Sunday, July 15, 2018

To make it clear...

Yet another week passes by- and yet another week of angst and outrage becomes a part and parcel of our lives. Fuelled by misinformation, a dash of tribal politics, a desire to cause mischief…or in some cases as Michael Caine said in "The Dark Knight"…."Some people…just want to watch the world burn".




A perfect example of that was set by observers watching the PM greeting the US President in Blenheim Palace in a red sleeveless dress- with a Libre device attached to her arm. For the uninitiated, here is some information as to what it exactly is. It is no secret she has Type 1 diabetes- so she was wearing a technology which enabled her- hopefully- to self manage her diabetes better. the reactions to that were…interesting..to say the least. Apart from the genuine ones of intrigue, there were ones which were aimed to be funny, but weren't; some humorous attempts- and some simply factually incorrect statements. What was fascinating to see the number of "RT"s and "Favs" to that tweet- including those from the medical fraternity.




So to some factual corrections- and before I start, and someone jumps in and taints with a particular political colour, I have voted for pretty much all colours- bar purple. I vote based on what I think is good for the overall population- not blindly follow any ideology.
Anyway, so for the chronology:

November 2017: Libre was put on the NHS Tariff-with help from the Department of Health- at a price about 30-35% lower than the price set out for those privately funding (Libre had been available for self purchase for about 2 years prior to that). This was does after all relevant cost analysis was done with finance teams etc

November 2017: The Regional medical Optimisation Committee released a statement to ensure this was approved for certain groups of people- to begin with- while further data was collected. The idea was to use that as a template to help minimise variation. A national audit was set up to help collect data which would further help estimate the efficacy of the device. The idea was the RMOC statement would help to minimise any financial burden by making it as cost neutral as feasible.

January 2018: To show support from NHS England, a letter was sent to all CCGs reminding them of the above statement- and encouraging to use this device in certain groups
Through 2018: Different areas took time to assess this device and make their individual decisions as to whether to fund this or not.

July 2018: As of now, 141 out of 207 CCGs have approved it- in some shape or form. Whole of Wales and Northern Ireland have approved it. A north and south divide emerged in Scotland- to counter which a statement was released last week- and hopefully will help reduce the variation too.

In pipeline: Change in DVLA regulations- likely to be make the cost effective argument even stronger

If you want to know, who has or hasn't approved, follow this map from Diabetes UK- may help understand the variation and situation.

In short, after 8 months of release, this has approved uptake- if one takes all 4 countries forming the United Kingdom- 100% in 2 countries (Wales & Northern Ireland); close to 60% in 1 (Scotland) and about 70% in another (England).

I appreciate for some its not quick enough, or wide enough etc but in NHS speak- and in a system which is sloth like in adopting any technology, my reading is that its not too bad.

So- to factually correct the tweet- No- its not blocked in England- and this has nothing to do with the PM. If anything, her wearing it publicly shows that she isn't worried about showing she has type 1 diabetes- and is using a device to help her manage it better. Maybe its up to CCGs to look at that- and understand the message underneath

A final few things. 

Next week is the All Party Parliamentary Group meeting on this- apologies I cant attend- but to make it crystal clear, the expectation is that the remaining minority of CCGs now adopt what the rest of the country has. We cant talk about "reducing variation" in meetings or glossy powerpoint presentations or mock our "fax machines"- if we ourselves are responsible for it.
We cant use NICE as a shielding tool on one hand and an advisory body to ignore at the same time. We cant say things like " we do diabetes differently"- that makes no sense- and that is exactly the response I have had from 1 CCG.
I repeat- again- if its good for Mr. Smith in Portsmouth, it MUST be good for Mr. Smith if he lived in Bournemouth. Especially when the bodies who have approved this are in the majority. The time for being technology laggards are over. In addition, in a system where we are starting to adopt technology with far less evidence than this particular device has, we need to be less hypocritical about our views towards those living with diabetes.

Lastly, to those HCPs who feel I shouldn't put pressure on CCGs or feel they are being "publicly outed"…let me make one thing- again- very clear. My job is to help those with diabetes, not sit back and see repeats of years of underfunding of diabetes, or cater to egos- while outcomes slip. Neither do I appreciate being undermined by academics- who will slate this device but champion device Y- while a little bit of digging shows how their entire research- or speaker talks or attending international educational events has been funded by company building device Y. My request- again- would be for the community to work together- not be internally divisive. The Type 1 technology pathway has been a good example of this. Divided -not only do we fall- we also do a disservice to those who we are supposed to look after.
The same applies to ALL the technology companies too…work together- whether you are Abbott, Dexcom, Roche, Medtronic etc…work together- the access to technology widens for all. Sending me letters carping why one technology is being "supported" (yup- one company decided to do so post letter of support from NHS England in January) is either narrow tribalism or a lack of understanding as to how this can be a fore-runner for widening technology access across all companies.

If you, in your policy role within a CCG, are not doing the right thing, or following advise from NHS England, or indeed single handedly creating post code lottery- or obstructing progress, then it is time to be challenged. It is time for those faceless individuals to step from behind their committee rooms and take questions directly from the public. You serve them- do your job- and if you cant do it, ask someone who can. If you think Libre pressure is one-off, you are mistaken….further use of technology, increased self management, safety in hospitals are all coming fast and sharp…this is only a test-run at best. I lead on this from a policy point off view from NHS England- and I am more than happy to travel to you- to discuss further. Its an open offer- take it if you wish ( Email: partha.kar@nhs.net)

Talent has never been my forte…determination always is. Lets do the right thing.




