Background
Before the discovery of insulin in 1922, little in the way of treatment was available for people with diabetes. Type 2 diabetes was relatively uncommon compared with today, and Type I diabetes was more or less untreatable. The introduction of insulin treatment transformed the situation. Soon hospital based diabetes clinics began to appear and they slowly spread across the country, so that by the 1960’s they were established in most districts in the UK.
The first diabetes clinic in Norwich was set up in the 1950’s by Dr. Kenneth Latter, a consultant general physician at the Norfolk & Norwich Hospital. This clinic was held in the St Stephen’s clock tower block at the old Norfolk & Norwich hospital and was organised by Audrey Capon, the chief dietician at the time. In the 1960s Dr Latter handed over the clinic to Dr James Campbell, a consultant physician with a special interest in diabetes. Under his guidance, a second clinic was opened at the Norfolk and Norwich Hospital. However by the 1970’s, both clinics had become very large and overcrowded, with over 100 patients attending each. They frequently had to wait for several hours before seeing unfamiliar junior doctors with varying levels of experience and competence. The clinics were supported mainly by dieticians. There were no trained nurses and this was a major problem.
Dr Campbell retired in 1979 and was replaced by Dr Richard Greenwood. In order to improve the service, he made a number of changes. With the help of colleagues in General Practice (especially Dr’s David Pearson and David Welsh both of whom worked as clinical assistants in the N&N clinics) guidelines for the management of Type II diabetes were drawn up and all patients not requiring insulin treatment were discharged to primary care unless they had some complication requiring hospital management. General Practitioners were encouraged to set up their own dedicated diabetic “mini clinics” which many did successfully. In order to reduce pressure on the N&N clinics and to save patients having to travel into Norwich, consultant-led satellite diabetic clinics were established at Cromer, Fakenham, North Walsham, Diss and Dereham. However, despite these measures, the Norwich clinics remained overcrowded and chaotic. Nevertheless the quality of care did improve, mainly as a result of the arrival of additional dedicated staff. Specialist Diabetes Nurses (Lynette Yaxley, Janet Almond and Vivien Aldridge were the first three) had a huge impact by providing practical education and on-going support to patients. There was also a new dietician (Judy Close) and a specialist diabetes chiropodist (Grace Dole). The local branch of the British Diabetic Association also gave invaluable support to the clinics.
In 1987 a second consultant specialising in diabetes, Dr Philip Heyburn, was appointed. This was an opportunity to radically redesign the service. Drs Greenwood and Heyburn visited other UK centres including Stoke Mandeville and Ipswich where dedicated diabetes centres had been established. It was clear that this was a promising way forward for Norwich because it would allow the creation of smaller, more manageable clinics with better access for patients and also provide a permanent base for the members of the expanding multidisciplinary team. However, it was also clear that creating a diabetes centre in Norwich would be a complex and expensive project and no NHS funds were available. For this reason it was planned to launch a charitable appeal to raise the required funds which were initially estimated to be about £100,000.
The Norfolk Diabetes Appeal (NDA)
It seemed that it would take several years to raise this amount of money but fortunately, at this point, the Bertram family became involved. Kip Bertram, the managing director of Bertram Books, suggested that his mother, Elsie, might be prepared to support the project.
She was indeed very interested and, in an act of extraordinary generosity, decided to donate £100,000 so that establishing a diabetes centre could start more or less immediately. In addition, she decided to actively support fund raising activities to raise the additional finance that would inevitably be needed to meet additional and on-going costs.
It was therefore decided that a public appeal (the Norfolk Diabetes Appeal) should be launched in order to focus the fund raising effort.
