Sunday, October 14, 2018

Small steps...




Another week…and a few more things progressed for diabetes care- or at the very least , some steps forward were made. Previous blogs have alluded to the work we have been planning regards the area of mental health support in diabetes care- and finally, an event earmarked to flag the start of this journey was made.
Mind Over Matter- to be fair- was the idea of specialist nurse colleagues based in Medway, Kent (Rebecca Watt and Amanda Epps)- and further with the support of Sanofi, a day was organised- which tied in well with the conversations NHS England mental health team and diabetes teams had already started.

The day showcased views and the challenges in front of us all- whether it be from a primary care perspective or indeed a patient charity point of view- while eloquently laid out were the views from a psychology and psychiatry point of view-as well as from a diabetes specialist angle- captivating the present audience of about 150. A big thanks from my end to Abbie Brooks, Chris Askew, Claire Reidy, Khaleda Ismail and Richard Holt for outlining their views as well as finding the time in their busy schedule to help- though as ever, the star of the day was Jen Grieves giving the person with diabetes a voice- and perhaps driving the point more forcefully than any statistic would- as to why mental health support is so important an issue.

The subsequent workshops were aimed at showing the art of the possible- even in challenging times and dwindling resource- as to what was actually possible in different areas of the country. It was fascinating to see and hear those examples- and the positivity was most encouraging. The next steps perhaps however are the most important- the aim is to do a literature review of the role of mental health support in diabetes care- and then try and work with all parties to come up with the ideal mental health support for anyone with diabetes- wherever they are. Possibly a mixture of IAPT, psychology, psychiatry…face to face along with virtual- lets see where this takes us- all in all- there is intent from both relevant NHS England teams- we shall find out how far we can travel down this less-trodden path.

The other event was the announcement of the Diabetes Hot House. If not sure, have a look here…in short, if you have something innovative in the tank that could improve certain pre-specified areas of diabetes care (inpatient diabetes, mental health, maternal health etc) then have a look- and see if this is something you maybe interested in. A joint working between NHS England Diabetes team and ABPI- suffice to say its taken a fair bit of time to work its way through all the process. In the end, its  venture the AHSNs are now facilitating- post all the negotiations done with 5 of 7 diabetes pharmaceutical companies. We talk aplenty about innovations- lets find out how much or many of them actually work- by looking at the evidence accrued. I suspect its a bit like what we are doing with using digital means to help prevent Type 2 diabetes. Does it work? We don't know. But we are investing in trying it in 5000 folks- and the results will tell us whether there is mileage in further roll out- or not. A personal thank you to UK divisions of NovoNordisk; Sanofi; BI; AstraZeneca and Takeda for supporting this venture- and for the ones who are asking- yes- it is completely product agnostic- rest assured.

Finally, it was another week of the debate around Freestyle Libre. We are now officially in the zone what is called the Laggards in an innovation curve. In that last area- where it doesn't matter what evidence you have, what those who live with the pathology want….folks who want to block it scramble to find a way- or have none but just say No. In that zone, it was heartening to see further progress across Lancashire in 8 CCGs- down to some sterling work by local folks- no small credit to Dr Rahul Thakur- which takes us close to 75% of CCGs who have now accepted the Libre in one form or another. It maybe worth for organisations who purport to speak for CCGs to speak to their members and see how this embarrassing situation for them could be salvaged- or a veritable question will continue to rise as to whether CCGs are any more fit for purpose- or whether we as a health system pay lip service to terms such as "improving variation"; "encouraging innovation" -or even the one that always make smile "-having the patient at the centre of care".
Heres a question for those CCGs- if you cant even deal with the Freestyle Libre- how will you deal with the complete disruption of the Type 1 diabetes technology market just over the horizon? If you serve the population- serve it properly. Or give it to someone who can. Or learn from a fellow colleague who seem to be doing it better.

