This is my first bulletin this year since the last publication of BJD in December 2018. The editorial team has recently taken the decision to reduce the number of paper issues of BJD. The reduction in frequency of hard copy issues of the journal is as a result of lower than expected submissions of quality articles and it also allows us to reduce our production costs a little and focus on timely processing of papers as they are submitted. We will continue to publish all accepted articles online and ahead of print. In order to prepare for submission to PubMed Central, I would like to urge all ABCD members to consider submitting their work to BJD in the form of interesting case reports, topical systematic review articles of interest and original research manuscripts.
I am delighted to announce that Dr Susannah Rowles has been appointed as honorary General Secretary of ABCD for a three-year tenure. Susannah has been a co-opted member of ABCD for many years, representing the organisation on all aspects of transitional care and represents ABCD on the Specialist Training Committee of the RCP.
Recent elections for the two positions to replace retiring members generated a healthy interest. We received a number of very high quality applications from consultant colleagues with excellent credentials. After careful deliberation, the executive team has decided unanimously to increase the number of elected members to serve on the ABCD committee. This decision has allowed us to take on four highly experienced colleagues, and our congratulations to Dr Parth Narendran, Dr Emma Wilmot, Professor Rob Andrews and Dr Alison Gallagher on their successful appointment. Our commiserations to the unsuccessful applicants; we hope this will not deter them from reapplying in the future.
I would like to report that ABCD has had some very constructive discussions with the Chair of the Primary Care Diabetes Society (PCDS), Dr Clare Hambling. We both are keen for the two organisations to work together on a number of areas (being ratified by respective committees). This, I believe, is a step in the right direction, not only for ABCD and PCDS but also for diabetes care in general. The recently published joint position statement on ‘Remission of type 2 diabetes’ is one such example and hopefully the beginning of a very positive and collaborative partnership.
The NHS has struggled over many years to create true integrated primary/secondary care working amongst healthcare professionals (HCPs). Both ABCD and PCDS are aware of some excellent models of joined-up working to address challenges in tackling diabetes in localities. We believe that a close scrutiny of these models to establish some broad themes which underlie their success is a worthy objective so that we can disseminate this important intelligence more widely.
I am pleased to inform you that the work undertaken following a national survey of midwives is nearing completion and will be available to thousands of midwives who care for pregnant women who have diabetes or develop it during pregnancy. This piece of work fits well with the recent strategic shift to ensure that ABCD contributes to the education and training of HCPs who contribute significantly to diabetes care.
The new venture of a fortnightly e-newsletter communication with members commenced at the beginning of this year and has been well received. Please help us create and disseminate important news to the diabetes community of specialists by e-mailing any relevant news you have to share with the membership via info@abcd.care. My thanks to Tricia Bryant and the team at Red Hot Irons who have made this possible.
ABCD has updated the position statement on ‘SGLT-2 inhibitors in Type 1 Diabetes’ since the licence has been awarded for the use of dapagliflozin in conjunction with insulin in people with type 1 diabetes. NICE are currently in the process of developing and publishing guidance, due in August. https://www.nice.org.uk/guidance/indevelopment/gid-ta10374
The Diabetes Technology Network (DTN) has recently produced a set of educational webinars to educate and train HCPs on technology-related issues. Since the introduction of these webinars the initial indication shows that they have been accessed by a significant number of HCPs and are available for download at https://abcd.care/node/778. This is a major new development and success and thank you to all colleagues at the DTN for their hard work.
Following the national announcement in November 2018 that FreeStyle Libre will be made available to patients with type 1 diabetes, we received the NHS revised criteria in March 2019. The funding for each locality is included in this announcement and is based on a calculation that approximately 20% of the population with type 1 diabetes will be eligible for flash glucose monitoring. Many health professionals including me believe that the criteria still remain too narrow and in reality there are significantly more individuals who can benefit from the use of this technology. An early indication of the benefits of this was presented at the recent Diabetes UK meeting by the ABCD FreeStyle Libre Audit group.
