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.

Sunday, February 11, 2018

Being there

I have been asked this question a fair times now in the diabetes world- more so recently- and I suspect bar those close to me, most folks won't know the answer- and opinions are formed based on what they see in the public persona, social media, blogs etc.

The question has been simple (or in some cases, its been more of a statement..well ya know what the world is like nowadays…the smorgasbord of instant opinions and all that!) -"Are you a Libre-Man or a CGM-man?" Forgetting the basic fact that nowadays they are deemed to be the same thing-yet on a paradigm (not by me, I MUST stress!) its  silly question to start with- but I suspect warranted to an extent by my very public and open support for getting this technology to people with diabetes. Its also come with the usual conspiracy theories…"He must have been paid, No?" / "Does he have shares in Abbott?" / "He must be lining up a job with them"…I won't rehash all the reasons here- but it maybe worth all those characters taking off their tin foil hats for a moment. Nope- not paid, didn't have any of my research or MD/PhD work funded by them, nor do I have shares or taking up a job.

Do also please give me some credit and don't insult my intelligence to that extent- if I wanted to make money off this, I wouldn't really be so public about my support for it, would I? I have even had some clever clogs whispering "he is close to industry"- it makes me chuckle when you see that view from even within NHS circles- someone must have forgotten to pass them the memo about the  "NHS drive to work closer to industry" or even the role of AHSNs to work with industry to accelerate innovation". Ah well- a blog on that some time soon too.

So the answer to the question is….well..neither. I couldn't care less about whether its a Roche CGM or a Medtronic super-pump or a Dexcom whiz-product- or for that matter Libre. I don't think any of them are the panacea or something I must favour..if I believe in 1 thing- its about something that is more ethereal- its funnily enough, not a product.
Its something I was taught by some of my best tutors in life…and it ain't a super tech. Not some fancy insulin either…so let me share a personal view. I have been a Consultant now for nearly 10 years now- and I have had a few "success stories"- none, I repeat, NONE of them down to me or a whiz-tech. A fair few of my patients are active on social media- they can verify- but I have never done a clinic in my life offering someone a Libre or a CGM as a panacea. On the contrary I have only 1 simple rule of doing diabetes care..whatever be the type. It goes as follows:

"You don't have diabetes; You don't live their lives; You don't have the same socio-economic situation. Thus, you have no right to judge them"

Thats pretty much is it, to be honest. I talk a lot about Type 1 diabetes- but am equally passionate about Type 2 diabetes- about working for the population (Super Six Model-remember that?), about treating the individual, de-prescribing where needed, keeping the frail elderly safe, using the appropriate drug or diet what suits the individual- not my personal preference. Its stood me well- and I plan to continue to do so. Its not about the Libre or the CGM- its about being a guide in the persons life- providing them with the tools they need- whether that be education, peer support, just a kind word- or sometimes? Just keeping quiet.

The reason for championing Libre has been the principle of moving the paradigm from finger pricking to the next phase of innovation. I couldn't care less if it was called "Mickey Mouse"- or produced by a start-up company. For me, its the principle of shifting the care paradigm to the next phase- and that extends to every part of diabetes care. If we genuinely want to improve diabetes care. we need to be nimble, flexible, accept that what controlled setting such as trials tell us is not the gospel- but guides at best to help us. That we may need to rethink our strategies such as providing education only by face to face means -is the only way or that it an only be given after 6-12 months after diagnosis in type 1 diabetes. Lets face it, beyond a few chosen centres of excellence, diabetes care in the main is about "You have diabetes; sorry thats a bit shite; here are some leaflets; An education programme on a set day: see you in 6-12 months". The person is left with their diabetes…alone, looking for direction, friends, support- but we as a system resist change…because? Evidence says we must do it in only 1 set way- damn the fact that not many are coming to the protocolised versions of education sessions or clinics.

