Welcome to Hospital - Here is your daily schedule

After all of the holiday festivities, January is the time of year when many peoples’ thoughts turn to planning their holidays for the next year. In the UK, the latest cruise industry figures estimate that for 2013, almost 2 million Brits will take an ocean cruise, a growth of more than 2% on 2012 (http://www.the-psa.co.uk/). The attractions of spending a week or two on the ocean wave are multiple but one important aspect is how slick everything is organised by the industry. Once on board, ships such as the Queen Mary 2 (2,600 passengers and 1255 crew) publish a daily schedule of activities providing a timetable of activities, events, restaurant and bar times as well as an exhaustive list of contact telephone numbers. There are also meetings scheduled for “Friends of Bill W” – onboard alcoholic anonymous sessions as well as for “Friends of Dorothy” – to accommodate gay and lesbian travellers.

Contrast the serine environment of a modern day cruise liner gently ambling its way for 5 days from Southampton to New York with the invariably chaotic nature of a stay in an NHS hospital for the same length of time. Admission to hospital can be both lonely and disturbing as the patient is expected to hand over much of their personal autonomy to complete strangers, spending most of their time in their nightwear within close proximity to people not of their choosing. Hospital patients also have to interact and be dependant upon multiple and complex groups of individuals often with unrecognisable uniforms and unpronounceable (and often unreadable) labels ending in “therapist” or “ologist”. Most frustrating however is the unpredictability of the experience - “the scan might be this afternoon or tomorrow”. Similarly, despite the creation of the new managerial mantra of discharge planning, the actual timing of release from hospital is often elusive, last minute and as can be highlighted by the media, in the middle of the night!

So for a 2013 new year’s resolution how about creating a “Your Daily Schedule” for hospital inpatients? This would be published the evening before and contain details of what is supposed to happen to include meal times, doctors rounds, visits from occupational therapists, physiotherapists and social workers, phlebotomy schedules and if linked to radiology, the proposed timing of the scan or angiogram. It could also provide the name of the Consultant in charge and phone numbers for social services, the patient liaison team and even the hospital shop so that the next day’s Daily Mail can be pre-ordered.  This system could also allow patients and relatives to email questions to the relevant department and book an appointment to see the doctor, nurse or social worker to discuss discharge planning.

This would probably work best where patients are admitted electively but would require NHS staff to improve scheduling and planning and embrace access by patients and their families. To become more widespread throughout NHS hospitals it would also need a significant cultural shift with the system evolving for the benefit of the patient rather than the organisation per se. The benefits might be (a) better communication and fewer complaints, (b) an improved public profile for NHS hospitals and (c) efficiency savings due to fewer cancelled investigations and enhanced discharge planning. If not then the only similarity between the NHS and the Cruise Travel Industry will remain the propensity of both to put people at risk of catching Norovirus.

Travel Insurance and Diabetes - shop around!

Travelling with diabetes is not always easy or straightforward - that is why we set up VoyageMD.com. One recurrent complaint we hear from people living diabetes is the cost of insurance for travel. As we mentioned in a previous post, for the insurance companies the main consideration is the cost of dealing with an unforeseen medical incident whilst the traveler is abroad. Some countries are notoriously expensive when it comes to medical care especially the USA but even within Europe the costs can also vary by huge amounts.

Although there are very many companies selling insurance, when it comes to travel, the majority use one system to work out the risk for an individual traveler by asking a set of standard questions (http://www.healix.com). For diabetes the questions relate to age, insulin or no insulin, recent hospital admissions (without specifying the reason), smoking history, presence of diabetes complications and whether or not the applicant has to take medicines for blood pressure or cholesterol (nearly everyone with type 2 diabetes!!). The interesting finding is what is NOT asked - the insurance companies do not appear to be interested in hypoglycaemia risk, HBA1c levels any aspect of glucose control. This seems surprising especially as hypoglycamia and problems with maintaining good control of blood glucose levels are two of the commonest problems related to travel and diabetes.

