In May 2017 I was elected as the new ABCD chair and this report marks the end of the first year of my term in office. These 12 months have been a fairly steep learning curve for me, but work has progressed with the support of the executive team, ex-officio support and ABCD secretariat. I have undertaken to formulate a strategy and business plan to deliver the change agenda. My vision and plan is to modernise the Association and implement new structures and processes to support member services and to underpin the work of the ABCD.
Improvements in the internal structure and processes of ABCD and its committee and subgroups and other work is in progress and will continue during 2018. This will mean that ABCD is well placed to enable greater strategic and external focus from the officers in pursuit of the Association’s core purposes. The completed strategy paper will be submitted to the committee for review at the June 2018 meeting.
From the draft strategy paper, the executive team has identified the following priority areas of development:
Therefore, during my first year there has been a considerable amount of activity which has focused on supporting the core ABCD work but also consolidating the new initiatives which were in progress when I took over the Chair from my predecessor Dr Rob Gregory.
I am fortunate to inherit such excellent support from my colleagues and peers in the ABCD committee and subgroups. I am delighted to be able to report that ABCD continues to be influential nationally, with representation on most of the diabetes advisory and decision-making bodies. This has allowed the executive team to focus on the following key areas.
Ongoing work which we have progressed
Some items of unfinished business identified by the previous Chair’s report have been concluded.
Medical Care
Completing the Diabetes and Endocrinology chapter for Medical Care, the RCPL online guide to medical specialties went live in July 2017. Based on the contents and recommendations of this report, consultant colleagues will be able to use this in discussions with commissioners and provider organisations. Furthermore the 'Getting it Right First Time' Lead for Diabetes will be able to cite it in their discussions with Trusts (https://www.rcplondon.ac.uk/projects/outputs/medical-care-0)
T1 DM Collaborative
The T1 Collaborative was officially launched in March this year with support from the DUK, and the session was popular and well attended. Dr Robert Gregory continues to lead this with his vision and hard work to ensure that it will deliver its objectives. This year we saw the change of ABCD IPN-UK to Diabetes Technology Network (DTN-UK), acknowledging that the network has a wider role than just insulin pumps. DTN continues to hold educational meetings regionally and this year we have planned three meetings in Coventry, Leeds and Manchester. ABCD supported the Clinical and Commissioning News Live event running for the third time this summer, with further improvements to make this event a success. This year meetings will take place in London, York and Bristol.
Website update
Our website redevelopment is a priority, making everything accessible from www.abcd.care. This work, undertaken as a priority, is nearing completion and the face of the new website was demonstrated during the ABCD executive committee meeting on 14 March 2018 and looks impressive. The new website will be live shortly and we will advise you of its launch.
Midwives National Survey
This has been completed and is in the process of being published and is available online (https://abcd.care/first-national-survey-diabetes-education-and-training-needs-midwives-uk). The survey was led by Dr Umesh Dashora and supported by the DCT. Thanks to the current Chairman of the DCT that we have completed this work. The survey has identified the need for education and training of midwives who care for people with diabetes during pregnancy. Further work is underway now in collaboration with the Royal College of Midwives to produce two modules which will be completed by the end of this year and, after quality assurance, made available for ongoing education for midwives. Communication plans are in place for this important work to raise its awareness.
Regional ABCD Meeting pilots
The first meeting was held at the University of Wolverhampton, which I was privileged to attend and open. This was an ABCD-backed full day education event where clinicians from primary care, specialist diabetes teams and GPs were present. The feedback was excellent and we are planning to run the second pilot event on 18 October in Yorkshire. A detailed report of these two meetings will be presented to the committee meeting in November 2018. Such meetings can be planned and delivered in geographically defined areas including Wales, Scotland and Ireland.
