Wednesday, December 27, 2017

The 2017 Chronicles

2017. Nearly done- and from a professional perspective, its been a year of getting to prefixed targets set- nothing more, nothing less.
No point in beating about the bush- the NHS is in turmoil- with a swirl of politics, elections, more changes beating an incessant drum which has made life suffocating, difficult to concentrate on the job at hand. Yet…albeit from a biased point of view, we in the NHS England diabetes team- can perhaps look back at 2017 with a bit of a smile.

Landing the Transformation funds was a big step forward- with the process of allocation of money-perhaps being…character-building. Either way, at the end of it all, 62 odd million £ were distributed out- with a further roll out of the National Type 2 Diabetes Prevention programme; about 5 million £ specifically to increase specialist nurses in hospitals to tackle hospital safety issues; about 11 million £ to improve uptake of structured education etc. Will money solve it? Nope- but it certainly goes a long way to answering some critics- as well as kickstarting some of the much needed processes that diabetes care needed.

Next step was the landing of the Diabetes NHS RightCare pathway. Blessed by eminent personalities such as Sir Muir Gray, it arrived with 7 key priority areas being focussed on- at a population level. The message coming out has been loud and clear- the days of a "community diabetologist" and a "hospital diabetologist" must be coming to an end. It has been of much personal satisfaction to see this..as I have always believed in…one is a specialist for the system- not of one particular bit of it.
The digital versions of the Type 2 diabetes prevention programme arrived too- a roll of the dice- to gather evidence, to test the theory that digital approaches may work- a preference of a nimble approach towards technology- in an effort to encourage innovation- yet with markers around it. The recently published data also showed the growth in numbers in the face to face T2D Prevention programme

The landing of the FreeStyle Libre was big news- an unconventional approach- yet- in my opinion- a much needed one to share up the status quo- it certainly has caused a stir- and for me, the big thing- apart from the technology- was the whole process of seeing what could be achieved if all forces joined together for the right thing. For me? Getting it to even one person beyond the capability to buy (which is what it was for 2-3 years)- thats a win. As was showing that when we negotiate, we do so for all 4 countries, not for one. We do so for adults and children, not for one segment. Diabetes does not stop at certain ages, nor at boundaries of countries….THAT is created by us as health care professionals- and this year- to me- was about setting the tone for changing that.

The year closed with updates to the DVLA rules for those living with diabetes. Some important first steps- especially removal of the legal barrier to change how glucose levels are to be looked at during driving. Much to be done yet- but this is a big step forward- just as Libre could be potentially opening the door to further technology in type 1 diabetes in the NHS. And finally, the opportunity of brining a Scottish piece of work (My Diabetes My Way) to England- and invest with an aim to develop it further- explore the possibilities of Artificial Intelligence & Diabetes

So whats up in the pipeline? Truckloads…will all of them land? Unlikely- but no harm in seeing where it takes us. I will list them below- to give an idea of what we are up to/ have in pipeline/on drawing board- in no particular order of preference:


  • Type 1 diabetes Digital platform
  • Type 2 Diabetes Digital education offerings
  • Accreditation of Education programmes
  • Discussion around QoF; individualised care- and especially frailty
  • The UK version of "Language Matters"
  • A focus on better technology uptake especially CGM access
  • Possibly Out of Hour support across the country
  • Liaison with pharmacist/ dietician/psychology organisations regards their roles
  • Collaboration with ABPI (umbrella organisation of all diabetes Pharma companies)
  • A possible Dragons Den style Innovation Day
  • Working with ambulance services regards treatments etc
  • Developing something for SE Asian people regards education in T2D management


Enough? I think so- and as mentioned, the NHSE Diabetes team is busy with ideas/thoughts/possibilities- working closely with Diabetes UK , JDRF et al

Personally, apart from all of the above, there's the TAD event, the T1D: Rise of the Machines; Episode 2 of the T1D Comic book….so much on plate- and so much fun to be had. 2017 has been a bit of a blitzkrieg, 2018 could be one step further- who knows. Throw in the GIRFT role to come..touring all hospitals around the country, discussing safety, care, data- and yup, it will be busy, won't it?