So there we are- yet another week whizzes by…as mentioned- slow and steady progress- but progress  none the less. Who knows whats next around the corner for diabetes- especially with the plans of the NHS being made for next 10 years.
Could there be something for early intervention with diets? Perhaps something for mental health support? Maybe even a technology fund to look at kickstarting the CGM/Pump sector? The future is laced with possibilities….but for now? Lets also be encouraged by the small steps of progress the community continues to make.

Saturday, October 6, 2018

Berlin Learning

A week away trying to do some learning- as well as catching up with old friends- whilst making some new…in the city of Berlin. 5 days of a lot of interesting events, meetings, discussions, symposium- all the while mixing the role of the clinician trying to get up to speed- while meeting companies about the latest developments, discussing policy, exploring avenues to increase access to new technologies, medications etc. Couple that with socialising with old friends- and it made for a weekend -mostly of rest!

Key highlights? To look at it from a very neutral point of view- they were the following:

The launch of "Libre 2" took many by surprise- I suppose even wrong footed many with their timing. The disruption in the world of technology continued at pace- and interesting time lies ahead of us all.

HARMONY confirmed or should I say solidified some of the continued evidence around GLP-1 analogues. Perhaps a weaker GLP-1 analogue-yet with similar results. A product which isn't being marketed heavily by the company concerned- but nonetheless, did the class no harm at all

Twincretins or a combination of GLP-1 and GIP analogue raised some eyebrows with their results. Much more to do before it comes to market- but the results were impressive. The key will sit in the balance between efficacy and tolerability- but interesting times nonetheless

CARMELINA reported- and didn't change any of the present dynamics- suggested it was a safe product- whether it be from a heart or kidney point of view. Suspect there will be a fair interest in CAROLINA- where it goes head to head against a sulphonylurea.

Oral GLP-1 analogues also caused a bit of a stir with their results- simply due to the delivery mode- as well as the whole debate churning with options galore on the table

SGLT-2 inhibitors in Type 1 diabetes came to the fore- and again- confirmed what many thought or knew. Good efficacy on many quarters- yet with the overhanging risk of DKA in some. It will be interesting to see how the diabetes world deals with this new information

The ADA/EASD consensus guidelines for Type 2 diabetes were published- and perhaps reflected changing times- and starting to take into account the changing paradigm regards CV outcomes with new classes of drugs such as SGLT-2 inhibitors and GLP-1 analogues. In my opinion, it needed something on frailty and has the potential to have to go through an amend after DECLARE study is published- but overall, much more simpler for many in diabetes care. It probably also puts a lot of pressure on NICE to look at their guidelines and debate whether CV outcome improvement now needs to be reflected accordingly.

Things which could have been more in its presence- and perhaps not put into fringe events? More focus on early interventions with diets, greater focus on patient stories, interactions with patients as well as discussion on patient led disruption of technology would have been very welcome- but hopefully this will become more of the norm in the future.

Its been fun and interesting- and we sit in the midst of interesting times for diabetes care- whether it be the role of diets in Type 2 diabetes; role of medications improving CV outcomes in Type 2 diabetes; disrupting of technology in Type 1 diabetes or indeed discussions around deprescribing where appropriate. How much of that will be reflected in the NHS going ahead- will indeed be interesting to observe.

Thank you to all who made the time to speak and catch up- and a final big thank you to IDF Europe for the opportunity to discuss Language matters as well as Diatribe- for a fabulous evening discussing anything & everything about diabetes.

Till the next time..but for now, a bit of rest beckons.



Sunday, September 30, 2018

Silly season

We seem to be entering crazy season very fast….the latest being a new wheeze from some Clinical Commissioning Group suggesting that General Practitioners have a go at doing Caesarian sections in women. I mean- where do you start with THAT level of banality? If it is as true as reported, its breathtaking in its scope of desperation - and in some ways, opens up new frontiers of policy making- which could only be seen as an episode of The Thick Of It.
Forget about safety, training..I suppose in this new era of technology- why wouldn't you think a Youtube video would teach you all you need? Plus lets not forget- GPs are there twaddling their thumbs- thinking- what ELSE should I do today? I despair at decisions CCGs take in diabetes which makes no sense, but compared to this, diabetes pales into significance.

