Friday, May 25, 2012

So...What EXACTLY do you do?

It's an odd conundrum being in the healthcare system nowadays. On the one hand you have the regular grind, the perennial pressure to do just that bit better at work, work that bit harder, start even earlier, finish later...all in the cause of trying to make someone better. You keep hearing the lack of finances and the buzzword of innovation zings all around you. Cynics say it's about doing the same thing at a cheaper cost, proponents haughtily claim to have discovered something no one else has even thought about. In short, work is damn hard...what the heck happened to those rounds on the golf courses, the Aston Martin DB7 I was supposed to have....sorry I digress...but shattering of those utopian lifestyle Consultants led or at least one heard about whilst a house officer has been bemusing to say the least. Anyhow, thats what you have on one hand..
On the other side of the coin lies damning statistics. Newspapers scream out headlines as to how poor diabetes care is in this country, how people are losing feet due to poor care, primary care are not fulfilling their responsibilities, specialist teams are failing patients within hospitals and you know what? Sometimes even the best get a bit weary, don't they?I am not sure I have met anyone yet in this business who doesn't give 2 hoots about the patients, everyone is working hard, the practice nurses, the GPs, specialist nurses,Consultants, podiatrists...they are trying..working hard, fighting the fight...and then you get damn statistics which just says...not good enough.

Problem is you can challenge statistics, rail against it...but at the end of the day, it does suggest we don't do as well as we would like to. Interestingly, inside the confines of a hospital, the problem squarely does lie with us Diabetologists. Yep, I blame no one, but ourselves. For once, we cant use the usual scape goat of siree...this one is totally our doing. For decades, we have allowed to be ridden roughshod over. We have managed to give a perception to the external world that all we do is "tweak a bit of insulin"and isn't most of the Consultant job do-able by a nurse anyway? Take any other colleague within the hospital....the refrain is "What EXACTLY do you do?" Surely we are there to look after patients who don't fit into a niche, who isn't a pure cardiology case, a pure respiratory case, a pure Gastroenterology case....isn't that your job? We are in a bizarre world where the refrain from others is that they function better when they concentrate on their specialist areas but oh no, that rule doesn't extend to diabetes specialists. We are the ones who take who others don't want. A recent example? " 82 year old lady..smells of urine...admit under Diabetes"... Does she have diabetes? Nope. Does she have anything that any other specialty will take? Nope. Default position? Admit to diabetes. And frankly, we have sat and let that happen. Mortality data suggests that people admitted due to any cause with a background of diabetes are suffering from poor care, some Trusts have shocking mortality data...but what are their diabetes specialists doing? They are mostly working as a peri-geriatric firm. Specialists have to be allowed to do what they do best, what they have been trained to do ergo concentrate on their specialty areas and if that rule is applicable to Gastroenterology, then it certainly is applicable to Diabetes too.

I can also appreciate the caring physician side which says "but we are generalists too"....and who IS going to look after that 82 year old lady if we don't? So she doesn't have diabetes, but we are a physician, aren't we? The rebellious lot will say "Not my problem...I am going to ape a Cardiologist and just concentrate on the heart"....but then again, if that's what my ethos was, I wouldn't have been in this specialty which is built on the bedrock of caring.  I say..we will but so should everyone else, every other physician. We cannot have different rules for different specialties and we, as a specialty, refuse to be a poor cousin anymore. My first and primary responsibility is towards any patients admitted to hospital who also has diabetes and then a shared responsibility with ALL other co-specialties to look after patients who don't fit into a niche. We are not the only ones who trained in General Medicine, every single other physician did too. The tax payer paid a lot of money to train all physicians to do general medicine, so why can the Gastroenterologist shirk that responsibility? That 82 year old lady should be the responsibility of the ward doctors where she is admitted, irrespective of what the ward specialty is. That is what makes us a physician, the ability and desire to heal, to care...not to pick and choose who we want to see.Locally, we are somewhat fortunate to have argued our case to a certain extent, but have no doubt, the battle to stick to that is daily, is regular, is..jarring.

