Friday, August 16, 2019

Brave enough...

One anniversary follows another....20 years of the NHS was the topic of the last blog- and then along came 15th August. 11 years ago- I stepped into the hospital where I had been a Specialist trainee, had done my a Consultant. Unquestionably the pinnacle of my career- that maybe surprising to some- but that was the high point to achieve. Due to many reasons- documented previously, my dada couldn't- and always wanted me to be one. So when I got there? The pinnacle was reached.

And I suspect that's why the 11 years since have been so much fun..I mean- its all just a bonus, isn't it? Throw in the most important ingredient- the folks I work with? And heck, its been such a fun ride indeed. Its the people who make the place- and till today, the diabetes department has been a sanctuary for me. The toughest days, the harshest criticism or even just general feeling of not belonging...always- invariably melted away when inside the diabetes department.

And its well known too- I may have my individual bias- but ask around the diabetes world in the UK- you will struggle to find a pack which exudes such bonhomie. Trainees who come here take their own views back- and we have always taken a lot of pride in the mirth and ribbing that seems to spur each other on. Time has flown, roles have changed...but the banter hasn't. And thereby lies the ingredient. Nothing gives me more pleasure than walking into the department and sitting in my comic book adorned room. Inside the department, I am always just...Partha. Theres no falsity in the welcomes, there's no underlying motives in the greetings, theres no hypocrisy in the chatter- its simply friends working together. Sounds like fantasy? Pop along and have a look. Lunch breaks together as a team are a common theme- as are social evenings or just popping into each others rooms and catching up.

Plain sailing? Nope. Relations with multiple arenas within the hospital have been fraught over the years- partly as we have refused to see ourselves as a second class specialty, partly because of my own personality- but inherently because I have always felt you fight for better care of your diabetes patients. They deserve no less than anyone with a heart issue, or stroke- they deserve as much care and the right to be safe as anyone else. And if anyone stands against that or disregards that, then I will counter that. Every single time. Managers have come and gone- of different hues and shapes- some understanding, some downright bullies, some two-faced but never has our focus shifted. Cue fractious relations with middle management -yet a good strong relation with Executives at all stages. I suppose similar to the wider NHS...its forever the middle tier, isn't it? Most have moved on- some have even come back as part of a revolving door- but we have stood firm- and the results do speak for itself. Hope springs eternal with the present crop- a shared interest in Liverpool football club with your CEO (Mark Cubbon) never hurts either!

Ironically, the strongest ally have been local CCGs- manager , clinician , medicines management- and I must admit to hearing stories from other parts- and appreciate how lucky we are locally too. Sensible, committed and always keen to try different things. Fusing 3 providers and multiple GP surgeries to one model of care has been interesting- yet nearly 8 years later? The alliance, albeit a loose one- has held.

All in all? Its been a fabulous 11 years- with some amazing friends. It would be inherently wrong not to finish a blog of this nature with some thank you to folks along the way- who have been instrumental in their support, kind words- and ability to help unlock puzzles when the road appeared shut- and more importantly? Not played politics behind your back. Jim Hogan, Tim Goulder as GP colleagues; Sarah Malcolm, Melissa Way and Lynn Derby as CCG managers, Simon Holmes as Medical Director during those years, Sue Harriman- initially with Southern Health- and then the head honcho of Solent....its been good to have them around too. There are many I could name on the "other side" of those I remember- but someday- maybe- in a book- albeit with changed names, huh?

In the end? We are where we are. One of the strongest diabetes teams around- with a fierce-some reputation of working as a pack. Any changes going ahead? Unlikely- we are a stable team- and there has been a much needed injection of youth via our Consultant colleague, Eveleigh. The rest- Mike, Darryl and Iain are exactly the same- maybe a bit older- but definitely not any mellower.

And that's the way it should be. Onwards and Upwards. As the quote from "Brave" goes....

"Some say fate is beyond our command, but I know better.Our destiny is within us. You just have to be brave enough to see it"

Sunday, August 4, 2019

20 years

4th August 1999. Still recall it ever so clearly. Walking into Kidderminster General Hospital, starting my career in the NHS- and meeting Dr. Alastair Miller, a consultant in Infectious Diseases. The nervousness of those initial times- making so many friends- and how time flies.
20 years later, not grey yet- and still enjoying the work as much as ever. On the way, the usual roller coaster has been part of the journey- yet been blessed by so many kind folks in the health community that one can only count ones blessings.

