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Just a few years ago FreeStyle Libre (FSL) was a rarely encountered device, used only by a select few people with type 1 diabetes who could afford to self-fund it. This small disc has a small cannula under the skin which allows for interstitial glucose measurements and remains in situ for 14 days. Over the last 4 years the number of people with access to this life-changing technology on the National Health Service (NHS) has increased rapidly. Although there were barriers to implementing access and encouraging uptake of this technology, including systems, healthcare professionals and the users themselves, innovative interventions from NHS England and diabetes organisations ensured those who stood to gain the most benefit were not impeded in their access, with a particular emphasis on enabling FSL use in those who are often the hardest to reach. This article reviews the impact of FSL on type 1 diabetes care in England, the key events to date and the lessons learnt that can be applied in the future for newer diabetes technologies.

Background aims Frustrated with the slow-pace of innovations in diabetes technologies, the type 1 diabetes community have started closing the loop by themselves to automate insulin delivery. While the regulatory and ethical concerns over the systems are still high, these have contributed to enhanced glycemic control characterized by improved estimated HbA1c and time-in-range above 90% as for many users. Our objective is to provide the real-world experience of the first successful patient from India on the Do-It-Yourself Artificial Pancreas (DIYAP) and the perspective of her physicians. Methods A narrative recounting of a personal experience on DIYAP. The patient completed a Hypoglycemia Fear Survey II and Diabetes Quality of Life instrument before and after looping. Results The patient emphasized the personal/social benefits and the concerns of using the system. Looping has produced a clinically meaningful difference in the quality of life, better sleep patterns, and reduced the disease management burden. We also highlighted the relevant perspectives of the physicians to give deeper insights into the aspect. Conclusion The patient highlighted better time-in-range, negligible time spent in hypoglycemia, and superior Quality of Life. Globally, more and more patients are adopting this technology; therefore, real-life patient stories will enlighten the medical community.

The world of Marvel movies and comics involves a whole multiverse where it can be hard to make sense of what’s really happening—which Spider-Man exists in which reality, or which main characters are actually dead or alive. As it’s a fantasy world, we can enjoy the moviemakers’ artistic licence in the spirit intended. A problem arises when that sort of fantastical approach starts to take hold in the NHS, when people create a parallel universe where the pandemic has been overcome, with no shred of the virus left. It’s in this world that government pronouncements on GP access have arrived. Amid some well meant intentions by the NHS to look at variation, along with “offers of help,” one initiative has caused much consternation—a government drive for more face-to-face consultations, despite an escalating infection rate and the near complete dismantling of social distancing rules and mask use. It’s as though Daily Mail readers or the tweets of a Paul3467 with two followers on Twitter have convinced everyone that, during a pandemic, face-to-face GP consultations are exactly the area to concentrate on. Add in the …

Data and process are both key. Without outcomes, however, they become yet another paperwork driven exercise with no final product. Healthcare, especially in the NHS, is blighted by such episodes. Despite having the right intentions, highlighting problems and developing processes, initiatives too often falter at the key bit: implementation to change outcomes. The problem is that, at some point, such repeated episodes culminate in stakeholder apathy and a loss of energy, or indeed a loss of belief among those whose lives you set out to improve. The reports of the Workforce Race Equality Standard (WRES) have had that sort of feel. There’s no doubting the passion behind the initiative, the data, or the process. Yet the implementation of these best laid plans has faltered, raising the question of how much will be achieved by yet another …

It’s all around you, especially if you venture into the world of social media: GPs against hospital specialists, hospital specialists against GPs, and specialists against one another. Everyone is eager to score points, having underlying angst about what others are doing, feeling hard done by and mistreated, or thinking that colleagues deserve more respect. And when a comment cuts too close to the bone, one person’s bit of old school stereotyping becomes another person’s disrespectful insult. Some seem to believe that this simply reflects the tough times we live in—perhaps the frustration of reduced resources or a huge patient backlog, combined with the aftermath of dealing with the pandemic …

