Sunday, September 17, 2017

Libre…What next?

Are we all a bit more calm now? Post the news breaking of Libre being available on NHS Tariff, the reactions have been pretty much on expected lines. Feverish excitement, wild speculations , a tiny minority expressing their concerns, views, forums abuzz with questions…its all happened. My inbox exploded- as did my Twitter feed- with views ranging from a former MP suggesting I be knighted to some suggesting I had little idea of what I was doing. To me, however, a measure of whether policy decision X or Y is good or bad is measured by the side on which the majority of reaction falls. This isn't a job to make everyone happy- its to do what would benefit the majority- beyond the white hot realms of social media. You listen to the views on social media- but you never accept that as gospel- after all, Twitter is where, depending on the social bubble extent, Brexit never happened, Hillary Clinton is POTUS and Corbyn is the PM of this country. However, its a good barometer too about public mood- and thankfully, doing a full time job, interacting with patients, seeing the pros and cons does come in handy. So- its no small sense of achievement to see the news- broadly greeted with optimism- though quite rightly, from sensible heads- with a degree of cautious optimism.

So whats next? I would encourage you to read below- as the majority- if not all- of the folks speculating etc haven't been involved with discussions or negotiations- so for want of a better word, here you go- from the horses mouth
The next stage of this process is to convince all local economies to put this in formulary. The justifiable concern is that it opens post code lottery-just as has happened with Pumps and CGM etc. To help avoid that, the Type 1 diabetes network are working to create a business case template that areas-if they are struggling- can use. The network is spearheaded by the Consultant Diabetes organisation, ABCD- with contributions from doyens of BOTH paediatrics and adult world- ergo Fiona Campbell and Stephanie Amiel; diabetes charities, leads of the Insulin Pump network, representation from all 4 countries, as well as respected experts, former NHS England National clinical directors- so a pretty good bunch of folks who can help steer this. I would also encourage anyone successful to get this on local formulary- to share with others. Its called cascading good practice- the N in the NHS is supposed to stand for National. Who knows- this could actually be a template of working we all learn from and tackle post code lottery in other areas of diabetes care!

The next phase of concern is that it will "eat into the CGM budget". So let me explain something to all and sundry. There is NOTHING called a CGM budget- there is in fact nothing called a Type 1 diabetes budget. There is a "Diabetes" budget.Which, on this instance, is a good thing. Here is something as regards how much we spend on diabetes drugs in the overall budget. Of every £9 we spend in the whole NHS, about £1 is spent solely for diabetes care. Thats a huge budget spend- is there opportunity to ensure that this is used appropriately? Yes- absolutely. Simply take your time and see the amount of expensive drugs we use in elderly people or folks who don't need them as per indications or indeed look at how over-treatment in elderly frail Type 2 diabetes causes more admissions. Stop those-save the money on the drugs and indeed the admission costs- use the money elsewhere- such as on this occasion, appropriate use of blood glucose monitoring. It is not rocket science, it is about being savvy, being focussed on what the whole diabetes population needs and use of appropriate medication. Needless to say? The majority of spend is NOT on strips- BUT on medications in Type 2 diabetes. They all have their place- just not for everyone- we need to be better at understanding population based care- and use of technology where appropriate.

Abbott also have a responsibility and we are working with them to ensure data collection is done on a national basis so we can see the impact of its use- which must be published too. We are also working with them to ensure the onus for educating patients and professionals simply doesn't fall back on the NHS. For the areas who may not necessarily have those programmes to hand, Abbott must have a commitment to help that process. I am aware they are working on it- and we are working closely on this too. Watch this space!
We are also working with patient charities- together- Diabetes UK, JDRF and INPUT- to ensure we manage expectations properly- and all appreciate that "going on tariff" is only step 1- albeit a big step. Be patient, avoid speculations- and if you want an official update, listen to what the charities put out- not forums or individuals who have little involvement in overall process.

Would you like to know the aim of our ambition? It involves CGM availability- uniformly across the NHS- and I can assure you conversations are ongoing with relevant companies such as Dexcom, Roche, Medtronic et al to tackle this chestnut too. Feel free to contact them and ask too.
It involves ensuring we have enough HCPs too- who know what they are doing-it involves financial assessments etc.
I am also keen to have a unified IT system which cuts across all systems- and ensures a diabetes patient has access to all thats needed as regards notes, data, results etc. I will make no bones about it- I admire the SCI-DC system the Scots have- the query there is whether a disease specific platform is the right way ahead-or not. I would like to have a out of hours hotline/Whatsapp system that is available to any ED in the country to ensure pump patients etc are safe….so many things, huh?

