Friday, March 17, 2017

The number game

Numbers. Audits. do you interpret them? With views of evangelism? Rose tinted spectacles? Shades of Doom? How much does our confirmation bias affect us? These sort of things do swirl in my mind whenever I am sent an audit to review.
I suppose it depends...if you genuinely believe that all fault is due to politicians, then it's natural to look for the gaps and blame it on them...that's the confirmation bias in full swing. On the flip side, if you want to be positive and believe in the fact that the NHS is unparalleled and will not tolerate a bad word about it, then the good news shine through.

So it is with similar swirls of thoughts that I looked at the National Diabetes Inpatient audit. What does it say? I suspect your interpretation will sit on how you want to see it. But let's take a step back and just take a time out for a second.
To begin with, this is categorically the most stand out data set as regards inpatient diabetes care across any country. 205 hospital sites contributed to it...this is no subset...this is an audit and a half. Much kudos to the energy and drive of many but especially Gerry Rayman from Ipswich who has helped us get to know what actually does go in hospitals- beyond the anecdotes, personal opinions etc

Let's look at some facts to cheer you up - and especially if you have diabetes and have to be admitted to a hospital for any reason whatsoever. More folks with diabetes are being seen by a specialist team- and hypoglycaemic rates in hospitals are down by about 20%. Foot ulcers picked up whilst in hospitals are also down- so to all the diabetes inpatient teams, especially the nurses who form the backbone of these, please, take a bow. A Herculean effort in present times and the diabetes community owes you all a collective thank you for that.

Now for the flip side...about a quarter of hospitals still don't have a diabetes inpatient team, 2 out of 5 diabetes drug-charts have errors in them while 1 in 25 patients with type 1 diabetes go into DKA as an inpatient- a mostly iatrogenic error where someone has forgot to give a type 1 diabetes patient their insulin. Take a pause and think of that. No insulin given in a hospital to a type 1 diabetes patient. In 2017. In a 1st world country. 
If you are a health care professional, that makes you wince a bit, no? And oh, yes, places which have e-prescribing have lesser errors. And lest we forget, patients aren't happy with content or timing of their meals in hospitals- though generally satisfied with care received.

So what next? We have done audits for about 5 years- we have seen some improvements, some haven't shifted...time to get cracking on those I reckon. Money is available specifically to help fund specialist nurses in the hope that this will drive those errors lower but it isn't just that. Simple initiatives such as policies of self management ( unbelievably those who live with diabetes seem to know more about their insulin needs and times than a fair few professionals...would you believe that....), learning from centres which do well, e-prescribing can make a difference too. Benchmarking is on its way too- and for sure, inpatient hospital safety for diabetes patients will figure very high on the list. At Diabetes UK conference, I heard some amazing examples from Southampton, Leicester and Derby while the work in areas such as Kings are well known too

It's time to get the negative bits right and we, as a diabetes community, have the levers in place, I reckon, to make it happen. Money, benchmarking and learning from areas of excellence are indeed nice but what gives me a ton of hope is the zeal of clinical leaders - whether it be from the nursing community via TREND or folks like Mayank Patel, Omar Mustafa, Kath Higgins etc. 
Lets look at this again- 2 out of 5 drug-charts have errors in them and 1 in 25 type 1 patients go into DKA while in hospital. 
So...Heres a challenge. Lets keep it 3 years, let's make that 1 out of 5 errors and get that DKA number to 1 in 100 and in 5, we aim for zero. 

Impossible, you say? Perhaps. But as the saying goes, if you aim high enough..even falling just short? Not too shabby. In my book, it's certainly within our gift to give it a try.

Tuesday, March 7, 2017

Hope…(And an Update)

Update from Diabetes UK….