On 19th October 1987 the Appeal Committee met for the first time with 18 members including doctors, nurses, patients, and hospital and health service managers. Dr Richard Greenwood was elected chairman and Dr Philip Heyburn vice chairman. The terms of reference were;
- To build and equip a diabetes centre at the West Norwich Hospital
- To establish a district diabetic computer register
- To assist with the funding of more educators including specialist nurses, chiropodists and dieticians
- To provide educational support for doctors nurses and other staff caring for diabetic patients in general practice
- To establish a screening programme for the early detection of diabetic eye problems
- To establish a diabetic foot clinic for the prevention and treatment of diabetic foot ulcers
- To support local research projects designed to develop better methods of treatment of diabetes and its related problems
The committee rapidly produced a logo, leaflets and a press release. It was decided to hold a public launch of the appeal in order to generate as much publicity as possible. This event took place on 7th December 1987 at the Castle Hotel in Norwich. It was supported by a host of local and national celebrities (mainly recruited through Elsie’s contacts in the book world). They included Patrick Moore, the well-known astronomer, Norris McWhirter, editor of the Guinness Book of Records, Dr David Devlin and Christine Webber of Anglia Television.
This ensured a great deal of local publicity and a very active programme of fundraising activities followed. Many local groups held fundraising events, of which the most successful were Elsie Bertram’s renowned book sales. Financial support was also obtained from national bodies including Children in Need, pharmaceutical companies, the Trustee Savings Bank and the Lady Hind Trust. Thus, with Elsie’s donation, sufficient funds became available to build and run a diabetes centre.
The Bertram Diabetes Centre
It was decided that the centre should be located in Norwich where the bulk of the population of central Norfolk live. It was clear that there was no possibility of building the centre on the overcrowded Norfolk & Norwich hospital site in Brunswick Road so attention turned to the West Norwich Hospital in Bowthorpe Road.
With the support of sympathetic hospital managers it was agreed that a small house located behind the Woodlands Nursing home which had previously been used as staff accommodation and was in need of renovation, would be made available. A plan was drawn up incorporating this house and adding a new wing containing a suite of clinic rooms. After the visits to Stoke Mandeville and Ipswich, the importance of group educational activities was appreciated and so the plan was modified to include a large central waiting and education area. This inevitably increased the cost of the project but the appeal was going so well that it was clear that sufficient funds would become available. Thus the appeal committee agreed to pay for the cost of building and equipping the centre and also to pay for any additional revenue consequences arising during the first two years. Thereafter, the District Health Authority agreed to absorb these costs.
Building commenced in the summer of 1988, and after some initial problems (including the discovery of a long forgotten air raid shelter under the lawn) steady progress was made and the keys of the completed building were handed over to the N & N by the main contractors, R. G. Carter, on 1st August 1989.
The official opening ceremony, once again designed to attract maximum local publicity, was held on 30th October 1989. This was performed by Sir Harry Secombe, the famous comedian, who was, at that time, the President of the British Diabetic Association.
At about the same time, the hospital diabetic clinics transferred to the new centre. Thus, instead of the huge overcrowded clinics in the old hospital, it was now possible to hold smaller clinics each day, with two doctors seeing no more than 15 patients each. One of the doctors was a consultant, the other a registrar or clinical assistant. Patients alternated between the two doctors, so all had the opportunity to see a consultant at least once a year and also the juniors were closely supervised. At the same time a formal system of an annual reviews for diabetes-related complications was introduced. The specialist nurses, dietician and chiropodist had their own offices and ran their own patient lists. The clinics were supported by friendly receptionists and the diabetes secretariat was based in the top floor of the old house. The centre was run by a dedicated manager, Dilys Goldspink. The improvements in the quality of patient care and team morale were immediate and substantial.
The Norwich and Norfolk Diabetes Trust (NNDT)
After the opening of the Bertram Diabetes Centre fundraising, led by Elsie Bertram, continued. This was extremely successful. Once the Diabetes Centre had been paid for it became clear that substantial additional finance would be available to fund further projects. As the programme would be on-going, it was decided to set up an independent charity called the Norwich and Norfolk Diabetes Trust. In October 1990, Drs Greenwood and Heyburn and Elsie Bertram met the chairman (Mr Michael Falcon) and senior executives of Norwich Health Authority. They explained that, in their opinion, there were compelling reasons for setting up a charitable trust to manage residual and future funds donated for improving diabetes services. At a time of financial uncertainty and cutbacks in the NHS it was felt that the funds would be safer if managed by an independent charitable trust rather than by the cash-strapped NHS. The officers of Norwich Health Authority agreed and, in April 1991, residual funds were transferred to NNDT.