So to NHS Diabetes and Diabetes UK, those powerhouses who are trying to raise the profile of diabetes, showcasing poor inpatient diabetes care....why not put some pressure on acute Trusts to think differently? Why not ask them to free Diabetologists from the tag of "accepting whatever is given to them"....and get them to do what they do best? Maybe that way a few less errors could happen, a few more Type 1 patients can actually get their insulin, a few more foot ulcers can be picked up in time...a few more lives saved. Maybe, just maybe it isn't just about asking for more resources, maybe it's about using what we already have, a bit more innovatively.

 Diabetes specialists are a funny breed...maybe it's just the subject which draws the mid mannered individuals towards it. Look around and the prototype of a diabetes specialist is a genteel, humble , soft spoken individual. Unfortunately in this world where the one who shouts loudest wins...we have been left far behind the macho snarl of the prototype Cardiologist. From a personal perspective, I am always in a hurry..a hurry to make things better. For me, when patient care isn't  as good as it can be, then I have little time for egos, little time for pacifying.....frankly I am not sure I would be able to explain to a patient that his/her diabetes care was compromised as I was more worried about how not to bruise the sensitivities of my Gastroenterology colleague. 

I have heard the refrain that we need to keep "our footprint" in general medicine to "ensure our existence"... ..break. We have national statistics showing that people with diabetes are getting poor care and we need to do something else to "justify our existence"?! Guys, stand up and make the case of what we are, what we can do, how we can help hospitals with their diabetes patients, how we can help primary care with the avalanche...if diabetes was that simple...why do we spend 5 to 7 years training in this?? Stop worrying about your job...the problems with diabetes are huge and we have a big role to play if we want to make things better. Humble acceptance of a "step-brother status" is certainly not going to do it!
We are specialists and we should be proud of it. This is not a trivial disease, this isn't something to smirk at and no ..we are not the "sugar boys".. we are diabetes specialists....and there is no harm in saying that loudly and clearly. I also do however accept that not everyone is like me...not everyone is comfortable with the snap, growl and thunder approach.And I also do accept that there are different ways to achieve resolution. All I am saying is whatever your care is let's stand up and in whatever way works, be vocal about our specialty...and let's do

"Men do less than they ought; unless they do all they can" said Thomas Carlyle...lets not come to the end of our lives as diabetes specialists, look back and think we didn't do all that we could....just because we were more worried about upsetting our fellow physicians rather than fighting the good fight for the patient.

Thursday, May 17, 2012

Bloody GPs...

I think there is probably something wrong with me. I am not sure why but somehow I have yet to master the art of saying "Sorry can't do that". A few months ago, I bump into a bubbly energetic brunette while doing a teaching session...turns out she was one of the GP educators, her name was  Lois Bowd (damn, don't they look young nowadays!) and she wondered whether I would be keen on doing some teaching for GP trainees. I could clearly hear in my mind the words..." Partha, say I will look in my diary, say No, say I will have a think" naturally I came out with those immortal words..."Oh yes, would love to". Damn...suckered....again! Intriguingly, a week or so later, a Respiratory colleague asked me to swap an on call which I couldn't do, as I had committed the day to teaching. His comment? "Teaching bloody GPs,eh?"