Arrived on Tuesday in Manchester- as mentioned with hope…and wasn't it such a fabulous experience!! Meeting the trainees to begin with, a catch up with old compadres…it was as ever, fun. The next generation-as ever- never fails to energise me- and I saw plenty to fill me with that that twinkly word…hope.
The next 3 days went in a blur- keeping to ones promise to make NHS England accessible had to take its toll. Back to back meetings, explaining whats coming, plenty of handshakes, talks, taking questions, interviews….exhausting yet satisfying indeed. In an atmosphere of darkness, where lack of funding or morale within the NHS has been all pervading, it was lovely to see what a bit of extra injection of funds- along with ensuring your next generation feels valued can do. The conference bristled with positivity- apart from anticipation as the results of the transformation funds await to be announced over the next few weeks.

A big step forward was perhaps finally agreeing the priorities in diabetes as per the Right Care pathway- and hopefully the importance and recognition of Type 1 diabetes as a priority area for improving care. Again- due out shortly- but it felt good to close all the multiple discussions after months of discussions with many organisations and parties. Factor in the soon to be announced type 1 digital / self management platform that is being planned- and it feels we are finally making progress indeed. Or at least trying.

Highlights? The positivity was certainly one- as was meeting all the patients who had attended the event. It was good to hear their feedback too- and encouragement to carry on the work we are doing at the NHSE Diabetes team. Evening fun with the "home away from home" (Portsmouth diabetes team-of course!) as ever were special- as was hearing some of the positive findings from the national diabetes inpatient audit. It was heartwarming to see the drop in severe hypos in hospitals- even without much change in staffing levels.
However, a personal stand out moment was hearing some warm words from Prof Steph Amiel. Last year, we had a blistering discussion- and she challenged me to step up. It was nice to hear what she said one year later…a very personal moment indeed. If Steph thinks I am on the right track- it buries any other negativity pretty quickly -at least to me.

Downsides? 1 in 25 patients go into DKA while in hospitals (as per the audit)- a sobering fact-and we must change that…factor that in- and then think of rates when people are outside hospital. Let that sink in a bit in 2017. That must- and will- change.

Finally,a personal social experiment. I am well known to be dressed casually at most events- for this event, on day 1, I had a 3 piece suit; day 2 was a suit and day 3 was T-shirt & jeans. It was fascinating to see and hear peoples reactions- both from those who know me- and those who don't. Is it about personality, quality- and how much bearing has what you wear and the impression you create? A fascinating personal exercise for me- one to be continued more I reckon. How much in the era of showbiz do we actually live in? 

To finish, much kudos to the organising committee and Chris Askew for hosting such a great event. I enjoyed it- I enjoyed the atmosphere and fed off the belief too. 
Hope to be back next year- with further good news- but I also have a request for all those who came. Take that positivity away- and believe in what you can do. We are here to support, to help and do what we can. It is also down to you to have the belief to convince your local colleagues and take diabetes care forward. 

If stuck, you know how to get hold of us…till then x
A week in Manchester- and to be honest, have been looking forward to this for some time. It's the annual conference for Diabetes UK where many colleagues mingle, share ideas, have a collective moan...and this year potentially bristles with the air of possibility. 

You don't need to be e recluse to know that the NHS is struggling. Any media outlet worth their salt is covering it and quite rightly too. You have to work in a hospital to know how "tough days" as regards the emergency pathway have become more of a norm, rather than a rarity. A "Black" status which even a few years back used to mean something is now on the verge of being normalised. It's not an unknown fact- we are struggling. Full stop. 

In the midst of that, there have been some good news for diabetes care. NHS England are on the verge of declaring which areas have won the transformation bids- about 40 million £ worth. Factor in the roll out of the National Diabetes Prevention programme and a few digital tools to help in education and self manahgement (on its way) and there just maybe something there for the diabetes community. The zeal is there amongst many organisations to work together...tough times have brought previously fractured parties together - and from the NHS England diabetes team, a willing desire to make use of the money- but with realisation that more of the same won't deliver much. The landscape of delivery is changing...if it passed you by, do take note of the 1st Consultant Pharmacist in Diabetes...Mr Phil Newland-Jones (Take a bow, laddie!!) 

The money is welcome and hopefully will help to improve basics such as safety in hospitals but this also does involve working...differently.