So- no- I aint in any camps- fact of the matter is- past the Libre- I am also starting to spearhead the CGM work (I bet the next query would be why I am supporting CGMs and not education!)- as much as working on individualised targets in the elderly- or championing different style of education programmes. They ALL matter to me- they all mean improving self management for those living with diabetes, keeping them safe….its not that tricky - we don't need to fit ourselves into boxes, we just need to see ourselves as support for those on their journey with diabetes.
I appreciate how tough that is as a professional, how tricky it is to let go of that control (thats not what our training teaches us)- but all I can say? That is what brings the best results- for what its worth- 10 years of being a Consultant has taught me that- as have my patients.

Go on- do give it a try. Just try and be there. It makes for much better diabetes care. And oh- easy on the conspiracy theories. Much better time spent on improving diabetes care. Honest.

Sunday, February 4, 2018

Perspective

This blog- for the first time, I will take this opportunity-to even the few who read my blog- to consider something-just as a favour.
Its for something which has made me think. Made me think of perspective. Made me think in the context of the job I do, the specialty I work in, the efforts I try to bring regards improving care- and more so, in the context of the blessed life I live.
Working in the NHS, a system which for all its flaws, purports to give folks what is needed irrespective of their social status, ability to buy etc; a system which has also given me a comfortable life, a good working condition, some fabulous colleagues and he golden opportunity in a national role- to make some difference, somewhere.

If you find a moment, do spare some time to have a look at "Spare A Rose". Much kudos to "Grumpy Pumper" aka Chris Aldred for drawing my attention to it- and in my role, the least I can do -apart from contribute- is to draw some attention towards it. We live in a country where insulin is "free", care is "free"… we debate, discuss, jostle, make snide remarks about the ability to get FreeStyle Libre,split hairs about evidence, post code lottery... we rail against the NHS for not providing all the latest technology…yet …well, have a look at the website- if you can.
In many countries, many children are not even able to access any insulin. Simply put, a life saving drug in Type 1 diabetes that many can't get.

A sobering thought- and perhaps also a time for perspective. A time for taking a moment and thanking our blessings that we -still- live in a country- where this rarely, if ever, enters our consideration. So if you can, have a look, take a moment- and see if you can contribute something.Beyond the bubbles of our world, there exists a vast one where healthcare isn't "free" for all- and if we can, even in a small way, the contribution would be most appreciated.

So- if you read my blogs, find my rants entertaining, then for this Valentines day, try and spare a rose. A simple gesture- but could help in perhaps saving a life-somewhere. I have donated- would be grateful if you could consider the same.

Thank you x

#SpareARose

Saturday, January 27, 2018

Murky




This week- no surprise- a blog to reflect upon the Bawa Garba case. This isn't one to discuss the intricacies of the case (its been already played out widely in the media -general or social) or the "closing of ranks" -as some have suggested- but a personal viewpoint from someone who has been in the NHS for 20 years now.

To begin with, my views as a parent. Whatever the rights & wrongs of this case, a father & mother lost their child- and nothing in the world can equate to that sorrow- unless one has faced that sort of tragic circumstances. My blood turns cold at the very thought of even the slightest harm to my children- and simply put, there is no words to comfort them enough for their grief. However much time maybe a healer, the scar will remain- as will the fact that errors contributed to a child passing away.
It also makes me wonder whether, we as a system, have contributed to the whole murky saga too. Past examples of patient harm- have never quite ended up anywhere much- beyond "We will learn- and move on". For the individual who has lost a loved one, its perhaps all vey good for someone else to say "we are looking to learn"- but the physicality of seeing an individual who you believe has caused the ending of life to your loved one, continue working…sucks. Its not unnatural to say "accountability needs to lie at the doorstep of someone- not the ethereal system" . I suspect those of us who- fortunately- haven't faced anything of that magnitude may not realise that sometimes in the cold light of day- the passion is likely to be ignited more when the harm is your "own".