So yesterday...that's what I did...a whole day of education for GP trainees in their formative years..helped, again, by those wonderful folk I work with...a dietetic colleague, podiatrist, nurse specialist...all there..trying to help pass on the knowledge which could help patients. And you know what? I really REALLY enjoyed myself! This was a whole day with junior docs who were going to be the workforce of the future, the workforce who would take the brunt of the expectations of the public, deal with the impending challenges....and what was striking was the refreshing lack of cynicism.In the audience sat folks I knew, folks who were junior doctors doing ward rounds with me...and they knew what I did, what I stood for.There was Laura, there was Nina...trainees I would give my right hand to be hospital doctors...but you have mixed feelings about that.Partly sad that such trainees chose not to do hospital medicine, but partly delighted that the first line of contact for patients were replete with some of the best trainees.
Let's face it, we need to seriously look at the workforce balance. If we are facing the reality that most patients need to be in primary care, then primary care training has to change. Due to the usual passion and drive of Clare Gerada, the pugnacious RCGP chair, finally a 4th year training haw been agreed and good on her for persisting with that! The outline she has given as to what the 4th year training should look like is also sensible and with a clear eye on the future. The challenge of the NHS lies in multiple disease management, not singular ones and say it softly, but do say so with conviction at least...this country needs more generalists and better trained generalists at that.

So where does that leave us, the diabetes specialists? Well I suppose you/I/we can make of it whatever we want of it. We can sit down, cry over a beer, curse those "bloody GPs" for mismanaging patients...or we can still and enjoy that beer while being part of the new revolution. Hang on...did I just hear someone say "but we do?" question for those "seen-it-all-before" many of you have formally approached your local Deanery, or the RCGP offering your specialist centre as training venues for the GP trainees? How many of you have said "come to our preconception clinics, pick up tips what to say to women with diabetes" that when those trainees are on the coal face they can apply them in reality? I will bet my shirt it's a number close to zero...but hang on Partha,I hear some say...we have done some guidelines, we have done some leaflets..we have put it in the post, emailed then...what do you mean we haven't cascaded knowledge? How very dare you challenge our educator status...We have sent a pigeon from our castle carrying our word to those minions in the will work, it has to work...why wouldn't it? 

And I come back again to what we as specialists can do. Teaching or educating is a skill. Just because we are Consultants doesn't make us all fantastic trainers, it's a skill we need to learn and acquire. Hands up how many of us have undergone formal training to educate? Well...if one of the major roles of a diabetes or chronic disease specialist is to teach, then it's a bit odd that only a few of us have done this,isn't it? Standing behind a lectern and reading through your PowerPoint slides does not make one a good's actually very boring and as a trainee, usually that involved me sloping off for a beer, just to avoid falling asleep! On the other hand, get me to listen to David Mathews, Edwin Gale, Jiten know what...the beers can genuinely wait. Not all of us have natural flair to teach, so shouldn't one of the aspects of our training include being how to be an educator?

So let's think outside the box, shall we? Let's think what clinics we run that would/could be useful for our primary care trainees? Let's be rational about point in getting them to an antenatal diabetes clinic ( as such patients will continue to be under specialist care) but surely there's mileage in a preconception clinic ( to advice the young woman with type 1 diabetes), surely benefit in showing them the intricacies of a foot clinic, what the end results are if early pick up is not done, how about low clearance renal clinic to understand which drugs causes hypos and why, what about an adolescent clinic..just to showcase the essential difference between the physiology, challenges and management of Type 1 and type 2 diabetes..better than any PowerPoint presentation....think different guys!! If we want to make patient care better, asking all patients to be sent to us is an unsustainable model. Rather support your primary care colleagues, help in their training so the right patients are picked up, the right patients get appropriate specialist help.  We cannot sit back and watch it all go past us and then complain when someone else does it for us.

I have said previously and continue to say how incredibly lucky I am. I am surrounded by incredible colleagues, specialists, primary care, nurses alike. I have been fortunate to have met Lois Bowd and Simon Tricker who are keen to help facilitate this, am fascinated to have met Mark Coombs, Andrew Holden, Sue Crane..all Gps engaged in training...who appreciate the knowledge gap and are keen to improve things. I also do not believe for a second that I work in an oasis of excellence and firmly have faith that such GPs exist's up to us to extend that hand and not be worried that sharing all this knowledge will "lessen our work load".
From August, we are ready to open our specialist centre to GP trainees in our area to sit in on specific clinics which Lois and Simon have felt were appropriate and would help in day to day practice. What stops anyone else from doing that? Did I hear someone say "will we get paid?" Instinctively I would say "get a life..aren't you doing this for the patient at the end of the day?"....but for the hard nosed business focussed's my tip...why don't you have a cost neutral arrangement, where in return for GP trainees attending your specialist centre, the specialist trainees spend time in GP surgeries understanding the pressures of a diabetes practice nurse, the pressures a GP lead has with their QoFs etc. Our trainees need to learn too, get trained for a future where they will be advising GP surgeries on a regular why not give them an understanding of how GP surgeries work? Training them for a job which may not exist in the future is not good training really, is it?