The variation in the price of insurance premiums related to diabetes is surprising. As an example, VoyageMD used a well known comparative website (www.moneysupermarket.com)  and compared the costs of buying insurance for a person living with type 1 and type 2 diabetes and compared the costs if the traveler had been in hospital recently: single male traveler with diabetes planning a single 2 week trip in December the quotes were:

Travelling to France
Type 1 diabetes with no recent hospital admissions     £10.60 - £37.88
Type 1 diabetes with a recent hospital admissions       £14.36 - £85.47
Type 2 diabetes with no recent hospital admissions     £11.36 - £15.05
Type 2 diabetes with a recent hospital admission         £14.36 - £95.48


Travelling to Spain
Type 1 diabetes with no recent hospital admissions     £10.60 - £37.85
Type 1 diabetes with a recent hospital admissions       £21.25 - £96.27
Type 2 diabetes with no recent hospital admissions     £12.66 - £79.78
Type 2 diabetes with a recent hospital admission         £30.77 - £95.46


Travelling to the USA
Type 1 diabetes with no recent hospital admissions     £31.69 - £120.32
Type 1 diabetes with a recent hospital admissions       £51.75 - £202.20
Type 2 diabetes with no recent hospital admissions     £25.99 - £147.04
Type 2 diabetes with a recent hospital admission         £66.00 - £231.97

The take home message is (a) shop around and (b) the insurance companies need to talk to people living with diabetes and  their diabetes teams to gain a better insight about the risk and realities of travel and diabetes so that people living with the condition are not unfairly penalised.

This is going to be one of the major campaigns for VoyageMD in 2013.

Happy New Year

VoyageMD and the House of Lords

Last week VoyageMD had the honour and privilege of meeting with a small number of members of the House of Lords in London. The meeting was organised by the Association of British Healthcare Industries (ABHI) (http://www.abhi.org.uk/) and took place at the House of Commons. The ABHI is the industry association for the medical technology sector in the UK, aiming to facilitate the adoption of medical technologies to ensure optimum patient outcomes for the UK and beyond. This UK industry has more than 3000 companies, employing over 64,000 people with a turnover £15 Billion. 

Following last year’s publication of the NHS Chief Executive’s review of innovation uptake in the NHS, entitled ‘Innovation, Health and Wealth’, and at a time when the NHS is expected to make considerable efficiency savings, there are opportunities for the technology industry to help improve patient outcomes and at the same time reduce the financial burden for the NHS

Unsurprisingly the main topic of discussion focussed around technology and diabetes and a number of themes emerged:

Access: In the area of access to insulin pump therapy the UK has an unenviable reputation. Insulin pump therapy has been around for a number of years, has a solid evidence base and has been approved by the National Institute for Health and Clinical Excellence (http://guidance.nice.org.uk/TA151) yet access to this form of insulin delivery is not equitable across the UK. It still depends on where you live! In a nutshell there are still a number of specialist diabetes centres in the UK that "don't do pumps" or have a limited number available. VoyageMD suggested that it may be an option to consider developing supra-regional pump centres that can offer assessment, pump initiation and on-going follow up for the first 12 months with the use of web-portals and other forms of digital communication to support on-going care once a patient returns to their usual point-of-care. Basic and high level training would also be offered by these centres. Controversially their Lordships were interested in whether this model would allow more patients to continue to have their care managed in the community.

Evaluation of New Technologies: The UK should be the gateway to Europe for new companies and established companies with new devices. The idea would be to create an environment whereby industry could have access to clinicians and patients at an early stage to facilitate device development especially the user "experience" - in other words make devices that (a) work (b) produce benefit and (c) patients will keep using. Their Lordships also touched upon the need to consider better regulation as recently suggested by the European Association for the Study of Diabetes following the PIP breast implant scandal.

Partnerships: A number of headlines in the media have highlighted deficiencies in diabetes care as well as the continued growth in the number of people developing the condition. Technology has an opportunity to promote behaviour change, encourage self-monitoring and provide "big data"  - the so-called quantified self philosophy (http://www.guardian.co.uk/science/2011/dec/02/psychology-human-biology). However to achieve progress there will need to be more partnerships between clinicians, patients and industry. Their Lordships appeared to be particularly interested in creating training programs for clinicians to provide training end expertise in clinical medicine, scientific methods and business - the latter giving insights into taking an idea, developing it and bringing it to market. More information on the UK Governments views on this are about to be unveiled in the forthcoming Life Science Strategy publication.

The discussion also covered other topics including the role of social media to improve diabetes care,  funding for the NHS in general and the need for new approaches to deal with increasing number of elderly people living with multiple chronic medical conditions.

A great deal was covered in the 3 hours and VoyageMD was delighted with the level of interest shown by the peers in encouraging more technological solutions for diabetes and other conditions. There was no sense of politicising the discussion for the benefit of one party or another rather a sense of "we are in this together". Further discussions are planned and VoyageMD will keep you up to date.