In short? My ambition to improve Type 1 care has no limits- but I am also fully aware that not all can or will be achieved. However, that shouldn't limit the efforts either. To all those who are worried re Libre, my appeal is this. You are one community. Be happy for those who may have access to Libre beyond the ability to pay. and work with us to ensure we also can ensure the other bits-as outlined above- can happen.
Finally, a big thank you to so many who have left messages of thanks- and more pertinently, have asked me not to be discouraged by the negativity of a few.That is unlikely to happen- I know my goals, I bank on the support of the majority and the day the overwhelming feedback is that I am getting it wrong, I will step down

I repeat-again. Together? Stronger.
Divided? We Fall.

Wednesday, September 13, 2017


Freestyle Libre. It captured the imagination of the public and professional as soon as it arrived. I suppose you could see why. I use the word "suppose" as for someone who isn't living with diabetes, it is slightly odd to say otherwise in my view. It opened up the prospect of "checking your glucose levels without having to prick your finger". Pretty revolutionary as a concept, no question. You put a disc like thing on you, it lasts for 2 weeks and just scan yourself-whenever you want and voila, you can see your glucose levels. I mean, what the heck, right? This was Star Trek level stuff and when it landed, the expressions of incredulity were understandably high.

However, post that, started, quite rightly, the questions. It looks fancy, sure, but does it do the job? Does it check glucose levels well? Does it stand the test of time? As someone who works in the field of diabetes, I always try to learn from evidence in the public domain, talk to colleagues using it as well as and perhaps more importantly the feedback of patients. It started with a degree of mixture of views from the "oh my Lord, where was this thing all my life" to the "Meh, doesn't really match with my needs in life". As time progressed, other issues emerged, such as evidence base or lack of it, problems with adhesive used, data fatigue for name a few.

As time progressed, reports started coming in about its improvement, it's use as well as local knowledge about patients needing it, benefitting from it, and my own understanding grew. What also grew was the clamour of why the NHS was standing by and encouraging a 2 tier system. Available to buy on the market, it became available to some, but not to many. Frustrations grew as those who really needed it couldn't afford it and some departments ended up begging their local CCGs for case by case scenario as well as use of charity funds etc. A non sustainable situation emerged as its efficacy-as per clinicians- grew, and the clamour for it being available grew with it.

It's been a fascinating experience working on this from within NHS England and liaising with Department of Health, NICE, diabetes charities such as JDRF, Diabetes UK and INPUT- as well as numerous individual patients and clinicians. Many issues emerged- such as the importance of training both clinicians and patients. What good is a device - however slick it is- if you don't know what to do with it? I have found views from academics fascinating- driven by numbers and asking for more trials - where do you go with that when a sizeable number of patients ask for it,should be having it and daily input from clinics suggest this could be a way ahead for the thousands who don't check their blood sugars at all? Or those who are fed up of testing? Or the kids who can be checked for night time lows without having to wake them up? Is it my role or those who don't have diabetes to make a judgement and make them wait? Or is it our role to listen yet ensure we have enough checks to facilitate the process of improved care? It's a tough one as as I also pick up the frustration on both sides- one clamouring for more data, one for quicker adoption. The whole sphere of medicine is forever engaged in this tough battle- with accusations of the NHS being archaic, old. An NHS which is afraid to use WhatsApp due to security yet send letters by post, uses fax machines....fascinating.

So what about this bit of kit? You want to have a bit of rough context? A bit of finances to whet your appetite? Each DKA admission costs approx £2000. You could approximately treat 20-25 patients with type 1 diabetes in a month and need to prevent 1 of them getting admitted - that month- give or take. One. That's all that's needed to "recoup" the cost.
Throw in the lesser strips needed, the benefit of added education, the impact behind sheer numbers such as A1c, relevance in hypos, engagement ...well...we may just have a case for it. This is a simply more innovative way of measuring your glucose levels- nothing else. In a world where Expo17 was mostly about adoption of technology and innovation, it's up to you as a payor how you see this in relation to existing blood sugar monitoring systems.

So we are here and the obvious questions are : what's next? Is it for anyone with diabetes? No. But given the right education with the right support, it indeed is for some. The device is not a toy- it is to be seen as a tool to help folks self manage- just as blood sugar monitoring is for those on intensive insulin- and without hesitation, that principle of "do you have the right education" applies to BOTH the patient and the healthcare professional. It is thus satisfying to see this "land" and have a place in type 1 diabetes management in the UK- it's about time we modernised ourselves a bit. It is now available on tariff- which I also appreciate does involve local negotiations. 
And ladies and gentlemen, this is exactly where specialists need to stand up and be the advocate for their patients. Use your relations, make your business case, learn from each other, if needed- do ask for help- but please, do make the case. If you can make the case for a GLP-1 analogue or a new swish insulin, you can make it for this too. That is YOUR role. My role was to work with all concerned and ensure it got to tariff- the next step is all yours. And if you don't believe this is for your patients? Then explain why to the patients when they come along- why they are being sucked into a post code lottery because of your personal beliefs.