Getting It Right First Time (GIRFT) work
ABCD is very supportive of these national initiatives and is working closely with National leads Dr Gerry Rayman and Dr Partha Kar. The data set is being sorted based on visits to specialist diabetes teams in four Trusts and this work is expected to be completed over the next two years. Dr Gerry Rayman has agreed to present the insights to the ABCD meeting in Spring 2019.
New Treasurer
I am delighted to announce that Dr Andrew Mackling was elected as Treasurer from a field of three strong candidates who expressed interest. Andrew will take over from our previous treasurer, Dr Tony Robinson, during the meeting in Glasgow. My personal thanks to Tony; we are indebted to him for all his hard work with the Association and his commitment to support the executive team for an extra year.
Working relationships with key stakeholders
Our relationship with key stakeholders continues to be strong and to flourish. I have recently been in touch with officers of the Society for Endocrinology (SfE) and I have identified four key areas where we can work together. This is something we have not done before. These include supporting taster days for recruitment into the specialty, a work lead by YDEF, Obesity Services and regional educational meetings for SpRS. ABCD has been approached by the RCP to contribute to the service assessments and also critical appraisal of case reviews requested by the Trusts and other societies. We are in the process of signing a memorandum of understanding with the RCP. There is a well organised infrastructure and process which the RCP follows and is based on Structure Case Notes reviewed adopted nationally and supported by the NHS.
British Journal of Diabetes (BJD)
Our journal is growing and we now have in post a new Editor, Dr Marie France Kong, on a permanent basis and we are in the process of applying for PubMed citation. The three Directors have a clear vision for the direction of travel of the journal which is shared with the wider committee. Arrangements have been put in place to inform the ABCD committee on both the editorial activities (the Editor) and Governance report (the Directors) for the journal on a six-monthly basis.
ABCD-RA Collaboration
The Collaboration has produced key guidelines which have been endorsed by RCP and DUK. We have three new position statements which are completed and ready for publication. These position statements will support specialist diabetes teams to contribute to improvements in care for people with diabetes.
Nationwide Audits
The nationwide audit of new therapies is established and continues to progress well under Bob Ryder’s leadership. This year we signed an agreement for a very key audit on FreeStyle Libre, the tool for which is ready, and we look forward to this audit producing some key data informing us about this new technology.
Position Statement
We have commissioned three new position statements which are nearing completion. These relate to the role of biosimilar insulin in the management of diabetes; the use of SGLT2 inhibitors in the management of type 1 diabetes; and the impact of GLP-1 analogues on cardiovascular outcomes in diabetes.
Corporate Funding Scheme
The funding for the Association is dependent on corporate support, and successive treasurers have designed schemes that comply with ABPI regulations to cover the whole range of activities. We are delighted that we have more interest in these schemes. We are planning to meet with all our sponsors – rather than just our gold sponsors – on 11 June 2018 in London after the ABCD committee meeting to discuss the corporate support for future years and whether the current scheme requires any revision and update. I am delighted to report that Lilly has announced that they are willing to support the National Consultant Diabetologists’ Mentorship Scheme for next year based on our revised funding scheme. I thank Lilly for their support for the scheme since its inception, and for their commitment to see it placed on a firm footing for the future.
I would like to thank my predecessor Dr Rob Gregory for his ongoing support and the executive team of Tony Robinson, Russell Drummond and Dipesh Patel for discharging their responsibilities so well and so conscientiously. Huw Jones continues to lead the academic subcommittee and we have plans to refresh and invigorate the research subgroups with new programmes and activities. Thanks also to Professor Dev Singh for his leadership on professional development, and Andy Macklin who has been the public face of ABCD on social media and who I welcome as the new Treasurer to the executive team. My personal thanks also to Professor Alan Sinclair for his lead role to support members for the National ACCEA award scheme. Alan will be demitting his role but has very kindly offered to support Professor Steve Baines from Swansea who will be taking over the role.
