Saturday, March 26, 2016

Alternates

Its a tricky conversation to have. Can anyone else do your job? Doctors are always caught in a bind- in fact- even within medicine, people find it a tricky conversation to engage in.
Lets say you say "No, I don't think anyone can"- you run the risk of it being a comment laced with arrogance. If you say "Yes, I think they can" - you run the risk of being asked what exactly is the point of having "you". Factor in then the discussion about evidence of quality of care, the cheaper labour and suddenly as ever, a sane discussion loses its thread and becomes embroiled in idealogical discussions.
For a moment, I am going to ignore the uninformed ones who spout their views without any basic understanding of medicine. I don't grudge them that- whether they are journalists or just opinionated hacks, in a democratic country, they must and should have their right of opinion- however ill informed they maybe. I pass opinions on how Klopp should run Liverpool- that neither makes me someone with credence on that matter, nor someone to be taken seriously. Its an opinion- which is and should be open to debate- at least in my view

Lets focus on those who are in charge of NHS policy- and hopefully better informed. lets focus on health care professionals who are of the view that doctors and nurses roles can be done- partially or fully by the alternates- a different grade of professionals. The question is many fold- are they trained? Are they qualified? Will they deliver same quality of care? Or are they just lesser paid than us?
It's also a question of what history teaches us- or what we, in the NHS chooses to learn from it.

About 10 years or so ago, the cry was to move diabetes into the community- because it was "simple". Because "anyone could do it". Sorry- GP colleagues- but at that time, many GP leaders stood by that - wanted it to happen- the sheer volume arrived but as time went on, GP colleagues understood the sucker punch they got delivered. The patients arrived- the money didn't.Whatever be that policy merit, today 10-15 years later, a majority of diabetes patients don't get their basic checks done. Slice that data anyway you wish- but its not really that fabulous.

Would specialists have done any better? Maybe not.Should they have taken the initiative at that stage and engaged with primary care better? Perhaps- and many ifs and buts- but the sole reason for that "Move into community/Anyone can do it" was down to one thing only- cost savings or cheaper labour. People who didn't necessarily have the required training or finances were asked deliver the impossible. Cue where we are today. Are primary care trained in Type 2 diabetes? Much better than the past and an ever improving feast. Are they trained at any stage about Type 1 diabetes? No- categorically not. But the drive to push patients into community/save money gave us variable care throughout the country. No one made any distinction even based on training of the professionals- it was all about "Move it out".

The fault for that? Didn't sit with the policy makers- in my opinion, it sat with us-as a community- where instead of playing our own siloed cards, we should have asked for assurances regards safety, primary care should have been clear about resources/support etc. We didn't- and we are here where we are.
So can others do our jobs? Of course- anyone can- with the appropriate training. Reducing cost indeed is an important plank- but not at the expense of quality or patient safety. The aim to reduce cost now could potentially translate into further costs down the line via errors, lesser quality care etc.

I will finish by a simple example- as a specialist, I do NOT see myself seeing every single patient with diabetes. I however do see the value of a specialists seeing patients such as antenatal diabetes, foot diabetes etc- as I don't want untrained people having a "crack at it".That's not arrogance- thats simply being clear about my skills. We talk a lot about airlines and their safety- I am pretty sure no pilot would be hesitant about making it crystal clear that the flight attendant may not have a go at it.As a specialist, beyond the specialism, I do have a role as an educator and support for 1 care- guiding others- but there will always be bits that no one else can and more importantly should do.

Can the alternates pave the way for the future? With the training. quality assurance -perhaps so. However, if money is the driving factor behind that-at the expense of compromising patient care, then as a healthcare professional, its not cockiness to raise a dissenting voice.

Its a thin line between confidence and arrogance...as the saying goes.."Arrogance is thinking you are above everyone else; Confidence is knowing no one is above you".

Saturday, March 19, 2016

Sugar and Spice

So it's happened..a Sugar Tax. Let's get this straight at the the outset. It's a good move and the fact that it has happened needs to be applauded.
Yes, on its own, it will do little and needs to be part of a bigger issue; yes, there could be many political reasons why it has happened...but the point is it has happened- and for sure, it's a start.

Whatever your views about them, the campaigns and work done by Jamie Oliver, Aseem Malhotra deserves admiration, even if it maybe grudging, if you aren't their fans. Simon Stevens, again, isn't everyone's cup of tea but with this backing of the sugar tax and prevention programmes, at least, he has shown a commitment to try and do something. One could again argue about impact, suitability, evidence etc but let's take a step back and look around us...obesity is an issue. Not just in the UK, but globally and there is a public health issue at stake. Everyone is welcome to their own opinion but as someone who looks after a lot of Type 2 diabetes patients, their complications and foremost as a parent, well done for it happening.
The next steps will be crucial to see the tangible benefits and there will be a consultation period ( Diabetes UK have already confirmed they will input) to try and ensure no one is disadvantaged by this. The issue? We can't say the system does nothing -then spend energy and time berating them for trying something at least.

