Sunday, April 15, 2018

Across the divide

August 2010. Its always a tad nostalgic to skim through old emails- but that's how long back was the 1st meeting to discuss how we wanted to change diabetes care in South East Hampshire & Portsmouth. Many late nights, many meetings later- it was around September 2011 that the redesign of the diabetes model came to being. In between that, there were the nervousness of contracts teams in hospitals, the debates with one's own Trust, the financial calculations involved, a lengthy conflict of interest panel, multiple negotiations,convincing colleagues....yet finally we got there -the birth of the Super Six Diabetes Model. Much has been written, many papers have been published- and the mists of time make one forget who did help along the way.

Those were the days of Jim Hogan and Koyih Tan as GP commissioners, Lyn Darby as the local Commissioner, Melissa Way as the Strategy Implementation manager, Richard Jones as the Medicine Chief; Lesley Munro as the manager from the local community provider....some steadfast supporters-and of course, 3 fabulous colleagues within the department who let you get on with it. The course of time has been kind to us- and about 6 and a half years later, the model continues as we discuss the next steps- ready to tweak and evolve as per local structural changes- whether they be Accountable or Integrated care organisations or Vanguards or Hubs. 2011 was the time the South East Hampshire & Fareham/Gosport CCGs came on board- another long process followed post that and  in 2012 we got Portsmouth to join- post a tendering process with 5 bidders...and what an experience that was too!

As of 2012, we finally had all 3 CCGs under one pathway, all 3 local providers under one pathway- with one fundamental aspect to it- the same team delivered care across the secondary and primary care- same Consultants- no different, no one to "compete" with- but be responsible for the outcomes across the whole sector. Which- to be honest, is how a long term condition should operate. Without having to think of competing bottom lines; competing for resources, trying to expand a community service at the expense of the acute...nope, that is NOT how you can improve care in a long term condition.

Results have taken their time to come through- and much kudos to local commissioners etc- present times having folks such as Paul Howden, Sarah Malcolm- holding their nerves with the model of care. It has been and continues to be one of the longest standing models of care- referenced in the NHS Right Care pathwayKings Fund ; Diabetes UK documents etc
Documented papers on reduction of admissions have been published- which have been greeted with as most things in modern times. Respect and cheer from those who have believed in the principle; a look for conspiracy theories or flaws in the datasets from those who haven't liked this approach towards diabetes care.

Recently NHS England has published the Diabetes CCG Improvement & Assessment Framework (IAF)- based on a few agreed principles nationally with clinicians and patient organisations- such as participation in national audits, attaining targets, people attending education programmes, amputation rates etc. Grading has been given as Outstanding, Good; Requires Improvement and Inadequate- similar to how CQC look at providers.

Taking Wessex and Dorset region as a pack, there are about 8 CCGs or 2 STPs. Of those 8 CCGs, 2 have been Outstanding (Fareham/Gosport & South East Hampshire); 4 Requiring Improvement (Portsmouth, Dorset; Isle of Wight & North Hampshire) with 2 rated as Inadequate.

I absolutely make no bones about the pride it gives us to see the fruition of many years of hard work to see this- and the vindication of the principle to which we and the model of care has worked. It also shows work to be done in 1 of the CCGs we cover- and focus will be on that area for sure. The workforce has been a fraction of what other systems have used- thus showing its not just about the sheer personnel but also about the ethos of having one team across the divide. When we work as a community team, we have no dispute with the acute team-….we are it.

Lessons to take away for us- or even to pass on? As this is the Super Six Diabetes model- here are 6:

  • Use acute hospital for high end stuff such as antenatal diabetes, foot MDTs etc
  • Access, access and more access to primary care- whatever means possible- physical or virtual
  • You don't need fancy tech or Apps to do all that- simple old school relation building with primary care is where it sits
  • One team across the "divide". No distinction between acute or community teams. The term "Community Diabetologist" is a tautology- the hospital is part of the community.
  • Have patience, a lot of it- and give things time. Most importantly find Commissioners who are willing to give you that time too.
  • Have a good team with you- who will look after you- and each other.
What next? Have a read if you want..time changes, so does every model need tweaks. However, the principle stands- one team across the divide- and as Sir Muir Gray always says to me: "You, Partha, are a Diabetologist for the population, not for the hospital. Or the Community.
You serve the population."