The ABCD committee is full of committed individuals who support the organisation and give their time generously to help ABCD deliver its activities. The trustees have backed the executive financially and with wise advice, and I am pleased that so many of them attend our conferences. Finally, I must thank the ABCD secretariat, Red Hot Irons – Tricia, Elise, Jen and Heather who remain the backbone of the Association’s operational activity and Joyce McCleary for supporting the Treasurer as book-keeper to the organisation.
Some of the ABCD highlights during 2017/18 were as follows:
Rowan Hillson Award 2017
Thanks to the teams who have submitted their entries for the best digital initiative for this prestigious award. The winner of the award was Dr Stuart Ritchie at Western General Hospital, Lothian for his project on the development of an inpatient diabetes dashboard to drive quality improvement. For details visit www.abcd.care/rhaward2017
National Diabetes Inpatient Audit highlights slight improvements in patient outcomes – though workforce issues remain
Diabetes UK, NHS Digital, Public Health England and the Healthcare Quality Improvement Partnership (HQIP) has published the latest National Diabetes Inpatient Audit (NaDIA). Since 2011, improvements included a reduction in medication errors from 40% to 31%, fewer episodes of hypoglycaemia from 26% to 18% and a lower percentage of patients developing foot ulcers from 1.6% to 1%. Of concern, however, 28% of hospital sites reported having no diabetes inpatient specialist nurses and only 20% of hospital sites had a multidisciplinary foot care team.
https://www.digital.nhs.uk/catalogue/PUB30248
NHS England’s Type 2 Diabetes Prevention Programme findings reveal dramatic improvements in weight loss for participants
NHS England have published the latest data on its type 2 diabetes prevention programme, which is a nine-month personalised lifestyle programme for individuals identified as at high risk of developing type 2 diabetes. Early findings found that participants lost on average 1 kg more than originally predicted for the programme. Over 50% of people completing the programme lost an average of 3.3 kg.
https://www.england.nhs.uk/2018/03/type-2-nhsdpp/
NHS England highlights progress in commissioning local diabetes services
NHS England has published the Clinical Commissioning Group Improvement and Assessment Framework (CCGIAF) results for local diabetes services in 2016/17. The Framework shows how local CCGs are performing against criteria across a number of therapeutic areas and rates CCGs accordingly. In 2016/17, 86 CCGs were rated good or outstanding for diabetes services, an increase of 26 on the previous year. The cause of this increase has been attributed to transformation funding linked to patients’ attendance at structured education and achieving all three NICE treatment targets for good management of diabetes. Quarter 3 allocations of the transformation funding covering 170 projects across England were made at the end of December 2017. NHS England also highlighted the appointment of new local diabetes network leads supporting CCGs that are poorly performing against the CCGIAF’s criteria.
| Authors | Type of study | Main results |
| Ahlqvist et al | Data-driven cluster analysis of six variables |
Diabetes can be re-classified into five groups with different patient characteristics and risk of complications. Some patients (Cluster 3) who are most insulin resistant are at higher risk of diabetic kidney disease. Others who are insulin deficient (Cluster 2) have a higher risk of retinopathy. Genetic associations of these clusters are also distinctive. |
| Ruiz-Nunez et al | Case–control study | Most chronic fatigue syndrome (CFS) patients had similar TSH levels but lower T3 levels and higher rT3 levels. 16/98 CSF patients vs. 7/99 controls had T3 levels below the reference range (OR 2.56; 95% CI 1.0 to 6.54). If confirmed, T3 and iodine supplements might be useful in this group of patients. https://www.frontiersin.org/articles/10.3389/fendo.2018.00097/full |