So there we are..some ideas of what we can do to improve the face of healthcare training. Try to get the primary care trainees in...get our trainees out...and don't need anyone's "permission" to do any of just need to find others who share your vision, will and endeavour to champion the cause of education. Step out from behind that lectern, ditch that PowerPoint....use your flair, show that passion which made you a Diabetologist and believe the end of it all, there will be a rapt audience who will take away something from that, something not as dry as the nth guideline, but something personal...for example...diabetes was, is and never will be about population based always will continue to be about individualised care. The 91 year old in a residential home does not deserve to be given a tablet induced hypoglycaemic event...just because a target has to be attained or a guideline "forbid" you from thinking of a safer option. If as a community we want to change that, then go and spread that message, not simply nod your head in disapproval at the "bloody GP".
When you are facing an avalanche, you put your faith and strongest bricks in your first line of defence...and those bloody GPs are exactly that. Step away from the shroud waving and stand next to's going to be one heck of a "party"....make sure you don't miss out. 

Thursday, May 10, 2012

Pigs and Lizards...

31st May 2003, the BMJ  published a cover story called “Food, flattery and Friendship” which was accompanied by a a thought provoking, one may even say, controversial cover  showing the pharmaceutical industry folks as lizards slinking around a table, while the doctors were depicted as pigs, gorging on the spread on the pigs. It unleashed a torrent of emotions amongst the medical fraternity, some stoutly defending their close affinity to the industry, while others nodded their heads in disapproval condemning their colleagues for selling their souls. Amongst the second group, there were 2 types, first the Edwin Gales, who were the quintessential traditionalists, the ones no one could challenge, not only because of their clinical expertise, but also because they firmly practiced what they preached and genuinely stayed away from the pharmaceutical industry. The second type were the more interesting ones, ones who could be labeled as being hypocritical and perhaps joined the queue of criticism because they weren't part of the gravy train, rather than having a logical reason. Sort of "I love you" if you take me to a fancy restaurant, "I hate you" if you don't...ahh...the fickleness of human beings!

The dichotomy of the situation continues to be fascinating and a recent informal meeting with a GP who had taken up the cudgels of being the Clinical Commissioning group in North London was quite informative to say the least. There was clear belief that education in primary care had to be improved, about appropriate use of drugs, appropriate use of strips and that would deliver the "holy grail"  of improving ling term outcomes, reducing drug costs etc argument that could be faulted and in fact he was one of many GPs who I have recently met who are passionate about making those necessary changes. At the same time, he was keen on not involving pharmaceutical industry as he didn’t want to "taint" the programme, didn't want them to "hard sell" their products. I had to ask..."So how do you commission this? Use finances from the NHS budget?" which he replied affirmatively. But then slowly, as the Jack Daniel made it's way into the system, realisation struck that this money would have to come via disinvesting from somewhere else, and surely there was too much wastage in the hospital on the hill. And that in a nutshell was the invest in the future; we are facing the stark reality of disinvesting in the present.  "Let's strip down the diabetes centre" to invest more in primary care is the mantra but that needs to be tempered with the provision of having those centers to take  care of the complications e.g. dialysis, retinopathy etc. You need the present to take care of the "sins" of the past, so who has time or money for the future?? When financial bottom lines end-March rule the roost and there are "evidence" of poor care in the  present being thrust in their face, where exactly is the energy of the former PCT or CCG leads to deal with the avalanche of the future?

