Sunday, November 29, 2015


It was actually, at least, what I thought, a very simple question..."In a patient diagnosed with type 1 diabetes, the first step of treatment must be: a)  Diet and exercise or b) Medication

A 24 hour Twitter poll came back with the result that of a total of 1064 people who kindly put their opinion, 27% or about 287 people went for option 1. Or translated about a quarter of folks went for diet and exercise as a first step of treatment.
Now before I go into any analysis of that result..2 salient caveats to make ..firstly this is NOT a scientific survey, so apologies for how question could have been framed etc and secondly, this is NOT a blog to mock, make fun of or berate anyone who have chosen option 1.  This is an opportunity to educate and raise awareness and I would be grateful if this analysis is read in that light.

So for starters, the correct answer is - simply- option 2. For someone diagnosed with type 1 diabetes, insulin keeps you alive. Yes, education, discussions about diet nd exercise is all important but without making any bones about it, if you don't give them Insulin, there there is no person around to teach them all that. So yes, education is important and in fact paramount, but that does not supersede the need to give someone diagnosed with type 1 diabetes the medication they need to keep alive.

Let's look at the group who chose "Medications". Again, to emphasise, it's Insulin, not anything else, but insulin. If you have someone with type 1 diabetes, they have a total insulin deficiency, and without that, they won't survive. So no, don't try anything else, if in doubt, use Insulin or please ask a specialist.
Now to the 27%...the important question..who are they..and there is no way of knowing that. It could indeed be a mixture of HCPs, Jo public or folks who work in the NHS but not involved directly with patients. Or it could be a question ( as confirmed by some) of reading the question wrong.
It does open up a few areas to look at..firstly ones who are simply part of Jo Public..does it reflect the amalgamation of type 2 and type 1 diabetes into 1 amorphous mass? The buzzword is all about diet and exercise and with celebrity chefs leading the charge, diabetes it all now the same? Without any hesitation, for type 2 diabetes, diet and exercise should be the first step...but is that what the public thinks when type 1 diabetes is mentioned?
If so, then that MUST be our responsibility as specialists to keep raising the flag in all forums. No, it isn't the responsibility of charities, policy makers, but us,as specialists, to be the voice for patients who have type 1 diabetes. Ideally, you would want patients to lead that charge themselves, but I suspect we all know how far we are from that yet.  Thus, for those who are Jo Public etc - my appeal? If you have voted, use this as an opportunity to understand the difference between type 1 and type 2 diabetes. It isn't the same by any stretch of imagination or science.

Finally, to the group which would worry a lot of parents, carers apart from patients themselves. If even 1 in that group who answered is an HCP ( and hadn't read the question right)..again..thank you for answering but here lies an opportunity for learning. In the future, if you have someone who has type 1 diabetes, there is NO other option...the only one is to give them the medication which will keep them alive. If you read that as Type 2...then use it as a learning exercise to make the distinction for the next patient you review.

It indeed has been a fascinating exercise...and I must admit to not being despaired at the outcome. It surely shows the work that needs to be done but also shows the willingness of many to engage and learn. Thereby lies the power of social media..thereby lies it's side which can indeed be used for improving care.

Thank you to all who contributed and hope this can spark some discussion as well as act as a learning exercise. To be honest, if this helps in even 1 patient being given the right treatment, being saved from being admitted in ketoacidosis or even lower the stigma a tiny bit, that Twitter poll was worth the time.

As Mr Mandela said.."Education is the most powerful weapon we can use to change the world". Amen Madiba

Tuesday, November 24, 2015

Game's afoot

Ring out the bells. Splay the festoons. The NHS has got  4 billion pounds..extra. Well, actually, not quite but let's not worry too much about details. The point is the promised extra money has indeed been front loaded..and cut it any way you want, it's there. Simon Stevens laid out his stall, flexed his muscles and got what he wanted. So in simple language what does it actually mean?

Well for starters, it's definitely welcome. Look at other areas and you have to take a deep breath...cuts galore in that context, rejoice indeed. Now the fun begins though...for starters Stevens authored the 5 year forward view, asked for 8 billion and promised a 22 billion efficiency. He got the 8 billion. Then he wanted it front loaded, he's got it too...Now? It's all down to him...reputation on the line...put all his political capital on the line...high stakes indeed.

