mean being soft. It doesn’t mean tolerating poor performance, laziness and lack of progress. It means we manage people as we would like to be managed with clarity, sensitivity, openness. WE need to be clear about our expectations of each other and we need to remember to praise people for the effort they put in and the successes they achieve.



AS a GP I have always tried to deliver the standard of care to patients that I would want for myself and my family. I am intolerant of poor care and I say so. I am sure that there have been times in my career when I have delivered less than best care. I am human after all. There are times when it feels so busy that I am concerned I cant give the person on front of me everything they need. I reflect on those moments, worry about them, and do my best to make changes to stop them happening again in the future. As a leader I try to do that same. I don’t get in right all the time but I am learning fast.



Collectively we have to have a strong shared belief that we can make a difference. That the culture in the NHS, even though it ia a huge organisation, can change. Bringing clinicians into management helps I think ( well I am bound to say that aren’t I?) Brining patients and the public into decision making in a real way is also vital. Developing an openness where we share our plans , our successes and failures is also key. And that isn’t about just having board meetings in public it is about talking at those meetings openly about the issues and challenges we face rather than just going through the motions ,and it is about getting out there and sharing with our public the really big and difficult issues we face and for which there are no simple answers. Should we fund IVF? If so where does the money come from? How do we decide between the many competing priorities for investment we receive, when there is no new money?



In the end rather than try to fix the big picture I will focus on trying to get it right here, in our little locality. That is a big enough challenge. If we are all doing that, all over the country there is hope that it will feed up into the centre from all the roots of the NHS…So it is about doing stuff differently and challenging the old ways… interesting that when I started writing this I wondered if it might been seen as critical by people above me in the NHS tree and then I wondered why that would matter if we truly are an open organisation happy to question ourselves and admit our faults….

So is this the begining of a quiet revolution?

Caring.. how do we put the caring back into health care?

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With the imminent publication of the Francis Report I guess we are all reflecting on what  “care” really means. There has also been much debate about the Liverpool Care Pathway and the potential for its misuse. Over the Christmas break I experienced health care as a relative. Not as a doctor or a manager but at the sharp end of care, and perhaps in the most challenging environment: the elderly care ward of a district general hospital. Perhaps the place where you can really judge an institution’s commitment to patient centred care. It isn’t fast paced or exciting. It  is all about individual patients who are frail and vulnerable and often cant speak up for themselves. Get it right here and surely the rest is easy.

 My uncle, who was 94 was sent into hospital from the care home where he lived because he was increasingly poorly. He had widespread prostate cancer and no one expected him to live very long. I don’t know why he ended up in hospital in the first place. I hope if he had been my patient I would have managed his last few days where he was used to being, as close to being in his own home as possible. He was admitted with dehydration and a chest infection to his local hospital, not to a hospice but to a general ward for elderly people.

We went to visit him on the Saturday between Christmas and New Year, a 6 hour round trip, across the other side of the country. When we got there he was in a twin bedded ward. It was noisy, crammed  but clean. It was visiting time and three nurses were huddled around the nursing station. We were told it was impossible to speak to a doctor at the weekend as there was only one on duty for the whole hospital and the nurse could only tell us  “ nursing” information. We asked if there was a care plan? A Liverpool care pathway in place ?? No one seemed to know much but there didn’t seem to be a pathway in place. We could talk to the consultant on Monday. A conversation  in the corridor. We felt unimportant. A bit of a nuisance and yet we were his next of kin.. his closest family. Were they too busy to take us to a quiet place to talk? Was it too much to expect to be spoken to like it mattered?

My uncle held my hand and asked me if he would be alive tomorrow. He looked and sounded scared. He had been a fighter pilot in the war. The only one of his squadron to make it through to the end. He was a husband and a successful business man who worked in his family’s business when he came back from the war. A father who had buried  his 3 children .To me  he had always been brave and dignified, funny and charming, invincible. Now he was dying and he was frightened. Did anyone here care? As I looked at him I could see what they would see…. another old bloke on his way. Yet to me he was so much more.

On the Monday.. and several increasingly irate phone calls later and we got to talk to the consultant. No, he wasn’t ill enough to be on the Liverpool care pathway but wasn’t on antibiotics and was just having fluids into his body through a needle in his tummy.. He had wondered if he would die of his chest infection over the weekend but seemed to be picking up. So I am thinking "how can he be both not ill enough to be on the pathway and yet might have slipped away over the previous weekend?"  He wasn’t giving him anything for his anxiety because it might suppress his appetite. And I am thinking.. "This man is dying.. today/ tomorrow /next week… does it matter if his appetite is suppressed.? . surely it matters more if he is lying there feeling scared"
Isn’t that what the Liverpool care pathway is all about? Allowing someone to die with dignity, as free from pain and fear as possible? But perhaps I am mistaken…. There has been much in the papers recently about the Liverpool Care Pathway but my experience of it is that used correctly it is brilliant. It is about building an agreed was forward for someone who will die soon between those who are giving care and the person and their family. Managed care…. Care that acknowledges that the persons feelings are what is most important.. There is so much written about this.. so many plans and strategies “patient centred care”  “the six Cs”.. I have read these throughout my career as a GP. What I know is that Peter didn’t want to die in pain or in fear.

Early the next morning, the first of the new year my uncle died.

 His care was not terrible. He was clean,  tended to every couple of hours by trained nursing staff who took care of his pressure areas and kept him hydrated. So he wasn’t thirsty or in pain.. But it could have been so much better. It wouldn’t have taken much to move his care from  adequate to fantastic.. It wouldn’t have cost anything. It is all about attitude and culture. He could have died at his care home where he as surrounded by his own things and where he felt at home. It was peaceful there. He could have been given medication to reduce his fears. He might have told them there how he felt. He didn’t say anything to the staff in the ward because he didn’t know them and he as strictly old school.. stiff upper lip and all that. He could have been seen for the person he was brave and  funny but tired.

Why do we as an NHS keep failing.? Why is benign neglect still more prevalent than caring.. that real connection between people which acknowledges our common humanity and is a giving of respect, understanding and empathy from one to another. See this old frail man as if it was you in his skin, lying in that bed, feeling scared and lonely after 94 years, not just some old bloke without his teeth.