I used to write blogs regularly- but have dropped it down- apart from the time involved, other forums to voice ones thoughts have appeared- plus the world is very different to that when I started blogging in 2012. Opinions are sharper, outrage is higher, misinterpretations are easier...don't know...somewhere its not quite that much fun being on social media. However, for this blog- perhaps one of the last ones- this is more about a personal one- to say thank you to those who have guided and helped over the years.

Tony Zalin was more like a father away from home- when I came along to Wordsley hospital before starting the NHS journey- and still there is nothing as calming as talking to the man from time to time. Alastair Miller was a guide par excellence, recognising the struggles of someone who had arrived from Calcutta and wanted to "prove himself". Then along the way, came Worcester where David Jenkins was pretty much what I would have loved to be- but didn't quite succeed. A calmer man I have yet to see- and always, always with a smile, always with a word of advice- always there to make you

Then came Wessex- and one key figure in my development was actually a Registrar in those times in the Wessex region. I struggled a lot in my first year in Bournemouth- the expectations were too high, it always felt like an exam...yet Tristan Richardson was always there with a coffee and calmly assuring. And then of course, came the quartet of Portsmouth. Ken Shaw, Dumbledore of Diabetes personified- followed by Mike Cummings, Iain Cranston and Darryl Meeking. Every step of the way-a helping hand- and eventually we became colleagues...and as they say? The rest is history.

Many friends along the way- Kate Gilson, Darren Carthew etc as amazing nurse colleagues in Kidderminster/Worcester, Matt Davis, Aparna Sinha, Kate Gilson etc as awesome fun SHO colleagues; Jeremy Marwick, James Shilvock, Paul Shone as my House Officers...heck they were fun times. Wessex brought many other -none more so than Mayank Patel, Sarita Naik, Ruth Poole ...national roles as a trainee brought me in touch with Pratik Choudhury and Emma Wilmot...much much good fun and friendships indeed.

Its been a fun 20 years- will I be here for another 20? Thats a categorical No- there's much more to do than just be a doctor. In my book? You train, you try, you learn from your mistakes, you give 100% and you try again- in an effort to give something back. You win some, you lose some- and as ever? There are marks in both columns- that's life too...however, in the end? If the wins outweigh the losses? Its not been half too bad a career.

Am I wiser? Perhaps. I am less trusting of people- which perhaps experience teaches you. My circle is smaller than previous- and you realise that many have other priorities, things in mind, things to achieve as they try to interact with you- suspect that's natural in todays day and age. How many genuinely try to be a friend- I suspect its a handful- and to be fair? I am ok with that. 

Whats not changed? The fire burns bright- and for the right cause which I firmly believe will benefit patients, there-still- isn't anyone I wouldn't go head to head with. My view of the NHS is that we all -rightly believe- that we should collaborate to improve care. That indeed is the ideal. The problem is that in most cases? When it comes down to a choice, the system opts to collaborate at the expense of improving care. Its more "important" to "keep stakeholders happy" than ruffle feathers to improve care. Harsh? Perhaps- but categorically true- I have been in enough meetings and been part of enough email trails to give a measured view on that.
Not in my book however- and after nearly 11 years as a senior? I suspect everyone knows that- whether that be local Trusts, CCGs, STPs, networks or any colleague if needed- and that doesn't change an iota. If anyone would hope for a bit of mellowing after 20 years, I mellow when I down tools. 

Till then? Thank you to many who continue to help- and especially those living with Type 1 diabetes- many of whose blessings and kind words have continued to be sources of strength in times of despair and angst. Little cards from those who I probably will never meet sit in my office- and during tough times? They make a big difference indeed.

Here's to the future- whatever it may hold. 

Sunday, June 30, 2019

Mid way point

So we are here - July- and always an opportunity to take stock at 6 months work done from the diabetes team at NHS England- has things been done beyond the chatter, has anything been delivered beyond the rhetoric? The judge will be the people with diabetes- as well as health care professionals on the ground- so I will leave that to the reader.

January brought the NHS Long term plan- beyond the continuance of the Transformation funds - albeit tapered- the big news was the move to make CGM available for all Type 1 diabetes pregnancies from 2020. Much work has gone on since to make sure the process to be smooth, educational modules being set up etc- and we are working towards a start as per promised date.