The ABCD Spring meeting took place in the beautiful campus of Loughborough university on 14/15th of May. It was very successful. On Thursday we had several high quality presentations from the technology experts, including a presentation from the service users. Dr Emma Wilmot announced that she will step down from her role as Chair of DTN after this meeting and hand over the reigns to Dr Pratik Choudhary and Dr Alistair Lumb. The ABCD Chair thanked Emma for her outstanding contribution to the DTN over the last three years.
The ABCD Autumn Meeting is scheduled to take place on Thursday/Friday 28/29 November in London; we continue to work on the extended programme over 1.5 days with inclusion of industry-led symposia. For the first time ABCD plans to run a parallel session for ST3 and ST4 trainees on the fundamentals of diabetes and endocrinology.
By the time this news is in paper format I will have completed two years as Chair of ABCD with my remaining term of office taking place during a time of great challenge for the NHS and its management of diabetes. One of the key areas of focus in my last year will be to build on the work we have done in the last two years with special emphasis on education and training of allied HCPs whilst ensuring that ABCD continues to deliver innovative and relevant programmes for the membership.
Finally, there have been concerns raised from several colleagues about the impact of a no-deal Brexit on the supply of medicines in the NHS, especially insulin. In the unlikely scenario of a shortage of insulin, there would be potentially serious implications. This was discussed at our joint meeting with Diabetes UK and we plan to produce some working guidance for insulin users as to the best ways to deal with this situation. ABCD is also concerned about the plans allowing pharmacists to switch insulins to an alternative. While it is somewhat reassuring to hear that there are contingency plans for this, ABCD remains concerned about the lack of clarity and any visible details.
ABCD is planning to seek intermediate to long term funding for the National ABCD Mentorship and Consultant development programme, which has been running for five years. Our thanks to Eli Lily for their unconditional support so far, but I believe that the time is right to ensure that we secure the long-term future of this unique programme, which has benefited many aspiring young diabetologists. Whilst an adequately trained workforce is critical to the delivery of quality diabetes care, promoting and supporting leadership within our specialty and more widely in the NHS remains crucial.
Goodbye until next time.
Thanks to colleagues who submitted their entries for this year’s competition which was for the ‘Best Inpatient Educational Diabetes Programme for Health Care Professionals’. This JBDS-IP project was led by Umesh Dashora, Debbie Stanisstreet and Erwin Castro. The entries were judged against predetermined criteria by an independent panel chaired by Rowan Hillson, and the winner will be awarded the prestigious annual Rowan Hillson Inpatient Safety Award at the ABCD Spring meeting.
Winner
Kath Higgins and the team at the University Hospitals of Leicester NHS Trust won the competition for their Inpatient Diabetes Training & Support (ITS) programme – an educational toolkit accessible to medical, nursing and pharmacy staff. Components included face-to-face training, e-learning module, monthly newsletter, social media communications with competency document and flashcards. Messages are consistent across the resources. The project had Executive support. The judges were impressed by the reduction in insulin errors and in in-hospital DKA.
Runners up
The runners up were so close to each other that they were both awarded second place:
Congratulations to Michael Lloyd and colleagues at St Helens and Knowsley Teaching Hospitals NHS Trust for their individualised and shared insulin prescribing error feedback system, Safe Insulin TiPS (SIPS), and multi-professional simulation based training.
Congratulations to Ruth Miller and colleagues in North West London for the project to implement Diabetes 10 Point Training in Acute Hospitals across North West London. This clinically-based teaching programme provided quick training specifically designed for all hospital settings to address the commonest diabetes errors.
A number of new diabetes guidelines from the Joint British Diabetes Societies for inpatients (JBDS-IP) and their positive impact are now published in Diabetic Medicine to support and standardise the care of inpatients with diabetes.
The National Severe Insulin Resistance (NSIR) Service is a highly specialised NHS service which provides a multidisciplinary service for adults and children with inherited or acquired severe insulin resistance and/or lipodystrophy. The service is funded directly by NHS England for patients residing in England with no extra cost to local CCGs. The service has been running since 2011 and we have now seen nearly 400 patients.