In the background is work with ABPI as well as all the technology companies to improve access, outcome based commissioning as well as a realisation that more needs to be done for populace at high risk such as South East Asian population. Watch this space...the game is indeed afoot. We are keen to focus on areas of high impact- while making sure primary care is squarely involved in any discussion regards QoF or indeed any models of care. Let's be categorical about this...asking primary care to take on more without resource, support or training is not something that works- it's time to stop that.

So I travel to Manchester with hope, optimism albeit,as ever, mixed with caution. I look forward to meeting our generation next, colleagues, patients as well as enjoying the evenings with my family away from home- the Portsmouth Diabetes team. If you have a question, come and ask. Yes, I work for NHS England, but I also do a full time job, am educational supervisor to many trainees- so always happy to take any queries- as long as done with a degree of respect. I don't think there has been any organisation involved with diabetes care we haven't tried to engage with- if there is, apologies- but come and say hello. I am always enthused to meet colleagues who are energetic, keen to make a difference - we need more of you indeed!

Let's see what this week brings. I travel with hope

Saturday, February 25, 2017

Changing Landscape?

Have you tried doing any talks on "NHS structures'? It's an absolute nightmare. Apart from the gazillions of bodies, there is the other small matter of having to change your slides every few years. Or depending on your experience of the NHS, maybe simply using some of your old slides!
Either way, it is no picnic at all- with the added problem being that no one quite knows whether the latest iteration is indeed the "final piece of the puzzle" or indeed adding one more layer of complexity.

Lets take a step back- and just use Diabetes as an example- just to avoid the usual dingbat response such as "what do you know about dementia, huh". So, we have NHS England, then we have 4 regional teams, we also now have 44 STPs and 50 Vanguards. Lets then add into the pot 15 Academic Health networks, 12 strategic Clinical networks. Then let's now factor in 209 (or whatever they are now) CCGs, 150 odd acute providers, who knows how many community providers and many many GP surgeries. My apologies to all those who forgot. 
Trying to have a unified policy- to tackle variation? Well, thank the Lord that the 12 labours of Hercules didn't involve sorting out care within the NHS- thats all I would say!

My personal view- (before tweets appear that NHS England says so-its good to clarify these things!)- is that in all those organisations, there are many, many individuals who are trying to do, in the main, the right thing. There isn't some massive conspiracy afoot from folks involved in them- they are trying to do the best they can- with the financial boundaries set, the challenges put forward- while trying to balance the needs of the population. The money- is a political thing- and all these bodies can only do what they are given with- as simple as that. If you want to direct your fire at anyone, these bodies are probably the wrong focus- yes, sometimes, the crunch of finances make people do things they wouldn't do to their loved ones- but thats where the lack of joined up system fails us all- the lack of appropriate checks etc.

So here's some crystal ball gazing. I see the commissioner-provider split melting away- as that has probably created more angst and variation than a lot of other things. I have worked with some fabulous clinicians who have been good Commissioners such as William Tong or Jim Hogan- but in the main, after doing this on many levels, we should leave commissioning and its structures with those who understand the nuances and are trained in it. Managers. 
Clinicians are trained to provide- and in times of need, gaps and locum crunch, please do so first.
Lets give you an example, if a GP spends lots of his or her time trying to shape services around the region while their own surgery is struggling with patients or data suggests about 7 in 10 people don't get their basic diabetes checks…then suggest you get your own house in order or help your colleagues at the ranch first. 

I see providers- acute and community fusing into bigger ones- and  gives primary care the chance to deal with one organisation rather than multiple- with multiple IT systems, personnels, lanyard colours or even fax numbers. Can primary care do it as a pack? It seems to be edging that way- and I see commissioners starting to focus on a few things-as identified by the Right Care work - universally- rather than each area having their own priorities and increasing variation. Vanguards were the kick start to look at new models of care- and they are here to stay. Lets be honest- if we believe nothing needs to change as regards models of care, and all can continue as is, then thats blatantly wrong. Don' like the Portsmouth Super six model? Well, go build your own- but don't tell me the system is perfect as it is with diabetologists working in isolation in the community.