| McIntyre et al | Observational study (n=1,516) | There was no evidence of excess fetal growth, hypertension in pregnancy or caesarean delivery in women with fasting venous plasma glucose <5.6 mmol/L. The authors therefore challenge the validity of the World Health Organisation 2013 threshold of >5.1 mmol/L as diagnostic of gestational diabetes in the Danish population. http://care.diabetesjournals.org/content/early/2018/03/16/dc17-2393 |
| Billings et al | RCT | In patients with uncontrolled type 2 diabetes on IGlar U100 and metformin, IDegLira treatment elicited HbA1c reductions comparable to basal bolus (p<0.0001), with statistically superior lower hypoglycemia rates and weight loss (−3.6 kg) versus weight gain. http://care.diabetesjournals.org/content/early/2018/02/23/dc17-1114 |
| ADA | Standards of Medical Care in Diabetes 2018 position statement | The new ADA position statement covers and updates a number of areas of medical care for people with diabetes, including testing for testosterone in males with signs and symptoms of hypogonadism, low carbohydrate diets in diabetes, CGMS for all adults with type 1 diabetes not meeting target glucose levels, new CGM devices that do not require confirmation by self-monitoring of capillary blood glucose before treatment decisions, consideration for medications that have shown cardiovascular benefits as a second-line therapy (liraglutide [benefit ASCVD], empagliflozin [benefit ASCVD and heart failure], canagliflozin [benefits: ASCVD and heart failure but caution bone fractures]) after metformin in people with type 2 diabetes, target BP <140/90 in patients with hypertension, self-measurement of BP, addition of ezetemibe or PCSK9 inhibitors in high-risk patients with LDL >70 mg% on statins, target CBG level of 7.8–10 in most hospitalised medical patients although in some a lower target of 6.1 may be acceptable. http://care.diabetesjournals.org/content/41/Supplement_1/S144#T1 |
| Iqbal et al | Review | Structured education can reduce the frequency of severe hypoglycaemia (by 50%) in type 1 diabetes. This is similar to the reduction achieved with improved technological advances and newer pumps. https://link.springer.com/article/10.1007%2Fs00125-017-4334-z |
| Choudhary et al | Review | The authors discuss the potential benefit of technology in reducing the risk of severe hypoglycaemia in patients with type 1 diabetes (CGMS, close-loop devices) but also its limitations such as the presence of an attached device and alarm fatigue. The importance of additional education and psychological input is emphasised. https://link.springer.com/content/pdf/10.1007%2Fs00125-018-4566-6.pdf |
| Zheng et al | Analysis of data from English Longitudinal Study of Ageing |
Analysis of this longitudinal study over 10 years suggests a significant association between higher HbA1c and cognitive decline. Compared with normal glucose levels, the cognitive decline was higher in patients with prediabetes (−0.012 SD/year) and diabetes (−0.031 SD/year). https://link.springer.com/content/pdf/10.1007%2Fs00125-017-4541-7.pdf |
| Cummings et al | Review | Metabolic surgery may help people with type 2 diabetes with better results than medical treatment options even in patients with BMI as low as 30 or 27.5 kg/m2 for Asians. https://link.springer.com/article/10.1007%2Fs00125-017-4513-y |
| Feig et al | Review | Continuous glucose monitoring in pregnant women with type 1 diabetes helps achieve lower HbA1c, more time spent in the target range and reduction in some adverse neonatal outcomes compared to standard care. Number needed to treat to prevent large for gestational age infant, neonatal unit admission and neonatal hypoglycaemia was 6–8. This was seen in pump as well as injection users. Macrosomia may have non-glucoserelated origin. https://onlinelibrary.wiley.com/doi/abs/10.1111/dme.13585 |
| Alqudah et al | Systematic review and meta-analysis | Metformin can reduce the incidence of pre-eclampsia (RR 0.68) in women with gestational diabetes especially when insulin is used. It also helps reduce weight gain during pregnancy. https://onlinelibrary.wiley.com/doi/abs/10.1111/dme.13523 |
| Algeffari et al | Systematic review and meta-analysis | Testosterone treatment can improve sexual desire and erectile function but not constitutional symptoms in patients with diabetes compared with control groups. https://onlinelibrary.wiley.com/doi/abs/10.1111/dme.13553 |