On 8th October the trustees met for the first time. They comprised Dr Greenwood (chairman) Dr Heyburn, (vice chairman), Joan Ford (treasurer), Elsie Bertram, Ray Fields (Barclays Bank) and Chris Freemantle (Larking Gowan, accountants). Henry Speer (Mills & Reeve, solicitors) was also appointed but was unable to attend this meeting. It was decided that the NDA should continue alongside NNDT and Elsie Bertram agreed to take over as chair. The trustees then worked out a modus operandi for NNDT and reviewed their strategic objectives. It was agreed that the first priority was to support the screening programme for diabetic eye complications which had been established the previous year with the help of the donation of a mobile camera unit by the British Diabetic Association and the Allied Dunbar Foundation. It was clear that there was little point in discovering eye problems if there were insufficient facilities for timely and effective treatment such as laser photocoagulation. Thus it was decided to continue raising funds in order to build a Diabetic Eye Unit adjacent to the Bertram Diabetes Centre.
However it was clear that an additional ophthalmologist with a specific responsibility for managing diabetic eye complications was necessary for such a unit to be viable. Therefore the trustees opened negotiations with the hospital and district health authority about this issue. Both were supportive and the consultant appointment was agreed. Planning for the eye unit commenced, construction began in 1992 and the Unit was completed in July 1993. In October of that year, Andrew Glenn, was appointed as the consultant ophthalmologist with a specific responsibility for running the unit. Before he started work, NNDT paid for him to visit leading centres in the USA to learn about the latest treatment techniques. He then compiled a list of ‘state of the art’ equipment including two modern laser machines which NNDT purchased for the unit. NNDT also agreed to underwrite the running costs of the unit for the first two years.
Opening of the Bertram Diabetes Eye Unit
On 5th January 1994 the trustees were delighted to welcome HRH the Prince of Wales who performed the official opening ceremony in the presence of a large number of hospital and diabetes centre staff, patients, supporters and local dignitaries. This event was arranged by Elsie Bertram through her connections at Sandringham and with the Royal Family.
At the end of the ceremony HRH caused considerable amusement by presenting Elsie with a basket of purple brussels sprouts in memory of a visit she had made to his gardens at Highgrove some months earlier. The opening was a truly memorable occasion which generated huge local publicity and thereby ensured the continuing success of the fund raising programme.
Subsequent activities
Elsie Bertram continued to chair the NDA Committee until 1994. She was the major fund raiser. As well as a variety of activities including city centre ‘flag days’ she held several successful book sales, one of which raised £27,000 in a single weekend. In December 1995 the £1 million milestone was reached. Recently funds raised by NDA and NNDT have passed the £2 million mark.
NNDT has continued to support the development of the community eye screening programme by purchasing an additional van with a retinal camera, a computer system (to collect and analyse the results) and a new digital imaging system. NNDT also facilitated the speedy development of the programme by ‘pump priming’ the appointment of key staff.
The screening unit, which was one of the first large scale community-based initiatives in the UK, became the focus of attention for other services wishing to develop similar programmes. The experience gained in Norwich then underpinned the development of a national screening programme which was introduced a few years later (Dr Greenwood chaired the NHS National Screening Programme Advisory Board for the first five years). This programme has undoubtedly saved the sight of many patients because diabetes was the leading cause of blindness in working age adults. Sight can only be saved if diabetic eye complications are detected at an early, treatable stage and this is best achieved by a systematic population-based screening programme.
NNDT has also funded a range of other activities including the development of a GP Mini Clinic system designed to improve the care of patients not attending hospital clinics and the publication of management guidelines designed to assist the staff working in these clinics and in primary care in general. These guidelines subsequently formed the basis of Regional Management Guidelines which had a big impact and they, in turn, informed the subsequent development of national guidelines for the management of diabetes in primary care.