Final bit? About STPS- and haven't they had a bad press. The ire about their "plans" does raise a wry smile- and I wonder how many have actually read financial plans of their own Trusts over the years- the projected cuts etc to make the balance sheet correct. Don't forget in the end, many of these executives also breach these very plans- as they realise the importance of patients & their safety- and rather take the heat on finances rather than safety. Its a generalisation- I admit- but isn't that far from the truth either. 
STPs- have some good ideas in them- a principle of "please work together as one body". Yes, there are flaws but then which NHS plan doesn't? Its for us to engage, try and shape the landscape in my view. The issue of money is key- and much kudos to those who raise the issue and keep the pressure on- but that should not, stop the work thats also needed to try and see whether we can join the silos of the NHS we work in.

Interesting times ahead- and those are my predictions- the biggest one of them? Let managers do what they are best at; let clinicians do what they are best at. 
Work together- we may get somewhere. Just.

Sunday, February 19, 2017

Good Ole Days

Last week was a bit of a throwback. You know…the one we doctors love referring to. The Good Ole Days. Away from the hustle bustle of NHS England, the politics or even the clinics I do for diabetes and endocrinology, this was a week on the wards.
I had been asked as part of the changing landscapes to help on short stay unit- once upon a time, I thought it worked well when we had one team throughout the journey of the patient- but all the leaders and great minds have decided that more silos are better…so fair enough. Help I will provide- though how that helps…ah well… thats maybe for another day.
Anyway, so a week on the wards it was. And I really enjoyed myself- a lot. We had about 4- 5 "junior" doctors- of different grades- and it was simply a pleasure. Forgive me for saying blasphemous things- but I didn't feel burnt out, we had time for breaks - we also had time for teaching. You don't have to believe me- you can ask the juniors who were there- I am sure they would be happy to go through how the week went.

What was observable was a few things which probably suggested where some of the future lies. I am sorry, but holding roundtables or even hands will make ruddy no difference- especially with an organisation which has been pushing for imposition of the contract in the first place. Thats a bit like Trump imposing the Muslim ban- then deciding to have a discussion with Muslims to discuss how it could be enforced properly. I am not mincing my words on this- its a waste of time. It may help tick some boxes for some folks- but just like the last attempt by HSJ, this will gather dust in some corner soon. You want to do something of relevance- do it properly with open and transparent engagement- or else, don't bother. Bar a twitter storm, it makes no dent in anything per se.

It was interesting to hear from the juniors their views of the senior workforce. A toxic cocktail of work pressure, lack of support or indeed belief that this ship has sailed has now percolated into many seniors. The enthusiasm isn't there- not my words- and that percolates into the juniors. When a "whoever" asks you to do something, the first thing a senior has to ask "how does this help the patient?" We are scientists- our job is to ask why. We are leaders of the wards- our job is to look after our juniors, our job is to make sure they are protected from banality….do we do enough?
The culture of acceptance seems to have seeped though- do we need to revisit our noble aim of vocation and the professionalism of a job? Forget everyone else. Do WE find time to thank our juniors, do WE find time to smile enough? I don't think we do. I repeat- there is NO junior contract amendment which will help morale- till we play our parts too. We have much to do…how much do all the Execs actually believe in the pastoral role- how many Trust CEOS would support the time needed for Consultants to do that- how many MDs would….or would they rather have yet another roundtable to consider all this?

I do diabetes. I do endocrinology. I do general medicine too. If there is a part of me which would do things out of "vocation"- that would be to find time for the juniors. Why? Because when I was one, I will never forget the role folks like David Jenkins or Tony Zalin played in my life. That is what made me who I am- learning to smile, see the positive side of things. I am not a complete idiot- I can see the pressures the NHS is under- and the optimism takes a beating every day. I also know that without looking after our future workforce, this game is over. It doesn't matter even if Bill Gates did a multi billion donation to the NHS tomorrow- there is no amount of money which can account for a junior feeling looked after. In my opinion- and I know many will disagree- we, as seniors, have to stand up and challenge things being asked of our juniors- which doesnt help patients. Medicine was, is and never will be a tickbox- however much anyone tries. 