And I can't put it any more succinctly than that.

* If you want to know more about the Diabetes CCG IAF- and how your CCG is doing:

** If you want to know more about the Super Six Diabetes model: 

Sunday, April 8, 2018

Up Next...

So, its April. For most people, thats spring time- for NHS circles- especially in financial terms- its the start of the yearly cycle. For us within the NHS England Diabetes team, its a fresh time for planning as well as ensuring some of last years good stories continue down the line.

The last year hangs over us as a start of hopefully something different in diabetes care- and much kudos to all in the NHS England diabetes team for what has been delivered so far:

  • Further roll out of the National (Type 2) Diabetes Prevention Programme 
  • Launching of the Digital arm of the NDPP- with assessments in place regards efficacy
  • NHS RightCare pathway for Diabetes to focus on specific priority areas for Return on Investment
  • In excess of 40 million £ invested to help in uplifting of education spaces (>90000 spaces) or increase in Diabetes nurses (>90 WTE nurses recruited) as well as improvement in foot care and treatment targets
  • Landing of Freestyle Libre in Nov 2017- and steady progress across the 4 nations
This year thus becomes more of taking some of the work forward. So- a sneak peek into whats in the pipeline over the next few months- or as much as feasible within the limits of reason. 

To begin with, a national website/ portal to help with self management of those diagnosed with Type 1 diabetes is long overdue- and hopefully will be finished shortly. Multiple stakeholders - including working with existing good portals such as T1resources , Diabetes UK, JDRF etc- but the focus of this has been / is to increase tools for self management; encourage peer-support and hopefully steer many towards much needed education courses. What has been educational has been working with many of those living with T1D and HCPs, under the guidance of NHS Digital, to develop this- hope the finished product will be what it says on the tin.

The recent acceptance of a paper in Diabetic Medicine hopefully opens the door for the much needed discussion on individualised care in diabetes and the relevance of QoF in this context. An ageing population. frailty are important factors- and diabetes care need to be adjusted accordingly- rather than incessant drive to targets which end up harming people. I anticipate a long road on this but so far, the signs have been positive with all relevant primary care stakeholders being receptive to this- so hopefully this will go ahead and take us - ironically- back to individualised care.

Language Matters- and the relevance of it is close to my heart- and delighted that this piece of work is in its final stages- many thanks to Anne Cooper, Bob Swindells, Cathy Young, Rosie Walker, Jen Nash, Sarita Naik- and many others. I have been much impressed by the willingness of all relevant diabetes organisations to engage in this piece of work- and glad its not taken us years to finish this. Hopefully out soon- but in my opinion, its a fundamental shift in culture as to how we interact with those living with diabetes- which holds a major key ti improving care. Let's see!

Treatment of diabetes patients via ambulance crews and paramedics have needed an upgrade with the existing guidelines being perhaps a bit out of date- plus protests to that effect has been noted. Again this hopefully should be complete soon too- and fingers crossed, helps with improved care- and maybe even reduce admission rates to hospitals across the country.

Another piece of work hopefully concluding soon is a nationally agreed pathway for access to diabetes technology- being developed by some of the brightest minds in Type 1 diabetes care- along with those living with diabetes. Hosted jointly by the NHS England diabetes team and Diabetes UK, hopefully this will help / aim to standardise access - as well as look at issues of procurement, education of staff etc etc. A HUGE piece of work- but the early signs are good- and much grit and patience will be needed by the collective to achieve progress on this in present times of financial strains and competing priorities.

