Touch site, sound?

I’m a great believer in recycling: “Touch site, sound?” was the title I gave to a presentation I first made in 2009.

The audience was healthcare professionals, mostly GPs and practice nurses.   Cheeky of me to re-use my materials in this way? Perhaps, but hey, why not!

Since fatty lumps at injection sites (lipos or lipohypertrophy) are experienced by the majority of people with diabetes who use injections, I truly believe this message will have much greater value when it is in the hands of people with diabetes.   Let’s find out if I’m correct…


I’m a lucky doc, I get to work with some excellent people.  One of these, diabetes specialist nurse Sister Jagjit Kaur, I credit with making me think much more about the injection sites and problems than I ever had before.  Here’s our rose between two thorns at DUK 2009, presenting our first informatics work (we’d achieved a change from 0% to 75% for pre-pregnancy advice to women with D of child-bearing age in a large local GP surgery 🙂 ).

My first Informatics project c2008, at DUK 2009

My first Informatics project c2008, at DUK 2009


A big thank you to Jagjit- she showed me just how important these factors are to people with diabetes trying to get stability of their glucose levels and reliable effect of insulin.

Indeed, to me, in theory the “boss”, the importance of these was a total blind spot. It had simply not featured in my training to become a diabetes consultant.  I would spend far more time considering differences between various types of insulin product.

So began a journey that saw us

  • Survey our patients concerning just how common lipos are (over half) & whether patients do get examined regularly (…er, no).
  • Become involved with the work of the Forum for Injection Technique, here are their latest recommendations (I’d so love to be more involved, if you are reading this FIT peeps…)
  • Make conference visits to the Becton Dickenson (BD) stand & visits from their reps. essential to get hold of the best educational resources for our patients

We were really knocked out by a European survey revealing that

  • 75% PWD who do not ‘rotate’ injection sites have lipos
  • 25% PWD who do ‘rotate’ injection sites still have lipos

Why does this happen? What makes a difference? Will lipos always go away. Hard to say.  We simply do not know enough about injection site issues.  It is reckoned you minimise your chances by

  • always moving 1-2 finger-breaths from one shot to the next and not going back to that spot for a while
  • never reusing the same needle (PWD were historically very frugal, a hard habit to break)
  • Using an appropriately short needle (4, 5, 6, 8 and 12.7 mm are available…)

At the last DUK conference, BD had one of their Reps, Kinsey Jones, great guy who has T1 himself, allowing delegates to examine his tummy lipos.  BD are recommending a ‘formal’ examination, on the couch, with healthcare professional applying K-Y Jelly and gently but firmly exploring with gloved-hands.  I’m not sure how that would go down with PWD.  I wonder about the scope for self-examination.  Do you think that may work?  Maybe backed up by show-and-tell.


A seminal moment for me was listening to a conference seminar from a BD expert Dr Ken Strauss at an European Association for Study of Diabetes. Some of his early work is here In 25 mins I learned the following

  • Epidermis and dermis is only 2mm thick, but as the latter is ‘scalloped’ it is a max. of 2.8mm thick. Any needle longer than 3mm will reach the subcutaneous space
  • 50% adults have lipos… but in kids the figure is 70%
  • Whether you are old/young, male/female, fatter/thinner, any race, 4mm needles will be plenty
  • Teach PWD to rotate early, they do; try to do this later, they don’t…

Does this REALLY make that much difference to insulin absorption and action? You tell me what you think.  It certainly did in the cases in my talk and seems to for many of the PWD I meet each week.  My own opinion is that this effect is as least as big as related issues of injection technique, e.g. resuspension of mixtures, differences between body areas, ambient temperature etc.  Whatever PWD can do to make the effects of insulin injections more predicable is certainly money in the bank.

I’m a pragmatist when it comes to clinical research- it really ought to be for the direct benefit of the people I see, if it is to be worth doing.  I’m still hopeful that one day soon my team and I can engage in some injection-site research, I think this will become a much more important issue as awareness grows.

In the meantime the lovely people at OurDiabetes #ourD have asked me to host a Twitter chat on Lipohypertrophy & insulin injection technique one Tuesday night soon.  The format is to choose 5 key questions which PWD answer between 8-9pm. Please leave a comment & maybe suggest what questions you would like to hear answers to.

I was going to ask PWD if they would wish to share lipo-selfies during that Twitter-chat. Would that stray over the boundary of good-taste, or could it help break down a D-taboo?  Thanks for reading.

More background materials here.


What gets you out of bed in the morning?

I’m feeling slightly abashed this evening. It’s been diabetes blog week and I’ve only managed one contribution… Well, that’s better than none, but I want to squeeze in a quickie before the week’s end.  Here goes, subject: what can get Healthcare professionals moving?

Get out of bed

Take a look at this YouTube video,

Focus on what he says 5 minutes 20 sec in.  It has the potential to change the face of health and healthcare delivery…

In his excellent presentation on improving patient safety Dr Peter Pronovost tells us how there are three things that may get healthcare professionals ‘out of bed in the morning’-

  1. Coercion- e.g. more/stricter regulations, more frequent CQC visits…
  2. Financial incentives- e.g. carrots if you work in primary care, sticks if you work in hospital care.
  3. Trying to inspire- coproduction: patients and healthcare professionals working together as part of a social movement

We use the first two rather a lot, but there is not much evidence that these work in the way in which they are intended.

Roy Lilly’s blogs at regularly makes the strong claim that

“you cannot inspect quality into systems”.  

Businesses that understand this have learned to use quality control & management techniques to good effect, rather than inspection.