Its not just that though- there seems to be a building rhetoric of "lets try this"- coupled with the boldness of ignorance. Hows this one at a more simpler level? An App company asks for their product to be introduced into the NHS Apps Library; they make a statement that the use of their App would improve diabetes markers by X, Y and Z; suggest economic benefits too. To a return question asking for data to justify that claim, the answer is "Why do you need that data?How is it relevant?"
Take a pause and mull that one over. Thats a bit like calling myself Batman. I will break it softly…its supposed to be a joke comment; its supposed to -on some days- even be a metaphor. I am actually not a leather clad vigilante who doesn't go to sleep at night. So if someone asks me "Are you actually the Dark Knight?" - I either need to show them my bat cave and my pointy eared costume- otherwise its just a silly claim. Geddit?

Its a very odd situation indeed. Lets take safety. A classic case of healthcare professionals self immolating themselves- amidst  a juxtaposition of self appointed gurus; some hashtag campaigns and a few folks masquerading as interested parties- yet mostly trying to drum up business for a conference or two. Thats the cocktail we have- while we -mostly- have a tick box approach towards actually listening to those lives whose safety we are purporting to improve. Multiple conversations I have- which starts as "really committed to improving safety or outcomes" ends up in "would you invest/fund this"? Take Resilience as an example. What is it supposed to be- the fortitude to work double shifts? The capability to cover for gaps- or simply a generation making judgement about the next one with that old rhetoric of "you ain't tough as us- we ate bullets for breakfast"? Or just an acknowledgement that resource issues cant be solved any more- not because of the lack of money- but the workforce doesn't exist? A classic example? You want to improve diabetes foot care? You need podiatrists- do we have enough of them? Nope. Not just about the money.

I suspect when we are in this sort of situation, it perhaps does fall on all of us and say "Hold on a second". Its upon us to raise the concerns, document it- and ensure its been raised. If you don't- and something goes wrong, I suspect we all become complicit. Pushing back against something - whether it be unqualified professional, technology or jumping into the latest hashtag effort- doesn't necessarily make you a luddite- sometimes its also about doing the core job- of ensuring we do no harm.

Sill season is here- and with the clock ticking as regards the gap between resource/workforce and demand ever-increasing- further outlandish ideas will emerge. Thats natural- its a question of what as a system we do about it. Technology will have a big role to play- as will processes- but the biggest crisis in front of us will be workforce. Its best we don't lose sight of that.

To quote Alexander Pope…."“A little learning is a dangerous thing; drink deep, or taste not the Pierian spring: there shallow draughts intoxicate the brain, and drinking largely sobers us again"
Amen to that.

Sunday, September 9, 2018

Step change?

Last week was ExpoNHS18. Lets just pause there for a second.
Does that actually mean anything to you? If you aren't on social media or indeed even if you are, does that bring:
a) warm fuzzy feeling from an uplifting event?
b) make you go "Meh"
c) quizzically ask "Whats that?"
For the uninitiated, I wish I could give you a concrete answer- but in short, is a mahoosive shindig/meeting/conference/gathering where the great and the good as regards NHS policy etc get together, bright new projects are discussed, people hang around for clues to understand where the next investment will be- and a lot of folks trying to sell their wares to the NHS. Thats pretty much it. Within a certain bubble, it feels amazing, it feels like you belong, it feels like things are changing- but the fact remains that for most folks within the NHS, its either b) or c). Don't believe me? Go back to your workplace- and ask 10 people in your department that question.

I will start with a caveat- I wasn't there this year- mostly due to the fact that I was doing previously committed hospital visits as part of GIRFT- plus genuinely had an evening booked in for dinner and drinks amongst the diabetes consultants in Portsmouth. The first could possibly have been rescheduled, the second- to be honest- was non-negotiable. In addition, the best of the national diabetes team were there- so no shortage of folks flying the flag. Throw in there the fact that you can track most similar minded conferences via social media nowadays- and nothing was lost by not attending.