World Diabetes Day

In anticipation of the forthcoming World Diabetes I was asked for some thoughts about diabetes for the people at Timesulin (http://timesulin.com/blog/). 

Endocrinologist Professor David Kerr was one of the first supporters of Timesulin, particularly because of his passion for smart technologies to help make life for people with diabetes easier. Professor Kerr and his endocrinology team have launched the fabulous www.VoyageMD.com, which provides very relevant advice for those of us who have to travel and maintain good diabetes control. Thank you for taking the time to share your love of shiny things with us, David! You can follow Professor Kerr on Twitter by clicking here.

I don’t have diabetes but I come across many thousands of people who do and who have to live with it every day of their life. Living with diabetes is certainly not easy especially the day-to-day juggling of insulin and I can completely understand how difficult it is to nail the HBA1c to the target range but at the same time avoiding the beast that is hypoglycaemia.

I do like shiny thing things and on World Diabetes Day I want to make sure that the scientists, engineers, boffins and money men understand that technology has an enormous potential to help the millions of people with diabetes. However, when they are thinking about new ventures and new designs they need to talk to their customers at an early stage to make sure what they create is of value to both people living with diabetes and healthcare professionals like myself.

I also need to make sure my colleagues working in health understand that diabetes – especially Type 1 diabetes – is for life and it is not easy. I did think of using the tag line “life is made up of moments” but that has recently been high-jacked by a major brewery!! Nevertheless it hasn’t stopped me thinking about how we can help to reduce the burden of diabetes by using future technologies.

The concept is simple – create a library of “Diabetes Moments” where anyone can take one of these moments and find practical information of how to make their life easier from a diabetes perspective. The first one is already available for people with diabetes who need to travel (www.VoyageMD.com) and we are about to launch our first app specifically for people with painful neuropathy caused by diabetes. We are also working on using the experience from the computer gaming world to look at making monitoring easier and more understandable. Future ideas will be around pregnancy planning, driving, hypoglycaemia detection etc.

Diabetes sucks – but that should not stop us from thinking laterally and creating new technologies to help, We also need to keep hearing from the people that matter – those living with diabetes. On World Diabetes Day I would like everyone with diabetes to look at what they do everyday and come up with one idea that could and would make a difference. A great example is the Timesulin device – simple idea fulfilling a real need – I wish I had thought of it!!

Pumps, Sensors and Airport Security

Travelling through Airport Security with an Insulin Pump and Glucose Sensor

A recent case published in the medical journal, Diabetes Technology & Therapeutics (2012, Volume 14, pages 984-5) highlighted the potential problem for people with diabetes using and insulin pump or glucose sensor when faced with the demands of airport security.

When an insulin pump (continuous subcutaneous insulin infusion - CSII) or glucose sensor (continuous glucose monitoring system-CGMS) is passed through airport security equipment there is the potential for the motor in the devices to be affected by electromagnetic fields. It does depend on the device. In a nutshell, insulin pumps and glucose sensors can pass relatively safely through airport metal detectors (these have low magnetic energy). However the airport body scanners is, in fact, a low energy X-ray system and can cause interference.

At a practical level the advice is to remove the devices if the traveller has to pass through a full-body scanner or alternatively request a pat-down by the security officer. The only exception is the Omnipod insulin pump (Insulet Corp, Bedford, MA, USA) which is made in such a way (no direct current motor) making it safe from electromagnetic fields.  

For more information on all aspects of travel and diabetes go to our main website at www.VoyageMD.com

Radical Thoughts on Funding Diabetes Care

Published first in Diabetes Digest, 2012, Vol 11, No 3, page 126

Many a small thing has been made large by the right kind of advertising.” Mark Twain

The so called “black art” of marketing is a ubiquitous feature of modern life, and daily examples such as television commercials can reach levels of supreme irritation. Fortunately, when it comes to marketing pharmaceuticals and medical devices, official regulations are in place to prevent advertising overload and to control the way in which marketing can be used to attract potential prescribers. However, we should bear in mind that marketing is not a straightforward exercise, nor is it easy, with companies often having to maximise benefit from a small amount of data. But, as Mark Twain noted, “many a small thing has been made large by the right kind of advertising.”