Sunday, July 8, 2018

Bright...

The sun is out. Its coming home. World Cup is in full swing- and maybe, for a fleeting moment, there is a space in the time continuum where one can be happy- albeit for a little bit. The NHS 70 parties have had their fair share of cake cutting- and the question is how one takes that spirit- for as long as it lasts- and takes things one step forward.
Yes, I know..Brexit hangs over us, the NHS has money but not quite, yes- no one quite knows how exactly the money will NOT be used to fill out staff costs, gaping holes in hospital budgets- when the ask is in primary care- or even social care. Stack that up against the blaze of technology- and the feeling of going from one extreme ("Can you send me that request by fax in triplicate?" to another ( "Artificial intelligence will detect those at risk of diabetes and solve it too")- and yes, I know its easy for that sense of euphoria to deflate quickly. And then you look at some of the old tripe coming out from some quarters of the NHS- whose role, I must say- even after 2 and a half years- I have not been able to fathom or understand- and you wonder….but come on folks…its coming home- so lets try and think a bit more positively, yup?

To me, the key of positivity- at least in the world of diabetes- sits in the gradual activation of those living with diabetes. Its been a work in progress- but over the last 3-4 years, undeniably, the voice has grown- and starting to make an impact. Multiple events have started to sprout up all over the country- especially those living with Type 1 diabetes- beyond simply the ones hosted by Diabetes UK or JDRF as patient charities. These are independent events- hosted by passionate people- and the slow yet discernible change is undoubtedly down to that. It is not easy for policymakers to continue to ignore these voices as they grow stronger- and start to have their impact as a collective.

Yesterday, I went to the #T1DGlobal18 event organised by Gavin Griffiths- and as ever, a huge learning experience listening to all- especially those from other parts of the world. Perspective hits hard- when we listen to parts of the world- where Type 1 diabetes is still a taboo issue, where insulin costs prohibit the simple issue of getting a life-saving medication- and the simple fortune of existing in a system such as the NHS comes to the fore. It also showed how the conversation is starting to steer slowly from being led by HCPs- to what those living with Type 1 diabetes are asking for. The voice is growing louder- and may it grow indeed. It is progressively difficult for some to hide behind faceless names and titles while making decisions on behalf of others- or using NICE guidelines as a convenient shield as and when it suits.

That is hugely encouraging for me- and if anything, want more of this sort of patient led disruption. Policy roles come with their own strait-jacket- but one thing that can be done- is give those living with diabetes their voice- whether it be access to specialists, knowledge about the level of knowledge out there- or indeed technology. So to those who want to speak up- do so- and continue to do so loudly. Those who make the decision to not give access to technology that works- needs to be bold enough to stand in front of those they serve and explain their decision- in public- not hide behind committees and minutes. The time is changing- and taking advantage of the present level of euphoria? I would suggest to all - do it more. Ask boldly, ask with strength- ask collectively- the force is much more stronger when done in a pack. There are now enough of a collective of HCPs who will provide you with the forum you need to say so.

4 years ago, the voice wasn't this strong- today it is…whenever you open social media, some event related to type 1 diabetes is happening- and that is brilliant. The space is laced with advocates- patients or HCPs- and it certainly feels like change is here; conferences also seem to have a new generation of HCPs keen to listen more- and bring changes to their service- and my job on this front is nearly done. So I will repeat it again…change will be brought by patient power- and at a policy level? You will have all the support you need.

Let's do this. Keep the voice strong..keep it united…keep it focussed…the system will change. Bear in mind, it is not obliging you by changing…it will change to stay relevant, it will change to adapt with the times- or be left behind. Whether that be in the way we interact, the way we give access or the way we deliver care. The time of the self appointed vanguards is drawing to a close- and it is up to you as those living with diabetes to end it.

The future is bright…seize it.







Wednesday, June 27, 2018

Diets and shaming

Give this a try. Walk up to someone you love or like. Remember to pick someone who, in your eyes, looks "overweight". And then say " Shame on you for not eating the right things. You will die early- and you deserve to". Go on, give it a try.
...Not easy, is it? Many things would stop you- most importantly, common decency- and of course issues such as not judging others by your own standards in life, your economic status etc etc etc. However, recently I discovered that sort of simple rules don't quite apply anymore. Body shaming is all very au fait amongst certain sectors of the populace- and to make it even more fascinating, it appears it's ok with some of our doctor colleagues too. Its the whole issue about the best diet to solve the issue of obesity...and the debate about advice given via official sources - in contrast to the world of disruption. Lower your intake, lower your calories, lower your carbohydrates....the options are many...and somehow over the years,e that's now morphed into if you don't lower your carbs, shame on you..or as a professional you must be taking backhanders from Cadbury ...or ...well...there are many myriad reasons.