Other bits of work -over the next few months will look at role of pharmacists, dieticians as well as mental health side of things in diabetes. 
Throw in discussions and mulling over Out of Hour support across the country, discussions around Type 2 diabetes education in digital context, some educational material specific to south east asian population and accreditation of existing education programmes…and we have a fair few things to keep us all busy. The work around reviewing hospital services in diabetes begins in earnest too from May (some pilot runs end April) - and hopefully all of this will come together to keep driving quality of diabetes care up.

Another update perhaps in July on how much we have delivered on the above and what subsequent plans are. As mentioned at the beginning, there are a few other bits - and hopefully we will have some further good news to share. 

Till then? Wish us luck- and thank you to all for the support and kind words- which makes it all very worthwhile x

Friday, March 30, 2018

100 million

Policy role can be much can also be very troubling...making judgement calls which may affect many is never easy- and it does always make me wonder- how much benefit would direct patient involvement help? I mean- lets get this right- absolutely a must, we all should do it...but how much would that help if- say- there came the question of allocating money to services? We at NHSE work extremely well with Diabetes UK- is that seen as enough?
Before you get the usual suspects all frothing at the mouth at the very thought of "questioning" patient involvement, lets make this clear- this is me thinking aloud- something I have even mooted discussing at a few national events- but most folks around me have fudged the answer- so for the sake of debate, why not? Who knows-may even hold an open day to have a chat about this?

So lets say- hypothetically, we have 100 million quid for diabetes care. 100 million you could invest to improve "diabetes"- as a whole. Sort of similar to the 40 million we got last year- and have for another year. This time around, we looked at evidence, looked at Return of investment and put it in 4 places- broadly covering safety; foot care; education and treatment targets. Lots of kind words- but there have been criticism too- why not more specifically for technology, why not for pregnancy care, what about renal care; what about Eating Disorder services etc etc, lets flip this, if say hypothetically we did have 100 million quid, could patients help or even directly advise where to allocate that money?

Or would they be dictated by their own niche? Would a person living with Type 1 diabetes be focussed on their need- or would gracefully give up, say access to technology, for better provision of prevention of Type 2 diabetes? Or would the whole community turn around and advocate giving that amount to social care- with socio economic divide being linked with poorer outcomes? Or would we want to divide it up based on proportion? 10% or 10 million for Type 1 diabetes- the rest for Type 2 diabetes. I mean, the simple maths of getting Continuous Glucose Monitoring to even 10% of the 10% of those with diabetes is nearly 100 million alone! Or should we give it to primary care for better provision, access, training? As some clever clog said recently, give it all to the  diabetes community in personalised health budgets- and it will be fine. Is that the answer?

Such questions intrigue me personally- simply because its very easy to be swayed by one's own bias- and its the same with all the specialists I meet too- very few (ironically most of them are primary care physicians- there's a story, huh!) actually would say something broad -beyond their specialist area. For some, technology is all that matters, for some, its all about safety, others, its foot care...come to think of it- if we have so many subdivisions within one specialty, how easy or difficult is it when you extend the reach of that? The argument that those who live with it- know more what to do with the money also falls a bit flat- when say a Type 1 diabetes person has to make a call over wider budget of diabetes- lest face it- their knowledge of living with Type 2 diabetes is the same as mine- nearly non-existent. Tricksy, isn't it? But I would be fascinated to see what top priorities those living with diabetes choose and what are the ones evidence says should be. This time around, we think we got it right- albeit as ever some would disagree but if there was a next time, this is a debate worth having I reckon

So to those living with diabetes or caring for those living with it, have a think- could you set aside your individual niche or bit and make a call for that 100 million....and how would you feel if your favoured bit didn't get the money that you felt should have? Would you like others making that decision on behalf of you?

So- go on- if you can- post some answers. 100 million at your disposal- where in diabetes care would you put it? And would it be an idea to have a fun debate around this- patients and policymakers- along with specialists & primary care? An open forum....would you be up for that- or should we leave it to patient organisations to have that debate? So many questions- but just an individual thought- which I thought would be worth mulling over in a blog. Who knows- some of your ideas...may even become policies.... 