Then comes the reaction of some professionals towards those who raise issues. I will give you the example of James Titcombe- some of the vitriol he takes is pretty..well…special. Comments such as "using his child death to make a point" angers me, annoys me- and belittles us many folds over. Cue? Entrenched camps where strong patient voices- driven by personal hurt- clash incessantly with many- strengthening the confirmation bias that professionals are just out to cover their own backs- losing out attempts at rational discussion. For many, there has been-frankly- no closure.

But none of these irk me- my views above are reflections of what I see- and part of me understands the angst. What irks me about this whole thing are a few other bits- and thats more about us, as the NHS, than anything else.

First- the factor of responsibility. However you want to couch it, this junior doctor was left high and dry by her Consultant. Period. The Consultant was aware of the pH and Lactate of the patient, wrote it in his notebook but decided not to review the patient as he expected her to "stress" the results.
I don't even know where to begin with this- but frankly? That irks me. I have always maintained that the Junior doctor strike/ contract issue was a reflection of something much bigger, a lack of support, many instances of seniors not standing by their juniors- and here we have the tip of the spear. Its little things you know, annual leaves, unjustified demands from management, making sure they are safe….and then the culture gets further worse- and there we have it.
Then there is the issue of corporate responsibility- how does any of this not reflect on the Trust and Execs/Managers at that time who allowed such conditions to appear- well, another bit which makes me shake my head. Basically, when it came down to it- and the system needed a "head", it was the junior doctor- someone who could be sacrificed as collateral damage.

Second- the issue of race & colour- that uncomfortable fact. Many many papers etc have been written about GMC convictions and how things are judged- and the perceived bias. Would this case have been looked at differently if the said person was locally trained & white? Its an uncomfortable question which the system needs to be keep asking- but my belief is Yes- it would have been.
Lets give you a simplistic example- a liver surgeon has a bit of lark, plays God- and brands his initials on a liver- gets a 12 month community order and a fine of 10K. Different case- but I can bet you if that surgeon was non-white, he would be doing a bit more than that. I say that from personal experience- the system struggles with anyone who doesn't fit the mould, the judgement of "success" or " failure" is different- however many powerpoint presentations or committees you create to make yourself feel a bit better.

Third- the long term implications. I have always debated here the issue about whether being a medic is a vocation or a job. If its the former, how far does that take you? How far would you cover- how far is that rubber band of safety? How far do you keep trying as "otherwise who will help the patients?" This ruling will challenge that more- and frankly? We are poorer for that. I may smile at their vocational drive- but privately I admire them- and appreciate them for that extra they do.
The impact on personal reflection has been well rehearsed already- and that irks me. A bugbear of mine is improving insulin safety in hospitals…this drives a spear through that endeavour…with a big part of this taking away reflective practice in a safe environment. It drives defensive medicine further up- the system is already creaking with the unnecessary tests we do- "just because" or "what if". This now changes that fact…lets be honest, you would rather organise a CT scan- rather than face the possibility of missing something which could compromise your career, yup?

A murky place indeed- much of our own doing- and some of it the GMC bid to appear muscular- when in the past, they and the NHS have been accused of being far too lenient to medical staff in the face of patient errors- its a crying shame that the pendulum swing has taken us to this place. It irks me especially when there is a such a strong commitment to improve safety for #diabetes patients within hospitals from our end.

If there is any silver lining to this cloud, it perhaps also bares some uncomfortable truths to us as a system- the role of seniors, the issue of race- and the culture of safety we love talking in aviation terms.
Ask any aviation expert, someone would certainly be accountable- its unlikely it would be the first officer flying the plane. The NHS just got a bit more murky.