Regrets from 2017? Very little. I never came into this role with any expectations- apart from having a bit of fun- and as long as it continues to be- we keep at it. The NHSE Diabetes team are laced with characters who have guided and supported me- yet let me run at my pace- which has been much noted and appreciated.

Resolutions for 2018? Not much to be honest- but maybe smile a bit more, try a bit more charm. I am perhaps a bit more relaxed, a bit more chilled - and the supporters have been far more than the detractors- which is always a good barometer. You can't satisfy all- trying to do so is probably the biggest error anyway. However, more than all? The biggest strength has been the folks who live with diabetes or care for those living with D. Very rarely, if ever, there has been any criticism from them- and I can't thank all of you enough for that. THAT is what has made 2017 so special.

Let's hope 2018 brings us more cheer- as we try different approaches and things- and we are always happy to listen- and hopefully, our work in NHSE shows- we have been trying our best. I wish you all a happy new Year- and look forward-as ever- to your support- as we try to make diabetes care…just that bit better.
Personally I always worry when my interest flags or wavers…or when I feel the challenge isn't there anymore. Not quite done yet to be honest in diabetes…the fire still burns well…lets see if we can make 2017 the warm up act for 2018, shall we?



                    Partha Kar & Jonathan Valabhji….The Maverick & The Statesman 😊


Tuesday, December 19, 2017

New Kid or New Clothes?

How much more change can the NHS take? Or are some changes absolutely necessary? Or are some changes needed to correct the wrongs of the last change? I mean...the only thing constant in life is change, right? These are the questions which -as ever- plagues the NHS- when anything new comes along- and based on our bias, belief, ideology or indeed even cynicism, we tag the latest change with a brush which fits the best description. Talk to senior enough folks- and they will nod sagely - the circles of change have left their mark on them...each cycle bringing something new, rehashing old wounds, bringing some fresh. Factor in that, in essence, we are a bit adverse to change in general, throw in the religion that the NHS is...and what a fascinating cocktail it indeed is.

In the context of all that arrives the latest version...the ACS (Accountable Care Systems). Or ACO. Or depending on your view- the Saviour of the NHS. Or the End of the NHS as we know it. There's been enough commentary on it from well known campaigners, political commentators etc so I won't bore you with that- but will give a personal perspective on it. I couldn't really care less what you call it, you can call it Mickey Mouse for all I care- but if anything purports to get organisations together, beyond their individual Key Performance Indicators- or indeed their bottom lines, then perhaps it can only be a good thing. Now I am not as clever as a lot of folks, perhaps even naïve, can't understand the politics of it all...but a vehicle which says get all your money in one place and work backwards for the benefit of the patients- seems like the ideology to which the NHS should be aspiring to anyway. I mean..I don't care what your Service Line Arrangements are- or how gleeful you feel about doing that extra coding to get more money- at the end of the day, it comes from someone elses bottom-line...Left Pocket, Right pocket, same bloody trousers, isn't it?

For years, I have sat and marvelled at the potential for organisations upping the ante at gaining that extra pound- off each other, off each departments...and after a point? It feels like monopoly money. I could give example after example from my time as Clinical Director of an acute and later community trust- where the arrangements could only be described as...cynical. Efforts to balance your own siloed bottom-line while the whole system tanked.

Anyhow, so what can ACS do? Well, very little to be honest- without the belief of the folks involved in it. Or their ability to convince the majority. Its not about convincing all- heck, we didn't manage that even with slavery or racism- so why try anyway. Its more about inspiring others to believe. A structure is as good as the players involved in it- a bit of a footballing analogy- but it doesn't really matter what sort of Tiki-Taka or False 9 you play with- if you don't have the folks to execute it. Or the belief they can. Or...more importantly- unlearn years of behaviour ingrained in them. As regards the scrutiny of the process, if the Healthcare Select Committee is looking into it,maybe the process will give some assurance- maybe it won't. I don't know- all I do know is this...it really doesn't matter even if all the money in the world appeared- the raw fact is we are still a fair bit away from having the ability to work together-as a system. We are still...primary care, secondary care, community providers....and so it has been for ever. Can we unlearn that? Can the system leaders switch their way of thinking? Or is it time for a fresh generation to try? To me, the structure gives the foundation- whether we can build on it, boils down to our thinking and approach

In short,  as ever- who knows. As Christmas approaches and we enter a period of bonhomie, maybe its time for us to save the NHS - just by gaining the ability to work together- from one pot of money- as well as developing the ability to argue for a bigger contribution to the pot-as a collective. Maybe we could. Maybe Santa may bestow that gift upon us all.