It appears the big step change was the big announcements about digital technology- and it sent the affectionados into absolute raptures. Each health secretary puts his flag down as a marker- and after Mr. Hunts "safety", clearly for Mr. Hancock, its "digital". All good too- as no doubt its time to modernise the NHS on that sector. The question as ever is whether we end up flying before we walk. I am- and always been a big fan of digital- but its always useful to analyse its effectiveness before national roll outs. Case in point is the Heart-Age app- which- how shall we put it- has had mixed reviews- and been slated by the governments own technical advisor now.
Some big things are being mentioned such as Virtual Reality, Artificial Intelligence etc- and am also a big fan of those. I genuinely believe they have potential to improve diabetes care- but let me tell you- at the moment- what a mature digital NHS should look like- or we could try aspiring to do:

It involves me walking into work- and logging in within 1-2 minutes, having a single log-in to all systems such as blood results, radiology, patient notes- and most importantly, a single system whereby me, primary care and the patient themselves have one place to input data, send letters etc.

Nothing too much to ask in 2018 I hope- but the fact remains we are about a few light years away from it. Some places have done it- but would we want to learn from them? Oh no- don't be silly!!Each hospital, Trust, CCG, STP, ICS, ACS tries its own thing, has a deal with someone somewhere…result? A fascinatingly fragmented system- while we discuss the possibilities of AI making life so much easier. Heck, in some places, folks are banned from emailing each other or communicating with their patients….THAT is the NHS for you too.

Throw in the numerous bodies who exist to make all this simpler-but don't/can't/won't…and you wonder what exactly would be needed for the actual step change- to avoid individual private companies to make a mint out of the new drive to improve digital uptake- and leave us stranded- again. NHS Digital are making all the right noises- got some really good personnel in place - the question is how it cascades post that. Once you move past the top layers and you go into regions…tribalism kicks in- as well as-frankly- a lot of immaturity- and folks not well versed in anything digital trying to have a go. Or indeed, not having the capital to invest. Or shying away from stopping something existing to fund digital work (quite rightly too in some circumstances)

The next few months if not years will be fascinating- as we explode into a world of "digital". In the world of diabetes, you will see similar- the question is this…..will it make a difference- or pass us by as another fad behind which we sunk public money? Or do we end up creating a 2 tier system based on digital maturity? Or do we succeed in helping to plug some of the gaps emerging in providing basic health care? Or become world leaders in showing what digital can do for healthcare- irrespective of your ability to pay?

Safety was the last big thing- have things changed by all our focus on it over the last 8-10 years? Depending on your confirmation bias- you will answer that question. It will interesting to see what this step change in 2018 will bring us.
Digital has the potential to help-and the national focussed leaders are there in Juliet Bauer, Indra Joshi et al….the question is how much we can harness the desire amongst many, use the resources creatively while collecting evidence, educate beyond the top echelons of the NHS- to show it actually making a difference.

Part of my job is talking to entrepreneurs who have the latest "digital innovation". Some of them are brilliant, some of them need a bit of a push…a lot of them also make unsubstantiated claims to attempt to get a piece of the pie. Beyond the glitz and the euphoria of digital explosion? Sits a fair bit of murkiness too. It will be a fascinating space to follow.


Friday, August 31, 2018

Language Matters…Universally

As a healthcare professional, there is no question about the issue of Language Matters- or indeed my personal belief in it. Started by the indomitable Renza along with Jane Speight - the further dedication to the theme by Jane Dickinson bears no debate about its relevance - and research as funded by NHS England and expertly marshalled by Cathy Young and Anthea Wilson has shown its importance in patient care too. Personally, my staunch support to it is well documented and a subtle, yet important difference between the Australian and American work on this and the UK one is the relevance of the national body leading on this with patient organisations- rather than the organisations leading it. We are proud of the work done, the steer given and the collaborative work across all sectors which has got us here. 