Sunday, January 21, 2018

Variation



Ever come across the often repeated sentence…"level the variation in the NHS?" I mean, you would probably have to be under a rock to ignore it- and frankly, there rarely is a conference or a meeting where this is not debated, slides presented, lots of policies made- and the barriers are well known. Plenty of work is being done, will continue to be done- and the drive continues to bring more to the "mean"- or at the very least bring the outliers a bit closer to the data pack. When you take that concept to innovation, then we walk into further complicated territories. The NHS, by nature, is cautious (you can't blame them - our fingers continue to be burnt by the latest fad out there); factor in many other issues such as finance, money etc- and its a cocktail of epic proportions

So- beyond the powerpoint and the glossy documents and the proposed solutions, how does it all work- or for that matter, not work? Thought I would share some personal experiences- my blog writes are becoming less- apart from time constraints, evidently whatever I say nowadays could be construed as NHS England…albeit it comprises less than 10% of my working time…so one has to be "careful". I suppose there's always a silver lining- someday I could write a book- ah the experiences I have collected is simply..well…lets just say you could run a season of W1A on it.

Anyway, I digress. So- back to innovation and adoption. One of the things I focussed on was getting technology to Type 1 diabetes patients- a bit more accessible. The Freestyle Libre was a case in point for me- I don't have any special love for it. I haven't got paid by Abbott, I don't have any shares in it- but I know a truck load of folks who could benefit from it- but can't as they don't have the finances. Plus for me, it was setting the tone, sort of a road test of the bigger challenges ahead- not just in Type 1 diabetes- but overall diabetes care. Could the community work together? What challenges would come along the way?

So- the first thing about innovation is "Its too costly". Thanks to the work done by DH and negotiations with Abbott, the company dropped their price by approximately 30%- a drop of £110/month to £70/month. I thought that was pretty good nifty negotiations by all concerned.
On top of that, we did a significant amount of financial work on this with the DH to ensure it wouldn't bust anyones budget- IF used in appropriate patients.
Next came-"Where's the guidance?"- so promptly came a national guidance- done by a group of folks comprising of CCGs, Pharmacy leads, Specialists, NICE, GPs etc etc
This was followed by "But NICE haven't approved it"- correct (Doing RCTs in technology takes time- and the world of tech doesn't quite stand static)- so we put tramlines as to who should get this device (NOT all)- and the company agreed to a national audit- data for which would be made transparent- and further inform NICE.
Then came "But this isn't Continuous Glucose Monitoring- so it can't replace it" - out came the International consensus statement suggesting it actually was exactly that- just a different type.

After all that, came the actual battle. Having to go through individual CCGs- its a bit like trench warfare. And THIS is where the variation REALLY kicks into gear.

Lets give you some good examples…Greater Manchester, Cumbria, Derby, Brighton…all agreed with the national guidance and said "Let's start". Then you have - let's say Somerset CCG who have said yes- but one of the mandatory criteria to getting a glucose monitoring device is to make sure your BP and Cholesterol is below "target". What glucose monitoring has to do with the other targets being on point…well…I have been left scratching my head a bit to be honest. The national guidance doesn't say that but the local one puts those stipulations in.
Then you have  Worcester who have said "No"- before the national guidance was published- but their next review will be in 2020. Why? Well, I don't know to be honest. Closer to home? Pan Hampshire- it looks good so far- final decisions due on 14 Feb. However, next to it sits Dorset who have said "No"- their documents doesn't even bother referring to the national guidance. So basically, if Hampshire says Yes, then if you drive up the A338 and take the M27 for about 45 minutes, you may get this innovative device if you fit the criteria. Same NHS…how intriguing is that? Or if you are a person with Type 1 diabetes, how shallow does the N in the NHS look at this point?

Finally, we have London- an absolute lynchpin to the process. Why? Because a huge amount of expertise sits there- as does the notion of this being a hotbed of technology. Hopes have been high due to the fantastic work done to get all working together regards the Transformation Funds. I have publicly said- and will repeat the laudable effort put in to work as a group.
However, at last check, as regards Libre it appears that there is no date to a decision- London evidently is so big and complicated it needs an "Implementation Guideline" which will come up with recommendations of "How to Implement" by April 2018. Factor in specialists themselves not agreeing where this device would sit- debating about changing the national guidance- and its a fascinating exercise in its whole self. Some may ask why make all the details public- well- I get emails/texts/twitter messages regularly from desperate parents or carers asking where things are- why people in Wales are getting it- and not England- so lets be transparent about all of this.