Or at the very least, one could always dream. I wish you all a very Merry Christmas indeed x

Wednesday, December 13, 2017

Diet Wars




It's unquestionably a sign of our times...the lack of mature,sensible and calm debate. The world of health is no different- and noticeably evident in recent debates about the relevance of diet. The views are absolute, there is no budging...and even if that be an admirable trait in some eyes, what hasn't been edifying is seeing the unfettered vitriol which comes with it.
The debate about low carbs and its efficacy in helping with diabetes (yes, all types) has been going on for some time...but recently seems to have slipped into a different gear with the publication of the DIRECT study. That study has been more about low calories followed by primary care based support- rather than low carbs- and the data is there for anyone to interpret. What however has been fascinating to see is believers in the science of low carbs use exactly the same tactics that they have, sometimes rightly, accused others of. The tactic of sneering at research which doesn't fit a view, the view that it needs to be discredited, rather than be seen as yet another option for the average Joe on the street.

Now I will be honest- as many advocates of low carbs will know too,I have no issues engaging with anyone- and I have- whether it be with Aseem Malhotra, David Unwin or indeed the folks at diabetes.co.uk  such as Charlotte & Arjun. I share cordial relations with all- as I see its potential and I also see that it may indeed work for some indeed. By the same token, I also have met Roy Taylor and Mike Lean, the brains behind the DIRECT study in an effort to understand what possible application can be brought to bear in real life- and perhaps seen as yet another option. By the very same token, I also met with the British Dietetic Association too...because give or take? They are all allies to me - giving ideas about what may help the population. As I would with anyone who brought another diet to the table which they believe will improve population health.

There is however a need for a reality check too. Albeit perhaps tongue in cheek, David Oliver makes a very relevant point about the #Carbsnatchers of NHS England. In a policy role, there is a need to strike a balance between what can and should be mandated (smoking in public places is a good example) and what interferes with personal choice. Is it about mandating or is it about giving people the information- and then letting them choose? And where does socioeconomic deprivation fit in with amount of carbohydrates in your food?

Either way, a rational debate is needed...simple mudslinging is likely to achieve little. Comments such as "if you don't eat low carbs, you will have your feet amputated" ...well..I am not sure who that actually helps.I have never been a big fan of shroud waving. There needs to be an acceptance that there maybe folks who consciously choose NOT to adapt a low carb or low calorie diet- that could be an individual call or driven by economy. It's not right to judge others when you don't live their lives.And I have had my share of abuse- as sizzlingly racist as they can get- specifically from the low carb lobby. What has fascinated me is the passion that drives such people to send things like that. I tweeted about it...condemnation from the big guns of low carb lobby? Miniscule - I saw it as tacit encouragement to the hordes...the problem is..if that's how you engage with national policymakers, then the chance of impacting on policy...well...minimal is the word I am looking for. What drives individuals to champion something to such an extent that it crosses all threshold of decency, ignores any science, feeds into the ethos that experts either know nothing or just corrupt? What creates this aura of being self appointed vanguards of public health...I mean , if you want to impact change, why do so from the outside? Why not apply to Public Health and join? Engage in a rational manner and make the case?

A personal viewpoint, if I may? I read regularly and would say am a reasonably informed person. So what diet I undertake to reduce my risk of type 2 diabetes should and is down to me. I have always loved my food and desserts but as time has passed, I am more aware and conscious - but that doesn't mean I have given up on things I have always loved. It's also about what I can afford. It's also about what I can sustain and feel well with. It doesn't matter if YOU feel great being on any new diet, what matters is how I feel on it after trying it. It's about perspective.