The problem? That pesky efficiency drive...hugely dependant on 2 restraint and new models of working. That pay restraint thing is nit going so well..(have you heard that thing about junior doctors) and the Consultants, for once, are starting to stir. Then you look at the GPs...and heck they are pretty pissed off too.
Those new models of care? Well Sam Jones is in charge of that..and good new concepts too- the problem? Can these go to scale? Will a disgruntled workforce play ball? How DO you get a workforce facing pay restraints/cuts to play ball...tricksy tricky.

To put some maths into it. We should have made about 4 billion efficiency savings by end March 2016...if you follow the 22 billion efficiency savings by 2020 mantra. Well, we are 1.6 billion over spent already...the new boss of NHS improvement suggests we will keep it at that by end March 2016. With winter yet to come, gaps galore in would like to see a feat even Houdini would be proud of.

So 4 billion buys you breathing space..buys you some time in a gasping environment...a bit like a pocket of oxygen a drowning man finds. The question is what next? A massive. Bit hinges on new ways of working...and with the greatest amount of respect to all our leaders, if you haven't achieved that in times of plenty, how do you do so in times of scarcity? Game on's time to test those leadership skills...history will be the judge for sure.

Finally, that little bit of Public Health and Health education coming outside the ring fence. As a Diabetologist, you can only wince...let's pay more for swanky coronary care units but not to prevent type 2 diabetes which causes the coronary events? Well then...that will be interesting indeed.

So...4 billion...yes- a massive win for Stevens, a breathing space for the NHS...the rest of the efficiency...I am not going to be negative and say no way...but it is going to be very very tricky. I, as part of NHS Survival, have always advocated an independent NHS funding review. I also accept thre have been instances of so- such as Wanless or Barker...problem being there has been no pr-agreement from all parties to accept the recommendations. By 2017/2018..the chorus for that will become louder..and it could indeed suit the government to ask for one in 2019. The question is whether by that time, quality of services would have dipped down too far..or not.

The game indeed is afoot.  A lot of national leaders will earn their corn or move on to other pasties. If they do achieve the impossible, then the nation as a whole, will indeed owe them a big thank you and perhaps also ensure Stevens is remembered as the genuine Messiah.  We shall see.

Friday, November 20, 2015

A poor joke

Utter tripe. Absolutely utter rubbish. Honestly, I don't do blogs when angry but it gets to a point when sometimes you just must. My thinly veiled casual contempt for PowerPoint warriors is well known..and in my last blog, I have constantly alluded to it. If you haven't achieved anything then please, do peddle your wares somewhere else...I have little time for a car salesman.

Add to that list the brigade of those who profess to understand and believe in the ethos of diversity. NHS Improvement announced its Head Honcho...followed by CQC. Then you need to have a look at NHS England, Health Education England, GMC...and you must wonder which exact century does this county exist in? A rudimentary joke of being white and male to get to to the top echelons of power is no longer one...but serious business. It is as if all the powers have decided to stick two fingers up at all the reports, all the chest thumping, fact finding about lack of diversity..and say "So what?" 

I was discussing this with someone who casually mentioned..."But hey, look how well you have done?" A learned, educated, well versed in modern political correctness lets go of some inner thoughts. Well, genius, let me tell you whose help I needed to get to where I own. Faced comments about "we don't employ your type in the South" from "respected" Consultants and I have gritted my teeth..determined to show to all that it didn't matter..I would work doubly hard..I would earn my corn. My disdain towards many in authority comes from many hard years as a junior doctor facing casual discrimination, turned down from jobs...and one always hoped that someday it would change..someday it would get better.

I sit here in 2015 and I don't know what bothers me most. The 2 fingers from the top tiers towards the workforce or the searing hypocrisy about having to do equality and diversity courses as part of my essential training. Read the report of Michael West...nothing has changed in 20 years...but hey the outcome is "we must try harder". I have no doubt Stevens, Keogh, Mackay et al are amazing guys who will do a fabulous job but are you telling me the whole country had absolutely no one who was a woman or of a different cultural background who had the same quality? No one at all?