So..the Good Ole Days? A lot - still- sits in our hands. Why wait till its impossible to turn this around?

Sunday, February 12, 2017

Vocation or Job?

It's probably best to start this one with a caveat. This-as ever-is a personal view- and perhaps more of a reflection of my personality- rather than a critique of larger mankind- especially in the world of healthcare. But it's always been a source of intrigue for me-as to how doctors see themselves- and where they feel they fit in the paradigm of life.

Is being a doctor a vocation? A higher calling? Some form of vision appeared to drive me to be a doctor? No- I will be very blunt- I grew up in a family of doctors- in the heart of Kolkata-when the economic boom had yet to hit- and my choice was made for me pretty much by my parents. I can't think of a time when I didn't want to be a doctor or indeed thought of a life as something different. In the hub-bub of Kolkata, the job came with prestige, respect and was important for my parents. Plus I grew up seeing my parents do what they do- working 7 days a week- long hours- yet always finding time for me and my sister, holidays etc.
So for me, it was never a vocation- it was something which was -maybe- natural? Times have changed and I don't see either my son or daughter doing it as "natural"- they will do in life what they want to do- explore opportunities (once non-existent in my times) but there certainly is no expectation per se.

So to me- its a job- I trained for it- worked hard, had lots of fun along the way, did long hours- and today, I try to do it to the best of my ability. There are lots of things I will get wrong, as any human beings would- and have exactly the same foibles as a nurse, a teacher or a pilot. All trained individuals, doing their job to the best of their ability- and trying their hardest to minimise errors due to human factors. Nothing more, nothing less.

Thus, to me, a job comes with its limits as to what can or cannot be done. I do try to help out beyond my contracted hours or indeed get involved in areas beyond what my designated roles are- but thats my choice- and not done due to a feeling that I have to do this. Thereby if I am tired, the fault lies no where else but me- as I CHOSE to do beyond what my job is. It's not a vocation, it's a job- and the ethos of that percolates through the team I work with. I hope no patients can say we don't try harder as anyone else- but on the other hand, it makes for a team which sits and has lunch together, laughs at each others inane jokes, finds time for trips to Nice to watch football....its a job, not a vocation where I have signed my life away endlessly to the system.

Maybe thats where a rethink is needed. When you say its a vocation, we are there much surprise when people then expect you to work more for nothing..its a vocation, right? You signed up to help others- no matter your personal consequences, right? Surely as an ethereal being, a bit more helping others isn't a big deal, right?

Maybe time to think whether to be treated as professionals, you need to see it as a job- not a vocation. Jobs come with rights, regulations, rules....vocations don't. And I appreciate thats maybe a difficult conversation for many- to actually think that we are not answering a higher calling. As I said at the beginning, its a personal perspective...and I certainly am not doing this just for love. I am a professional trying to do my job to the best of my ability- and its a job which I love doing everyday.

Does that make me a lesser being to some? Perhaps- but then again, I am happy doing what I do- and wake up each morning genuinely looking forward to enjoying the job I do.
And that, ladies and gentlemen, is good enough for me.

Sunday, February 5, 2017

Wry smiles

In my last blog, I touched upon the last 8-9 months- the projects which have taken fruition, the ideas which have taken shape while doing the NHS England role- and its been fun…really good fun- while being an amazing experience to chalk up. But a query has been from a few quarters via emails etc- "what about any obstacles?"

And it brings to the fore the question- how open can one be while doing the role that I do? Well…if leadership is about openness and honesty, its worth a try- bearing also in mind sensitivities and bigger picture too …whats the point in saying some facts which may be a bit too close for comfort…you end up losing the job- and the opportunity to benefit many others. 

