GP LINK Lunches – Prof David Simmons

Dr Kenneth McCroary, Chair of Sydney South West GP Link, hosts a series of meetings with clinical/political/regional individuals or organisations to discuss issues and solutions for GPs working in South Western Sydney.

Ken McCroary – Welcome all to another instalment of GP Link Lunches.  Following a recent interaction with the South West Sydney Diabetes Quality Network I thought who better to speak to than the clinical lead of the program Professor David Simmons.

Distinguished Professor Simmons is Professor of Medicine at Western Sydney University Macarthur Clinical School, Head of Campbelltown Hospital Endocrinology Department and Director of the Diabetes, Obesity and Metabolism Translation Unit.

He has worked both nationally and internationally. Prof Simmons was Foundation Chair in Rural Health at University of Melbourne (1998–2002); Inaugural Professor of Medicine, University of Auckland, Waikato Clinical School New Zealand (2003-2007); and lead diabetes consultant at Cambridge University Hospitals NHS Foundation Trust (2007–2014); before joining Western Sydney University in January 2015.

With more than 380 refereed publications, he has won several national and international awards for his work in diabetes epidemiology, diabetes in pregnancy and diabetes service development. He is a past president of the Australasian Diabetes in Pregnancy Society (ADIPS) and was a member of the World Health Organisation technical working group on the criteria for hyperglycaemia in pregnancy. He was previously chair of the Diabetes UK Health Professional Education Steering Group. Professor Simmons works with the University of Örebro, Sweden, and is a Professorial Fellow at the University of Melbourne.

Professor Simmons is the recipient of the American Diabetes Association 2020 Norbert Freinkel Award for his outstanding contribution to the understanding and treatment of diabetes in pregnancy.

Ken McCroary – Welcome David and thank you for your time today speaking to the General Practitioners of South Western Sydney.

David Simmons – Hi Ken it is great to be meeting with GP Link again.

Ken McCroary – Thank you very much, can you tell us a bit about you and the organisation you are representing today please.

David Simmons – So I have many, many hats. I am the Professor of Medicine at Western Sydney

University. I am also the Director of Endocrinology at Campbelltown Hospital for the South West Sydney Local Health District. I am the District Advisor on Diabetes for South West Sydney Local Health District.

I am also the Director of the Diabetes Obesity Metabolism Research Unit which was set out to be a joint collaboration between the university and the local health district. I am also the head of the clinical academic group for diabetes and metabolism for an academic health partnership called Sphere which is the Sydney Partnership for Health Education Research and Enterprise, which covers quite a

big part of Sydney.

All these groups I am working with relate to Primary Health Networks, GPs and how we work to really improve the care of those with diabetes, how we prevent diabetes and how we improve the lives of the wider population as well because really everyone potentially will go on to get diabetes, so we want to look at the whole picture including prevention.

Ken McCroary – Thank you. Many hats there so thanks for giving up some of your time today and talking to us.  Now with your groups, what sort of mission do you have overall but also specifically to the operations in South Western Sydney?

David Simmons – So the mission I have, and I have had, and which we have documented, is to prevent the harm diabetes and its complications does on a population basis. Population health includes the public health side but also the clinical care. People always think about clinical care as being about oneto-one but all that adds up into population health.

In fact there has just been a paper out from the Baker Institute showing the impact of a sugar tax versus a diabetes prevention program type of approach where you identify people who have got dysglycemia, so impaired glucose tolerance, and you intervene with lifestyle versus introducing SGLT2 inhibitors in a systematic way, along with ARBS and Ace Inhibitors, and the one that has the biggest impact on renal failure is actually the drugs once you have identified people with diabetes.

Our role is also to try to reduce the number of people who are coming to us at specialist services, so our role is to work particularly with General Practice and the wider primary care for education, for advice, for training and just working together as a team. We have outreach clinics, we have telephone advice, we have case conferencing where one of my endocrinologists comes to the practice and will just discuss a patient with a GP and the Practice Nurse and say ‘well have you thought about this, this and this’. We are starting off on the people with HbA1c above 9%, women who are of reproductive age, people with nehpropathy and hospital frequent flyers. We only need one contact with the GP for a patient and when we review that downstream the HbA1c is down about 0.91%, blood pressure is down, just by discussing that patient over 15 minutes with the GP and the practice team. Because all we need to do is fill some of those gaps and then you guys go ahead.

So this is what we are trying to do. We don’t have to actually (hopefully) see that many people with type 2 diabetes at all because you guys are doing the work in general practice and we are here to help guide, to support to identify the ones who maybe sometimes are a bit tricky. They are tricky because maybe the diagnosis is they actually have type 1 diabetes.

It sounds easy but actually in the UK 25% of people in the GP databases are mis-coded as type 1 diabetes, when actually they are maybe treated type 2 diabetes. It goes the other way as well, many of those with type 1 diabetes are thought to develop type 2 diabetes on insulin and then you say ‘oh let’s put this person on GLP1’ and you take them off the insulin because insulin and GLP1 can be equally effective but with weight loss and then they go into DKA.