I am a big supporter of a campaign called "HeForShe" and in my household, there is not an iota of difference between my son and daughter. It's because I have seen and continue to see - at interview panels, at casual chats..the throwaway comments about women and their "penchant for getting pregnant"; how "bad it would be for the continuity of the department" and it absolutely makes me boil with anger and disappointment...indeed is this the world to which my daughter will walk into? What kind of archaic bilge is that?

So to all managers, politicians, doctors, leaders or whatever title you equality and diversity if you genuinely believe in it. Please don't tick a box and feel your soul has been saved. At least let's bring some honesty and say that if you are of a certain type, we would like you to do so far..but please don't try any further. Otherwise as recent appointments have shown, it's just a joke...and a pretty poor one at that too.

Have a good weekend, won't you?    

Friday, November 13, 2015

Respect the outcomes

Irreverence...always has been my calling card. Many a times it's been mentioned and to be honest, I have never been one to hide that either. A question automatically you respect anyone? To perhaps the utter bemusement of some, I actually do..and unquestionably so. Let's take the world of diabetes...foot care? Mike Edmunds. Paediatric diabetes care? Fiona Campbell. Pituitary disease? Will Drake. There's actually a theme's called outcomes and what they have done. Technology? Iain Cranston- I work with him, see what he does, the respect is total, it's unflinching, it's unshakeable...and it doesn't have to be someone old or in a position of authority...take pumps...without batting an eyelid, it would be Pratik's the work they do and the outcomes they get. A theme there...respect has to be earned. A position means nothing to me, never has, never will. It's about what have you done.

What about in the wider world? Well, in the NHS, to be honest, it's most Chief Executives I know. We throw brickbats at them from the sanctuary of Twitter or a blog, but let's be perfectly clear...these guys take an enormous amount of beating- and collectively, all of these folks decided to take the hit on financial issues rather than compromise care, not hire locums, not go to agency staff when needed. For that, respect is's about the outcomes they have decided to deliver..not on the spreadsheets but on the issue of care. Sam Jones, Umesh Prabhu some other names stand out...bold enough to step up to the mark and not being a paper leader...enough time in my world to have respect for that.

So what about its relation to World Diabetes Day? It's relation is to what we could do, as a community to do exactly that...improve outcomes. A fixation on targets, a non evidence based approach to diabetes care has brought us to the state where as a country about 60% of diabetes patients are having their basic checks...yes..that's 60%. We are in a state where we froth over technology and Google glasses when we over treat the elderly and cause hypoglycaemic events, hospital admissions and much harm. Someone, albeit admittedly in a different context, mentioned recently that some medicine need to be taken without evidence. No- that's called homeopathy.

As a country, what stops us as a community to saying we can improve this, and we will stop doing unnecessary stuff? The tariff system associated with QoF targets ( once a great tool now a mere hindrance for an ageing population) has left integration firmly on the glossy power points. Only a few handful of excellence sits amongst us all....integration has stayed away from reality. Patients implore us just to talk to each other..we still struggle to have IT systems which interact smoothly between hospitals and rest of community.

How about for a change we try something different? How about, we, as specialists, say it's time for us to improve things? Not point lazy fingers but genuinely try? Do Vanguards provide an opportunity to flatten the barriers..or have we dismissed them already as another fictional policy? How radical can we be? How passionate are we about system wide improvement of care? How motivated are we to judge ourselves, not anyone else, on outcomes? Not HbA1c, not number of hospital appointments, but hard outcome measures...amputations, retinopathy, myocardial infarcts, hospital admits? How about we measure our hospital services based on how many incidences of insulin errors we have stopped in hospitals? How many specialist centres can stand up and say in antenatal Diabetes care they have achieved the St Vincent declaration?  1989...we promised the outcomes of a pregnant woman was to be the same as one without diabetes...26 years later, what has stopped us from doing so?

Negativity is around us..but we need to be careful that we don't suck ourselves into a echo chamber. Every day I meet people who a doing some amazing work, but in silos, in pockets...we must get to scale...we must be able to flatten the hierarchies and improve care.