Maybe this is where the relationship between healthcare professionals and pharmaceutical industry need to change. Recently, I spent some time with a scientist who works for a reputed company and I sat and listened to her teams journey in trying to discover a new type of Insulin. I heard about the struggles, the endless nights of toil, the boardroom negotiations, the failed experiments and the unbridled joy amongst the team when they felt that perhaps the right chain mutation may have been found........wasn't this someone who shared the same passion as me to improve things, someone who was fighting the same battle, just in a different format? The cynics will, rightly, argue that it's simply because there is a need of the relevant company to increase their profit margins and yes indeed, the industry is a profit driven business, not a charity. However, to simply label companies such as Novo Nor disk or Eli Lilly as money grabbing heartless souls is also turning a blind eye to the contribution done over the years to diabetes care. As with most things in life, nothing is black and white and if one is silly enough to believe that because Company X paid for the registration of an educational event, one is going to start prescribing their product and ignore all clinical and safety data, then that’s just treating educated adults as mindless drones. If someone does do that, then, my healthcare colleague, you have forgotten the basic tenet of the Hippocratic oath ego "Do no harm".  For want of a better word, if that's what you do, then you are disingenuous and deserve all the criticism the system can offer you.
So perhaps we need to think as to how we can engage pharmaceutical companies to help us to improve patient care. How about thinking of asking companies to scrap all the bits and bobs or scatter gun approach to education in certain areas or regions? Why not invest that money and time into doing structured education led by a group of individuals from primary and secondary care to deliver it? How about creating something like a Diabetes Practice Passport (thank you to my good colleague Mike Cummings for coming up with that one!) whereby you device minimal standards each surgery should have before they are "qualified" to provide diabetes care to the population. To give it more teeth, how about Commissioners mentioning to GP surgeries that they risk losing their Diabetes QoF points to another surgery of they don' t have the "passport"? So many things we can do to improve diabetes care and such big roles pharmaceutical industry can have to improve that...think of the logistical structure, support, experience they can bring into it.

What about the other side of the coin? Well, if we have to adapt and learn, so does the industry. Let me take this opportunity to talk to you...directly - if you are reading this blog. Its time for YOU to act as support structures of professionals, showing a genuine interest in improving things rather than talking about your drug for the umpteenth time.  I get it, it's the best thing ever invented since Adam strode this earth, but can you please back off and let me make my judgment on that please? Time for you all to also think outside the box, think of skills you have and we don't. More and more, healthcare professionals are being asked to become "business minded", " data analysts"...well, do try and help us with that a bit, if you can? You can help facilitate warring organisations, petulant colleagues to get around a do give it a try. Think of social media, think of what Innovation you can bring to the NHS, think of Joint Working Initiatives, try and see what you can do to make my life easier and no, it doesn't always or just involve money. Supporting good research, research grants, education portfolios...the possibilities are me, even in a hard nosed business climate of the NHS, good relations and "being there" is far more likely to help your product rather than stuffing it down our throats with ultra aggressive marketing. And then again, if your drug is truly and genuinely good and scientific evidence backs that, fear not, it will come to the fore!

The good news is that the signs are there...companies such as Sanofi, MSD, BI etc are light years away from what I remembered them as a trainee...and good on them too. Some were already there, some are trying to get there and that can only be a good thing for the benefit of a struggling NHS.  There is indeed no such thing as a free lunch but I always have one and only 1 challenge for those who criticize pharmaceutical industry or even fellow professionals for their "association". A bit like Tom Cruise in Jerry Maguire I say..." Show me the money". In a tax based system which s creaking at the edges, struggling to provide universal high quality care in the present...where is the money, motivation or drive to invest in the future...which is exactly what education and research is. We are struggling with the present, what hope does the future have??  Anyone who has tried to go through a research application process via "normal" channels will understand what I mean....trying to get the Ring to Mordor seems like a walk in the park in comparison!
So possibly time for all of us to grow up, mature and treat each other for what we are. We are not folks who will blindly write your drugs neither are you organisations who just represent a dollar or pound sign. Let's be honest, without any pharmaceutical support, organisations such as the Young Diabetologists Forum, that forum of educational support for trainees in diabetes, would, simply...cease to exist. As would a specialist organisation such as ABCD or PCDS.