So what about low carbs or indeed low calories? From a policy point of view, it's fascinating- we like the work going on..and encouraging signs are there about ensuring this starts to get looked into - take for example the digital programmes in type 2 diabetes management green lighted to help collect data or indeed the conversations ongoing with the DIRECT team about application of their work in type 2 diabetes. Or indeed recognition of David Unwins work in many forums. You can look for a conspiracy wherever you choose but there isn't one to find on this occasion I am afraid. In short? The work is fascinating, it's got potential - but we also need to focus on the fact that this doesn't become the bubble created by a degree of Middle class privilege. Datasets continue to show the impact socioeconomic divides have on what food folks take, what they can afford, what they can give their children- and brushing that aside is symptomatic of modern times where "our view" of the world is what matters most, not anyone else's. Let's put it this way, when you are standing in line in a food bank? A tin of beans is like manna and you aren't quite taking into consideration whether you should be having eggs and bacon...and smirking in disdain at your brioche bread. So in short? Yes, at a policy level, we are looking closely at all types of diets and its application...and no, I haven't been paid or sponsored by Nestle..though sometimes when I have missed breakfast, lunch and dinner, I have been known to have a Kit-Kat.

So to the distasteful bit. To some extent, I perhaps understand the anger and angst of some when they target dieticians. They feel - rightly or wrongly- cheated by advice given and having shifted to  advice given in forums such as diabetes.co.uk they feel their lives transformed.  However, what I have not been able to fathom is why fellow health care professionals have fanned that flame. I appreciate the age old view ...it's more sexy to be a rebel, it's cool to be seen as anti-establishment, it draws eyeballs...trust me, I know this. I am myself a graduate of that particular school. The rebel with a cause..fighting against the big bad world, standing up for the common people. However, when that starts coming at the expense of a profession, it starts to get a bit sour. Our GMC guidelines are clear about denigrating fellow professionals...yet it doesn't appear to stop some. The focussed ire on dieticians seems to also follow a degree of hypocrisy. If you rail against dieticians who have had their conference sponsored by Nestle or Cadbury, how come you don't bring the same ire to fellow doctors who push for technology X....with evidence of their whole research grants, conference attendances funded by the companies who make technology X? Is it because dieticians are an easy target to pick and no one dares to challenge doctors...or does the GMC rules apply selectively?

Colleagues such as Tim Noakes, Zoe Harcombe, Aseem Malhotra or David Unwin are doing good work- and to put some balance, some of the stuff they receive are neither fair or balanced either. However, they indeed are figure heads now- and if their followers are now going on to body shaming individuals, then it's time for them to stop that, rather than staying quiet on this. There's a subtle yet huge difference in silence and speaking up. With leadership - comes responsibility and it's been great to see David stating that rudeness of this nature is neither desired or acceptable- frankly it makes it far more easier for us in a policy role to engage and take the debate further. So a personal appeal to all those respected individuals, please don't encourage such behaviour- and even in the light of treatment you have had? 2 wrongs never made a right.

Finally, let me be crystal clear on this. Body shaming is not acceptable- and that is not some politically correct nonsense. We don't live others lives..we simply therefore do not have the authority to lecture them. It is about information, it is about then adults being able to decide based on that information what they want to choose, what they can afford, what they can sustain. Type 2 diabetes care is changing- and there is no doubt that what was once labelled as a progressive disease that cannot be reversed, is now looked at something that can be put into remission with certain individuals. That's a fundamental change- and we need to be able to put all those options on the table- low calories, low carbs for individuals to choose from- along with usual medications etc etc. But let's not try and mock others in the process. A few words typed from behind a keyboard in the shade of anonymity can leave much impact on others- try and be mindful of that.
To fellow professionals in the UK, a simple note from me. 
"Body shaming is not acceptable"....the sentence ends there. There is no "But" after that. There is no justification for that. 
For context? Try adding "But" after the words "Sexism/Racism is not acceptable". Doesn't work, does it?

Sunday, June 17, 2018

A bit of a break

Mallorca. Sunshine, friends, drinks, food and some much needed down time. You never quite realise how jaded the mind can get in the hustle bustle of day to day life- and how important "taking a break" can be.
Its that ever gnawing feeling of wondering whether it's "enough" or have we done as much as can be done - and it's the consistent worry whether you are doing the right thing, whether you are qualified to do the job you are (ah yes, the dreaded imposter syndrome, isn't it) and as I type this while setting off for Mallorca, I suppose self reflection brings the usual queries...is it.."enough"? In the midst of all that landed a most beautiful message from Chris Askew, CEO of Diabetes UK. Sometimes the little words matter...behind the ultra secure confidence of my personality still sits that boy from school wracked with doubts, wondering whether it's "enough". Someday when I feel brave enough..that will be some story to tell too. But for now, as I power down, so to speak, looking back at the week has given me a little bit of belief that maybe somethings are coming together.

The week has been one of considerable activity. Monday brought the release of Language Matters for diabetes...and as one of the co-authors pointed out? One with the lowest troll: praise ratios he had seen any campaign garner. A major testimony to the hard work of many - and well documented in the paper itself- but to me, this held two fundamental differences between other works done in Australia or the USA. One: this was now official NHS policy- a fundamental statement of intent from the national policy body of diabetes and more importantly? Two: it showed it was possible for ALL diabetes bodies to work together on something- and actually deliver- quickly. The camaraderie was noticeable, the desire to improve care was palpable- and my role was very simple...get them together? The rest? It's there for you to see and judge. My tip? Don't dismiss it as politically correct nonsense...this is what those living with diabetes are telling us- and could hold a major key to improving care. Money matters- but so does some basics of how we provide care.