The NSIR service offers biochemical and genetic testing and access to specialised dietetic support and medication. We are currently the only UK centre permitted to prescribe metreleptin therapy to patients with lipodystrophy. After an initial review at our clinic, we usually continue shared care with the local team. We also offer telephone appointments for ongoing follow-up if preferred.
Referral criteria
We are happy to accept referrals or to discuss patients with known or suspected:
Contact us
E-mail: insulinresistanceservice@addenbrookes.nhs.uk
Website: https://www.cuh.nhs.uk/national-severe-insulin-resistance-service
Telephone: 01223 768455
Post: c/o Mrs Elaine Withers, National Severe Insulin Resistance Service, Level 4, Institute of Metabolic Science, Box 289, Addenbrooke’s Hospital, Hills Road, Cambridge CB2 0QQ
Congratulations to Professor Jonathan Valabhji, National Clinical Director for Diabetes and Obesity at NHS England for being awarded the OBE for services to diabetes and obesity care.
Dr Partha Kar provided an overview of what the NHS Diabetes team has delivered in 2018 in his Christmas blog, which includes many achievements of which many of you reading this will have been part. Read it on the below link to access additional information on fabulous projects such as Language Matters, the new T1 Diabetes Resource and the implementation of low calorie diets to help in the remission of type 2 diabetes, to name but a few.
http://nhssugardoc.blogspot.com/2018/12/and-thats-wrap.html
The NHS Long Term Plan was launched, which can be found via the link https://www.gov.uk/government/news/nhs-long-term-plan-launched and, more specifically, the diabetes section can be found at https://www.longtermplan.nhs.uk/online-version/chapter-3-further-progress-on-care-quality-and-outcomes/better-care-for-major-health-conditions/diabetes/. Chapters One and Two set out a range of actions the NHS will be taking to prevent type 2 diabetes and reduce the variation in the quality of diabetes. For those people living with a diagnosis of type 1 or type 2 diabetes the NHS will enhance its support offer. We will support people who are newly diagnosed to manage their own health by further expanding provision of structured education and digital self-management support tools, including expanding access to HeLP Diabetes, an online self-management tool for those with type 2 diabetes. The NHS will ensure that, in line with clinical guidelines, patients with type 1 diabetes benefit from life-changing flash glucose monitors from April 2019, ending the variation patients in some parts of the country are facing. In addition, by 2020/21, all pregnant women with type 1 diabetes will be offered continuous glucose monitoring, helping to improve neonatal outcomes. Through continuing investment in supporting delivery across primary care, we will enable more people to achieve the recommended diabetes treatment targets and drive down variation between CCGs and practices to minimise their risk of future complications. Further, for those who periodically need secondary care support we will ensure that all hospitals in future provide access to multidisciplinary footcare teams and diabetes inpatient specialist nursing teams to improve recovery and to reduce lengths of stay and future readmission rates.
NCEPOD is pleased to have released a new report summarising a review of the care received by adults age 16 and over with diabetes who underwent a surgical procedure. The report takes a critical look at what could have been improved. There are 13 recommendations made to improve the care for any person over the age of 16 with diabetes undergoing surgery.
https://www.ncepod.org.uk/2018pd.html
In response to an earlier consultation, the Medicines and Healthcare products Regulatory Agency (MHRA) has issued further guidance in the event that the UK and EU fail to reach a deal on Brexit, resulting in a ‘no-deal’ situation from 29 March 2019. Key arrangements the MHRA will undertake in a no-deal Brexit include automatically converting Centrally Authorised Products to UK Marketing Authorisations (MAs), targeted assessments for products containing new active substances (NAS), a 2-year grace period to amend packaging and leaflets for products already on the market and allowing parallel imports of medicines holding a MA in the EU. On clinical trials, the MHRA has pledged to continue recognition of existing approvals for clinical trials and aligning, where possible, with the EU Clinical Trials Regulation when it comes into force.