Now to an issue which has been a reflection of the times. The media have gone heavy on it...."sugar causes diabetes" and understandably has managed to upset many a folk who once again have felt all diabetes lumped into one.
First- the facts, obesity is linked to Type 2 diabetes, doesn't "cause" it. It certainly doesn't cause Type 1 diabetes, neither does it cause any of the genetic types. It's perhaps a bit easier for me to observe this from a neutral position as I don't have any form of diabetes at the moment but fully appreciate the angst the association it generates.
If you have type 2, the instinctive assumption is you have "too many cakes"...when it may not be factually or scientifically correct. If you have type 1, it certainly is enough to make you angry as for starters it's not something you wanted to happen, then to be painted in same brush understandably riles many a person and carer. If you have a genetic type of diabetes (and some of them don't even need treatment) you can only sigh.

However, maybe it isn't right to blame the media. They catch on to perception that exists- or perhaps allowed to exist by many. Patients try their utmost but my question is what the NHS does to allay that opinion. Let's look at some things...let's say the "National Diabetes Prevention Programme". In its own, a laudable project but where is the distinction? For anyone who hasn't read medicine etc, the message is diabetes is preventable, isn't it? If we are saying Type 2 is preventable, why haven't we,as a system, specified that?
Where were all the big guns of diabetes care when the name came along? Did they forget to represent all the other types? For that matter, where indeed was I? The fault may not be with others.

How about the title of "National Clinical Director of Diabetes & Obesity"? Again, a great role and some amazingly laudable work being done...but if I was a media person, is it too much to make the association that diabetes and obesity are interchangeable? We, as a system, accepted that, so why blame media now? You can call them ill informed but much much before that, the misinformation sits with us,as providers and commissioners, it's about language, it's about responsibility and it's about doing what is right.

In 2016, my attitude has been pretty simple...let's try together. If mistakes are made, correct them as best as you can, but most importantly? Let's work as a collective. We, as specialists, are the sole voice within the system to improve things. It should be patients but unfortunately it's still a rarity. We have perhaps moved from the total disregard to a cursory presence on some boards. The David Gilbert's in the world are rare, and more strength to them in their efforts but we have a job to help as well as be the advocate for patients, help with the misconceptions being cleared, help with raising awareness.

Much to be done and it's time to be calm, work together and do so one step at a time. It's going to hard, it's going to take time but I am not planning on going anywhere in a rush.To all those with Type 1 diabetes and/or their carers, I can't say I feel your pain when obesity and diabetes is mentioned in the same breath. But I do see the visible angst and I get it why it's the case. Work with me, Pratik, Emma...we are trying..give us time and stand by us.

I have a feeling times are changing ...I genuinely do. So let's keep the collective...strong. 

Tuesday, March 15, 2016

#TADtalk2016



It was a chilly evening in Scotland. And there were 3 folks in the back of the taxi - travelling in the dark to Pitlochry....invited by the Scottish Study Group to talk about type 1 diabetes. We had already made our introductions and past the initial awkward silences, the chatter had begun as regards what we did, type 1 diabetes care etc. There was myself, Catherine Peters from GOSH and there was Peter Hindmarsh from UCL. And in the conversation, somewhere was born the idea of having TED style talks - delivered by those with Type 1 diabetes to an open audience. To show that Type 1 wasn't a barrier, to show what could be done in life, to inspire..maybe even to give hope to those who struggle with Type 1 diabetes, whether as a carer or as someone who lives with it.

The rest, I suppose , just flowed from there on- we all naturally took on roles and responsibilities  and before we knew it, the day itself arrived. I won't go into details regards the day as blogs from speakers and attendees are already out there...but you know what? It was simply magic. None of us as organisers even thought twice about it being a Saturday or it being done without payment...it was just something we wanted to do. Those evil money grabbing, golf playing, lazy Consultants, eh?

The speakers were,as expected awesome..our UK speakers like Lis, Laura, Anne, Jamie and Richard inspired and made us all reflect, laugh, smile while our overseas colleagues Joe and Weston were simply magical in their inspiration to make a change. Justin Webb brought the celebrity gravitas and I must admit to rarely having been to a day when all the speakers were of such high calibre.
There was of course some pesky dust in the air watering many eyes when Weston spoke but perhaps no more a sombre moment when a young girl asked Richard Lane, the country's first islet cell transplant recipient .."how did it feel to be without insulin?"  An innocent question with layers of pathos in it..which to all the researchers around the world sends out 1 message....let's not make the cure yet another 5 years away.

A brilliant interactive audience made it all the more fun...though one could also sense the frustration with care, the stories of misdiagnosis, the lack of basic care, the over stretched resources HCPs are battling with...as well as sometimes forgetting the basics of medicine. Much to learn, much to absorb...much to try and get better.