How much of a problem for doctors is imposter syndrome? Is it just a term used by those who struggle to fit in? Is it a manifestation of totally natural self-doubt? Over the years we’ve lived with the rhetoric that successful people “don’t show weakness” or “don’t cry.” When interacting virtually in the online world, it’s far easier to make such judgments about others without knowing them as individuals. In doing so we may be reinforcing false beliefs or perhaps even forcing someone to conform to a set opinion or view. In the past decade or so—helped by the work of some amazing people such as Stephen Fry and Dwayne Johnson—far more of us have realised the importance of talking …

One of the biggest challenges for any healthcare system is how to support patients with chronic disease. While focusing on the availability of healthcare professionals is understandable, this may mean neglecting the basic tenets of chronic disease management and the greater challenge that lies elsewhere. To me, managing chronic disease well is founded on three basic principles: self- management, peer support, and access to trained professionals. We do not spend enough time and effort on the first two. For instance, in self-management much attention is given to what the healthcare system perceives to be the best way to deliver it instead of what is actually needed or even relevant today. A case in point is education programmes in diabetes care. Until the start of the covid-19 pandemic these programmes still …

It’s that time of the year again—when the Workforce Race Equality Standard programme publishes its data.1 And, like clockwork, it’s also time for the annual reflections, soul searching, and pledges to improve things. In due course we’ll have webinars or perhaps a dedicated hashtag campaign on social media—someone may even throw in some TikTok videos. And then we’ll move on, until next year. If you want to convince yourself of improvement, let your confirmation bias take over and you’ll find some bits to help you: 10% of board members in NHS trusts are now from minority ethnic backgrounds, up from 7% in 2017. And 21.0% of staff in NHS trusts and clinical commissioning groups (CCGs) in England are now from a minority ethnic background, up 2.9 percentage points since 2017. Surely cause to rejoice? I suspect that it depends on your outlook—on whether you think that being offered crumbs from the table is a win, or that continuing with the “Please sir, may I?” …

Ripples of hope have emerged in recent weeks, with the possibility of a working covid-19 vaccine. There are still many hurdles—demonstrating safety and efficacy, overcoming production challenges, and convincing the public amid a torrent of fake news and anti-vaxxer rhetoric. But an overarching optimism has arisen, after the tough months the world has lived through this year. The next phase will be hugely important for the NHS—delivery. Expect heated discussions around who will get a vaccine “first”: if it’s healthcare professionals, why not teachers or shielded groups? As ever, the debate will be played out in public, shot through with politics, bias, and vested interests. We must also consider the practicalities of delivering the vaccine during a …

There’s a commonly held public assumption that the NHS can provide everything medical science has to offer, to all who need it—or, at least, that this is the stated aim. Yet prioritisation has always existed in healthcare, whether driven by policy or the embedding of the “inverse care law.” It’s just that, as a system, the NHS has rarely been able to acknowledge this publicly. Political rhetoric around the NHS from all parties may mean that healthcare leaders have balked at the idea that prioritisation of services can be openly discussed. As a result, the NHS finds itself caught between its public perception as the country’s “jewel in the crown”—offering …

Obesity is a focus of political and media discussion, since multiple datasets have shown that being overweight puts people at greater risk of serious illness from covid-19. But, if we want to improve the way we manage obesity, we need better research on what works in weight management—and a rethink of our approach to service provision. NICE’s most recent guidance on identifying, assessing, and managing obesity was published in 20141: in the six years since, has there been no new evidence that would warrant an update? At that time, a lot of NICE’s recommendations were based on thin evidence, and NICE clearly accepted in its guidance that there were gaps in the research that needed covering. So, why hasn’t the research community or …

The COVID-19 pandemic is a major international emergency leading to unprecedented medical, economic and societal challenges. Countries around the globe are facing challenges with diabetes care and are similarly adapting care delivery, with local cultural nuances. People with diabetes suffer disproportionately from acute COVID-19 with higher rates of serious complications and death. In-patient services need specialist support to appropriately manage glycaemia in people with known and undiagnosed diabetes presenting with COVID-19. Due to the restrictions imposed by the pandemic, people with diabetes may suffer longer-term harm caused by inadequate clinical support and less frequent monitoring of their condition and diabetes-related complications. Outpatient management need to be reorganised to maintain remote advice and support services, focusing on proactive care for the highest risk, and using telehealth and digital services for consultations, self-management and remote monitoring, where appropriate. Stratification of patients for face-to-face or remote follow-up should be based on a balanced risk assessment. Public health and national organisations have generally responded rapidly with guidance on care management, but the pandemic has created a tension around prioritisation of communicable vs non-communicable disease. Resulting challenges in clinical decision-making are compounded by a reduced clinical workforce. For many years, increasing diabetes mellitus incidence has been mirrored by rising preventable morbidity and mortality due to complications, yet innovation in service delivery has been slow. While the current focus is on limiting the terrible harm caused by the pandemic, it is possible that a positive lasting legacy of COVID-19 might include accelerated innovation in chronic disease management.