Each year the UK’s Chief Medical Officer (CMO), Professor Dame Sally Davies, publishes an annual report. For 2018, her annual report focuses on the state of public health in England in 2040. The CMO suggests that the state of public health in England is currently at a critical moment in deciding whether current trends widen gaps in life expectancy, or where policy and digital technologies can be utilised to ‘bring prevention to the public’. The report highlights a number of recommendations, particularly around tackling childhood obesity, although there are other recommendations of interest. In particular, the CMO is calling on NICE to develop multi-disease guidelines for common clusters of disease to avoid multiple disease guidelines applying to the same groups of patients and for the NIHR and MRC to commission research to identify and understand the disease clusters that make up common multi-morbidity.
Diabetes UK has published new data indicating that lower limb amputations have increased by 19.4% from 2013 to 2017 – with 26,378 lower limb amputations occurring between 2014 and 2017. They have also highlighted that at least £1 in every £140 of NHS spending goes towards foot care for people with diabetes. Diabetes UK used the new data to call on NHS England to commit to maintaining the Diabetes Transformation Fund beyond 2019. Since 2017, NHS England’s Diabetes Transformation Fund has invested more than £80 million to improve access to specialist foot care teams for people with diabetes across England.
https://www.diabetes.org.uk/about_us/news/lower-limb-amputations
Following the publication of the National Diabetes Inpatient Audit, Diabetes UK has proposed new recommendations to improve inpatient care for people with diabetes. Currently, one in six hospital beds are occupied by someone with diabetes, and by 2030 it is predicted that this will rise to one in four. Inpatient care for diabetes also costs the NHS £2.5 billion, 11% of the total cost of inpatient care. A key recommendation from the report included ensuring that there are multidisciplinary diabetes inpatient teams in all hospital. Diabetes UK estimated that an investment of £5 million on new diabetes inpatient specialist nursing services in 54 trusts would yield approximately £14 million savings per year, resulting in net savings of £9 million. Further recommendations included improving the knowledge of other healthcare professionals in diabetes, better support in hospital for people to take care of their own diabetes, enhancing access to systems and technology and more support for hospitals to learn from mistakes.
Following the NHS Long Term Plan commitment to deliver a step change in mental health treatment and young people’s health, NHS England has announced that it will pilot a new service to tackle the rare eating disorder, diabulimia. Diabulimia is a condition where people with type 1 diabetes restrict their insulin intake to lose weight and can lead to serious complications including blindness and amputations. It is most common in young people aged between 15 and 30. The service, which will be piloted in London and the South Coast, will establish specialist day care centres providing structured meal planning and advice on glucose and insulin management. These will be staffed by new eating disorder teams specialising in mental healthcare and type 1 diabetes. The pilot will also include training for other HCPs to increase their knowledge of the condition.
Diabetes UK (DUK) has published a new analysis of the number of people living with type 2 diabetes in the UK. According to this analysis there are currently 3.8 million people living with a diagnosis of diabetes in the UK, and 90% of this population have type 2. Further to this, DUK estimates that there are in addition 1 million people living with type 2 diabetes without a diagnosis, bringing the total number up to 4.7 million. DUK estimates that, by 2030, this number will rise to 5.5 million. DUK used the figures to call for the UK to do more to address rising obesity rates, as well as encouraging the public to use the ‘Know Your Risk’ online tool and urging people over 40 to get a free NHS Health Check.
https://www.diabetes.org.uk/about_us/news/new-stats-people-living-with-diabetes
New data from the Diabetes Foot Care Profiles, published by PHE’s National Cardiovascular Intelligence Network, reveals that the overall number of lower limb amputations continues to rise, with white males having the highest: 7,545 major amputations between 2015 and 2018 compared with 6,957 between 2012 and 2015. The overall number of major amputations is increasing as the number of people diagnosed with diabetes rises, but the rate among people with diabetes is not significantly increasing.