Sunday, March 18, 2018

One Tribe...

This year I walked into the London EXCEL on a Tuesday morning with interest…the annual diabetes conference….was it to be more of the same or something different? Diabetes has had a reasonably good year- especially when you compare it to other areas- be it in the extra money to improve care, spread the type 2 diabetes prevention programme, a move into the sphere of digital technology…as well as on the background of studies such as DIRECT- its been interesting times. So how would that translate into on the ground- how would the general health care community feedback on that?

Tuesday started with the trainees day- and I have rarely been surprised at the ideas our trainees can bring to the table- if "Allowed". Tuesday was no different- a particular session where we asked trainees to come up with a few ideas to improve safety was fun along with being informative- and the plan is to take a few of those forward-with the folks who formed the ideas- involved in it. Who knows where it takes us- but the issues around blood sugar alerts to flag potential safety issues or indeed increasing better access to preconception advise…well, we have talked about them long enough- maybe with trainees involved, we can do better or at the least, improve the variation on this.

The next few days- to be honest- were a blur- and at the end -mentally, I felt fatigued, tired..yet perhaps quite happy.
A few things stood out- Simon Stevens, the NHS CEO announcing 40 million £ to continue the work done so far in 2017/18 was a big plus- but more poignant was him calling me and Jonathan Valabhji on stage to sit next to him as we took questions from the audience. A very clear signal of intent- as well as support if there ever was one- as well as showing the relation the diabetes team shared with the top tiers of the NHS.

Other things were moving things forward as regards the relevance of education- and a big shift towards the community backing initiatives being done so far- and further appetite for more. Talking to many companies as well as individuals, it was clear that many were keen on also looking at variation of professionals education- for example in the field of technology- and it was much pleasing to see all concerned happy to work as one pack-rather than as separate entities

Kind words from luminaries such as Andrew Hattersley, Gerry Rayman, Roy Taylor, George Alberti, Stephanie Amiel, Kamlesh Khunti, Melanie Davies et al stood out- and perhaps the biggest vote of confidence the national diabetes team needed from a professional perspective. It was also personally pleasing to hear the words- sometimes, it helps to heal the wounds this job creates too. A hug from Pratik & Emma meant a lot too- sometimes friends don't need to say much more.

It was a privilege to be able to introduce Mayank and May for their respective lectures- inspirational leaders whose never-give-up attitude sums up their successes- and more strengths to their arms too! Hope they inspired another generation too- at the end, its not just the money, the algorithm or the policy- its the drive of individuals -open to working with those living with diabetes- which opens the door to success too. A workshop- standing in for Jane Speight- along with Bob Swindells was fun too- as well as giving the #LanguageMatters group information we can use for the national document in the pipelines.

And then of course, there was the #DUKPCInsider event. I won't say much about it- simply because to me, this is fundamental to me learning- as well as improving care. Whether it be the TAD events or Rise of the Machines, working with those who live with diabetes has been a key thing for me- and part of my professional development. It was an honour to be invited, to talk with Chris Aldred aka Grumpy Pumper- as well as take questions from the audience. To me, the strength I get from encouraging words from those living with diabetes- negates in a flash any negativity from professionals or industry.

Finally? A big personal thanks to Chris Askew and in his team in Diabetes UK- who have landed this conference with the added insider day. There indeed was a good buzz- and the right challenges seem to be being laid to all. There was  a lot of positivity- and hopefully people will take that back home- and renew their battle to improve care. And we, in NHS England Diabetes team- are here to help. Just ask.

Will leave you with a few links of interest:

1. Technology & Diabetes: Link to best practice as regards Insulin Pumps etc:
Under Emma Wilmots guidance, I expect the DTN (Diabetes Technology Network) to be a game changer as regards technology access

2. Nurse specialists in Diabetes: A facebook group set up by Amanda Epps from Medway for Diabetes Nurse specialists- feel free to join and exchange ideas:

Thank you to all who made time to chat- and apologies to those who I couldn't give much time to. We take back home much to cherish…we must carry the momentum forward too.
We must be able to work together, channel all the passion we have- whether you are a doctor, nurse, carer, pharmacist, living with diabetes or in any way connected to diabetes.