Maybe someday we will be able to re draw that BMJ front cover...maybe no longer lizards and pigs but maybe, just maybe as 2 different breeds of the same species…both trying to improve patient care.  Those who read this blog know my geeky comic book side, so why not a reference to that? It's the time of comic book movies…Avengers is out there doing great business. Watch the movie, read the will find disparate heroes with their foibles, big egos with their own agendas. However when the time came to fight a bigger cause, they all came together and saved the day.

Question is whether the industry will answer the call of "Assemble"....if you do, that will make a far better BMJ cover, I assure you. 

Friday, May 4, 2012

What's in a type?

I met a wonderful teenager last week in my Type 1 adolescent diabetes clinic. Bouncy, vibrant, bright sparkly clothes..plugged into her IPhone...all seemed well..except that something just didn't seem right. Too many admissions, too many records in the notes of "non compliance" and on face value seemed like someone who just didn't want to do what the professionals wanted....or in simple parlance was probably not yet ready. For me, it had been a long hard day..another day explaining to my Respiratory brethren that seeing the lady with a urinary tract infection wasn't the unique domain of the "sugar boys" but our collective responsibility as physicians ( but more on that in the future!)...and the urge to fall back into a comfort zone of simply offering support " if you need it" was tempting. But then that annoying thing kicked in. That cocky belief that maybe I could make a difference...and it was time to at least try...keep the ego inflated enough, keep the self-aura what the heck...a try it was going to be.

Now I maybe a lot of things but lacking self confidence certainly isn't one of them, so I went on the charm offensive...chatting about anything but diabetes. We talked about Dave Grohl, we talked about Glee, we talked about the Hunger Games and then what we thought was the coolest apps around. it was fun and she was full of ideas about what she wanted to do when she finished her degree, how she wanted to set up a charity for animals...I sat there, chatted and frankly, got out-charmed by a mile and a half!
And then she paused and said..." So what's up doc? Genuinely interested in me and my diabetes or just being nice?" The next 10 minutes we chatted...somewhere in there she mentioned why she didn't take her insulin..she wanted to lose weight, her sugars weren't an issue for her, what was a priority was the drive to be slim...which I marvelled at as she wasn't by any stretch of imagination overweight.
And then the penny dropped. Her diabetes to the general folks around her, her college mates, her peers was the same as Type 2 diabetes. Everyone had made possibly friendly banter, possible snide remarks about how she was clearly "porky" as otherwise she wouldn't have diabetes and she had to "show them". her practice nurse had mentioned that she needed to have fasting blood tests as it was very important, which she had refused and been labelled as being difficult. The had been no conversation about preconception counselling, there had been no conversation about contraception....but there certainly had been how she could die of a heart attack. So there it the eyes of her peers and some of her healthcare professionals, she just had "diabetes"...a condition which the Daily Mail had simply helped to ensconce in the public consciousness as " the problem that fat people get"...and sadly in the sea of type 2 diabetes, the poor patients with type 1 diabetes had simply got drowned. Forget the fact that the whole pathology is different, the physiological changes are different, the treatment is different, the approach is it is one and the's just...diabetes.