February brought a host of things into play- namely the DVLA announcement of acceptance of Flash Glucose monitoring & CGM into monitoring during driving- as well as the change of the QoF introducing the element of frailty into diabetes care- aimed at individualising care in an ageing population. Announcement of the Diabulimia pilots followed too- specifically with the aim to assess impact of intervention in this high risk population. On a personal level? We had the second "Type 1 Diabetes: Rise of the machines"- aimed at looking at technology, innovation- and how to embrace the worldwide phenomena in Type 1 Diabetes: Open APS

March brought along updated data from the DIRECT study- along with the National (Type 2) Diabetes Prevention programme- as well as formal launch of the updated Libre guidelines- with a different way of securing funding to ensure a uniform way of access. Right at the end came the 4th edition of Talking About Diabetes- and event bringing along many with Type 1 diabetes- and a day of fun, promise, hope- as well as emotions all around.

April saw the kickstart of the Flash glucose access- with the NHS mandate coming into play across the NHS- much has been discussed about this- but in short, a concerted focus on access has and continues to pay dividends. Further work in this month was around starting the work on mental health support in diabetes care- and the core group continues to work towards better clarity and access around needs for those living with diabetes.

May saw the launch of the Type 2 online educational platform- initially started in 10 areas- before further roll out across the country. This month also saw completion of the Virtual Reality wok looking at improving safety within NHS hospitals- and are going through trials with hospitals in Southampton & Portsmouth to assess its efficacy. A spread to Scotland of the Rise of the Machines event was also fun!

June had a flurry of activity- not to mention the TAD event going on tour. From a policy point of view, we agreed on trialling e-Diabetes passports and assess their efficacy improving safety. Trials are due to start across Wessex shortly. Post lots of discussions and conversations / consultations, NICE also agreed to update the Type 1 diabetes & Type 2 diabetes pathways- a welcome move with evidence shifting quickly- and the need to ensure patients get what evidence base suggests too. The much controversial blood glucose strip consultation ended too- with a view that further work on quality of strips are to be done- before making any recommendations to be made on procurement simply based on pricing. This will be an important and interesting development too
Finally, June saw an event at 10 Downing Street with the outgoing PM thanking many from the diabetes community for the work they do- a satisfying wrap up go 6 months worth of work.

The NHS England diabetes team has been growing- and quite rightly too- with multiple portfolios- as well as projects to monitor and deliver. Many folks will stay out of the limelight but their work continues to be fundamental to delivering all what has been done so far- and what is to come.

We reach July- and its time for a bit of a pause- mostly as summer holidays start to loom- but also as its time to decide whether the clinical duo of Jonathan and I stay on- or be broken up- or indeed make way for fresh energy or vision. Personally, as mentioned previously, have made a decison- and a few things to finish- and a key sits in the partnership created with Jonathan- its indeed the classic duo of passion and calmness which seems to have worked well so far.

Either way? Its been a good 6 months to look back on- but more than that- there continues to be a palpable buzz amongst diabetes professionals to step up more to the plate, pick up the gauntlet and run with it. And that? Is part of the role too. Thank you to all for the support, love and kind words throughout 2019- lets see what the second half brings.

Tuesday, June 25, 2019

Whatever It Takes

And finally, datasets start to emerge. I am -of course-talking about data on uptake of the Freestyle Libre/Flash Glucose in the NHS. End-April data shows the picture within the NHS- with all indications of continued rise with a bit more uniformity than the past.

Have a look at the map- can't make it more simpler for any of you- data is what it is- and contains all scripts being prescribed- whether it be in primary care or secondary care  and the colour code tells you the variation too.
A few key things stand out:

1. No area any longer is saying No- which is what the whole purpose of the NHS Long Term plan announcement was. A commitment was made to ensure all areas had access- so we have moved from "Yes" and " No" to "Yes" with variation in uptake. The refusals are over.

2. As expected, areas which had said No for about 18 months- now are starting off- so have a lag period- but hopefully, further data will show colours changing. East of England is one to keep eyes on -as they have been a region of interest for some time now. We shall see how that progresses.

3. A fair few areas have seen the 20% as the MINIMAL to be provided- and are soldiering on- as they also see the benefit coming through from all data sets. The message is clear- give it to the folks who need it most- with adequate support? It works. Better than a lot of interventions around at the moment. Most importantly? It works at a mass level. Other areas would do good to note that.

Stage 1 was about ensuring all CCGs accept this intervention as a key feature of Type 1 diabetes care- that is complete. Stage 2 is about making sure each area has a minimal of 20% uptake- we are on our way. Stage 3 is about using the pathway created to see greater access for all technology- but with adequate training & support. Its not really that complicated- its all about how complicated we make it in the NHS for any innovation to happen- uniformly.