However, something has started to gradually come sharper into focus. It started as gentle conversations with fellow HCPs about the pressures they face, the language sometimes they face and what impact it had on them too. Recent forays into some patient social media groups has been interesting- no question about the educational element to it but also the realisation of the sharp context of some words and how that would land with me- if I knew that particular point was about me as a clinician. There's also the issue of conversations amongst those living with diabetes and it has left me intrigued, maybe a bit chastened to realise that the whole issue of "language we use" is perhaps not just about HCPs, but about all of us. 

Let me give you three examples. The first one was about the PM, Theresa May. Whether you agree with her politics is a personal issue for us all in a democracy but that shouldn't extend - in my opinion- to " I wouldn't wish anyone a DKA, but with her, I wish she does". It made me wince given that it was from another person with type 1 diabetes- where indeed does the language stand in this situation? Our political allegiance wants someone to go into ketoacidosis? Imagine a healthcare professional saying that...quite rightly, they should be censured for that. What about those who aren't? It's an intriguing space - mixed in with the lethal way as to how social media sometimes functions- but adjoin it with "Language Matters"...and we suddenly have a conundrum.

The second one was about a nurse colleague. Words used to describe here were "fat", "ignorant", a use of the "c" word and a follow up from others joining in to laugh at this particular HCP who should eat "less carbs", "wish she gets diabetes"...and some other interesting comments. All from those living with diabetes. Perhaps a reflection of a frustrating consultation or indeed the person concerned not feeling being listened to- but how does that translate to those sort of language in a public forum? After all, flip it around...unless you live in a parallel universe, the pressure on HCPs in the NHS is huge, the staffing issues are paramount- and in the main, most are going above and beyond what their designated jobs are. How would that HCP feel if she read those? What impact could it have on her well being, her motivation etc? Intriguing space indeed- and I do tend to see a fair bit of how it was the HCPs to blame for X,Y and Z. If we want to move to a culture of no blame, then as much as we don't castigate a person living with diabetes for anything, the reverse also perhaps needs to be true. HCPs are human beings too- and words matter. To many? It's not just a job, it's much more than that...it is indeed their vocation.

The final example was which I saw recently- the Gary Mabutt story about rats- and I must admit to raising an eyebrow. On one hand, it could have been a misquote and media looking for a sensational headline ( on this case, it wasn't); on the other it is his story to tell anyway he wants. His view perhaps would be to use this as an example to raise awareness of the issue...the question I had where that leaves a HCP. I have never practiced shroud waving to any patient of mine- neither am I to start- and frankly I don't think it works. Chris Aldred work on this strikes the right chord and is something to explore more indeed for HCPs- but given Gary said his story like that, how does it pan out for others? How would a 6 year old child read that? Or their parents? 

How would it work if HCPs use that as an example? Can they? Should they? I must admit to having no idea whatsoever. It also opened up a new avenue for me- seeing the view from Gavin Griffiths on it- and the subsequent response from others within the #gbdoc community and wider. Was this a case of stopping folks voicing their opinion in a democratic society or wasn't it? Some of the comments against him made me wince and have a wry smile- as frankly Gavin's commitment to improve care or raise profile of Type 1 diabetes is above any doubt in my book. He was voicing his opinion- but the response? Fascinating indeed.

So to be honest? I don't know much about what is the right answer to this- and I suspect I will always be a Muggle in the #doc - and rightly too- I don't live with diabetes- and there are aspects I will never get. But if there is a gentle request from someone who tries his best to bridge the 2 worlds, my appeal to all is simply this. Language matters all the time. Whether it's from HCP to person living with diabetes- or between folks living with diabetes- or indeed the other way around.

In a nutshell? Words matter. However resilient we all are, we all have a breaking point, we all have chink in the armour which breaks the barriers. In today's world, asking for kindness to each other is perhaps due to fall on deaf ears but maybe a moments pause before hitting the "post" or "tweet" button won't do any of us, including me, any harm.