There is some evidence that incentive payments to GPs such as the quality and outcomes framework, or QoF, can have an effect. Yet look more closely and there is also a story of how incentives can lead to gaming & shifting of the goalposts.  If you don’t believe me, take a look at GP Contract website, you can look up the QoF figures and outcomes for all the conditions with incentives.

Look closely at the diabetes figures for your own practice and try and work out why a proportion of people with diabetes are excluded from a number of the indicators.  I sometimes show figures to individual practices and even they scratch their head.  Figures for diabetes care at my own GP surgery can be found here.  Why, for instance, are 62/387 people excluded from DM17 ‘cholesterol under 5.0’?  There are certainly some legitimate reasons for some patients to be excluded, but when I’ve looked at these returns, which are all linked to payment, none of this is transparent or open.

Financial reliance upon incentives creates a mindset to oppose any further developments until new extra incentives are offered.  One recent example is the move towards opening up record access to patients.  Things are beginning to happen because of incentives specifically for making and changing appointments and ordering prescription repeats.  Even though most GP systems could allow records access right now, it is rare to find this happening.  A notable exception to the rule is GP Dr Amir Hannan, his practice website is open to all and makes inspiring reading.  From next April, there will be extra incentives for all GPs to offer… very limited record access.

So how about we try number 3? It surely must be worth a go?

I do so admire that famous Margaret Mead quote:

“Never doubt that a small group of thoughtful, committed, citizens can change the world. Indeed, it is the only thing that ever has.” 


Could this be the right time for a social movement that brings together patients with long-term conditions like diabetes along with healthcare professionals?

I understand many barriers stand in the way; it’s probably a good thing that I doubtless do not know them all.  What I do not accept is that these will ever be removed by fear/coecion or by being incentivised to do.

Let’s start a social movement.  Hang on… a revolution has already started.

“A social movement that only moves people is merely a revolt. A movement that changes both people and institutions is a revolution.” 
― Martin Luther King Jr.Why We Can’t Wait

Pile ’em high. Sell ’em cheap.

This week, I have mostly been having twitter conversations about inflexibilities built in to diabetes specialist care.  Experiencing this type of problem? To quote Douglas Adams, “We are sorry for the inconvenience.”  When I reflect on this, this is the image I see in my minds eye:

How to reach us



I’ve met many people with diabetes who are passionate about helping dismantle these barriers and obstacles, social media has been invaluable in helping me connect them (you!), whilst at the same time it’s also been really useful in helping me to extend my circle of fellow healthcare professional colleagues, many of whom are doing amazing work to change this.

The subject of this short blog is, why has diabetes care been regarded as ‘crowd control’ by many services & healthcare professionals?  Let me unpack my ideas…

My specific diabetes training began with some wonderful, inspirational bosses in a service which was nationally and internationally regarded.  I learned so much from them.  Yet there were aspects of the service which lacked any kind of compassion, dignity or respect.

Picture the scene, NHS in the 1980s. The clinics were truly enormous. No, I’m remembering it all wrong… they were humongous.  The waiting area resembled an aircraft hanger with rows of people seemingly as far as the eye could see.  The timing for the clinic was… well, a movable feast.  It was a war of attrition – who would crack first? Would people with diabetes get fed up and go home at 7 PM, or would they,  despite disapproving looks from the clinic staff, remain bloody minded and stay to the bitter end?

When it was your turn to be seen consultations were held in an open plan space (designed, perhaps for minor surgery, very stark and clinical) with several desks, simple plastic chairs (just one for the patient, no relatives or friends were allowed) and no privacy at all.  As a very junior doctor I remember finding it surreal when a patient across the room, hard of hearing, was having such a loud consultation with their doctor that my patient and I just had to wait until they had finished.

Talking to an ex-diabetes specialist nurse who worked at one of the U.K.’s first dedicated diabetes centres, our patients ‘didn’t know they were born’… At their institution, the doctor sat at the desk in their white coat; whilst there was a chair for the patient, this was pushed in hard under the desk.

Woe-betides anyone who dared pull the chair out and actually sat down…

last see dad

When I was on-call, one of my first evening jobs was to prescribe insulin for every patient in the hospital who needed it.  Probably 75-90% were on fixed-mixture insulins, names like Protophane (still used in Europe I believe). Looking back on those days, it seems so crazy that the most junior doctor in the hospital was being asked to make prescribing decisions about the most dangerous types of drugs (this was also true for warfarin and for a drug called heparin, gladly safer versions of heparin are now in more widespread use).  On each ward I would be presented with a stack of insulin prescription charts along with glucose test result-charts.  There was no sense of what type of diabetes the person had, nor the context (i.e. what was expected of their diabetes control, glucose would be higher during infection for example).

total wipeout


Here I am, attempting to make it through all my insulin prescription-jobs, before I could go and get something to eat after a long day at work… well, forgive me for using artistic license on that.  Did I ever ‘fall in the water’?  In-hospital hypoglycaemia rates suggest I frequently did…

When I became a consultant, I was determined that this would not continue.  Gladly my colleagues and I had the full support of our organisation in changing things.  That said, there still seems to be a belief the doctors and nurses should be measured by how many patients they can process in a session. That kind of thinking gives me my title for this blog, attributed to Jack Cohen, founder of Tesco’s.  Such an approach “sells people cheap“.

Our aim must be quality diabetes services, but most of the quality is around compassion, dignity and respect.  There is no point in being the sharpest tool in the box if all you do is to cut human relationships into ribbons.

In my opinion, there is only one show in town: patient experience.  Everything else we do leads us back to that.