The Kar Report: Is it time to stop trying to do everything in diabetes care?

In the first of a new opinion series, Dr Partha Kar questions whether NHS diabetes care has reached a tipping point – and whether prioritising just three key areas could be the bold decision needed to reverse declining standards.

Let’s be honest. We are in troubling times. Whether in diabetes care or more broadly, there is no question that there is an underlying anxiety, even among the most optimistic in diabetes care. Things seem to be on a slide compared with where they have been. This may very well be a reflection of the present financial conundrum the NHS finds itself in, and diabetes is no exception to the continued decline the healthcare system faces.

In this environment, the question is whether we need to start having conversations around prioritisation in diabetes care.  Should we? And would it be bold enough to suggest that the community, together, could focus on only three, possibly four, areas? At the same time, we would have to accept the risk that this would involve deprioritising a fair few things.

The reality is that, at present, we seem to have regressed into mediocrity across the board, with pockets of good care dictated by a combination of local leadership, luck, relationships and the longevity of individuals in key roles. Yet, if one looks across the board, there is no question that parameters are sliding.

Obesity care probably sticks out like a sore thumb. Very little beyond lip service is currently being paid to care, while existing criteria serve no one other than acting as a funnel- restricting access. The description of wraparound care, and who is commissioning it, is never easy. Combined, these factors have created a situation where very few people are actually able to access the medication.

Wider debates about the societal changes needed to tackle obesity continue to be confined to PowerPoint presentations. In the absence of a clear medical or surgical plan to tackle obesity, we tend to carry on as we are, without a strategy per se.

From my point of view, I think obesity care will see a change around 2029, when GLP-1 agonists in this space start to become generic. This may be a reflection of the present times, but I think there is a need for honesty with industry. At the moment, if one looks at the strategy taken with SGLT2 inhibitors, it has been heavily reliant on that approach, with a rise in prescribing coinciding with generic availability. Obesity care is unlikely to be any different.

The question, therefore, is whether we should spend time creating pathways that cannot currently be implemented, or whether we should be ready for what is likely to come in 2029.

This brings me back to the issue of prioritisation across diabetes and obesity care, and opening up the debate as to whether there are certain things that we, as a community, need to turn around and say no to.

This will undoubtedly make certain sectors, academics and vested interests unhappy. But carrying on as we are gives us a choice: we either allow everything to drop to a level of mediocrity-if not lower, or we pick some areas in which we can excel and deliver the biggest possible return on investment for the country.

The big question is whether such boldness exists among the diabetes leadership? Or whether we carry on trying to accommodate everything. But at lesser quality.

As the saying goes-with a twist? ‘Karpe Diem’. I know my top three- do you?