A few observations for what its worth. 

Firstly-the disparity between what the NHS is going through regards innovation at the "top tables"- with multiple organisations such as NHSX, NHS digital, AHSN etc having folks committed to improving access- and what is going on in the ground is pretty stark. One's like a Marvel universe- colourful, cheery, happening; the other being dark, angsty, pathos-laden- and somehow this gap has to be overcome. The support to help spread innovation needs to be a bit more than glossy powerpoints and twitter hashtags

Secondly- why this relentless focus on one device? Its not about the device- to me- its about the principle- and the message it sends. Its about finishing a job- and perhaps most importantly- its something for the whole diabetes community to look at- and believe. Believe that X or Y can be done. Believe that if you persist? It can be done. Understand that with the right focus- and the faith that you have patient care improvement at your heart? It isn't impossible- even within the NHS.

For years, HCPs in diabetes care have tried and efforts have stalled- bar a few areas whose progress has been driven by a few. No longer- I want you ALL to believe that if it feels like it can't be progressed? You dust yourself off, you take a deep breath- and you go again. You persist, you try- and if you ask for help, as long as I am in this role, I will always try to help. But you don't leave a job unfinished- you don't give up. Because when you do? You feel bad for a few days- but the person whose care you were trying to improve? Suffers much longer.

So you try again. Whether it be for inpatient safety; whether it be for improvement off foot care- you try again. Whatever it takes to make it happen. The map above? Will all be green in a few months- and let nobody tell you things can't be done. It absolutely can- and we all try- together. It doesn't matter who you are- and what your profession is. 

An infectious amount of buzz was apparent on social media and other avenues about the diabetes community visiting Number 10, Downing Street- and as a whole, the diabetes community was appreciated via the ones who represented us all. Thats now done- and we go back to the business of trying again. 

We do what we need to do. We try again. We fight to improve diabetes care- whatever it takes.

Thursday, June 13, 2019

SF Musings

SF; City by the Bay; Frisco; The Golden city- or Baghdad by the Bay….call it what you want- but San Francisco is always a delight to visit. Venue for this years American Diabetes Association conference- and an opportunity to learn. Mingle, make new friends, plan journeys anew- all in all- a conference to satisfy the needs of many.

So what were the headlines or take-home messages. I am not going to go through intricate details- as luminaries such as Daniel Drucker or Kamlesh Khunti will summarise the ins and outs of the relevant studies in detail- but I will try and look at it from a clinician and policy-maker point of view- and gauge impact on the NHS-so to speak

1.       Studies, more studies: This refers to the barrage of studies coming through on the cardiovascular outcomes as well as renal outcomes via the “not-so new-any-more” class of drugs: GLP-1 analogues and SGLT2-inhibitors. Whether it be REWIND, PIONEER, CREDENCE, DECLARE? The fundamental paradigm of Type 2 diabetes care is changing as regards cardio or reno-protection or indeed heart failure- and the clamour for NICE having to update lest we risk falling further behind- grows louder. Having said that- was NICE right to hold off till all relevant studies published- or did the ADA steal a march with a “living guideline”- i.e. update as quickly as feasible post trial publication? Or are there lessons we can adapt for the future?

2.       Resurrection: A possible "saving" of the class called Sulphonylureas. For long, the rhetoric has been about –perhaps demonising this class- while the focus needs to be on individualised care- not blanket “take them off”. Lest we forget- the drug is cheap- an important consideration in any economy- and has just reported a dead-heat in CV outcomes with a class of drug which has based its whole game plan on safety. Did you say “hospital admissions”? Look closely at the data on both sides of that trial would be my tip. And then there was Canagliflozin- their rise halted by queries and signals of amputation (CANVAS)- and now back with a ringing endorsement from….the nephrology community (CREDENCE). And that is no small deal- however you cut the data.

3.       The war of the “Glutides”: The space for battle of supremacy continues between Novo and Lilly based on the CV outcomes of their respective products. People will pick their favourite based on their reading of the study. If you look at all the studies published? They both continue to exist and survive well – though the game will continue to evolve or disrupt once the oral version arrives- followed by the dual GLP-1/GIP class. Did someone say “living guideline”?

4.       False death? : This would be class of medications called DPP-4 inhibitors or the “Gliptins” on the back of CAROLINA & CARMELINA. As Mark Twain said? “The reports of my death are greatly exaggerated” – so is likely to be the case on this. In a population where 1 in 5 of Type 2 diabetes are frail- and the other classes have their own side effects to contend with- a softer, smoother drug may not be quite dead in the water. Lets see- but there is a reason why the NHS has focussed so much on frailty in diabetes. Outcomes are important- as is quality of life. Its one thing for specialists to opine- its another thing for the practice nurse seeing the patient in front of them and making the call.