I had to read through the email a few times to digest what a consultant had written to me. “Conflating covid with institutional racism amongst your friends and colleagues is utterly shameful,” it said. “Nobody knows the genetics of covid, but you see fit to suggest that its predilection for BAME [black and minority ethnic people] is down to racism. Your views nauseate me—there is no room for them in today’s NHS.” The email was in response to my column in May for The BMJ ,1 in which I discussed whether racism was a factor in the increased mortality rate from covid-19 among people from ethnic minority backgrounds. Subsequently, further investigations and a report from Public Health England2 have established that racism and discrimination may have contributed to the increased risk of death from covid-19 among ethnic minority groups. Yet, for the consultant who sent …

Recent data on the impact of covid-19 on people with diabetes has produced a range of responses.1 The data suggest that diabetes is an independent risk factor for mortality related to covid-19, with type 1 diabetes carrying a higher risk than type 2. The scientific community has tried to decipher the signals, and reactions in the diabetes community have ranged from relief to anxiety. Overall, the data don’t present huge surprises, but some nuggets require further investigation. The fact that diabetes is a risk factor for a poor outcome with any infection is not a surprise per se. Splitting risks on the basis of type, although eyebrow raising to some, is again not fundamentally new. As any physiology or medical textbook will tell you, the basic tenets of types 1 and 2 diabetes …

I’ve been reflecting on how much has changed in diabetes care over the past decade and what changes we may see over the next 10 years. The changes in the 2010s were nothing short of seismic, with fundamental shifts of treatment and approach towards tackling diabetes, irrespective of type. Healthcare professionals have struggled to cope with some of the fast paced changes and the shifting evidence base, but the NHS itself has largely stayed ahead of the curve, although the National Institute for Health and Care Excellence has been criticised for not doing so. And people with diabetes have been even more nimble and aware, innovating themselves when necessary, such as with the DIY artificial pancreas system (APS). Prevention of type 2 diabetes came to the fore …

“Interoperability,” “AI,” “tech”: these phrases fly around in discussions about the NHS, but what do they mean to us? Are they just fancy buzzwords, a new fad the NHS has latched onto? Do they conjure up images of Skynet, the Terminator, and a desolate future world? Or do they suggest a much needed step change for an NHS stuck in a technological time warp? The reality, as ever, is somewhere in the middle, with emotions in the NHS ranging from unbridled enthusiasm to jaded cynicism. One fundamental issue—and this isn’t necessarily a problem—is that the NHS can’t be seen to fail. Any failure is seen as a waste …

It’s nearly that time of the year again—or at least it used to be. Now the drive to “improve flow” is pretty much a year round phenomenon. And what started as a well intentioned goal of ensuring that 95% of patients attending emergency departments were admitted, transferred, or discharged within four hours has become a tool for measuring the success of departments, hospitals, and trusts. The “four hour target” has become a political football, and views about its use are becoming ever more sharply polarised. The problem, as ever, is not the target itself but the NHS’s obsession with following it like a moth to a flame. Hospital after hospital has …

It’s not actually the overt comments that really hurt. At least things are out in the open—in your face, even. They may be unpleasant, but you can choose to stand up to them or walk away. What’s worse is the seeping undercurrent, festering beneath the surface. It’s never in your face, but it’s always there. I’m talking, of course, about racism. It’s well and truly alive in our society, the NHS, and the medical profession, lurking around a corner with a smirk, a nudge, or a nod. I’ve worked in the NHS for over two decades, and attitudes to race have changed in that time, though perhaps only marginally. What used to be overt is now more …