The Type1 diabetes technology pathway also came out and an absolute brilliant piece of work- attempting to simplify and amalgamate the multiple guidelines out there as regards diabetes technology. Again, this involved a significant number of organisations and experts to work together- and the collective effort showed what a common goal could achieve. On a personal level, that is the purpose of any leadership role...trying to get all the boundless energy and passion into a focus...which can improve care. This document is a starting point as regards improving access to technology- and we have much yet to do...but it's certainly a step in the right direction. Education and procurement will be the next areas to focus on...exciting times....change takes time and patience and let's see how this evolves 

In addition, a trip to Belfast gave the opportunity to meet some amazing teams in Northern Ireland but more importantly, sight of a simple yet effective way of tackling insulin errors in hospitals. It wasn't any swish technology, nor any mandatory module to complete...yet something so basic that it made me wonder why we hadn't actually considered it. Bold, yet simple and to effect that will probably need Health education England; NHS England and NHS Improvement working together. Is it possible? Potentially yes - and as ever, littered with obstacles but worth a role of the dice for sure. We shall see - but certainly was an eye opener in the concept of its simplicity yet potential  effectiveness.   

Other bits involved securing speakers for what could be an exciting day showcasing relevance of mental health and diabetes- and highlighting good examples. This is something we are all really keen on...and involved in setting up the initial work around tackling this issue around the country. It's a challenge worth taking on- and it's been encouraging to see the level of keenness - at all levels- to try and improve this. In addition- confirming the 4th edition of Talking About Diabetes event. 30th March 2019...it will been..again. The last 3 years have been absolutely amazing as regards the education it has given me..as well as seeing so many folks with Type 1 diabetes come together...laugh, smile, enjoy their day together? Worth every single moment.

So a week of much fun...blitzed in between the clinics at work, meetings regards Language Matters ....a constant theme of being in the space...while wondering whether it's "enough". So we try more, we try again...we keep at it...we finish one project and we move to the next one. The amazing thing? The HCPs around you- who keep offering to help, the folks loving with diabetes who keep stepping up to help...their infectious enthusiasm making the next project the next "fun" thing to do.

But now? It's time for a bit of a break. Just with friends. Enjoy some football. Drink some beers. Just to get the energy levels back up. And then we go again. Mental health, technology, out of hour support, self management platform, comic book, safety in hospitals, frailty issues...the list is never endless- but that's part of the fun too. And therein lies the trick. The day the job isn't fun anymore? It's time to do something else. Till then? Thank you all for your support and constructive criticisms ...they all do indeed help.

See you all in a bit x

Sunday, June 3, 2018

Ugly,Bad & Good

In a world of fast changing news cycles, its difficult to keep up with whats actually worth paying attention to…but some invariably do…and I think I am starting to compartmentalise them basically into the Good, Bad and Ugly. Yup- there's always some Good- its a question of finding them too.

So lets start with the Ugly. 
Well- some report has suggested that re-admission rates in hospitals have gone up. I mean..No way, really? How is this possible, huh? Its frankly unreal that some folks find this remotely surprising. As I have said many time before, the 4 hour target is now an industry- a marker of all thats good- and the gearing of processes across the NHS has made this into a simple quest- get it better. Cos- as you know, a good 4 hour target result suggests there is little to worry about the hospital.
Once upon a time I used to love being on the wards- now I mostly try do my bit, help the juniors and try my best to bite my tongue. Inane processes abound, multiple events- al designed at one simple thing- get the patient home. Most medics will tell you the risk they now take- the edge of reasoning they hover on- and if not sure, ask our GP colleagues. They will smile wryly- and mention the patients coming back without enough time or support needed to look after them.
Turn medicine into a tick box process? Some day it will come back to bite you. We have gone from one extreme to another- and lets be honest- we send patients home quicker than most of us would do to our own loved ones- whether that be based on acuity or indeed support in the community. Thats simply…Ugly.

What about the Bad? 
Well- in my personal opinion, all this visa outcry- is indeed one. The desire to fill rota gaps - seems to have airbrushed the second class citizen treatment plenty of folks from the Indian subcontinent have- and continue to have. We just now need someone to somehow fill those gaps- those gaps created by us-as a system due to poor workforce planning, treating the workforce like children and labour..cue? Gaps- so where do we turn to? Somewhere else. This is a repeat of the 90s- when gaps existed- the doctors were wooed by all concerned- with the promises of much- with many turning up and then realising that it wasn't quite cracked out to be as suggested. You had to go and prove yourself twice over- you weren't "local" enough for that training post- until- obviously- there was a gap. Fast forward to 2018- and here we are again. No visas? What a blinking outrage- how dare the system stop us from filling gaps.
3/300 CEOs in the NHS- I hear- are of BME background. 1%. ONE percent. ever heard of the NHS getting visas to hire CEOs or equivalent folks from other countries? Naah- these are important posts- got to be filled locally. Rota gaps- to do the basic work- or bring them in as trust grades with lesser training privileges than local folks- oh yes- we are all over it. Was a close call as to what category this gem fitted in…Bad or Ugly…but went for the Bad on this occasion.