So…here goes…

Organisations: This has always been one of bemusement for me. We always talk about the importance of working together, criticise acute or community trusts and GPs not "working together"- yet in the world of diabetes, theres a separate organisation for specialists, primary care, nurses…all of whose views have to be taken into account- and rightly too. 
Then amongst specialists, theres one for adults and one for paediatrics….excuse me while I have a wry smile. I suspect this is where my co-conspirator Jonathan comes in- pretty amazing at trying to get everyone together…but I must admit to looking at this all with a degree of amazement….all for patients, right? So why the silos - I can only dream of- I suppose - of a united healthcare professional body championing the cause of diabetes. Some battles, you learn with age, to let pass…and perhaps uniting them is beyond ones power…but for sake of patients, it would be nice..No?

Are patient organisations any different? Well…theres Diabetes UK, JDRF, INPUT, - and I see nothing but amazing, motivated, passionate folks trying to improve care. Togetherness would be nice…yes, I know, naive…but a wry smile is all I can offer- while one tries to negotiate the myriads of patient needs

Patients: No- don't worry- I am not that brave to say anything ill-advised about patients. They are who I do this job for…but I do have an appeal for expert patients., or patient leaders. Don't forget that there are many who you may not represent…there is no absolute as regards  needs of patients. Be respectful of pressures and multiple pulls on the NHSE team too- and we are trying to work in extremely tough circumstances. So, yes, do engage, do put your views forward- but with respect. I do this job because it's something I want to do…but the job specs never said abuse would come with it. So- do allow me a wry smile, when an expert patients view has to be the "only one". No, it isn't- there are many others whose views we miss..and it is the silent majority whose lives we need to improve too..

Condescension:I suspect this always evokes the best wry smile of them all. Maybe its my age, maybe its me…but you pick up a degree of condescension which is pretty fascinating. I get it from some specialists - (Heres a comment: "what exactly does he know about Type 1 care- he wasn't trained in London, you know" Another? "I suppose we have to accept someone like you is developing diabetes plans")- and the thinly veiled mask of disdain sometimes slips. I suppose the position I hold makes it necessary for some to hold that mask- but its bemusing nonetheless. 
Perhaps time will change that perspective and for now, one can only offer a gallic shrug. Sometimes its just like being a Registrar again but then again, if I never felt I had to prove myself as a trainee, why would I start now? 
Beyond colleagues, it has also been seen in some NHSE/NHS quarters- while steeped in irony has been the respect shown by folks such as Simon, Bruce, Jane, Samantha et al. But among some quarters…"do you know enough, do you know what to say" has been an interesting if not slightly painful experience. Best example till date? Someone reading a document to me- which I had written,,,but really, it couldn't possibly be me, could it? So young….
The pressure to conform - blissfully unaware that I was asked to join because of my maverick self, not the ability to conform.

System: And finally, the system itself. I am still trying to understand what roles of some organisations are - bar actually- at least, in my view, possibly slow down progress. People always ask "what's the hurry?"…well, I have no idea whats around the corner for me, so I want to get things moving NOW, not sit and wait. So the time is now- not later. we talk about variation, yet all CCGs have their own way of doing diabetes, own pathways of treatment- why? I don't know. But I certainly intend to find out. So when I see yet another email from someone with a title I have no idea what that means, a wry smile passes ones lips for sure. And to be honest, its now started prompting emails such as "Sorry, can you clarify your role?" Bar those who live or care for diabetes- or indeed those who have an understanding of the pathophysiology…aren't the others simply to facilitate rather than obstruct?

So there you are….some issues- put as politely as feasible. Maybe someday if I write a book, I may say more- free of the complications of the role one holds.
Its not been plain sailing at all- and if there is one thing I could change- it would be the ability to quicken things up. Will it happen? I intend to try- and I can absolutely assure you that I indeed have the "license" to do exactly that.  Lots of wry smiles over last 8-9 months- as I said, its been a fascinating experience.

Lets see what the future brings..would I recommend it to someone else? Absolutely 100%. All things considered, I would do it all over again- and the team that I work with makes it all worth while indeed. 

Monday, January 23, 2017

On the horizon...