Finally, the question has been why only Libre for Abbott. The answer to the question is simple- because it is the first of its type - at a financial competitive margin. Does this open up the door for others? Possibly but it needs engagement, it needs working with policy makers, not doing silly things like denigrating your competition. I would like to see ALL relevant technology available to patients- but there needs to be balance, there needs to be evidence that professionals know how to use them, there needs to be financial considerations, there needs to be dialogue. Working with industry is a 2 way street. This could be the start of something exciting- the environment seems ripe for digital innovation- this is only but a part of it.

I would like to finish this by thanking Diabetes UK, JDRF and INPUT for their consistent support and help while putting up my flashes of temper & impertinence ( no puns), the team of Lord O'Shaughnessy in the Department of Health, NICE team who helped with the Innovation briefing and the finance team within NHS England as well as clinicians like Pratik Chaudhury, Emma Wilmot, Marc Atkins,Iain Cranston, Gerry Rayman, Mark Evans,David Russell-Jones, Stephanie Amiel, et al who have been fabulously supportive as well as has had kind words of advice when needed. It's been a tortuous journey but we are here. 
But most of all? Thank you to the numerous patients, either those on social media or those I meet who continue to be a source of strength- supportive, encouraging, helping- especially during those late nights when the knocks taken hurt just a little bit more.

The journey however isn't complete. This is perhaps only the end of the first quarter. The second will need to show adoption of this technology uniformly while the following ones will look at other relevant technology such as CGMS devices, sensor augmented pumps, further non invasive glucose monitoring, OpenAPS technology et al.

Can we do it? I have faith in you all we can. This has been a perfect example of what can be done if all relevant bodies join forces for need of patients. 
Together, ladies & gentlemen, we are much stronger.

Saturday, September 9, 2017

More please?

You know it that time of the year- its pretty much become like a well scratched vinyl. And on cue it appeared- the ask for more money- as the "worst" winter is about to hit. More money for the acute Trusts, more beds needed to somehow scramble past yet another winter. I must admit to finding it all very fascinating - not to mention even more so now- as our local hospital -like most others- try to fill in gaps-helping out acute medicine- as a shortage continues to recruit folks to do that role.

Over the years, I have always taken more than a passing interest in this- and my recent experience has  piqued my interest even further. Our desperation to get more senior staff to see patients has now ended in square pegs into round holes- somewhere, somehow exists the belief that "any" senior seeing the patient is better than one of those pesky, unsafe, untrained folks called "junior doctors". So we all pile in- the drumbeat for generalism beats louder- sadly showing signs of losing focus at which point a generalist seeing a patient is actually more dangerous than the patient seeing a specialist at the right time. Lets give you an example- I would say I am reasonably ok as a generalist- is it safe for me to review a patient who has issues which have made the cardiologist admit the patient to a cardiology bed? Do I do anything apart from saying " Carry on?" Should I? Could I? Somewhere it clocks as a senior review- when what that patient needs is the right senior seeing them to progress their care.There is a balance- cross that- and a generalist has their limits- you move into areas of uncertainty prompting further investigations, more delay, more angst…Beyond that, all you are doing- well…you may as well as call me a "Senior Registrar".

So is more beds the answer? And if it is, why would that change now? What exactly is changing that would make the need for beds less next year? For this blog,I have a couple of things (beyond the usual of social care) -improving which, in my mind- would go a long way to solving -at least a few things.

To begin with? Process. Look at all the hashtag campaigns running- whether it be #Red2Green or #EndPJparalysis the fundamental is about process- the process to get patients moving quicker. You can't quite quicken up the pace of antibiotics- but you can certainly quicken up the post -recovery period. We, in the NHS, run process in some of the most archaic and frustrating ways possible- all aimed at short term gains- without any note of the future. If you want to invest money? Worth their weight in gold- are operational managers who know how to hold their nerve.

Secondly? Over investigations. You think juniors do that? Wrong. So do seniors who haven't had exposure to high end specialist stuff or indeed much stuff beyond their specialism for years. It is a fruitless exercise- it doesn't matter the tag says "Consultant"- they are as much laced with self doubt as anyone else when seeing someone they haven't seen for ages. Defensive medicine rages all around us- and in a litigious culture, cue "image" anything that moves. Ask any radiologist- how unnecessary requests clog up their time while those who need it- wait. A Consultant is only as good as what they are keeping themselves up dated with, what their existing jobs are- we forget that, we put others at risk. A senior review isn't the mandate, the appropriate senior review is perhaps more apt. Right people, right seniors. Push everything else into a herd, you slow down the process.