Anyhoos- lest finish with the Good. 
A release of the list of providers who can look at digital education in the sphere of Type 2 diabetes within the NHS. An eclectic mix- and simply with an effort to collect data across the country- using different means- and see how things go. Its not a roll out -or even replacing traditional face to face - but giving another option on the table.
In an environment where <25% folks attend their education as offered (whatever be the reason)- options need to be there to help many who cant find time to do face to face education sessions in groups. There are 10 of them- and the ask is simple- commission some of them (money within transformation funds- plus extra money via test beds to come)- and lets see what the results are as regards uptake and completion of them. Its 2018- and providing simply more of the same isn't really an option. To all those who don't like digital - well, its happening- BUT in parallel with existing programmes- with clear aim at collecting data. Its not your academic ego that matters but whether the person living with diabetes has found it useful or not.

So there we go- a bit of the Ugly; a bit of the Bad….and a bit of the Good. Maybe thats what I should go for in future blogs- a round up of the headlines that capture the eye!
Hope you all have a fabulous week ahead.





Monday, May 28, 2018

No ones servant- or God

How many times have you heard that one? The old stereotype built in by years of media, bluster and self-aggrandisation...the all-powerful doctor who knew it all, blew everyone away with their knowledge, their skills, their arrogance...whisper it softly perhaps even God like in their ability and demeanour...healers weren't they? They told the patients what to do...and they did. They told the nurses what to do...and it happened. A paternalistic model doesn't develop overnight, does it? 

But then times changed...the world changed...patients, quite rightly, found their voice, became more inquisitive about their care, tried to know more about why their care may have faltered.and then found their Gods, self-styled or otherwise, wanting. And as sure as what happens when you see your hero or deity slip, obeisance changed to disappointment, disappointment then moved to anger. How dare they? How dare they fail their duties? The disappointment in seeing these God like creatures be fallible, be prone to the same errors as others, with the same foibles hurt...the angst was palpable. But slowly but surely the tide has started to change...even the media has started to move on. Yes, most of the Consultants are still ridiculously charming, handsome, sweeping folks off their feet, but the George Clooneys and Patrick Dempseys were also fallible, with emotions, making mistakes.perception is key, isn't it? How big a role the media plays in the depiction of anything...all you need to look is at the public perception of success of CPRs and the disproportionate attachment to reality.

The bigger question is who wanted the God like status...perhaps it was society in those ages, perhaps it was the desire of some, perhaps it was the wish of many..who knows. What I do know is that in  a modern era, that's not a title most young guns who have become Consultants want...(though recently a vascular trainee did do his best to change my romantic view on that) and to be honest, unless we shed such ridiculous artificial notions, you can forget about any level of patient or staff engagement.

Lets make it crystal clear what doctors areHuman beings, trained to do a specific job, at the cost of the taxpayer. Human beings with exactly the same amount of foibles as anyone elsePossessing the same level of angst, empathy, indifference, passion, tiredness as anyone else. Lets not elevate them to the level of Gods as I can guarantee you it will, as it already has, end in disappointment.  

By the same token, don't say they are servants either. That implies lesser rights than others, a person at the whim of others, a person who must serve their masters, come day, night or otherwise. Let me repeat again...they are human beings with same needs, same desire to sit down with their families at end of day, same need to enjoy the latest Marvel movie and talk silly with their kids, same interest to go out with their friends and enjoy a drink or two.  I know there are many who like to label themselves as servants, public servants, servant leaderswrong terminology, wrong perception- and by your evangelism, you tar the majority who are struggling to battle the everyday pressures while balancing their own lives. Use that tag...you can kiss engagement goodbye too. They/We are paid by the tax payers...do please hold us to account but don't give us tags that create an illusion.   

The system, as I say, with any topic of discussion, is always like a pendulum.swinging from one extreme to another. Yesterdays God needs to be todays servant is the chant- the reality is that patient engagement or staff engagement, as always, is a 2 way street. Treat patients with respect, they engage.doctors are no different either. I am pretty sure I echo many when I say I am no God, neither am I anyones servant. Just a professional trying to do his job, with passion and desire to improve patient care. On the way, mistakes will be made and all one can promise is to learn from that and make things better. 

Treat me as a God.absolute power in the end corrupts absolutelytreat me as a servantin the words of Charles De Gaulle..In order to be come the master, the politician poses as the servant

I have no desire for that either. Have a great week ahead.


Sunday, May 20, 2018

Mind over Matter



Its an aspect - no bones about it- we in the NHS England diabetes team haven't focussed much on as regards diabetes care. . Yet.
Theres been a lot of work on prevention of type 2 diabetes, investment into safety in hospitals, improving foot care, treatment targets, education uptake, more of digital work being encouraged, encouraging use of modern technology such as Libre…but so far, cupboards a bit blank as regards mental health.