At a time when the wind of austerity blows through the NHS, there is increasing pressure on drug and device spending. This is taking many forms and disguises, and the reality is that the days of enthusiastically embracing new (and invariably expensive) therapies and shiny technologies based on “feel-good” factors alone are over. However, universal adoption of this rationing approach must also be cautioned against as it can lead to people with diabetes being denied equitable access to beneficial new treatment approaches. This has been seen over recent years with insulin pump therapy, for which rates of uptake have been determined by “geography” – the UK still lags significantly behind most of Europe in terms of insulin pump provision.

To borrow a phrase from the lexicon of Tony Blair, perhaps there is a “third way” when it comes to the provision of new therapies and medical devices? This concept is simple and based on purchasing “outcomes” for people with diabetes. For new drugs, the NHS would “buy” treatment outcomes based on evidence yielded from clinical trials. If the drug is then offered to the target population and treatment achieves pre-determined outcomes (over an agreed pre-determined time), then the funding of this drug would continue. However, if pre-determined outcomes are not met, assuming that it was used appropriately, the NHS would receive a rebate.

The advantages of this approach would be as follows: (a) the clinical trial subject participants would need to reflect the background population for whom the drug is being considered; (b) clinical trial outcomes would need to be relevant to the tax payers; and (c) the pharmaceutical industry would be encouraged to act as more than simple purveyors of medicines by providing support to optimise the benefits of their products. The caveat would be to take into consideration factors such as treatment compliance, but the onus would be on the pharmaceutical companies to help develop new approaches to this perennial problem.

The “third way” approach to treatment provision in the UK would also be appropriate for the adoption of medical devices, for example for insulin pump therapy. It would make more sense to “buy” a pre-determined number of days of continuous subcutaneous insulin infusion with the cost including the device, consumables, insulin and blood-glucose monitoring as well as established outcomes around hypoglycaemia risk reduction and improved quality of life. The same would apply to glucose-sensing devices where people would purchase days of sensing rather than the device itself, therefore passing the risk from device failure onto the device manufacturers. The advent of outcomes-based risk-sharing schemes has seen some progress being made, but there is still much to do.

The polarisation of views on new approaches to therapies and monitoring devices in diabetes care is, I doubt, helpful nor is it reassuring for people living with the condition. Furthermore, the high-profile cases of unhealthy relationships between the industry and the professions have changed this particular landscape forever. The need now is for lateral thinking and avoidance of a siege mentality.

For the NHS, change is not often easy nor is it straightforward, but to quote Steve Jobs from his 2005 commencement speech to Stanford University graduates, “If today were the last day of my life, would I want to do what I am about to do today?”

New Thinking on Paying for Diabetes Innovations

In the UK, improving access to new medicines and medical technologies is not always straightforward and in these current harsh economic times, the costs of innovation are the major concern.

For new medicines and devices, a novel approach might be to consider passing some of the risk back to the company by "buying outcomes" rather than the drug or technology per se. For new drugs, this would mean buying outcomes based on research evidence from clinical trials so that if a new drug achieves the pre-determined desired outcomes over a fixed period of time then it would be continued to be funded. However if it did not achieve this there would be a rebate for the healthcare system. This is equivalent to having a warranty on a new car. The advantage of this approach would be (a) clinical trial subject participants would need to reflect the background population,  (b) the outcomes of clinical trials would need to be relevant to the payers and (c) industry would be encouraged to act as more than simple purveyors of medicines by providing support to optimise the benefits of their products.

The same approach could be used for new medical devices so with this in mind we are sending this request to the companies that manufacture real-time continuous glucose sensors for people with diabetes.

Re: Real-time glucose sensors

As you are aware we are very enthusiastic about the role of technology in helping to deliver excellence in diabetes care. This includes continuous glucose monitoring systems. Although the latter systems.

In 2011, many of our patients benefitted from the data provided by CGMS and for 2012-13 we would like to develop this further. Recently barriers to accessing technologies for diabetes care were discussed at a All-Parliamentary Committee at the UK House of Commons.

Therefore rather than adopting the traditional cost model of purchasing up-front systems and equipment that offers blocks of days of sensing at a time, we would like to explore a new approach to funding CGMS for patients with diabetes.

Consequently we are writing to the 3 main sensor companies (Medtronic, Abbott Diabetes Care and Dexcom) to ask them to provide the costs of delivering 500 and 1000 days of real-time continuous glucose monitoring data which includes all hardware, any equipment failures as well as VAT (tax).

We will let you know the response???

15/10/12

Dexcom: No response
Abbott Diabetes Care: No response
Medtronic: Very interested in developing this idea