References:



Saturday, August 25, 2018

Ten…and 5

A decade. 10 years. That's a fair bit of time as  a Consultant in the NHS-  a lot of which has been spent in interesting times for the NHS- and boy, hasn't it been some roller coaster! Beyond the day job, exploring roles in management within an acute Trust, community Trust, Think tank, Regulatory body- and finally, national roles..and experiences to last a lifetime; anecdotes to regale dinner parties with- and much to look back and smile at- and as ever, mistakes galore along the way. For what its worth- and mostly aimed at colleagues less experienced, here are my personal top five reflections and tips….hope at least one of them helps along your journey!

1. Core team: Always choose your team well. Remember how much time you will spend with them- and how much you will rely on each other. Its absolutely critical to survival- learning to relax- and be secure in the knowledge that they will always be there for you. Its not easy to find such a team- and I have been extremely lucky - but we chose each other. Don't rush into an environment- a bit of considered planning will give you much benefit in the longer run.

2. Fear no one: I genuinely mean that one- and it goes hand in hand with the above point. If you have patient care at your heart and the sole goal, you stand your ground- with your team next to you. I have been thrown out of meetings, shouted at, had others spit on my face as they raged a few centimetres from my face….but I believed what I was asking for was going to improve care for diabetes patients. Time has shown that to be true…but you fear no one. At the end? They are all humans, all with foibles…I have met many a leader…they are only that…humans.

3. Bias exists: Don't anyone tell you it doesn't. It does. Heavily. The system talks a lot about equality & diversity; creates powerpoint; holds conferences - but in the main, does a lot of tokenism. If you are non-white, then you have to work harder; you have to prove yourself double; you will be treated with disdain by many; they will doubt what you can do…but if you believe in what you are doing, it will stand. Again- it boils down to that basic thing- team and their support.Bottom line? In general- if you are not white, you will have to struggle harder- so be prepared for that.

4. Mistakes/Failures happen: Don't be afraid of mistakes. It will happen- not only is this the job, but also a part of us all being human beings. The question is how much we learn from it. Its easy to talk about your success stories- less so about your failures. For what its worth, my 10 year career is littered with failures, stories of unsuccessful interviews (in fact I have flunked more than I have got through) and mistakes. Of course I regret some- but turning back the clock isn't in my gift, so you try and learn as best as you can from them.

5, The core job: Whatever roles you do- and I do encourage all to try different things to avoid any monotony settling in- never forget the day job- because thats what you are there for. Always ensure you never lose focus of that and the huge role you can play for generation next. You try-as best as you can- to have a moment for a smile or an encouraging word - it doesn't have to be grandiose or a gift- just simply a hello is enough. The core job keeps you sane, it also comes with the responsibility the Consultant tag brings.

Bar that? Not much really- do the job to the best of your ability, go home- and enjoy your time. Don't take work home- because you cant solve everything- but at least go home in the knowledge you gave it your all.

Finally, if you are lucky to be graced with success along the way, don't lose the ability to laugh at yourself. The day you believe your own hype, is the day its pretty much done. At this ten year juncture…I will let you in on a secret…which only a few very close to me know….the cockiness, the brashness, the outrageous confidence or indeed the iron clad belief that "I am right"?
Its mostly a well honed act- beyond which actually sits someone who loves his comic books, his food, his whiskey and a continued wide eyed disbelief at the opportunity fate has landed him to hopefully help some one else.

A decade has whizzed by. What next? I actually don't know….and I choose to leave it exactly like that. I work with the best team in the land….and I wouldn't change it for a thing.


Saturday, August 11, 2018

Tenacious

Talent. I must say its always eluded me in life. Never quite got there. Tried my hand in musical instruments- distinctly average was being polite. Tried my luck with painting- nope; singing- No go; sports- ditto…and sort of became a theme of my life in school and college. Became a medic- and nothing much changed to be fair- nothing sparkling or anything much to shout about, no gazillions of papers in respected journals, no earth shattering research to write home about, an MD thesis which wouldn't change the face of medicine- and neither blessed with skills that would mark me as the next generation House- bar the occasional cranky mood of course.