I suppose this is where social media has been good- you lurk, you listen, you engage- and you start to get a grasp as to how much mental health support is a key issue. You don't just ned to read papers to get policy direction, sometimes listening works too. As the national work has focussed on issues such as #LanguageMatters and then the Type 1 diabetes self-management platform- the feedback has been strong and equivocal- mental health support is patchy- or maybe I am being polite. Its actually not that good. Somehow it continues to be a cinderella service- and thinking of it, if we are doing work to relook at the contributions dieticians and pharmacists can make to diabetes care, mental health cant be glaring gap in the whole paradigm

Over the last few months, we have been working on gaining some information, talking to psychologists, psychiatrists- and boy, there are many things to cover. This sent simply about money or lack of support- theres a lot about which patients needs what support, where- and how. Juxtaposed in there is the ethos of digital- which needs a bit of tempering too. Digital IS important- but that shouldn't be at the expense of the value of face to face - so there needs to be a balance, a coherent strategy. Mental Health isn't just about "Phone IAPTs" either- we will likely need a varied options on the table- and more importantly, for health care professionals- the ability to recognise- and then be able to signpost to the right resource. What exactly is the point of raising awareness if there isn't an appropriate service to send to?

Having said all that, my approach to this is probably going to be the same as with what we have done with the Diabetes technology pathway- work on which is going through the final touches. Get the right cohort in the room- patients, psychologists, psychiatrists- and come up with a coherent strategy. There are- encouragingly- good examples of diabetes and mental health being tied in 1 strand- whether it be West Hertfordshire, parts of London, Cambridge- the key is too to see what we can learn from them, what stops us from adopting that as a national template- and what leeway we need to give for different economies

So we shall start the process- very soon. Diabetes UK have been doing some excellent work in this space- and as ever, will be a strong ally in this work- and invites will be out soon to some to contribute to this- who will then take things forward; ask for contributions etc as needed. The basic remit is very simple- for a population of say 10000 people living with diabetes- what does mental health support look like? How does it fit in with other chronic disease facilities around? What good practice can we encourage?

To the many who have helped- and made a few pointers along the way- thank you. We have focussed on some important things over the last few years- and proud too of whats been achieved. At the same time, no hesitation in saying this particular area needs its deserved focus too. So lets see where it takes us. As ever, if you live with diabetes or care for someone who has diabetes, your views are always welcome.

And oh…just in passing…there will be something called "Diabetes :Mind Over Matter" in the not too distant future- co-organised with Amanda Epps. Keep your eyes peeled- could be something of interest….




Monday, May 7, 2018

A Litany...

The definition of litany is fascinating …"a litany of things means you have heard it many time before, and it is boring or insincere" while a "litany can also be a part of a church service where the priest say a set group of words- and the people reply also using a set group of words". How fascinating it is when you start thinking how applicable either could be to where junior doctors find themselves. No- I am not referring to the whole saga of whats happened regards the Royal College of Physicians (we will come to it later) - but more of a reflection of my recent times during weekends or doing wards- finding time to sit down and chat to our generation Next.

The tired smiles say much, the wry cynicism says enough- and the system has struggled to adapt to the generational change - period. My views are well documented on this- and the contract saga was an unmitigated disaster. It has achieved absolute sweet Fanny Adams- bar increasing locum bills- and then for many to tag everything on "if we only had more immigrant doctors, we would be fine"- and wash their hand off the whole episode. It's a sorry, poor mess indeed- and I cannot even begin to say how angry it makes me to see the system continue to treat adults like children- and in some cases, as labour. No other industry would deem it fit to give an adult a room to live in where the bed is broken, no other profession would turn around and suggest our young colleagues should go through this ritual as "we did it too". But we do- regularly- at every quarters. And the sad thing? The helplessness is such that bar a few fiesty characters, the majority are starting to feel this to be the norm- and accept it with a rueful shrug

Look at social media- the indignation is laced with hypocrisy- we all want to be leaders, we all evidently need to be able to say sorry-as its a mark of strength, not weakness- yet when it comes to it, I have yet to see a single character, a single one who firmly backed a contract imposition to appear "muscular"- step forward and say- "you know what- we messed that up, we really did". A consistent theme is to ratchet up the rhetoric of money….there is no money in the world thats worth anything without the staff to back it. The central characters are all around- yet has a perfect duck & weave answer to a simple question…"On hindsight, would you do that again?" Why? Because deep down they know they were wrong- yet pride and all that trumps the powerpoint presentations of a leadership course.
It feeds the rhetoric of management against doctors- yet lest we forget, it is us as seniors, who ok rotas to finish at 1:45 in the night; not 2 am- as that would "change the banding". It is us as seniors who sign off job plans for our future colleagues with distinctly less SPA time in those job plans. It is us as seniors who say that education can wait ahead of service commitment, it is us who don't validate the time needed for pastoral roles….not just senior management. "Management" becomes a nice caricature to blame- while the seniors- i.e. us don't do what we would have loved, perhaps even begged our seniors to do for us.

I sat in the canteen this weekend with a bunch of junior doctors and felt sad about what I was hearing. Coffee breaks were rare, "well done" was rare, "Thank you" were few and far between….where exactly did we get so busy that we couldn't smile at a junior and not scowl at each request? Why blame Executive teams and "management" when we can do better? And please- don't give me that rhetoric of how busy life is. It is- and we are all busy- the question is why a senior support should be a rarity -not a common theme.

The sad thing is that in the midst of all that? Even genuine errors (hopefully so) such as the RCP fiasco leaves a bitter taste. The transparency and clear apologies have been welcome- but somewhere is the nagging feeling that the consequences of this will linger- at many a juncture. Jane Dacre and Bob Goddard will hurt from this- and those who know them will know this to be true. This will sting and the reputational hit will take time to heal too- whether some like it or not.