Last month an outcry erupted over comments by Dido Harding, former head of Test and Trace, who has applied to succeed Simon Stevens as chief executive of NHS England. Harding was quoted in a Sunday Times story about her pitch for the role, headlined “Dido Harding: Make NHS less reliant on foreigners.” Gabriel Pogrund, the paper’s Whitehall correspondent, wrote: “Baroness Harding of Winscombe has vowed to end England’s reliance on foreign doctors and nurses if she becomes the next head of the NHS . . . Harding, 53, would challenge the ‘prevailing orthodoxy’ in government that it is better to import medical professionals from overseas and benefit from the investment of other countries because of the huge cost of training a doctor.” Putting aside the …

I have a strong sense of deja vu, witnessing the scenes of carnage in India as covid rips through the country. Perhaps I’m feeling the pain more intensely because, having seen the impact that covid had in January in the country where I live, I’m now seeing it replicated in the country where my heart lies. Thousands in the Indian diaspora—especially those working in the NHS—are watching with similar, heart wrenching anguish and worry about families and friends. It’s frustrating, as somehow India seemed to have dodged the bullet the first time around. Yet a toxic mixture of political myopia, religious sentiments, and perhaps a degree of overconfidence has culminated in a mostly self-inflicted rise of covid-19 and …

It’s awkward—really awkward—to look back at something you’ve written and realise it hasn’t aged well. I’ve reached the point where I need to reassess an issue I wrote about for The BMJ in March 2020, where I argued that “we must keep faith in our experts.”1 Spending time on wards full of patients with covid-19 in recent weeks has made things hit home. I’ve worked with teams who are tired, gritting their teeth, and battling exhaustion, looking after so many when the spirit of the first wave has long passed. Among all the suffering, some patients stand out. Walking into side rooms or closed bays, I’ve seen sheer fright in the eyes of those who teetered on the edge—those patients’ imploring looks as oxygen saturations were held just high …

At the start of this new year, even as we’re buffeted by the unwelcome news of a more infective strain of covid, it feels at times as if we’re nearing the end of a long tunnel, with light just around the corner. Vaccines are being approved, and the health service is ramping up systems to ensure that vulnerable groups are protected. The ongoing controversy around who is prioritised for covid vaccinations was probably to be expected, given all of the opinions, vested interests, politics, and stupidity surrounding discussion of the pandemic. The uproar is understandable given the inexplicable resistance to prioritising healthcare staff, especially in the face of a new variant. While we dithered, weighed up evidence, and debated, more healthcare professionals lost their lives. What’s surprised me is the reluctance of many organisations to highlight this issue …

The National Institute for Health and Care Excellence (NICE) is simultaneously vilified and admired. The way it assesses evidence, the way it’s been set up and structured, and the very fact it exists have all been criticised and praised, with some asking (unfairly, I’d say) whether it’s relevant in today’s healthcare system. Yet it still holds a prime position in the eyes of those who commission services in the NHS, whether at local or national level. NICE was set up to review data, assess cost effectiveness, and help a publicly funded health system to use its resources judiciously. However, much of the criticism aimed at NICE stems from wrongly held beliefs—particularly, that NICE is …

The higher covid-19 mortality rate among people from black and minority ethnic (BME) backgrounds—both in healthcare workers and the general population—has shone a spotlight on an important matter. For those unfamiliar with the issue it may be a shock to realise that people from BME backgrounds, as a whole, have poorer outcomes than other groups. There’s a well established link between mortality rates and socioeconomic deprivation, and there’s been enough of a hint that people from BME backgrounds sometimes experience carer apathy too, whether it’s down to language barriers or downright racism. The NHS’s general response has been to produce lots of platitudes, a few glossy documents, and lots of verbal commitments to improve. Anyone looking for a previous example need …

In the NHS, the term “leadership” generates a huge range of emotions. Sometimes it’s ethereal and inspiring. At other times it prompts disdain or even derision. Leadership quangos abound, courses are drip fed into email inboxes, and conferences keep springing up. Yet every analysis of the NHS’s failings tells us the same story—one of a “lack of leadership.” Why? Because we don’t have the right type of leader? Because we don’t have enough “completer-finishers”? Because “leadership” is now seen as a career opportunity? In my view, all of these have contributed to …