At a policy level, we are indeed looking at all the evidence and perhaps a change in guidelines will happen- engage with the process in a sensible adult like fashion and there are enough people willing to listen. And as much as it may be surprising, no, there isn't some Bond-villain style conspiracy going on. You can't impact change by simply being reactive and angry- it's more about winning over people, not continuing in a bubble of folks who believe the same.

And genuinely? If you want to improve diet and create a healthy population, we should perhaps concentrate our efforts on access to the right food- which links with socio economic deprivation. When you are sleeping rough, shivering in the cold, it's not the low carbs or low cals which are at the foremost of your thoughts. A tin of baked beans or a packet of crisp feels like a gift from heaven. 
We would do good to bear that in mind - before tweeting our righteous anger from a smartphone, while comfortably tucked up in a nice warm house- enjoying the blessings life has provided us with.

Sunday, December 3, 2017

Next?

Appraisals are always interesting- but I have mostly actually enjoyed them. Perhaps its been more about who I have done them with. Whatever be the reason, it has always given a reason to reflect, a time to think, a moment to take stock. This year, my appraiser had a fantastic question- at which point - somehow it felt that time stopped momentarily. It was a simple one…"What next?" You would have thought the answer would be simple…surely it was planned? Surely, I had an idea mapped out in my head?

You know the honest answer? I absolutely have no idea. I have rarely had a grand plan- not because I didn't want to but because things have simply happened for me along the way. When my parents sent me to this country, they had one and one ambition for me- something they tried but due to a multitude of reasons didn't quite happen. Times were different, the prism through which folks were judged were different- and I came with a burning ambition to become a Consultant in the NHS. Nothing else mattered- it was a laser like focus. Somehow it was a way of saying thank you to my parents- who sacrificed so much to get me across to a different country. And it happened finally in August 2008. I cant tell you what it meant for my parents- it perhaps chokes me slightly when I think of it- but the pinnacle was achieved.
Post that? Everything has been a bonus. Being Clinical Director of Portsmouth Diabetes team, Super six model, type 1 service…its been fun. And thats what a role tho me is all about- having fun.

Fast forward a few years- and thats been exactly the philosophy - fun. Take it as it goes along, try and focus on a few problems that folks with diabetes go through- and give it a whirl of the dice. Is it a step to something else? Not really. Its been being fortunate enough to be in a position to help others- try a few things, win some battles, concede others- but never failing to have fun. So far, life has been kind to me- met some amazing people along the way, so...whats next? Whatever is around the corner I suppose. I do keep hearing how tough life is as a Consultant- and it can be- no question. I also personally believe it is an opportunity very few people are fortunate enough to have- a spectacular once in a life time opportunity to make a difference to many others. Many dream to get in the position I find myself- and i am certainly going to give it a wholesome try while I am at it. Do I fail? Many many times- made mistakes, made errors of judgement…but thats about being a human being too, I suppose. As fallible as anyone, as prone to errors as anyone else.

Being in the position where I am- just into the 10th year of my Consultant life, its unbelievable where I have got to- mostly by luck, a lot due to being in the right place at right time- and a major part due to colleagues who have always been there…encouraging, supporting, helping. What next? There is no next per se…as ever, the chapter is blank…the book is written as I go along. Its a fascinating journey- they key is to enjoy it as one goes along, learn as best as one can from mistakes- and be humble enough to accept when those who you do this work for, folks living with diabetes, turn around and say "you may have got this wrong". The rest? A smorgasbord of genuine well-wishers, jealousy, politics, personalities….if I am brutally honest.

So I really don't know what's next in my career. Frankly, thats because I never set out to be anything but a Consultant in the NHS. Post that? Its a ride which I am enjoying…some doors will open, some will close…but its pretty much why I try different things like comic books, TED style talks…its just…different..its just…fun. Along the way? If one ends up helping a few folks beyond the day job? Its can't be that bad a thing.

So what's next? I don't know but you are welcome to join me in the ride. I promise you it will always be fun x