Finally, throwing money into acute hospitals will solve- nothing- unless you believe a sticking plaster on a  compound fracture is a good thing. Money is awash in the acute system for those who want it-especially as a senior. So many gaps in acute medicine - you can pick up shifts at any point of time- I get emails on a regular basis asking. Its called locum rates- internal or external- or Waiting list initiatives in old parlance. It helps no one- bar the senior making some more money- that is the brutal truth. Why open more beds- when you don't have the staff- and stretch existing staff to do more? You want to give more money- then lobby for more money into the system- into better community services, better primary care, NOT more beds. We cant man the ones we have at the moment- while better primary care support is what will help.

The freudian irony of NHS Providers leading this call hasn't escaped me either. They now lament the lack of staff- an organisation which was one of the few to ask of imposition of the junior doctors contract. "Look after your staff" should be more than powerpoint sound bites- the actions must match that. Many, including me, had said that this would come back to bite- and it is now. There now is a lot of money to be made if you want to do "front door senior work"…I would respectfully suggest that money be put to better use, not acute Trusts - especially in a system where we are now all supposed to be "one", not "separate". And if you do want to use money in an acute trust, get the process right, get the right people seeing patients- then- we may just make some headway.

Saturday, September 2, 2017

Care & Quality

Where do you start? What do you do when a Care & Quality Commission report lands reporting on your trust which is difficult reading? Its perhaps slightly weird having done a blog on this before- back in June 2016. The report would suggest a further regression- and there are always many emotions that emerge out of that.

I think the NHS has now been through enough of the fallacy that is of its view of the CQC. Reports became something to be shared widely and celebrated if it was a good one and ignored with disdain if it was negative. It is but a natural phenomena to look at bad data or results and conveniently label it as a cock up or a conspiracy. I know it- I have done it many times before in my career- I recall the days of poor amputation data- surely couldn't be us, could it? 

And as much as some would perhaps want it, this blog isn't a forum to go through the whys and hows of where we are. Its about what happens next. The report is what it is- and as an organisation, its time to say there are many instances where we have fallen short. The Trust has a new CEO and MD in place- and I will be honest- so far, their presence, visibility and most importantly, the frankness of accepting the report as it is- has been welcome- if not endearing. Sometimes you just have to- and rebuild again. History nowadays seem to have a very interesting way of viewing leaders- we appear to remember them more by their foibles and failings rather than their successes. Maybe take an example of British prime ministers over the years- would history have judged Churchill as kindly as they have in an era of 24 hour news, social media etc? I very much doubt so. Our NHS leaders are no different I suspect- its easy to look back at predecessors amongst Portsmouth Execs and point fingers at them- quickly forgetting the achievements too. I worked in pretty dire wards back in 2002- today we have sparkly new building- much more open, much more clean….individual leaders are rarely to blame- its more about who they take along with them in my experience.

So- to the now and future. What has been noticeable has been an attempt to redraw the lines and start again at the top tiers. A fresh start without denigrating the past- which to me, is good. And I will tell you this- I have been part of this Trust for nearly 15 years now- as a junior doctor, research fellow and now a Consultant- and it buzzes with people who are keen to help, keen to make a difference- the key as ever will sit in listening- and time will tell. The initial indications? Very positive - so lets see where it takes us. In my book, leaders should be judged by outcomes- and thats where the bottom line lies. Have you improved care for patients under your stewardship? If the answer is yes, you have succeeded- and the barometer for that, in the present system, whether we like it or not, is indeed the CQC. Use that as your appraisal, use that as your indicator- the aim is simple- make the next CQC report better.

I have said this before and I will say it again. I work in a fantastic Trust- and I could close my eyes and reel off umpteen names -doctor, nurse, physiology, pharmacist, manager etc- who are some of the best staff I have ever worked with. The trick as ever is to harness that. Individually? Always here to do ones job-mixing up generalism & specialism, try best to ensure staff stay motivated within my own sphere- and advice always at hand if deemed to be relevant or worth listening to with wider system experience accrued over time.

In Mark Cubbon, we have someone new-a new man at the helm- attempting to bring back the glory days. I hear he supports Liverpool football club too- somewhere there's a freudian analogy there indeed. 
It would be thus impolite not to finish with a quote from Klopp himself… "I have only one understanding of development and making success -and thats by going step by step". 
Wise words indeed.