Personally, I am amused. I rarely get frustrated- (after all- I have enough fun in life not to get frustrated by such oddities)- and I also do know that just like the other areas going "live", so will London and other areas "happen" too. Some are taking more time, looking at others, perhaps will need more nudging- and to those who ask, No, we in NHS England can't and to be honest, shouldn't mandate this. It HAS to be up to local professionals to find the way, learn from other areas- thats the whole point of localism, rather than command and control!
But as a fore-runner, it also gives a sense of challenges ahead to any technology implementation- or indeed any work in variation. As a national body, we have negotiated the price, helped set up a transparent national audit as well as provided national guidance. Its not always the "national" team who can sort it- its also down to local economies to learn from each other- and not set out rules which makes variation worse.

To patients out there, I appreciate and feel your frustration- but this blog is to highlight the challenges we face too. I applaud all those areas who have worked together to help get this device to patients- as well as charities such as Diabetes UK and JDRF who have been tireless in their efforts. All I can say is we are trying- and with time, many more will come on board.
To the diabetes community:My genuine appeal? If we can't crack this simple bit, then the next phase of CGMs is far more challenging in present financial times. Think beyond your own centre, your own unit…we may- just- be able to do something good together.

Key to Map below:

Blue: Approved
Orange: Not Approved
Grey: To Decide

Link: (Courtesy of Diabetes UK):

https://www.diabetes.org.uk/get_involved/campaigning/flash-glucose-monitoring





Friday, January 12, 2018

Lost?

You can sense the despair in the air...you can literally reach out and perhaps even touch it. Enough has been documented about the sheer incessant pressure within hospitals, the ramp up of the noise in the media, the chatter on social media...you can't escape it. And with it has come a sense of inevitability about the cycle- yet perhaps a bit more tighter each year. The tough times brings forward a discussion of "how do we solve this problem?" along with the sharp divides of opinions, the same rhetoric of what may or may not work, the health care professionals saying "its the worst ever" and some sticking to smart alec comments about what should be done.

I mean...is it the worst ever? Or do we healthcare professionals harm our own cause by saying so each year- and we get to the "crying wolf" phase- where we get ignored when it actually is the worst ever? I don't know- but facebook posts from former years can be educational...it appears most winters, we struggled. Personally, how bad is it? Let me just say after a long, long time, I was reminded of my days in Kolkata...the sheer volume, the look of desperation in the poor doctors or nurse face...the annoyance that they couldn't do better. Heck, I even discovered places in the hospital I didn't even know existed- or at the very least, never expected to visit as a Consultant Physician. Problem is caught in the sheer white heat of social media, the message does get the counter of "here we go again"- albeit unfairly. Or at least it certainly feels so. It feels different for sure- something has to give soon.

Then there is the inevitability of the debate of "What next?". Take your pick. Hypothecated tax? Immediately appears a raft of idea why its a daft idea/scourge of the world/an evil plan to destroy Bevan's legacy. How about a cross-party commission? Well, that isn't good either- not all parties like it- because lets be honest, why get rid of a political football that has served many so well for so many years? Ok- lets ramp it up- how about a Royal Commission? Pfft, they say- it takes too long- long grass issue. Well, that's really funny and makes me smile. About 2 years and a bit ago, was part of a group which asked for it. Response then? Oh-it would take 2 years- and the NHS "doesn't have 2 years!!" Looking back, it seems we have had a lot of chat, a lot of political commentators have opined, but what has happened as regards funding the NHS question? Fanny Adams. I don't know- maybe, just maybe..if we had done something 2 years ago, we may have had something to discuss, implement, debate etc. But nope, heck, some tin foiled hat people even said we were pushing privatisation. Well, blow me over. 2 years later, welcome to GroundHog Day.