5.       Burying a myth: This refers to the VItamin D trial in prediabetes- does it help prevent Type 2 diabetes development? No. Let’s stop doing quackery- and focus on interventions which actually help- look at DIRECT and debate VIRTA properly. The answer is there- not with medications.

6.       A New Hope? A phase 2 trial showing delay of onset of Type 1 diabetes in high risk patients was exciting- and certainly raised a few eyebrows. The product raising yet another wave of hope? Teplizumab- an anti CD-3 antibody. Watch this space- could be something exciting

7.       Told you so: This is in reference to data coming out from across the UK as regards use of Freestyle Libre. Much kudos to Association for British Clinical Diabetologists for getting the national audit together- and an even bigger doff of the cap to Dr Fraser Gibb for his excellent work in firstly being a pioneer in helping folks get access- and secondly the relevant data crunch. The outcomes don’t come as any surprise to me- but hopefully it will satisy some of the critics. Lets be honest- if you don’t think a device which improves self management by better visualisation of your own blood sugar readings in diabetes will result in better outcomes? Then either you don’t understand diabetes or deliberately trying not to or consumed too much in your own confirmation bias.

 Finally- some words of caution:

1.       It’s very easy to say guidelines should be adopted and the NHS should get on with it. However, let’s not ignore completely one basic thing. HbA1c attainments in the Type 2 diabetes population are not bad at all –neither are admission rates compared to other countries. If we do move “newer” agents up the paradigm, that will come with a cost. There is no extra money- so something will need to be disinvested right now to get that money. Yes- it maybe recouped back via outcomes in 2;3;5;10 years- but the money invested upfront will have to come from something else. And lest we forget? The clinical system is reluctant to stop anything per se.

2.       With data etc coming through, class of products such as SGLT-2 I is likely to be prescribed more – by primary care, nephrologists etc. In short, the bulk will go up –with many clinicians also driving change of guidelines locally – overturning existing NICE guidelines. Apart from the money side of things, it would be fool hardy to ignore signals- however small- of DKA etc in trials. In adequately monitored patients, its there- albeit small. Extrapolate that to the population in a system struggling to do a lot of basics? Caution is also order of the day. The data and impact is undeniable but as clinicians, its always a balance too.

So that’s another year done. From a personal perspective- it was exciting to meet with all the technology companies as well as researchers such as Roman Hovorka  and discuss closed loops, future work, education platforms, CGM in Type 1 diabetes pregnancy etc…and then there is the exciting potential work of doing something in India.

All in all? Good learning, good networking – and looking back- some wonderful evenings too. The world of diabetes continues to evolve- and we are in an exciting space in these times. Can the NHS continue to be part of that?
Time will tell.

Saturday, June 8, 2019

Decisions...Part Deux

This blog is more like a continuance of the last blog…somehow it wouldn’t feel right to leave things in the ether- especially when this blog has been a means of connecting with so many living with diabetes. And its been about making the decision- does one go for another round of the national role or sit back on the laurels?

And its not been easy- mulled many times over it, spoke to many people, including the ones who are the closest- but in the end? As Andy Cowper wryly mentioned on twitter…”Partha Kar is the only one who knows what Partha Kar will do”. So- you bite the bullet and take the plunge- throw your hat in the ring- mostly to finish off a few projects which seem to have direction, seem to have, I think,  a way through the maze of the NHS. By no means it implies I will get the job- but a National Specialty Advisor role with a specific focus on Type 1 diabetes and technology is one which has potential- one which has the wherewithal to take things a step further.

Whoever gets it, one bit will always please me. A national role with a specific role for Type 1 diabetes? A dream to be honest. Raising the profile of Type 1 diabetes has been a sole focus of mine- and everything that has been done- has been with that aim in mind. Now to have it formally recognised- does make me smile with a great degree of pleasure- Type 1 diabetes is now firmly on the map- its now there on the table. Its no longer part of “Diabetes” alone- enmeshed and forgotten amidst all the other relevant drives on prevention etc- but as a separate entity.