So you know our job is, as part of our population approach, is to see the most complex people ourselves, type 1 diabetes some of those with type 2 diabetes hopefully only once or twice – some are very complex with nephropathy. We should be working in partnership with the renal physicians as well as yoursleves – and then we are out there helping you guys deliver your care.

Ken McCroary – Excellent thank you very much for that. Now us being a local organisation we are wondering if you are aware of any particular issues and challenges that are facing GPs working in South Western Sydney.

David Simmons – Many, many, many. I think when I first arrived, which was six years ago, one of the things that shocked me was the number of women turning up with their type 1 and type 2 diabetes under-managed, not prepared, not understanding what was going to happen to them and their baby, the tears when I explained the risk, the tears when perhaps they found they had a malformed baby. Major malformations, some of which I had not actually seen for years since I used to work in South Auckland 20-25 years ago with poorer people particularly from the Maori and Pacific communities and I was seeing things in South West Sydney. The malformation rate was 12%, and at Liverpool it was shown to be 7%. Well the background rate is 2% and around the world people with diabetes is usually about 4% so we knew this was the tip of the iceberg, the tip of the sphere, there is some major failing in the way diabetes is being managed across us all. It is a systems failure that we have been trying to address.

Then there are a whole load of people who we see with type 1 diabetes where they actually are not aware that pumps exist, they don’t know how to manage their glucose, they don’t manage their carbs they don’t know how to manage their food they don’t understand the rules of insulin they don’t actually understand the condition. How you self-manage type 1 diabetes without knowing these things and this is probably the majority of people with type 1 diabetes that I see.

We now have a pre-pregnancy clinic so please do refer those women of reproductive age with type 1 or type 2 diabetes and we can do whatever is needed – we are happy to send them back to you  once you are ready.

The other ones that come into our service are those with DKA and HHS or with foot problems or with renal disease. These can come in with hyperglycaemia of many, many years – often with severe infections, with life threatening conditions – then they are referred to us as an inpatient under a general team. You look at the person’s sugars, and ask how long has it been like that? Oh a long time and type 1 and type 2 diabetes as well and they are not being referred, which is why I set up the case conferencing. We want to proactively meet with each practice and say ‘right show us all of the people about 9%, let’s go through them, what should we do with them”.

We have a model and an approach where we can support general practice and I think we can really rip through some big numbers with that, if GPs want to. Sadly we have only 43 out of 400 practices participating and as you know we have asked around at Diabetes Quality Network clinical reference group meetings and many GPs don’t even know this happens even though it has been advertised by the PHN and elsewhere. We have even had endocrinologists go to the front desk at General Practices and ask to speak to the GP? When asked “who are you” we say “I am a district endocrinologist, I have been trying to make an appointment to see the GP, can we talk to the GP about diabetes case conferencing?”. They say “Oh no, the GP is busy, no time”. “Can we make an appointment?” “No too busy”. You know we need to be able to GPs, past the receptionists and practice managers, and work together because that is what works.

Ken McCroary – Absolutely, thank you so much. Our final question today. What are some of the things you and your groups can do to help and support general practice and general practitioners in South West Sydney?

David Simmons – Everything you want and everything you need to do with diabetes care, and if we haven’t got it now we will work with you Ken, with the PHN, with the LHD, with NSW Health, to see how can we address this problem because when we find solutions together it is very hard for the powers that be to actually say no.

We have got our case conferencing, we have got our conferences we have got our Practice Nurse meetings for the education. We have got our masterclasses we have got online masterclass joined in with Western Sydney and the Blue Mountains and Hunter New England. We have got an education program, we are just about to change our name to the Western Diabetes Education Program online. Bit by bit people can do a competency thing. It can say ‘yes you know enough already’ or ‘look these are your holes, go to those holes very, very quickly’ you know what you are doing takes a bit longer if you still have to learn new stuff.

Ken McCroary – And so my GP members with our patients coming in and they may be type 1 or type 2, and they are not controlled and they are thinking about utilising some of your services how specifically do they go about organising that. Are there numbers, websites, referral, how does it work?

David Simmons – Absolutely, so first of all through HealthPathways you get onto that we know not everyone uses it but it is a good source of information. Second of all, you can always ring the hospital. Try to get through and leave a message on 4634 3192. We do have a referral place for case conferencing which is through our DOMTRU site (SWSLHD-CampbelltownIDC@health.nsw.gov.au) and you know we would be very happy to send you the information which you can then send around to your members; and then we have the clinical reference groups where are you know, we have a nice meal and you can meet us – we are very friendly. Everyone is welcome although we have kept the numbers down to 25, but if we know more can come and we don’t have COVID limits, then we will increase the numbers. We have had hybrid meetings where the first 25 come and then the others can ring in it is perhaps a one hour, two hour meeting. After one hour I get pretty tired in the these webinar type things so you know we can tailor it if people want one hour we make one hour we are completely responsive toward GPs.

Ken McCroary – That is superb, that is fantastic thank you so much David it has been great talking to you and thank so much for all your time.