Lets try something positive in this blog, shall we? Its a tough ask- and when you relate to the NHS, its doubly tough. If I criticise something within the NHS nowadays, I get "how could you do that as an NHS England bod?"- whilst lauded by some for being "transparent"…while the same folks turn on you for being positive- "how could you say its not all bad when the NHS is on the verge of utter obliteration?' In the cold light of day, Trump did actually win- simply by eliminating from our lives balance or a rational debate.

Anyway, let's try to write something positive- something related to the job I do with NHS England.
When I started off on this journey regards diabetes, I wrote about the top three priorities and to an extent, all of them are nicely on track. However you cut it, diabetes -for sure- has had an uplift of funding and at least in my experience, many seem to be talking from the same page. Whatever be the organisation, diabetes is up there- after spending years lying on the scrap heap. Whatever be the reason behind it, its certainly a priority and that is not a bad thing.

Around August, I gave a sort of update as to where things were at - and in the new Year, here's the next instalment! Read if you are interested in diabetes care-here's what the diabetes team at NHS England have been up to.

1. Transformation Funds: The forms for the bids (all 43 million£ of it) were finally released- and considering the extent of the work, money involved, short time spans etc etc…it has been an absolute joy and pleasure to see the number of bids from across the country. Final figures are to be confirmed but they are in excess of 200 and the work put in by all involved is simply fantastic. Much kudos to all for taking the time-and yes, much beyond working hours- to do all the work- whatever be the outcomes- this can only result in improving diabetes care across the country. A gauntlet was laid down- and for sure, the community has responded.

2. Diabetes care pathway/ model of care: This has been something CCGs have grappled for with ages- finally we are getting a pathway from NHS England- which should hopefully help CCGs/ Vanguards/STPs to get all parties to work towards it. Some clarity about different types of diabetes -especially while commissioning- will be welcome- as the nonsense of "all diabetes needs similar treatment" needs to stop if we are to improve care.

3. Digital Strategy: Plans are being formalised- and the scale of ambition is high- with a phased approach towards it. It is time for educational modules to be available online- and plans are on track- albeit admittedly it could all happen much quicker. One to keep an eye on- but a Type 1 portal with options of downloads, interactivity are all in the mix…the question is of feasibility rather than simply finance. If all goes to plan, it could be something quite exciting indeed.

4. Access to technology- continues to be high up the agenda. Ongoing conversations with Abbott re Libre, discussions with companies regards CGM/Pump access- all are happening…all I can say is that progress is there- yet its not all down to either CCGs or indeed the companies…a large part of it is education or even willingness on all quarters to adapt technology. What is the point of opening up technology to all…if the diabetes community doesn't wholeheartedly believe in it yet…or indeed have evidence of training in them? However, there is no doubting the desire on all to make it happen.

Other relevant bits have been exploring nurse education with the diabetes nurse organisation, TREND, discussing options with the Trainees via the YDEF, conversations with the BMA-GP group regards QoF- revisiting areas such as targets in frailty….many strands indeed- it's a question of which bits land- at the least. Conversations with ABPI on outcome based commissioning for pharmaceutical companies are yet another strand…it's been a busy few months indeed.

Around the corner, sits something exciting…the chance to visit all specialist centres, use data to discuss gaps, highlight good practice, have discussions with executive teams about diabetes care (remember the impossible tour? )…all in all, lots of ideas, thoughts…all to hopefully help in improving diabetes care. Will all the ideas work? Unlikely- but even if some do, that would be progress.

Its been a pleasure to work with some dedicated folks within the team…but has all of this been a doddle? Not in the slightest….want to know more about the obstacles, challenges and hiccups? Next week it is then…about "patient leaders", "structures", "interference" , "email/Twitter abuse" and much more. It's not been a picnic for sure- but progress regards diabetes care certainly seems to be in the right direction.

Time will tell whether all of this was worth the time. Or not. Till then, its all been a fabulous learning experience, if nothing else.

(With thanks to Jonathan, Matt and Jeff for tolerating me for the last 9 months or so! )