All in all...it appeared to be a pretty successful day...which brings us to the question..why do it? What next? We did it because the idea is to spread the message that type 1 diabetes isn't a barrier, it's something as Lis said..gives you more than it takes. In that journey, we as HCPs, have a role to support, to help, to be part of the journey. There needs to be the learning that the best technology, super insulin, targets to hit are of no use whatsoever till we have learnt the importance of asking "how are you" first and "how are your blood sugars" later.  Not everything in the world needs resources, some of it is also because of why we chose to do what we do.
More of the same? Perhaps. I suspect we need a breather, look at the feedback and then plan again- and look at ways at spreading the learning not only amongst patients and carers, but also amongst HCPs.


Finally..a big thank you to my co-conspirators for the help and support...Catherine and Peter, thank you..you have been legends. Thank you to all those who gave up their Saturday to be there and be part of this inaugural event..thank you to our super speakers...and a special word of thanks to some who came simply based on asking (Roy, Theresa,Elaine, Jonathan,Pratik,Stuart,Reza)...it meant a lot to see the support.

There is much we can do to raise awareness and improve care..and we keep trying. I do have some further ideas and plans to do so...the key is that in my view, it can be done...it just needs a collective of like minded HCPs and patients to do so. And ladies and gentlemen, slowly and surely, if the "TalkT1" event end January was a start, the TADtalk gives it momentum. The collective is indeed building...and I would encourage others to join. Will we succeed in making everything better? I don't know..but wouldn't it be a darned shame if we didn't give it a full crack of the whip?

Shall we? 

Saturday, March 5, 2016

Scottish Sojourn

Conferences are always a variable feast and I suppose it depends why you go to conferences. Could be the pure educational aspect, could be the networking, could be the emulating or perhaps to escape from the daily routine of the work we do.
Diabetes UK annual professional conference has always been an event for me to attend for a mixture of all of the above and this year was no different...and after a few days, I walk away with a mixture of feelings..some positive, some worrying and some perhaps more of an individual reflection.
Tuesday was about coming to the meeting of the next generation...meeting a few future leaders and there were a fair few. There also was the feeling of them being a bit lost, caught between the need to improve diabetes care or to balance that with the struggles of general medicine. It was interesting but as ever, there were few who would own the stage and limelight I years to come, while a big portion would be perhaps invisible, work silently but try perhaps in their own way.
The nest few days were interesting, seeing a lot of old faces, always finding time for the ones you respect without batting an eyelid - such as Edwin Gale, David Mathews, Andrew Hattersley, Melanie Davis, Stephanie Amiel, Kamlesh Khunti- and always learning from them. Immense individuals who contribute so much to diabetes care and great teachers along the line for me.
Was good to see patient participation with familiar faces such as Laura and Mike while meeting folks from Twitter such as Andy, Kelly, Dani, Kris etc.-all individuals trying to help HCPs engage more..great work you all..and keep it going!
Meetings with Jonathan Valabhji and Chris Askew etc showed the willingness on part of many to try and help - committed folks trying to make a difference for folks with diabetes- and that has to be lauded. It gives me hope that things may indeed continue to move in the right direction.
Overall a good conference with some learnings to take back home

What about the negatives? Perhaps not a huge amount but was interesting to pick up on some of the disdain from Type 1 specialists about my "new found" love for Type 1 diabetes. Some of it was open, some veiled..what was I doing talking about the NICE Type 1 guidelines? As ever, the NHS amazes judgements on individuals based on not much facts...it was intriguing as well as mildly amusing too. Just for the sake of the doubters, I am interested in improving diabetes care..so have focussed on model of care initially and now working on improving type 1 diabetes care and provision. If YOU can't do that in your role, then maybe best not to try and stop others trying to...as the kids say..#justsaying
Think of this..if I as a professional get that response - what does a patient get ..food for thought,eh?
I am no expert but as I said in my talk, no one actually is - apart from those who love with it- day in, day out. The rest? Specialists of variable levels of knowledge - at best.

Evenings were spent with friends and the family away from home -the diabetes team of Portsmouth - and fun times intermingled with learning opportunities. Most of the important bit which seemed to be gathering steam was the growing realisation amongst the community about relationships. Whether it be charities, HCP organisations or patients- if we want to improve care in this country, we must walk past our self created silos. If we can't, 10-15 years later, we will all turn back and think what if. And not only relationships amongst ourselves but the key one..that bit amongst the patients and us. I will say this again and again...as this is my mantra of what I do. It isn't about the latest super insulin, it isn't about the flashy technology, it isn't about the "cloud", it isn't about Apps or offering education programmes...it's only about one thing- YOUR ability as a professional to engage and communicate with the patient- move away from the "how's your blood sugars?" to "how are you"....till that day, we will not be able to improve outcomes- however much resource we magic up.

So to Chris Askew and the rest of Diabetes UK, thank you for getting the whole community together- it indeed was a lovely Scottish sojourn. Thank you to Paul Newman for asking me to be part of the event (wasn't that a fun session!?) Will we be able to come together and do what's needed? I don't know but personally, am willing to keep trying. It's time to unwind, it's time to relax a bit...but hey, next weekend is something special too- the first TAD event for folks with Type 1 diabetes.
New, quirky stuff to improve care? Ah yes, that's certainly me- knowledge or no knowledge about type 1 diabetes ;-)