As we enter deeper into the covid-19 lockdown there’s a confused smog of data, speculation, and media hunger for news of anything that may be deemed controversial. Some clarity does seem to be emerging, however, alongside questions about what will have changed when the current crisis passes. For example, there are disparities in the people affected. Figures show a higher proportion from ethnic minorities being admitted to intensive care units with covid-19. Of course, we must consider the baseline population of different areas when we interpret these figures. But there’s a growing feeling that, while cultural habits and clustering of families may have a bearing on the situation, these figures also reflect social economic disparities. We should hope that, once the current crisis …

We live in the age of information overload. Once you factor in the unregulated world of social media and self-appointed experts, as well as the urge for people to jump in with their two pennies’ worth and a disregard for real experts, it becomes quite difficult to find sources you can trust. Then covid-19 appears, and the information world looks like a maze full of pitfalls for anyone trying to ascertain the correct information. Understandable worries abound, and recent times have also shown the impact that healthcare professionals can have, in positive and negative …

We live in a world where discussion around the issue of race gets caught up in a maze of debates about what’s politically correct, what’s part of “woke” culture, and what’s simply unacceptable in 2020. In this febrile environment, it’s not always easy to be a doctor from an ethnic minority in the NHS. Whatever your view on Brexit, it’s clear that the 2016 referendum has opened wounds that will take decades to heal. And many doctors from ethnic minorities feel a sense of deja vu as controversies erupt about immigrants, race, ethnicity, and religion. It’s not easy to say whether the UK is racist or not: there’s no doubt that it’s largely more accepting than other countries, but, as a qualifying argument, that holds little …

Last month the world lost Stan Lee, the great comic book creator. I was one of many who mourned his loss. As a child I loved the colourful panels and stories of heroism in comic books, and as I’ve grown older I’ve become aware of some important life lessons they’ve taught me. Those lessons—around management, leadership, and equality—are ever more important as the NHS faces an uphill struggle to maintain staff morale. For one thing, comic books help us understand our colleagues by creating vivid characters who personify specific personality types. Personality types have been …

A spinelessness towards tackling offensive comments and behaviour seems to have afflicted people attending some recent healthcare and scientific conferences. Let me give you some examples. At the World Airway Management Meeting last month a speaker made some “jokes” about a man choking a female partner but was not interrupted or challenged about the comments. Some people did protest on social media, and the organisers apologised “if any offence was taken by any of the comments or slides presented.”1 But what stopped anyone there from interrupting the speaker to say that such a “joke” was not acceptable? …

The NHS always polarises opinion, and many who work there are constantly divided over whether we should highlight its faults or champion it as a great place to work. If we dwell on its faults we can seem like dour shroud wavers, set on deterring the next generation from following in our footsteps. But, if we champion it unreservedly, we risk coming across as blindly optimistic evangelists. I interact with enough junior doctors to know that they’re as dedicated to working hard and helping people as the doctors I trained with. It’s not their fault if today’s working hours …

Patient choice. Patient empowerment. As doctors we may say that we welcome, want, or support these things—but how much do we mean it? How much does the system actually allow it? How often are we doing any more than the bare minimum to tick a box, in terms of providing patient choice? The uncomfortable answer is that we’ve only just moved beyond paying it lip service. But giving choice to patients can be tricky. If we say that the patient knows best, we’re bound to spark a debate with colleagues. And the extent to which any …

A fundamental problem with the NHS and its workforce issues sometimes tends to be us—the workforce itself. We can all make small changes that add up to making a big difference. Yet we shy away from them because we think they’re too inconsequential, we’re too beaten down by the process, or because, frankly, we don’t care enough. A classic example of this has been how doctors have looked after the next generation of the workforce. This issue of pastoral care often comes up when junior colleagues talk about not having leave requests granted, even for special occasions such as weddings. When these issues arise I wonder: …

Give this a try. Walk up to someone you love or like. Pick someone who, in your eyes, looks “overweight.” And then say, “Shame on you for not eating the right things. You will die early, and you deserve to.” Many things would stop you doing this: most importantly, common decency, but also recognition of the importance of not judging others against your own situation, economic status, or cultural background. And yet body shaming is treated by some sectors of society as if it were perfectly normal and even acceptable. Social media show that healthcare professionals are not exempt either, with quick judgments about others’ bodies not …