I have said this before- and will say so again…as a collective of senior doctors, we have the ability to change a lot of things- and the least we can do is improve the lives of our generation Next. If our time was bad, then its our job to make sure their time is not- it doesn't take much for a senior to intervene when things like someone not getting leave for their marriage happens. Its a simple thing- its that thing we as doctors pride ourselves on- empathy…compassion. And if we cant do that bit for our own, how exactly are we supposed to do that for anyone else?

Maybe we cant change folks who are set in their ways but if this makes you think even for a second, do so please. Our job is not just to fill in the latest CBD request- its also to make sure they are ok, that you can give them assurance in tough times, they can come and ask for help. Try it tomorrow when back from a bank holiday break. Ask your junior how they are- or even with a smile. And if they say they are struggling, maybe make a phonecall or two to help them out.


Sunday, April 29, 2018

TAD 3




You know once in a while you have a warm fuzzy moment? Saturday 28th April...about 4 pm -as I sat down in the empty Royal college of physicians main lecture theatre with Catherine Peters and Peter Hindmarsh- post the end of the 3rd Talking about Diabetes aka TAD event...it was there. About 3 years and a bit ago,we met each other for the first time on a trip to Scotland- shared a taxi ride and got talking. And the rest was history.

I have been very lucky to have been involved with many a things in my life- many a projects...but this particular one has and will always hold a special place in my heart. It continues to be one of the most educational days in my calendar year- and I can't put in words simply the pride it gives me. Every year we have made a slight tweak in an effort to make things more attractive...year 2 brought in the "TADpoles"; this year had a panel of youngsters- and each year, it has felt a little bit better, a little bit more about the community.

This is something very close to my belief, my ethos of doing diabetes care. It's not about the swish insulin, not about the technology, not about the amazing App or the education programme, they are all- at the end- a paradigm in helping someone whose life I do not lead. No one can give a type 1 diabetes patient better advise than someone who lives it too...I can give the evidence, my experience, my thoughts, my encouragement....but that's about it. I am a specialist, not an expert- and the best thing you can offer someone living with type 1 diabetes is the support of a peer- and yours when they need it. And that is pretty much what TAD has all been about. Having a conversation about type 1 diabetes- by those living with type 1 diabetes; learning from each other; being inspired; understanding that it's not and should not be an "exam" when you see a health care professional...it's about managing it the best you can, with your life and it's ups and downs.

I am not going to spend much time about the speakers as the videos will be online soon but a few things touched me- a lot. I saw the sparkling pride in Lydia's parents eyes- how could you not be proud of that? My daughter is nearly 16 and in Lydia I saw a young lady who will go places- and to her parents? You have brought up a most wonderful lady indeed.
I saw Peter visibly inspiring many in the audience- and it made me smile...how apt in the modern world when we associate passion only with youth, Peter was giving a schooling to many of us what grit, determination and sheer attitude could do. Mike charmed us all with his talk and I have known Mike for a few years now. I recall seeing him those years ago- and it gives me so much pride to see him where he is now. His sheer will to fly that plane again- that's a story in itself...and the whole purpose of these events has always been to show that type 1 diabetes can't be a barrier to anything you want. The right support - whether professional or peer- holds a magical key indeed

Beckys journey was again worth every single second listening to...and I must say I felt something in my throat when she mentioned what she would give up just for a few more years with her. What a story and what an inspirational woman indeed. Katie talked about where she has taken her passion to- and how she has channeled that to helping many others with Type 1 diabetes- a very normal person who talked openly about her holidays, love for food, having a baby...a beautiful story to listen to indeed.
The kids panel stood out and am sure many will keep talking about Joe, Isaac and Laura. Kids say the sweetest things..they also say so without prejudice. If kids of those ages are saying we need to give them better information, that we need to learn how to speak properly as "it hurts", then we have a responsibility to do that. As simple as that.    

To end with a huge thank you to the ever bubbly Jen grieves- who lit up the event with her energy and laughs. Also immense gratitude to JDRF for getting a message from the PM, Theresa May as well as the sponsors. Great support from individuals such as Sam Rowlands and Becky Hess for their support to run the day - and much appreciated as was the help from the volunteers from #gbdoc who came from all parts to help. Jane Dacre was instrumental in helping us with the venue and finally my specialist colleagues who found time to come and lend support.

At the end however? It was all about the community...what stood out was the buzz in the place and it felt that the purpose of the TAD event ie to start a conversation - was well and truly happening.There is this concept in leadership called "servant leadership"....having never done a course in my life, I don't understand what that is all about...and buzzwords really tick me off. And to be honest, I am doing a job, not anyone's servant. However, it indeed is a privilege to be part of the journey of many of those living with type 1 diabetes and this event does give me, albeit fleetingly, the opportunity to have a glimpse of the challenges you all- living with Type 1 diabetes-face.

And for that I do indeed thank you all. It is and continues to be a great privilege to be able to be in a position to do this- not many have this opportunity indeed. I have always said- and will continue to maintain that being a Consultant gives you many opportunities- beyond the scope of doing our day- to-day clinical work. "Resilience" has now been converted to a buzz word- but I do recall reading somewhere how burn out can be prevented if you spent some bit of your work doing what you really enjoy…I suppose the T1D comic book; the TAD are all part of that.