| Paisey et al | Peer review | Diabetes-related lower limb amputations are strongly related to the diabetes foot service provisions with elements like administrative support, standardised general practice foot screening, improved community podiatry staffing, hospital multidisciplinary foot clinics, effective care pathways, availability of an orthotist and audit (p=0.0024). https://onlinelibrary.wiley.com/doi/abs/10.1111/dme.13512 |
| Ndosi et al | Prospective observational study | Prognosis of infected foot ulcer in patients with diabetes remains grim with death in 15.1% of patients, non-healing of ulcer in 54.5%, recurrence in 9.6%, lower limb amputation in 17.4% and revascularisation surgery in 6% within 1 year. Ulcer present for over 2 months, poor perfusion and multiple ulcers are bad prognostic factors. https://onlinelibrary.wiley.com/doi/abs/10.1111/dme.13537 |
| Marjot et al | Survey followed by screening | The prevalence of non-alcoholic fatty liver disease in diabetes can be as high as 63.6%. The authors suggest a screening tool Fib-4 index to improve detection of patients at higher risk and manage them better. https://onlinelibrary.wiley.com/doi/abs/10.1111/dme.13540 |
| Del Prato et al | Post-hoc analysis of RCTs | This post-hoc analysis suggests that dapagliflozin, sexagliptin and metformin therapy is safe and tolerable either as concomitant or sequential add-on regimens with either agent added to metformin. Urinary tract infections were less common in concomitant therapy and genital infections were only seen in sequential therapy. https://onlinelibrary.wiley.com/doi/abs/10.1111/dom.13258 |
| Yamada et al |
Systematic review and meta-analysis of RCTs |
SGLT-2 inhibitors added to type 1 diabetes reduced HbA1c by 0.4%, fasting glucose by 1.14 mmol/L, body weight by 2.68 kg, SBP by 3.37 mmHg, basal insulin dose by 3.6 U/day, bolus insulin dose 4.2 units/day without any increase in hypoglycaemia. SGLT-2 inhibitors increased DKA (OR 3.38) and genital tract infection (OR 3.44). If used, caution should therefore be exercised. https://onlinelibrary.wiley.com/doi/abs/10.1111/dom.13260 |
| Hallow et al | Review and hypothesis | SGLT-2 inhibitors may reduce heart failure because of their differential diuretic effect on electrolyte-free fluid leading to reduction in interstitial fluid with minimum effect on blood volume, arterial filling and perfusion. A new hypothesis and mathematical model is proposed. https://onlinelibrary.wiley.com/doi/abs/10.1111/dom.13126 |
| Ritzel et al | Meta-analysis of EDITION trials | Insulin glargine U300/ml leads to better glycaemic control (least square mean difference in change from baseline −1.09 mmol/mol) with a lower rate of hypoglycaemia (confirmed or severe hypoglycaemia lower by 15% at night and 6% at any time of the day and rate of hypoglycaemia lower by 18%) compared with insulin glargine U100/ml. HbA1c <7.0% without nocturnal hypoglycaemia was achieved by 24% more participants in the Gla-300 arm. https://onlinelibrary.wiley.com/doi/abs/10.1111/dom.13105 |
| Yuan et al | Retrospective cohort study | Rate of lower limb amputations in patients on SGLT-2 inhibitors is 1.22, 1.26 and 1.87 events per 1000 person-years with SGLT-2 inhibitors, canagliflozin and non-SGLT-2 inhibitors antihyperglycaemic agents. https://onlinelibrary.wiley.com/doi/abs/10.1111/dom.13115 |
| Lean et al | Cluster-randomised diabetes remission clinical trial | DiRECT was published in the Lancet in December 2017, reporting reversal of type 2 diabetes in 46% of a primary care cohort with a low calorie diet. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)33102-1 |
| Benson et al | Experimental study in human volunteers | A single fat meal can increase erythrocyte modelling and myeloperoxidase levels which can increase the risk of acute coronary syndrome. https://www.nature.com/articles/s41374-018-0038-3#Sec2 |
The year ahead promises to be a busy one, but we are all ready for the challenge. We have progressed and strengthened our team, taking on new challenges under the leadership of Amar Puttanna (West Midlands). However, he has now stepped down as Chair and passed the baton on to Myuri Moorthy (London).
