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.

Sunday, April 15, 2018

Across the divide



August 2010. Its always a tad nostalgic to skim through old emails- but that's how long back was the 1st meeting to discuss how we wanted to change diabetes care in South East Hampshire & Portsmouth. Many late nights, many meetings later- it was around September 2011 that the redesign of the diabetes model came to being. In between that, there were the nervousness of contracts teams in hospitals, the debates with one's own Trust, the financial calculations involved, a lengthy conflict of interest panel, multiple negotiations,convincing colleagues....yet finally we got there -the birth of the Super Six Diabetes Model. Much has been written, many papers have been published- and the mists of time make one forget who did help along the way.

Those were the days of Jim Hogan and Koyih Tan as GP commissioners, Lyn Darby as the local Commissioner, Melissa Way as the Strategy Implementation manager, Richard Jones as the Medicine Chief; Lesley Munro as the manager from the local community provider....some steadfast supporters-and of course, 3 fabulous colleagues within the department who let you get on with it. The course of time has been kind to us- and about 6 and a half years later, the model continues as we discuss the next steps- ready to tweak and evolve as per local structural changes- whether they be Accountable or Integrated care organisations or Vanguards or Hubs. 2011 was the time the South East Hampshire & Fareham/Gosport CCGs came on board- another long process followed post that and  in 2012 we got Portsmouth to join- post a tendering process with 5 bidders...and what an experience that was too!

As of 2012, we finally had all 3 CCGs under one pathway, all 3 local providers under one pathway- with one fundamental aspect to it- the same team delivered care across the secondary and primary care- same Consultants- no different, no one to "compete" with- but be responsible for the outcomes across the whole sector. Which- to be honest, is how a long term condition should operate. Without having to think of competing bottom lines; competing for resources, trying to expand a community service at the expense of the acute...nope, that is NOT how you can improve care in a long term condition.

Results have taken their time to come through- and much kudos to local commissioners etc- present times having folks such as Paul Howden, Sarah Malcolm- holding their nerves with the model of care. It has been and continues to be one of the longest standing models of care- referenced in the NHS Right Care pathwayKings Fund ; Diabetes UK documents etc
Documented papers on reduction of admissions have been published- which have been greeted with as most things in modern times. Respect and cheer from those who have believed in the principle; a look for conspiracy theories or flaws in the datasets from those who haven't liked this approach towards diabetes care.

Recently NHS England has published the Diabetes CCG Improvement & Assessment Framework (IAF)- based on a few agreed principles nationally with clinicians and patient organisations- such as participation in national audits, attaining targets, people attending education programmes, amputation rates etc. Grading has been given as Outstanding, Good; Requires Improvement and Inadequate- similar to how CQC look at providers.

Taking Wessex and Dorset region as a pack, there are about 8 CCGs or 2 STPs. Of those 8 CCGs, 2 have been Outstanding (Fareham/Gosport & South East Hampshire); 4 Requiring Improvement (Portsmouth, Dorset; Isle of Wight & North Hampshire) with 2 rated as Inadequate.

I absolutely make no bones about the pride it gives us to see the fruition of many years of hard work to see this- and the vindication of the principle to which we and the model of care has worked. It also shows work to be done in 1 of the CCGs we cover- and focus will be on that area for sure. The workforce has been a fraction of what other systems have used- thus showing its not just about the sheer personnel but also about the ethos of having one team across the divide. When we work as a community team, we have no dispute with the acute team-….we are it.


Lessons to take away for us- or even to pass on? As this is the Super Six Diabetes model- here are 6:

  • Use acute hospital for high end stuff such as antenatal diabetes, foot MDTs etc
  • Access, access and more access to primary care- whatever means possible- physical or virtual
  • You don't need fancy tech or Apps to do all that- simple old school relation building with primary care is where it sits
  • One team across the "divide". No distinction between acute or community teams. The term "Community Diabetologist" is a tautology- the hospital is part of the community.
  • Have patience, a lot of it- and give things time. Most importantly find Commissioners who are willing to give you that time too.
  • Have a good team with you- who will look after you- and each other.
What next? Have a read if you want..time changes, so does every model need tweaks. However, the principle stands- one team across the divide- and as Sir Muir Gray always says to me: "You, Partha, are a Diabetologist for the population, not for the hospital. Or the Community.
You serve the population."

And I can't put it any more succinctly than that.