Will there be a TAD 2019? Let's see. For the moment, I don't know...if the principle is to start a conversation, it's happening and perhaps that mission is accomplished.
Or maybe, there's much yet to be done. Give us (Catherine, Peter and I) some time to recover and then mull over it. Maybe there could be one..after all. Lets leave it at that- for now.


Thursday, April 26, 2018

The Tour

Variation is a word that evokes many forms of reactions in the healthcare setting. For some, it's a buzzword, a theme on which their careers hinge- the desire to ensure the "outliers" improve and/or learn from the "good uns"...driving their work. For some, it's a dirty word which doesn't take into context the ethos of regional variation, personnel mix, case complexities etc etc. Throw in that petrol bomb of "this will help efficiency savings" in an NHS choking due to lack of funds- and no surprise that bar some quarters, it gets short shrift.

In the midst of that - arrives GIRFT or Getting It Right First Time..and there are - again- many varying opinions as to its significance, impact etc- but I will approach this from the diabetes point of view. In the world of diabetes, we have data...I mean, we have tons of data. Data largely from primary care- if you want, you can find out exactly which surgery is checking feet regularly, you can find out how a CCG is doing but rarely will you find much about how the hospitals are doing. It's become a tad easier to assess the impact of community diabetes teams- that's pretty much why the CCG Improvement Assessment Framework exists. I mean..if as the community team you can't help local GP surgeries who are swamped with work get to better treatment targets for local diabetes patients etc, what exactly are you doing...right?   

But then if you take that to hospital diabetes teams, not much. There's some on safety- albeit with criticism that it's a snapshot of a day in the year- but there is some on inpatient diabetes performance via the National Diabetes Inpatient audit. The rest of them? National foot audit, pregnancy audit, pump audit- all voluntary and with variable amount of input - thus struggling to give a proper national or even local picture. So if you want to know more about-say..is your local team delivering education, what are the waiting times on it, how do they do on length of stay in hospital- comparing it to similar hospitals or even on a national scale....very little to nothing.

So- we have started that work- gently piloting it across 4 Trusts (Portsmouth; Southampton; Leicester; Northampton) so far...bringing data on many markers and meeting with the teams to discuss reasons...laud the good outcomes, discuss the outlying ones. It's not an exam, it's not a performance review...its an attempt to help local teams get better- if at all. In the same room, the presence of management, Executive team, local commissioners, surgeons, anaesthetists....an opportunity to discuss, make concrete plans to improve, ask the Exec team what support is available if safety markers are not good, enquire what level of data analysis available for local team....as well as give the local specialists the opportunity to show their clinical leadership.

So far- it's been a fascinating experience. The engagement has been good in most, patchy in some. Lest we forget, this is the first time anyone has done this in diabetes care- and I am not aware of any other country doing this- for every single hospital either. Ambitious? Hugely, Challenging? No doubt about it. Doable? Yes indeed. We have faced and will continue to face challenges and denial when uncomfortable data arises. There is nothing wrong with that either...if anything, that shows the professional pride the individuals have. It also means that with the discussions being non confrontational, these same individuals will also lead the much needed change.

Let's mention some initial findings. A Trust which has mandatory training on insulin safety has very low harms in their Trust. With up to 20% of inpatients having diabetes, it's not really rocket science, is it? If you have more access to diabetes specialist nurses, your length of stay is lower...in a day and age when we want to get home quicker, it's as valid - if not more- than say, taking their pyjamas away. I jest of course- but you see the point. Pyjama or no pyjama, an insulin error keeps you in hospital longer- and is still one of the topmost areas of errors in a hospital- mostly iatrogenic.
How about one more statistic? 1 in 25 Type 1 patients inside a hospital go into ketoacidosis - why? Because someone somewhere either forgot to ask the person concerned, or took their insulin away or didn't actually remember that without insulin, a type 1 diabetes patient can't survive. No, not even on low carbs.

So you see...variation is not always a dirty word. Sometimes it's about the basics. A fair few months ago, I mused about the "Impossible Tour"- the desire to go around all the hospitals around the country, meet the teams and sit & have a chat about their services. And here we are- the tour is on. Between me and Gerry Rayman, we will do it indeed- and with data too about your local hospital diabetes services. We would encourage Trust Execs and local commissioners to be firmly a part of the process - Trust Execs if you are interested in safety, length of stay and generally in 20% of patients under your care; Commissioners to understand what is going on in your local hospital- hospitals you are commissioning to provide good care for folks with diabetes. If you don't, the loss -perhaps- is yours- and frankly, ducking away from a problem rarely makes the problem go away.

To the local teams? A great opportunity to look at data, understand and see where things can get better but also feel proud of some things you do. From my experience up and and down the country, there is no lack of desire to improve things and let's see what we can do to help you too. The end game? No- it's not to "improve variation and make efficiency savings". It's to ensure safety improves, it's to ensure people with diabetes are not afraid to go into hospitals, it's to ensure hospitals are delivering good care, to reduce post code lottery- and ultimately? The savings will come.

On behalf of Gerry Rayman and me- along with the rest of the GIRFT diabetes team, we look forward to meeting you all- very soon.