We had a very successful recruitment process this year, and are delighted to welcome four fantastic new members to our committee. Najaf, Giulia, Tim and Swarupini are sure to enhance our team and continue to drive what we do for years to come. We sadly had to say goodbye to two very valuable members, Adam Nicholls and Sophie Harris, as they focus on their consultant post and completing training, respectively.
Najaf Haider is an ST5 trainee in Wessex Deanery. He has worked in three different health systems in three countries, which gives him a unique vantage point to see how things are done in the NHS. He is interested in how diabetes affects different ethnic populations and neuroendocrine disorders. He is a tech enthusiast.
Giulia Argentesi is an ST4 diabetes and endocrinology trainee at University College London Hospitals. She is also an NIHR academic clinical fellow pursuing research into obesity. Her other interests include teaching, particularly for membership examinations, and she teaches regularly on the leading professional paces course.
Tim Robbins is an academic diabetes and endocrine SpR in the West Midlands, pursuing a PhD with the Institute of Digital Healthcare at the University of Warwick. His cross-discipline research focuses on risk stratification of patients with diabetes at discharge from hospital and matches to his research interests in diabetes, healthcare organisation and health informatics.
Swarupini Ponnampalam is an ST5 at Whittington Health (NCL deanery). She came to the UK in 2014 from Malaysia before joining the NHS. She has a keen interest in teaching.
Our main event of the year was organised by Sophie Harris and was another resounding success. The theme of the days was transformation and variation, with the aim of inspiring and empowering trainees to reduce inequalities in care. Partha Kar, who delivered an NHS England update, set the scene. This was followed by an incredibly informative and engaging plenary lecture by Amanda Adler ‘Evidence-based medicine, data and NICE’. Six enjoyable workshops ran throughout the day focusing on setting up, developing and changing clinical services. Melanie Davies’ closing keynote lecture ‘Designing and implementing self-care models now and in the future’ concluded the sessions nicely. To end the day, our panel of experts were put on the spot with some quick-fire questions. As always, YDEF Day was followed by a fun dinner for delegates and faculty.
Over the last year we have carried out two important surveys, the Trainee Wellbeing Survey and the Variations in Training Survey. The first demonstrated that 61 out of the 103 D&E trainees surveyed experienced some form of burnout and that contributory factors identified were heavy GIM workload and lack of specialty exposure. The Variations in Training Survey found that there is great variation in specialty only training across the country with some deaneries offering their trainees up to 2 years of specialty only training, whereas other trainees did not have any. This year we hope to work with the Diabetes & Endocrinology Specialty Advisory Committee to see what we can do to improve training experience and reduce national variations in training.
The National D&E taster day in Birmingham was very well received, but in order to reach a much wider audience we feel it would prudent to hold regional taster days and are keen to support anyone who is interested in organising one for their region.
YDEF Pump Course
6–8 June 2018
Our pump course is an essential course for all those working with patients on insulin pumps. It offers 2 days of practical hands-on experience, with the opportunity to try and become comfortable with a range of different insulin pumps. It will be held in Oxford on 6–8 June 2018.
ABC of D&E
28–29 June 2018
We will be running ABC of D&E for the first time this year. It promises to be a fundamental course for all new SpRs to Diabetes and Endocrinology. It will take place on 28–29 June 2018 in Birmingham.
National D&E Taster Day
15th September 2018
After the success of last year’s taster course in Birmingham, we have decided to run this course annually. Please keep an eye on our website for details of when and where it will be held this year.
Dr Amar Puttanna
Email: amarputtanna@doctors.org.uk