https://www.gov.uk/government/news/preventing-amputations-major-concern-as-diabetes-numbers-rise
The healthcare think-tank Nuffield Trust has published a report assessing the health of children and young people aged 10–24 against comparable countries. The report, which analysed 17 measures of health and wellbeing, found that, while young people make healthier choices such as drinking less alcohol and smoking less, the burden of long-term conditions such as asthma and diabetes was far higher in the UK. In particular, the report found that the UK had the highest rates of obesity for 15–19-year-olds amongst the EU15, as well as the third highest rate of young people aged 16–24 with a long-term condition (aside from Finland and Sweden). For asthma, the UK had a far higher mortality rate for young people aged 10–24 (0.28 per 100,000 in 2016) than other European comparators, but was lower than Australia, New Zealand and the USA. However, for young people aged 10–14 the incidence was far higher (0.31 per 100,000 in 2016), with the UK ranking behind only New Zealand in this category.
A rapid-fire collection of interesting recent developments in diabetes
One of the great pleasures of our speciality is the nature of diabetes and endocrinology as a rapidly evolving field, with a constant supply of new information to nourish our life-long learning needs (and, of course, provide content for trainee e-portfolio reflections!).
YDEF (the Young Diabetologist & Endocrinologist Forum) strives to be at the heart of supporting trainees to learn the information they need either for their daily professional practice or to explore areas of personal specialist interest. The last few months have been particularly busy and we are delighted by the opportunity to share some of those activities here.
The flagship event in our calendar is the YDEF Annual Day, hosted immediately before the Diabetes UK Professional Conference and culminating in a networking social event in the evening. This year attendees enjoyed presentations from Dana Lewis on Open Source Technology, Abd Tahrani on Obesity and Ben Whitelaw on Checkpoint Inhibitors. Particular congratulations are due to Shang Shao and the diabetes team at Newham Hospital who won the annual poster prize with a great poster considering practical approaches to reducing inpatient hypoglycaemia.
The Diabetes UK Professional Conference provided a further opportunity for both learning and networking. The professional interest group proved to be particularly stimulating with the chairs of both YDEF and ABCD exploring exemplars of good practice in balancing speciality and general internal medicine clinical demands with some fantastic examples from across the country. The YDEF Travel Award was shared this year by Sheila Grecian and Hanieh Yaghootkar, and it was a delight to see a trainee (Peter Jacob) win the Lilly Diabetes Clinical Science Poster Award.
Each year we have run an insulin pump course that has been particularly popular with trainees. However, this year, acknowledging how quickly technology has changed, the course was restructured to a new format called the ‘YDEF Diabetes Technology Course’, which was held at the delightful Eynsham Hall venue in Witney, Oxfordshire. The course proved as popular as ever and was rapidly oversubscribed. We will, of course, be running it again next year and recommend anyone interested to book early. We are grateful to Giulia Argentesi for coordinating the course from a YDEF perspective and the tireless efforts of Pratik Choudhary and all the other speakers.
Looking to the future, we have a new president (Clare Whicher) from Southampton who co-ordinated the YDEF Annual Day described above and, after a competitive application process and interviews, we are delighted to welcome five new members to our committee: Peter Jacob, Fahad Arshad, Meera Ladwa, Thomas Crabtree and Anne De Bray. We look forward to working with them to curate the next series of YDEF educational events. On the horizon we have a collaborative YDEF/ABCD/SfE Taster Day planned for September in Newcastle, a repeat of the ‘ABC of D&E’ course for new trainees to the speciality and are finalising the Lilly EASD Scholarship Programme.
We hope this meets our mission to enable advocacy, education and support of trainees in our speciality and we would welcome any other suggestions or ideas!
Dr Tim Robbins
A speciality trainee in the West Midlands Region, a member of the YDEF Committee and trainee representative to the Health Education West Midlands Specialist Training Committee. He is organising the next YDEF Training Day in Northern England.
Contact: timothy.robbins@nhs.net