So when life deals you that sort of hand- (and theres nothing wrong about it-as lets face it- most CV applications are lies.No one REALLY can be awesome at everything bar a Bollywood hero)- you start looking at things which in some quarters would be seen as a positive. And thats when you discover a trait associated with dogs- and frankly, I see nothing but pride in sharing something with dogs…if only we could be more dog, so much would be better. Anyhow I digress- and the fact I found out about myself was something called "Tenacious". (I recall who said that too and I don't think he said it in a complimentary way…it was the time of the creation of the Super Six model and the person concerned wanted me to give up diabetes and do more general medicine...)
And sometimes, its not been a good thing- but sometimes, its been a boon…and perhaps never more while doing this national role. Some like calling it "Resilience"- I think thats a stretch as that term is better reserved to folks such as the marines - and we don't do stuff to that degree…..plus I like the dog association- tenacious.

The last few months have been amazing -as regards testing that character. Looking first hand at the degree of variation around the country- and yes, I am speaking about something which has been a personal battle- getting access to technology- with Freestyle Libre being the spearhead of that process. And heck it needs tenacity, it needs a whole lot of gritted teeth….and you start discovering how banal we all can be when we position ourselves as self appointed vanguards of patient care. We have seminars as to "how do we spread innovation"; we have organisations funded to do this sort of work; we have folks employed to do exactly that…and yet….

How on earth can anyone justify saying "our area" is different to rest of the country- is beyond my comprehension. I mean- the reasons and excuses have varied from the sensible to the absolute banal. Lets take a step back and see what has been done so far- and simply because NHS England are criticised for not doing enough to tackle variation or indeed pricing or data collection.

  • Negotiation of lower price than market: Yup- about a 30% drop in price
  • Negotiation to make data collection part of process: Yup- via national specialist organisation
  • Creation of a narrow framework at national basis: Yup- RMOC guidance
  • Cascading of good practice: Yup- agreed guidelines from London, Leeds etc sent when asked
  • Clear ask from NHS England: Yup- via letter issued to all CCGs
  • Clear strategy that this is a priority: Check letter or indeed social media outputs

Yet….we have some areas saying they have to review the guidelines themselves, they have to do the finances themselves, some networks saying they did not know it was a priority, some saying they do diabetes differently (funnily enough the CCG outcome framework doesn't suggest so-unless "different" means "poorly")- and then some areas come up with guidelines which is so laughable that they may as well say No. I mean, why do you have to get your cholesterol normal to have access to a glucose monitoring device. Thats not even science.

So we are back to that characteristic I have- like a dog. Tenacity- and through gritted teeth, I will have to keep at it- whether some like it. Or not. Some will feel its personal, some will not want to be friends- but this is anything but personal- this is simply asking a question: "If you are funded by tax payers money to do something, why are you not doing it? And if you can't- give it to someone who can"

Listening to patients and all that lark should not be confined to power points- neither is there any leadership quality in hiding behind board meeting minutes. So if your job title says "Improve Innovation" or "Improve Diabetes outcomes" or "Serve the local population"- then do so. And while you are it, be open to learning from other who are; don't think of your area as something special compared to others- you categorically are not. And if you can't, lets move that money to other areas where it possibly would be better used.

So- go back and check your local CCG policy regards access- whether you are a local diabetes network, AHSN or CCG lead. If its still a no- YOU are now in the minority- and I will keep asking, keep putting things in public till this is done. Consistently- tenaciously- dog-like focus. And I have got bundles of energy left on this. Your choice whether you feel its worth a scrap -or whether its worth looking around, learning from others -and most importantly listening to those living with diabetes. Someone asked me recently- "70% coverage is amazing- why not leave it there and give it time?"…the answer is simple…"My target when I started was 100%- and I am not in the habit of shifting them". To those who feel "under pressure" or want to "lodge a complaint about pressure"- be my guest. I have no career ambitions beyond this role- so little to "lose" either.

To those who still are in the 30%? I am doing my job. Are you? Or are you now the Laggards as per the well-known innovation curve? We are but a whisker away….get it done.