The Big Interview – Professor Kamlesh Khunti

Professor Kamlesh Khunti tells The Diabetes Times his thoughts on the importance of early diagnosis and what he thinks of diabetes care in the UK.

He is one of the founders of the Leicester Diabetes Centre which is an international centre of excellence in diabetes research, education and innovation.

How is primary care coping with the rise in type 2 diabetes?

Overall primary care in certain areas such as Leicestershire is coping well because the CCG is supporting all the primary care practices in terms of education and training. I am aware that in some areas, primary care is struggling to cope with the increased workload. Overall there has been a rise in the number of chronic diseases because of the aging population and that will be the challenge over the next few years on how primary care manages multimorbidity.

What’s your assessment of the updated diabetes NICE guidelines published last year now there has been time for them to be implemented?

Surprisingly there is not much mention of the new NICE guidance and I haven’t seen a huge amount in terms of implementation within a primary care setting. Many people who lead diabetes management are aware of the ADA-EASD position statement and the new NICE guidance is very similar. The question remains of how the prescribing advisors will monitor the implementation of NICE guidance.

In your opinion, which three diabetes-related research studies have seen the most impact on clinical care in the last decade?

Obviously the UKPDS has a major impact on how we manage type 2 diabetes.

The prevention studies have also had an impact and we have contributed in terms of conducting the systematic reviews and primary studies on prevention of diabetes in people at high risk of diabetes.

The studies on management of other risk factors, in particular hyperlipidaemia with statins and blood pressure control have had a major impact in reducing the cardiovascular morbidity and mortality.

Recent studies on SGLT-2 inhibitors and GLP-1 receptor agonists which have shown cardiovascular benefits will be of interest over the next few years on how the findings are implemented to reduce cardiovascular risk in people who are at high risk.

What are your views on the early treatment intensification in type 2 diabetes?

I firmly believe that the evidence shows that we need to reach very tight targets early on from diagnosis and keep people at those targets to reap the benefits in the future. Much of our work has been in the area of clinical inertia which clearly showed that in the UK we are not aggressive at managing type 2 diabetes with the result that there are higher rates of morbidity and mortality.

What do you think to the new the CCG Improvement and Assessment Framework and what it will mean for diabetes?

This is welcomed whole-heartedly. Diabetes is one of the six clinical priority areas and two matrix for CCG performance include diabetes patients having received all NICE recommended treatment targets and people with diabetes diagnosed less than a year who attend a structured education program.

However I feel a lot more could have been done because the targets being set are similar to QOF targets and we know that we need to go for much lower targets in certain populations, especially those early on in the diseases’ trajectory and young patients with type 2 diabetes. In terms of structured education I think the assessment framework could have gone further and recommended that people with type 2 diabetes should have structured education programmes annually.

What are your research priorities?

The research priorities continue the same as we have done at the Leicester Diabetes Centre which include methods of early screening and prevention of diabetes and management of people with established diabetes including risk factor control and long-term cardiovascular outcomes. The areas of clinical inertia and hyperglycaemia are also key areas of our research. There is a lot of interest in precision medicine and that is an area of work that we have an interest in.

What’s been your biggest achievement?

I think that clearly has to be the establishment of the Leicester Diabetes Centre with Professor Davies. We are now one of the largest education and research departments within the UK and I am really grateful to the whole of the Leicester Diabetes Centre team who have made this possible.

What would your one message to GPs treating people with diabetes be?

Keep updated with the evidence as the evidence base for diabetes is changing rapidly.

How can primary and secondary care better work together in relation to diabetes?

Integrated care models are the way forward in management of type 2 diabetes. Leicester has been at the forefront because of our fantastic relationship between primary care and specialist care and we have shown that such models can work well and can be cost-effective.

What is the future of diabetes care in the UK?

I think overall diabetes care in the UK is an exemplar not just in clinical terms but in research terms globally. The area of multimorbidity however is gaining interest where we treat people with a number of diseases rather than treating in single disease entities.