And this year? I got the feeling, we just might x

Sunday, March 11, 2018

Balance of power

The jostling for power is probably one of the most fascinating things being played out in the world of health. Science, technology, anecdotes have collided in a most interesting manner- and if you throw in the usual hierarchy of healthcare, the cocktail is complete/

There are the academics- for whom their science is rigid, the randomised controlled trials being the one and only barometer of success; there are the super centre specialists for whom the bubble only extends to their own centres, their own selected patients, there are the decision makers who hop between being "totally supportive" to "not really" for evidence based material- based on the cost involved; there are the healthcare professionals who would like to have their bit funded the most- above all- as obviously their own speciality or profession is THE most important above all....and finally, there are those who live with X, Y and Z.

Lets face it...very rarely do the policy makers or indeed academics who create the studies stand up and face the patients face to face. Rarely are decisions to fund- or not- made with a patient in the room- ensconced securely begins a layer of bureaucracy, decisions are not that tough to make. Public engagement events to explain why X, Y or Z can't be funded? Rare as hens teeth. Mostly due to lack f cojones to be honest.

In the midst of that all, the landscape is slowly changing- and its fascinating to see it develop. Maybe its a generational thing but folks are starting to question "Why" a bit more. Reasons such as "I am a Professor and I said so" doesn't wash much- and quite rightly too. People are starting to make their own innovations, their own adjustments to their lives and asking the profession and system to fall in line. Its a bit like any disruption...started with a few rabble-rousers- ignored conveniently by the system...but as their numbers and voice have grown, the system is being forced to listen. Whether it be a policymaker, healthcare professional or industry, there certainly is a subtle change in the air.

The trillion dollar question is as a healthcare professional where does our role it to resist, deny those who live with a condition what they feel they need using the shields of evidence or do we encourage disruption? Or do we help them to change the paradigm of the system? My experience in 2 years of doing this is that evidence is an interesting term- used differently by different people- to justify the reasoning for inclusion or exclusion- based on their personal prejudice or politics.

Personally. I am all for change...mostly because the rigid way if "we know best" ain't seem to be working that well per se. We deny folks a technology, they find a way around it; we restrict them to diet X or diet Y, they find out what works for them and use it- more to the point, they then cascade that info to others- whether we like it or not. My fundamental role is to pass on information, ensure safety is maintained and at the end of it all, id the individual uses something that works, surely that's exactly why we do this job? So I am all in favour of guiding such individuals, encourage their own innovation...why indeed not? If it works, why indeed not.

I suspect at the end - it does boil down to power- how much one is prepared to "give up"- or whether you see this as a power thing at all. The power thing has always bemused me- and in spite of what impression social media may give you, Consultants have, still, a lot of power in the system. The question is whether we use it to facilitate what patients need - or to maintain the status quo of hierarchy. My personal experience and tip after 10 years? Use it the right way...the rewards are far more. Using it to obstruct patients or what they need because of what a trial- not applicable in real life- showed is silly. Or simply just delaying the inevitable.

In any business, consumers drive is just about starting to wake up to it...times are changing...the power base is indeed...shifting.

And may it continue to gather force and pace. Amen.

Tuesday, February 27, 2018

Letting go...

I will be honest…the last few months have been tough. And at times it has felt very lonely. The barbs, the comments, the critiques, the arm chair opinions, sometimes simply the blunt brutal comments- mostly to do with an effort to bring a new technology to the NHS has hurt. I have smiled- in the most but its felt lonely. And there have been evenings when I have sat down and wondered whether this is all worth it. I tend to have a casual approach to most things…but even all that can wear thin after the umpteenth shot across the bows from yet another fellow professional or expert. If the intention was to hurt, it certainly left its effect.