Then we have the debate about structures and funding. The main opposition-for example-to an Accountable Care System seems to vary between- oh its American- that's all evil OR we possibly can't integrate services as it opens the whole service to privatisation. So are we objecting to the structure, the concept or do we want to ban private companies from bidding? Who knows- but integration / working together sounded like a good thing. I have an idea- lets give it a different name...how about National Health Service?

Then we have the "appeal for funding". An ask which each year gets even more....well...peak bonkers. We all know where extra money "should" go- social care, primary care, better prevention health, better community support....where however it does go to? Acute Trusts bottom lines, PFI bills, locum bills, anything to do with improving "flow" with a few hand downs to the other areas which would be more useful longer term....total net effect of using the money? A big zero. A plaster- till next year- when "its the worst ever ever ever...so can we have some money please?" To make it peak W1A season, the ask is led by NHS Providers- the same organisation which was one of the few bodies to support imposing a contract on junior doctors. I may have missed their apology for getting that wrong- but all the money in the world is no good if you don't have the staff. The junior doctors issue was far more about money, it was about morale- it was about the future- it was about a workforce we could ill afford to lose.  It was about standing by your workforce, not disrespecting them...it was much bigger than a pay dispute.Combine that with Brexit, the uncertain economy, an opposition which is level in the opinion polls with the ruling party...and we are a bit...lost,aren't we?

Normally, I always like to say something upbeat, something positive. I am not sure I do about this whole mess. The narrative seems to be lost between - we need more money/ Corbyn will save us/We are the best in the world/Stop Privatisation/ACS is the Devils spawn...all of this means very little when you are standing in the middle of a Medical Assessment Unit and thinking..."This can't be right"- or looking at your duty hospital manager and thinking ..."Dude, you need a hug".

So please- all you clever people- try and come up with a coherent plan- because I am not aware of one- and neither can I see anyway out of this rut- unless we try and get our heads together- and perhaps, just perhaps be open to suggestions beyond our firmly entrenched position.
I don't care what system it is- but I would like to provide a better service than what we are starting to at the moment.

Till the next year.

Wednesday, December 27, 2017

The 2017 Chronicles

2017. Nearly done- and from a professional perspective, its been a year of getting to prefixed targets set- nothing more, nothing less.
No point in beating about the bush- the NHS is in turmoil- with a swirl of politics, elections, more changes beating an incessant drum which has made life suffocating, difficult to concentrate on the job at hand. Yet…albeit from a biased point of view, we in the NHS England diabetes team- can perhaps look back at 2017 with a bit of a smile.

Landing the Transformation funds was a big step forward- with the process of allocation of money-perhaps being…character-building. Either way, at the end of it all, 62 odd million £ were distributed out- with a further roll out of the National Type 2 Diabetes Prevention programme; about 5 million £ specifically to increase specialist nurses in hospitals to tackle hospital safety issues; about 11 million £ to improve uptake of structured education etc. Will money solve it? Nope- but it certainly goes a long way to answering some critics- as well as kickstarting some of the much needed processes that diabetes care needed.

Next step was the landing of the Diabetes NHS RightCare pathway. Blessed by eminent personalities such as Sir Muir Gray, it arrived with 7 key priority areas being focussed on- at a population level. The message coming out has been loud and clear- the days of a "community diabetologist" and a "hospital diabetologist" must be coming to an end. It has been of much personal satisfaction to see this..as I have always believed in…one is a specialist for the system- not of one particular bit of it.
The digital versions of the Type 2 diabetes prevention programme arrived too- a roll of the dice- to gather evidence, to test the theory that digital approaches may work- a preference of a nimble approach towards technology- in an effort to encourage innovation- yet with markers around it. The recently published data also showed the growth in numbers in the face to face T2D Prevention programme