* If you want to know more about the Diabetes CCG IAF- and how your CCG is doing:
https://www.nhs.uk/service-search/Performance/Search

** If you want to know more about the Super Six Diabetes model:
http://www.porthosp.nhs.uk/departments/Diabetes-and-Endocrinology/super-six-diabetes-model.htm 

Sunday, April 8, 2018

Up Next...

So, its April. For most people, thats spring time- for NHS circles- especially in financial terms- its the start of the yearly cycle. For us within the NHS England Diabetes team, its a fresh time for planning as well as ensuring some of last years good stories continue down the line.

The last year hangs over us as a start of hopefully something different in diabetes care- and much kudos to all in the NHS England diabetes team for what has been delivered so far:

  • Further roll out of the National (Type 2) Diabetes Prevention Programme 
  • Launching of the Digital arm of the NDPP- with assessments in place regards efficacy
  • NHS RightCare pathway for Diabetes to focus on specific priority areas for Return on Investment
  • In excess of 40 million £ invested to help in uplifting of education spaces (>90000 spaces) or increase in Diabetes nurses (>90 WTE nurses recruited) as well as improvement in foot care and treatment targets
  • Landing of Freestyle Libre in Nov 2017- and steady progress across the 4 nations
This year thus becomes more of taking some of the work forward. So- a sneak peek into whats in the pipeline over the next few months- or as much as feasible within the limits of reason. 

To begin with, a national website/ portal to help with self management of those diagnosed with Type 1 diabetes is long overdue- and hopefully will be finished shortly. Multiple stakeholders - including working with existing good portals such as T1resources , Diabetes UK, JDRF etc- but the focus of this has been / is to increase tools for self management; encourage peer-support and hopefully steer many towards much needed education courses. What has been educational has been working with many of those living with T1D and HCPs, under the guidance of NHS Digital, to develop this- hope the finished product will be what it says on the tin.

The recent acceptance of a paper in Diabetic Medicine hopefully opens the door for the much needed discussion on individualised care in diabetes and the relevance of QoF in this context. An ageing population. frailty are important factors- and diabetes care need to be adjusted accordingly- rather than incessant drive to targets which end up harming people. I anticipate a long road on this but so far, the signs have been positive with all relevant primary care stakeholders being receptive to this- so hopefully this will go ahead and take us - ironically- back to individualised care.

Language Matters- and the relevance of it is close to my heart- and delighted that this piece of work is in its final stages- many thanks to Anne Cooper, Bob Swindells, Cathy Young, Rosie Walker, Jen Nash, Sarita Naik- and many others. I have been much impressed by the willingness of all relevant diabetes organisations to engage in this piece of work- and glad its not taken us years to finish this. Hopefully out soon- but in my opinion, its a fundamental shift in culture as to how we interact with those living with diabetes- which holds a major key ti improving care. Let's see!

Treatment of diabetes patients via ambulance crews and paramedics have needed an upgrade with the existing guidelines being perhaps a bit out of date- plus protests to that effect has been noted. Again this hopefully should be complete soon too- and fingers crossed, helps with improved care- and maybe even reduce admission rates to hospitals across the country.

Another piece of work hopefully concluding soon is a nationally agreed pathway for access to diabetes technology- being developed by some of the brightest minds in Type 1 diabetes care- along with those living with diabetes. Hosted jointly by the NHS England diabetes team and Diabetes UK, hopefully this will help / aim to standardise access - as well as look at issues of procurement, education of staff etc etc. A HUGE piece of work- but the early signs are good- and much grit and patience will be needed by the collective to achieve progress on this in present times of financial strains and competing priorities.

Other bits of work -over the next few months will look at role of pharmacists, dieticians as well as mental health side of things in diabetes. 
Throw in discussions and mulling over Out of Hour support across the country, discussions around Type 2 diabetes education in digital context, some educational material specific to south east asian population and accreditation of existing education programmes…and we have a fair few things to keep us all busy. The work around reviewing hospital services in diabetes begins in earnest too from May (some pilot runs end April) - and hopefully all of this will come together to keep driving quality of diabetes care up.

Another update perhaps in July on how much we have delivered on the above and what subsequent plans are. As mentioned at the beginning, there are a few other bits - and hopefully we will have some further good news to share. 

Till then? Wish us luck- and thank you to all for the support and kind words- which makes it all very worthwhile x


Friday, March 30, 2018

100 million




Policy role can be much fun...it 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 etc....so, 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....