Dr Peter Winocour
Consultant Diabetologist and ABCD executive, Queen Elizabeth II Hospital, Welwyn Garden City, Herts, UK
The Association of British Clinical Diabetologists (ABCD) was founded in 1997, at a time of yet further restructuring of the NHS. Our first Newsletter appeared in the autumn of 2002 just after the launch of the National Service Framework (NSF) for Diabetes, which set out ambitious 10 year standards with a later delivery document and strategy. Our first editor Peter Daggett served for over 5 years and offered challenges to us and the broader systems we worked in, using his ‘Controversy’ section to deliver exactly what ‘it said on the tin’. More specialists was the mantra – we need to keep on banging the drum whilst recognising that the role of the diabetologist is expanding to serving the population through service integration and the support of primary care in addition to the key role in specialist areas of diabetes, endocrinology and the ongoing commitment to acute and general internal medicine.
The difference of views as to whether we will develop as a specialty by embracing the ‘Future Hospital’ and ‘Shape of Training’ themes of generalism or are better served by focusing on work as specialists will become clearer with time. I nail my colours to the mast by promoting the concept of a pool of consultants in diabetes and endocrinology expanding posts in all hospital settings, enabling the contribution to acute general internal medicine to be paralleled by specialist service expansion. Whether prescient or through chance, I led a discussion at the Spring 2002 meeting and offered conclusions to enable an ABCD response to the NSF standards which Peter Daggett published in the Newsletter.
We were sceptical of the standard to reduce the risk of type 2 diabetes without societal change. The only change since has been in the wrong direction in terms of incident obesity and a 10% chance of developing type 2 diabetes in adult life. Unselected population screening for diabetes was not supported. The more recent adoption of the NHS cardiovascular disease (CVD) risk check for all aged 45 or more is indeed probably not cost effective if not targeted but is going ahead – let’s see how much avoidable morbidity results. We endorsed shared care and have since led the drive for integrated diabetes services – now hopefully the only show in town. We supported an end to cattle market diabetes clinics and strongly pushed for better care for children and young people with diabetes, pushing for mandatory training in diabetes amongst paediatric registrars – sadly never realised. In-patient diabetes was high on the NSF agenda and education of health care professionals about diabetes through an in-patient diabetes specialist nurse was promoted by ABCD. The ongoing push spearheaded by Gerry Rayman may prove to be one of the major deliverables for the NSF along with integrated ante-natal diabetes care.
So here we are over 10 years on after the NSF delivery document. I think we have spent the decade revising systems and structures and focusing on care processes and measuring them. We have more data on diabetes from the National Diabetes Audit than we know what to do with. The local information may or may not be utilised depending on the drive and support of commissioners and public health – not always guaranteed to be present in large quantity.
I have always felt that, whilst our expertise in supporting the care of patients with type 1 diabetes required separation and commissioning, the current standard approach to clinic based services would not deliver the best results. Similarly, the understandable suggestion that type 2 diabetes required predominant primary care recognised firstly the high prevalence and the clear fact that many patients could be adequately managed through primary care support and education using best practice guidelines. However, by presenting type 2 diabetes as a condition managed by algorithm, I think we have done many patients a disservice. The evidence base for the guidance is not there; the individualization of care is absolutely necessary but not at all straightforward. When we consider the option for the 12 classes of agent in managing type 2 diabetes and delegate the task to many excellent practice nurses, I can understand the failure to shift the adverse outcomes shown in the National Diabetes Audit and the recent description of therapeutic inertia in the primary care setting. The lessons of the need to front end intensify treatment of diabetes and related CVD risk in newly diagnosed type 2 diabetes especially when younger, whilst taking a more measured conservative approach in older patients with established CVD, is I think yet to factor into routine primary care of type 2 diabetes. If specialists rely on being 'complicationologists' for type 2 diabetes whilst the system does not look to do more earlier, I anticipate more complicated diabetes in the next decade. There is a way forward and it is NOT through the separation of care into different sectors. Diabetologists embracing new technologies and smarter means of behaviour change may make the difference. Since Roy Taylor disproved the dogma that type 2 diabetes is inevitably linked with progressive beta cell damage, the opportunity exists to reverse the tide of diabetes and complications BUT it still needs more front end care.
John Wales was the first chairman of ABCD. In his valedictory in our first Newsletter talked of the need to work closely with the Colleges of Physicians and in the intervening period we have been represented on the College Council and taken a lead role in delivery of the SCE examination, and serving as rotating secretary - chairman on the Joint Specialty Certificate for Diabetes and Endocrinology.
Whilst the association has gone from strength to strength over the 12 years, the Newsletter also evolved. Mark Savage took on the mantle of editor in 2008. Like Peter Daggett, Mark was not backward in coming forward in expressing his views, and when I took over from Mark when he escaped to Oz, I also relished the opportunity to ‘offer a view’.
I think the time is ripe for a move from the more conversational tone of the Newsletter to the more disciplined requirements of our new journal, which I am certain will prove a great success and will be a testament to the vision of our outgoing chairman Chris Walton. However in establishing the values and objectives of the main substance of the journal, we have agreed that the ethos of the Newsletter should remain, with the ABCDâNews section taking a topical view of the challenges we face in balancing our commitments to providing best quality diabetes care with the other aspects of our day jobs.
I think ABCD has grown up. As the UK specialist diabetes association, we could look to our role on the wider stage. The JBDS guidelines have resonance internationally and we need to promote this important output beyond our shores. We are now supporting an expansion into subspecialist areas through our collaboration with the Renal Association.
We can and should take an active role in supporting better UK hospital care. Many years ago Chris Walton and others had a dream that peer review of diabetes services was a possibility. Given the multidisciplinary nature of the team this was always going to be a challenge. However through peer review of diabetes services for children and young people, and the likely expansion to transitional care of adolescents, there is the first opportunity to start the process. The recent engagement between ABCD, Diabetes UK and the Care Quality Commission to support in-patient hospital diabetes peer review initially is an exciting opportunity for the years ahead.
One advertising slogan stated ‘the future is bright the future is orange’. This is only partly correct – the future is indeed bright but the future is actually a pyramid of multiple hues of blue!
Address for correspondence:
Dr Peter Winocour, Queen Elizabeth II Hospital,
Howlands, Welwyn Garden City, Herts,
AL7 4HQ, UK.
E-mail: peter.winocour@nhs.net
Conflict of interest: None
http://dx.doi.org/10.15277/bjdvd.2014.010