Friday, March 30, 2018

100 million

Policy role can be much can also be very troubling...making judgement calls which may affect many is never easy- and it does always make me wonder- how much benefit would direct patient involvement help? I mean- lets get this right- absolutely a must, we all should do it...but how much would that help if- say- there came the question of allocating money to services? We at NHSE work extremely well with Diabetes UK- is that seen as enough?
Before you get the usual suspects all frothing at the mouth at the very thought of "questioning" patient involvement, lets make this clear- this is me thinking aloud- something I have even mooted discussing at a few national events- but most folks around me have fudged the answer- so for the sake of debate, why not? Who knows-may even hold an open day to have a chat about this?

So lets say- hypothetically, we have 100 million quid for diabetes care. 100 million you could invest to improve "diabetes"- as a whole. Sort of similar to the 40 million we got last year- and have for another year. This time around, we looked at evidence, looked at Return of investment and put it in 4 places- broadly covering safety; foot care; education and treatment targets. Lots of kind words- but there have been criticism too- why not more specifically for technology, why not for pregnancy care, what about renal care; what about Eating Disorder services etc etc, lets flip this, if say hypothetically we did have 100 million quid, could patients help or even directly advise where to allocate that money?

Or would they be dictated by their own niche? Would a person living with Type 1 diabetes be focussed on their need- or would gracefully give up, say access to technology, for better provision of prevention of Type 2 diabetes? Or would the whole community turn around and advocate giving that amount to social care- with socio economic divide being linked with poorer outcomes? Or would we want to divide it up based on proportion? 10% or 10 million for Type 1 diabetes- the rest for Type 2 diabetes. I mean, the simple maths of getting Continuous Glucose Monitoring to even 10% of the 10% of those with diabetes is nearly 100 million alone! Or should we give it to primary care for better provision, access, training? As some clever clog said recently, give it all to the  diabetes community in personalised health budgets- and it will be fine. Is that the answer?

Such questions intrigue me personally- simply because its very easy to be swayed by one's own bias- and its the same with all the specialists I meet too- very few (ironically most of them are primary care physicians- there's a story, huh!) actually would say something broad -beyond their specialist area. For some, technology is all that matters, for some, its all about safety, others, its foot care...come to think of it- if we have so many subdivisions within one specialty, how easy or difficult is it when you extend the reach of that? The argument that those who live with it- know more what to do with the money also falls a bit flat- when say a Type 1 diabetes person has to make a call over wider budget of diabetes- lest face it- their knowledge of living with Type 2 diabetes is the same as mine- nearly non-existent. Tricksy, isn't it? But I would be fascinated to see what top priorities those living with diabetes choose and what are the ones evidence says should be. This time around, we think we got it right- albeit as ever some would disagree but if there was a next time, this is a debate worth having I reckon

So to those living with diabetes or caring for those living with it, have a think- could you set aside your individual niche or bit and make a call for that 100 million....and how would you feel if your favoured bit didn't get the money that you felt should have? Would you like others making that decision on behalf of you?

So- go on- if you can- post some answers. 100 million at your disposal- where in diabetes care would you put it? And would it be an idea to have a fun debate around this- patients and policymakers- along with specialists & primary care? An open forum....would you be up for that- or should we leave it to patient organisations to have that debate? So many questions- but just an individual thought- which I thought would be worth mulling over in a blog. Who knows- some of your ideas...may even become policies.... 


  1. Happy Easter Partha :)

    It is so concerning that around 70% of Type 1s in the UK are still running HbA1cs above 58.

    I wonder how many patients run high simply to avoid the risk of hypos, and to an extent as clinicians we've supported the view of permissive hyperglycaemia as being safer overall.

    The modern analogue insulins are a gift, and do make optimisation of BG control so much easier. But how many patients are using them to best effect?

    From personal experience I found the change from NPH insulin to levemir quite remarkable in terms of it's precision and lack of variability, and two papers from the RCP National Guideline Centre that I've read recently really resonate with me:

    Basal insulin regimes for adults with Type 1 diabetes mellitus: a cost-utility analysis - Value in Health 20(2017) 1279-1287


    Basal insulin regimes for adults with Type 1 diabetes mellitus: a systematic review and network meta analysis - Value in Health 21(2018) 176-184

    Their conclusions are that levemir twice daily is the optimal basal insulin for MDI both in terms of effectiveness and cost.

    Do we have any figures for how many T1D patients are still struggling on with basal NPH?

    Another brilliant recent review from Kings is on the optimal prandial timing of bolus insulin by Slattery, Amiel and Choudhary:

    Optimal prandial timing of bolus insulin in diabetes management: a review - Diabetic Medicine 35(2018) 306-316

    They conclude that simple things like taking the rapid acting bolus 15-20 minutes before eating reduces the post-meal BG spike by 30% and reduces the risk of hypoglycaemia. How many patients do this?

    These simple changes - changing patients over to twice daily levemir and pre-bolusing could make a huge difference to overall control.

    As to the priority for spending resources I would focus first on education and prevention. We need to do far more with regard to lifestyle medicine, from medical school through to patient education. The debate on carbs has become silly and we should focus the advice onto avoiding processed and refined carbs and eating 'good' fats. All these fad diets have one good thing in common: they're not 'junk food' :)

    I can see the cost of CGMs for all being astronomical. But as an educational tool they are fantastic. It would be great to pilot CGM use with say one or two of the DAFNE centres and see what outcomes can be achieved. I believe the synergy between education and CGM information has the potential to be huge.

    CGMs will of course be invaluable to maintain the tight control needed through pregnancy as one example.

    I'm now using an Apple Watch with the Dexcom G5 (and I know I'm very fortunate to be in a position to self fund this). The instant feedback and alarms in the background really do make life with diabetes so much easier to manage. And optimising the basal is so straightforward with the median curve from the AGP profile.

    The reaction I get from showing the watch to my colleagues (from nurses to fellow anaesthetists, and vascular surgeons) is uniformly 'Wow! I didn't know that was available - does the NHS provide it?" and "that would be so cost effective in terms of reducing complications".

    I hope the pricing on the new Dexcom G6 and subsequent rtCGMs will be more affordable - for me it's currently about £150 per month, but I'm hopeful that the pricing will come down soon.

    Thank you ever so much again for all your time and hard work, and for your unifying influence on the diabetes community.

    With best wishes,


    PS: I'll email copies of the above papers to you

  2. Hi Partha,

    I would perhaps be inclined to allow a greater portion of the diabetes budget pie be allocated towards "prevention of type 2 diabetes" IF there was sufficient evidence to support allocation of such funds. I have seen millions of dollars being poured into "prevention" with no follow up or scientific rigour in analysing the effects of such budget allocations. Is there any scientific rigour behind "prevention" or is it just good money after bad (it is in most of the Aussie campaigns I've seen) but perhaps there is good evidence elsewhere?