The saving grace in all this has been the diabetes community. In tough times, reading back some of the DMs or emails from someone I have never met has made me shake off the feeling of "why bother", put that flak jacket on one more time, battle yet another opinionated professional or manager within a CCG or even NHS England. And to all those who have asked why I embarked on the road to host an event which basically was encouraging the "rebels"- that pretty much was the reason. On Saturday just gone by, amongst many of those living with Type 1 diabetes, I felt at home, I felt happy, comfortable- and not having to do most things with my shields up, having to be wary of what would be interpreted in what way…I felt amongst friends. It perhaps is a telling tale of the NHS that in my last 18-20 months of doing the national role, the obstructions, the resistance has come from fellow NHS colleagues, not from those living with diabetes. Make of that what you want.

So Saturday was all about folks who were doing things…differently. I won't go through the details but if you fancy having a look at their presentations- have a peek here  Its -simply put- a different world- and something which could fundamentally change the game as regards Type 1 diabetes care goes. This is disruptive innovation at its finest- flipping on its head all conventional research, science and lobbing a stun-grenade into the world of diabetes technology. And the world is waking up to the concept of "OpenAPS"…no idea what that means? Have a look- here and take your time to absorb the level of disruption this can and is causing in the present world of Type 1 diabetes.

Is it for all? Nope. Could it be a game changer for some? Yup. The trillion dollar question is what we-as a system- do about it. Wait to see what happens? Wonder about the regulatory consequences for us rather than the patient? Or step into the breach and try and give some folks what works for them? Its clearly shaking up the industry- with companies looking at it; JDRF committing to it….could this be a big movement in science- or do we stay confined to what an RCT told us- and deny those who live with diabetes what THEY have come up with? Can we - or should we do that as people not living with diabetes? Do we become self appointed vanguards and make rules up to obstruct? Or do we do so more to protect ourselves rather than help the ones we undertook this job for?

It was fabulous to see all the relevant companies at this meeting- as well as the leading charities- and I am eternally grateful that they came on request. Its not an easy space for them to work in either- but they were there- and that is a big step forward for us all. It would be a travesty not to pay a huge amount of acknowledgement to Ben Moody and his super team at TechUK- without whom this wouldn't have happened.
And of course Tim Street- his energy is infectious- and frankly- I cant understand much of what he says- but what I do know? He knows how to look after himself- and he is dead keen to help others- and in my book? That deserves utmost respect.

Of course- who can forget Dana Lewis- all the way from Seattle- now there's a maverick and a half. I sat in silence- listening to her talk 2 days on the trot- and I had goosebumps listening to her drive and passion. I am honoured to know her- and be an acquaintance and who knows what the future holds? For now? A big thank you from me- you touched many hearts and inspired many- do come back again.

Finally? To many healthcare professionals out there…fear less- and perhaps worry less about "patients taking control". Trust me- its a good thing- it makes our job easier. Our job is to keep folks safe- not be vanguards of what they can or cannot have. If we genuinely want to improve diabetes care, self management is where it sits- however it is achieved…whether it is via an App, simple peer support or folks making their own algorithms. Be ready and feel comfortable about letting go; guide them as much as you can….the long term benefits are far more rewarding than anything else.

"Word cloud from "Type 1 Diabetes: Rise of the Machines"

Saturday, February 17, 2018

A Viennese whirl

Vienna. A short hop from the UK- and an effort to get some continuous professional development attending the Advanced Technology and Treatment for Diabetes.  I attended this event- just to get some education update- as well as take an overview from a policy point of view. Whats feasible for the NHS? Beyond the shiny tech, beyond the dazzle and dazzle, where in sits the technology which may benefit the many, not the few?

I must say I came back with mixed feelings- as well as reinforcement of some views I have held for a long time. To begin with, a slick, well organised event- and a pleasure to meet Tadej Battelino who along with individuals such as Moshe Phillips have been a driving force behind it. A great event to showcase the latest advancements in technology and the differing approach many other countries have towards it. The bias towards data we may or may not have, the little silos we work in, the strong beliefs we have….they were all on show- whatever be the country.