And sadly, this wasn't the first time I had heard that either. Plenty of my patients say how fed up they are with the lack of realisation from all and sundry how this particular condition "works", what needs to be different. Here are 2 examples...a young type 1 tried on Metformin as the practice nurse felt that the withdrawal of a particular type of insulin opened the opportunity to "try tablets" ( didn't he just look a bit porky...??)...result..patient ends up in hospital with ketoacidosis. Second one, an elderly chap with a stroke ends up in acidosis, as the doctor on the wards thought taking him off the sliding scale didn't need any insulin..after all this was just diabetes..and he was surely an old man couldn't have type 1 diabetes? Well guess what Sherlock, old people DO have type 1 diabetes, try asking his GP, his wife...or maybe, shock and horror..even him.

Many a times I have said this and the more I work within medicine, a fact becomes clearer. We as healthcare professionals are too polite, too afraid to challenge each other. Forget the fact that a patient may have come to harm...oh no...far more important to keep the "team dynamics" ticking...ssshhh...lets not rock the boat.Too often, we politely mention the error with the challenger being the apologetic one! Sounds familiar?Yep, because we do so regularly. Well, maybe it's time to put not too fine a point on it. Withdraw insulin from a type 1 diabetes, they are without any intervention, more than likely to...hold on while i think of the physiology of insulin..oh yes..die. It's the same level of error as taking off the wrong leg, leaving a surgical towel inside the let's tackle all this with the same level of intensity.

Type 1 diabetes is NOT the same as Type 2 diabetes. In the political blizzard of "where should patients be cared for", with or without specialist input, Type 2 diabetes in general moved out.. and quite rightly too. What did happen at the same time was discharges of Type 1 patients or the non referral of Type 1 diabetes patients to specialists, and by failing to defend that, we, as specialists, did our patients a dis-service. Suddenly there was a belief that type 1 could be looked after in the community and maybe the well controlled, switched on, engaged can indeed, but the ones who need greater input, access to education programmes, access to pumps cannot. Is saying that arrogance? No, it's about the same level of arrogance as saying primary care can do everything. We all have specific skill sets and frankly the taxpayer paid a lot of money to train me as a specialist, understand the nuances of a type 1 diabetes patient, so why deprive the patient or the taxpayer? Primary care colleagues can, will and should look after majority of type 2 diabetes but please when you find a struggling type 1 teenager, then do, please, let me know and I will try my damnedest to make him/her a bit better. Sometimes it's not even treatment, but about just being there...ready for them when they want to make that change.

Part of me craves for a charismatic celebrity who had type 1 diabetes...look at what Stephen Fry has done for Mental Health or even Jade Goody achieved for cervical screening ( god rest her soul ) contrast we have pretty much no one! Well, we do have the gorgeous Halle Berry who after the Bond movie looked like she had potential, but alas, then she had to go and do Catwoman....
Jokes aside, a celebrity backer would be useful but till that happens, we, who passionately believe in improving Type 1 diabetes, need to up our game. We need to engage with our local CCG, national bodies of power such as the NHSCB and explain why Type 1 diabetes needs to stay away from being commissioned with "diabetes". Maybe the condition itself needs a new name...I don't know...but something to showcase that it's not the same as type 2 diabetes. In people like Peter Hammond and Stephanie Amiel, we have powerful and passionate folks who all should pause and listen to. Shining examples which we all should aspire to be.

So, to anyone who reads this blog, specialist, generalist, nurse, patient...let's give it a try. If you have type 1 diabetes, then don't shy away from asking your GP for specialist help if you feel you need it. If your specialist isn't doing what they should, point it out. The rest of us..let's try to change the dynamics... Let's engage with the powers that be and try and actually make a difference in care, try and improve glucose control in patients where the evidence of long term outcomes is actually specialists, let's face it, we don't provide the best possible care to our type 1 patients universally.

Maybe with shrinking resources, it's time to prioritise our Type 1 patients, adapt into educators or support structures for primary care as regards Type 2 diabetes, think about we can do and try and do it well, rather than not.
And oh yes, next time an Orthopaedic junior thinks its passé to omit Insulin in your type 1 patient, bring a bit of growl into that that moment, you are fighting the good fight for that patient who has ended up in ITU because of a callous mistake. Make sure it's never repeated again.