The landing of the FreeStyle Libre was big news- an unconventional approach- yet- in my opinion- a much needed one to share up the status quo- it certainly has caused a stir- and for me, the big thing- apart from the technology- was the whole process of seeing what could be achieved if all forces joined together for the right thing. For me? Getting it to even one person beyond the capability to buy (which is what it was for 2-3 years)- thats a win. As was showing that when we negotiate, we do so for all 4 countries, not for one. We do so for adults and children, not for one segment. Diabetes does not stop at certain ages, nor at boundaries of countries….THAT is created by us as health care professionals- and this year- to me- was about setting the tone for changing that.

The year closed with updates to the DVLA rules for those living with diabetes. Some important first steps- especially removal of the legal barrier to change how glucose levels are to be looked at during driving. Much to be done yet- but this is a big step forward- just as Libre could be potentially opening the door to further technology in type 1 diabetes in the NHS. And finally, the opportunity of brining a Scottish piece of work (My Diabetes My Way) to England- and invest with an aim to develop it further- explore the possibilities of Artificial Intelligence & Diabetes

So whats up in the pipeline? Truckloads…will all of them land? Unlikely- but no harm in seeing where it takes us. I will list them below- to give an idea of what we are up to/ have in pipeline/on drawing board- in no particular order of preference:


  • Type 1 diabetes Digital platform
  • Type 2 Diabetes Digital education offerings
  • Accreditation of Education programmes
  • Discussion around QoF; individualised care- and especially frailty
  • The UK version of "Language Matters"
  • A focus on better technology uptake especially CGM access
  • Possibly Out of Hour support across the country
  • Liaison with pharmacist/ dietician/psychology organisations regards their roles
  • Collaboration with ABPI (umbrella organisation of all diabetes Pharma companies)
  • A possible Dragons Den style Innovation Day
  • Working with ambulance services regards treatments etc
  • Developing something for SE Asian people regards education in T2D management


Enough? I think so- and as mentioned, the NHSE Diabetes team is busy with ideas/thoughts/possibilities- working closely with Diabetes UK , JDRF et al

Personally, apart from all of the above, there's the TAD event, the T1D: Rise of the Machines; Episode 2 of the T1D Comic book….so much on plate- and so much fun to be had. 2017 has been a bit of a blitzkrieg, 2018 could be one step further- who knows. Throw in the GIRFT role to come..touring all hospitals around the country, discussing safety, care, data- and yup, it will be busy, won't it?

Regrets from 2017? Very little. I never came into this role with any expectations- apart from having a bit of fun- and as long as it continues to be- we keep at it. The NHSE Diabetes team are laced with characters who have guided and supported me- yet let me run at my pace- which has been much noted and appreciated.

Resolutions for 2018? Not much to be honest- but maybe smile a bit more, try a bit more charm. I am perhaps a bit more relaxed, a bit more chilled - and the supporters have been far more than the detractors- which is always a good barometer. You can't satisfy all- trying to do so is probably the biggest error anyway. However, more than all? The biggest strength has been the folks who live with diabetes or care for those living with D. Very rarely, if ever, there has been any criticism from them- and I can't thank all of you enough for that. THAT is what has made 2017 so special.

Let's hope 2018 brings us more cheer- as we try different approaches and things- and we are always happy to listen- and hopefully, our work in NHSE shows- we have been trying our best. I wish you all a happy new Year- and look forward-as ever- to your support- as we try to make diabetes care…just that bit better.
Personally I always worry when my interest flags or wavers…or when I feel the challenge isn't there anymore. Not quite done yet to be honest in diabetes…the fire still burns well…lets see if we can make 2017 the warm up act for 2018, shall we?



                    Partha Kar & Jonathan Valabhji….The Maverick & The Statesman 😊