On World Diabetes Day, why don't we all as a community say we will genuinely try and improve outcomes? Measure ourselves on the reasons why we went to medical or nursing school? I didn't go there to drop a number, I went there to improve amputations, lessen admissions....and that's what we should be bold enough to measure ourselves on. Do you know why? Because if you do so, you bring many of the doubters on board. Doubters not very dissimilar to me when it comes to "names" and "personalities". The title means little to me if you can't show me outcomes ..without's empty rhetoric at best. We, as a community, should be mindful of that..when we say we wants patients to work with us, work together to improve must, and absolutely must be more than empty rhetoric. It must be based on genuine outcomes, outcomes that improve care..outcomes that justify why we do what we do.

Let's give it a year, this day...I shall hopefully write a blog mentioning how far we have come since November 14 2015.

Happy World Diabetes Day.

Tuesday, November 3, 2015

Bigger Picture

An email pinged into the inbox today..."Have they got to you?"...was the heading. With intrigue I opened it to a query why my blogs had stopped- had to assure that it was down to something more parents were visiting- and simply put- was just enjoying some family time- and as ever, was warm, fuzzy and simply...lovely.

It did make me think though about the culture we live in- where in spite of multiple conferences, hashtags, "Francis", self styled defenders of patients safety etc etc...such an email does come along. Either way, to reassure, nope, no ones muzzled me- and to be fair, none in management have never ever asked me to tone things down or stop writing.

So to this blog...and I must talk about Pete Deveson- and I must say the fella did make me sit up and listen. It was at the BMJ Big Debate- and in the middle of all the fun and laughter, the jokes and banter, Pete talked about "Learned Helplessness". Delivered with panache, fun but with a striking message underneath, he talked about how many had forgotten the art of speaking up when needed. Many a times,  I am told how its about the "Bigger Picture" our leaders can't say things openly because the bigger picture is more important- and I must admit I am starting to struggle with that. What does that actually mean- a bigger picture for the person themselves or a bigger picture for healthcare?

Keith Willett recently spoke at  Kings Fund conference- Director for Acute Episodes of Care or the Emergency Czar in old parlance. I watched on twitter as he spoke about the challenges, spoke about recruitment, spoke about working differently...and I waited..and waited..waited for this clever intelligent leader to utter one word about recruitment crisis, low morale, junior doctors...but nothing came along. What does that mean...he thinks the emergency care crisis is solvable without improving morale or tackling the recruitment issue...or is there a bigger issue at hand I am not aware of?

Sir Bruce Keogh recently spoke at "Agents of Change"...he spoke about leadership, challenges, issues to tackle..and I waited..waited..waited for 1 line, 1 word about junior doctors, waited for something about mortality issues- and I kept waiting. Let me get this crystal clear- read my previous blogs- I actually hold him in high esteem- I suppose it sucks even more when one of your heroes let you down. So what's the message for budding leaders? Keep quiet or is silence tacit admission of support?  Or is this all a form of learned helplessness? Or is there a bigger picture?

Recently I wrote a blog for CQC- and on balance I still felt it had a role...and then it goes and commits the most spectacular own goal ever. Hike your price up in an environment where money is gold dust- hike your price up for which evidence is still flaky, hike your price up in a tax funded system when patient care is stalling....CQC says it isn't their fault- but the DH that they are passing on the costs. What stops an "independent body" from publicly pushing back- learned helplessness or some nebulous big picture which escapes mere ordinary mortals?

We have exposes being run by HSJ- like the Daily mirror and Sun into NHS gaps- honestly- don't have to do anything fancy- just pop along into your local trust and you will find gaps. What stops from collectively raising the question of prioritisation or funding? A bigger picture? I can raise a national campaign tomorrow showing gaps in diabetes services bigger than "safe staffing"- what will it achieve if you haven't tackled the basic question? A few kudos for a few, a few blogs and then we move on to the next gap or crisis. Bigger picture anyone?

We criticise others about silos-we ourselves live in our own- and till we collectively ask what needs to stop, its all futile- and a circular debate in an echo chamber at best. Ask yourself this: You want safe ward staffing- fancy stopping screening for diabetes to do that? You want access to insulin pumps- fancy stopping funding shinier CCUs? That, ladies and gentlemen, is what the bigger picture is about for the health of people. Beyond that, the bigger picture is one of individuals and their ambitions.

In Sanskrit there is a saying .."Maunam Sammati Lakshanam" means "Silence is Half-consent". Have a think of the Big Picture tonight, won't you?