So where to next? Bar the ones which have already had work started such as Mental Health support, concluding the GIRFT work etc, a few things come off the bat instantaneously. Flash Glucose monitoring is moving- and now in the system-data sets coming out will make it practically impossible for anyone to stop funding it- but it does feel like a job not quite done. So on we move to a few things which could have big ramifications

Out Of Hours Support for Type 1 diabetes: It would be fab to land this- similar to what exists in paediatrics. As use of technology advances, this can only be a good thing- lets see

Uniform education: The GIRFT work has made for some startling yet perhaps not surprising finding. Rather than focus all our efforts on how to educate patients- we should look a bit inwards. Specialists need to be uniformly trained if we want to increase access to technology- and so we shall via uniform platforms of education- and transparency around who is doing the training- and who isn’t. We need to benchmark adult Type 1 diabetes service- and appropriately trained staff has to be the cornerstone of that

Closed Loops and Technology: This is the future- and indeed is the way we can improve Type 1 diabetes- making the case for its funding is indeed the job- and I would like to try. The basic question is how one does that without making the good better and pushing the bad to worse…how does one get technology access better without making socioeconomic divides worse. It’s a challenge- but one worth taking on.

So we go one more time, another shot at it- if appointed to the post. As I sit here in san Francisco typing this? The energy is there- and I have seen many whose kind words have touched me, whose unflinching support have emboldened- as well as seeing some avenues of advancement which I would like to bring to the lives of those living with Type 1 diabetes.

To some? This will be a moment of "Good Lord, not again"- but to the many who have stood by me through thick and thin? Thank you- whatever is achieved in the future- or not? I can assure you I will give it everything. The decision is made, the dye is cast. Lets see where it takes us all.

Saturday, June 1, 2019

Decisions. Decisions.

3 years -and then we get to a decision point. The national roles have been re-advertised- with a rebadging of some roles- to focus on the integration between NHS England and NHS Improvement- or as some smart-alec mentioned NHS-SI 

Its that point where you sit and think whether its time to make way for fresh blood, weigh up the last 3 years, impact on ones personal life and completion of all that one set out to do. And I will be honest- its been blisteringly good fun. Huge amounts of experience gained, some good friends made, much learning about the system which I would be happy to pass on- but with the added flip side of having dark days, days of feeling the ageing process catching up too quickly- and the balance of friends, family, kids growing up…. 

I must say I am not sure what the decision will be or should be as regards continuing. To me, leadership roles are about achieving a finite few things which make a difference to peoples lives- and then knowing when to go, making the way for a new burst of energy from someone fresh. That way, the whole community benefits too. There’s also the issue of looking at the “To-do” list and wondering whether those that haven’t been done, could do with one more tilt at it- and at the moment, I must admit to being torn. There’s no doubt that the kind words from many of those living with Type 1 diabetes continues to be a spur- there’s also the fact that at the end, people remember you for your legacy. Stay too long- and it’s the failures one recalls, rarely the success.

Putting Type 1 diabetes care on the map- and pushing all to understand why its important was always the focus- and via the vehicle of Freestyle Libre- the focus has come. The NHS Right Care pathway separated out Type 1 diabetes care from the overarching paradigm of “diabetes”- and the technology battle against the issues in the system was something I relished. I think focus on this in the NHS Long term plan has also set the agenda- and there is no denying that technology and Type 1 diabetes isn’t something that can be brushed away any longer. Fuelled by a fabulous and growing mass of those living with Type 1 diabetes, its certainly moving in the right direction.

There's also much to do- and post the CCGs, the focus is starting to shift to specialists too. Its no longer ok to carry on as usual. I would like to see all centres trained to a minimal specification- and that information be available publicly. If you are not trained? Train up- or give the work to someone who is willing, keen and ready. I want to see Out of hour helpline provision nationally in adults with Type 1 diabetes- similar to what paediatrics have. I would like to see greater access to CGM, Pumps- and to be honest? I can see a path for that too.

Should I hand that to someone else- or does it risk the chance of losing focus as someone else may have other priorities? Its like something personal- and you aren’t sure whether to let go- or not. Stop now- and walk away with what's been done so far- or have one more year at it?

Much to mull about- but most importantly balance that with the one thing that matters most- family. I suppose in the end? When all's done and dusted, they will be the ones beside you- and that is never to be compromised or forgotten. So much thinking to do, much considering and discussions to be had- but whatever be the final call, a huge thank you to all who have supported and helped- and mostly to the Type 1 diabetes population at large…its been a pleasure to be able to be of – hopefully- some help. Not many get this sort of chance to benefit a wider population-and for that I am grateful to all concerned. Its been a blast.