For me, it was a bit beyond that too- what- from a policy point of view- could work? Some of it felt like a technological world beyond the scope of many; some of it felt like the opinions of a few who lived in a bubble…a bubble of looking after certain groups of individuals, a bubble where other issues rarely pervade. The inherent strong views and "camps" of technology were stark- whether as a clinician one favoured Dexcom or Medtronic- whilst the aim perhaps should be to look at technology as a whole. We all benefit I suppose if we are not stuck in "camps" but hey ho, such is the world we live in. I also looked at, got told, was informed many times over about the importance of Continuous Glucose Monitoring or as as the parlance now should be "rtCGM".

Then there is the bigger picture of the world beyond Type 1 diabetes- or even diabetes itself. In the bigger context of things, and as someone who does work with patients of all types (yes, MODY too!) we perhaps forget context. Lets do some simple maths for you. I get pointed emails/tweets suggesting how rtCGM should be made available to all with Hypoglycaemia unawareness. Ok, thats about 15-20% of the Type 1 population- thats about 50-60 K folks- at a pop of £3K / year. Rough maths- but thats about 150 million£/ year. Take a pause. Yes, thats 150 million £.

And I haven't even added the staff cost to it. At the moment, we have about 5k folks on this tech in the country- so we are ready for an increase of that number? In a system where we are scared of patients actually taking charge? I mean I haven't even added up the numbers for those who are pregnant- as CGM would be fab for them too- plus to put that approx 150 million£ / year into context, we -after a serious degree of "making the case" got 42 million£ for the WHOLE of diabetes care in the UK. And Type 1 diabetes is about 10% of the whole diabetes population

Lets even say we make the argument- as the benefits all "bear itself out" in the future- but answer me this…if we did make the argument for 150 million£ with the department of Health and NHS England…did you want to invest that into better safety in hospitals? Or go wider- and look into better lifestyle choices? Or mental health? Or better community support? Or more practice / district nurses? Or better managers? Or better social care? Or improve inequality? Not easy, is it? When you start looking beyond your super-centre or your own super specialised silo of work…demanding that money doesn't look as easy, does it? Neither does it when you are a patient champion or an expert patient…do you champion your own "bit" or do you make tough choices as the elderly frail person at hoe needs better social care- and you give up on your championing of that "wonderful tech" for the greater good?

Tough call, isnt it? Hurts a bit too, no? And how fortunate are many that these choices are not ones you have to make. That role falls on the policy makers- and the burden of that we live with too. So shall I give you the good news? The good news is that the tech access is possible- some of it will depend on companies who also need to have a reality check about their prices and where it sits as regards the NHS. Simply saying we have a premium product and thus our price is premium isnt good enough- its a balance…if you do want to genuinely help patients, it cuts both ways. There also- is perhaps - just about enough money within overall diabetes budgets to do much more than what we do- and yes, I include access to 670G pumps, G6 sensors or whatever else is the latest tech in town

The not so good news? I am not convinced the UK is ready yet- to make that level of change. Whether it be clinicians, industry, charities or patient champions/experts, there needs to be much better unity than at present- lot less sneering, lot less siloed thinking, a whole lot less of "we know better than you"and a lot more of "lets see whats feasible"-rather than "how dare you don't do X,Y or Z". A long way to go yet- though a collective is slowly starting to build. It will be interesting to see where the next piece of work takes us. The whirlwind trip of Vienna was fun- but it was a mixed one too. As a clinician, the technology was exciting. As someone in a policy role, it was less so- with more of a worry about lack of coherence or perhaps unwillingness of super-specialists to look beyond their own views and thoughts.

A final thank you to the ATTD folks for their time and effort - lets see whether next year, we can share some stories of success from the UK regards uptake of technology. THAT is our challenge. Cos the best tech isnt the one which gives us papers in a journal or tick boxes in a CV but the ones which improves the life of someone living with the pathology.

We shall see.