Research programme
In 1994 Dr Greenwood was appointed Medical Director of the new Norfolk & Norwich Hospital NHS Trust. This necessitated him giving up some of his clinical work and this led to the appointment of an additional consultant diabetologist, Dr Michael Sampson.
Dr Sampson has a strong interest in diabetes and vascular research and, as the NNDT had accumulated substantial reserve funds, it was decided that this was an important area in which to invest. This would not only improve the understanding of the causes and management of diabetes and its complications but would also raise the profile of the Norwich Unit both nationally and internationally. This would then help the Unit to attract high quality staff with consequent benefit for patient care.
NNDT agreed to fund a diabetes research unit located near the Diabetes Centre at West Norwich Hospital. NNDT provided £50,000 to pay for the conversion of an old storage unit into suitable premises for clinical trial and other research work. The Bertram Diabetes Research Unit was opened by Elsie Bertram in November 1996. The NDT also provided £300,000 5 years funding to support research programmes led br Dr Mike Sampson
NNDT also provided funds to employ a part-time medical research fellow who carried out a valuable survey of lower limb complications in the diabetic population of Norfolk. This led to the development of a pioneering community foot screening programme which identified many patients at risk of developing foot ulceration who were then given appropriate advice and, when necessary, podiatry, footwear or surgical treatment. This may well have prevented many lower limb amputations in vulnerable patients.
In 1998 the Trust funded a full time research fellow at the University of East Anglia who carried out studies
Separate from this programme, the Trust also funded a medical research fellow at NNUH who carried out a study of the eye complications of diabetes in the population of Norfolk. He utilised the results of the successful community retinopathy screening programme which were stored in the computer database funded by NNDT. The large amount of data collected from the programme over many years later provided valuable information about the natural history of diabetic retinopathy and patients at high risk of visual loss. This has formed the basis of a series of papers published in national and international diabetes and eye journals.
Other activities
In addition to the substantial investment in the local diabetes research programme, the Trust has funded many other initiatives designed to improve the quality of patient care. These have included the purchase of several items of ‘state of the art’ equipment for the investigation and management of foot problems (Pedobarograph, Tekscan, Versajet) and diabetic impotence (Rigiscan). NNDT has also funded the purchase of more modern lasers for treating retinopathy and several computer systems for the Diabetes Centre.
In addition, NNDT has provided pump priming funds for other service developments. These have included a diabetes inpatient facilitator, an eye screening data entry clerk and a diabetes audit nurse. The Trust also provided funds to allow the early appointment of a second specialist registrar.NNDT has provided substantial support for a variety of educational initiatives, including the DAFNE diet/control programme for type 1 patients, educational programmes for type 2 patients and training a group of Patient Champions to provide peer support for patients.
All of these developments have had a substantial impact on the quality of diabetes patient care in Norfolk and this was recognised nationally by the aware of a Charter Mark for Quality in December 1997. The Charter Mark was re-awarded in 2001 and at that time Norwich was the only UK diabetes unit to achieve this accolade. In 2002 the Norwich unit was judged to be the best in England and Wales in a survey of general practice perception of local diabetes services.
The Norfolk & Norwich University Hospital
In 2001, the N&N transferred from its City Centre and West Norwich sites to a new District General Hospital at Colney, just outside Norwich. This necessitated moving the Bertram Diabetes Centre and the Research Centre to the new hospital. The BDC moved into a tailor-made department in the east outpatient wing which re-created and extended the facilities at the West Norwich Hospital, thus effectively preserving the NNDT’s charitable investment. At the same time, the Bertram Diabetic Eye Unit transferred to the new ophthalmology department in the west wing of outpatients. In these new facilities, both parts of the service have continued to develop and improve. Much of this is due to continuing support provided by NNDT.
Mrs Elsie Bertram MBE Memorial Lecture
Sadly, our patron and main inspiration, Elsie Bertram MBE, passed away in 2003. In recognition of her huge contribution the new diabetes centre was re-named the Elsie Bertram Diabetes Centre. On 1st April 2004 an annual lecture for health care professionals, patients and the general public was initiated. This was called the Elsie Bertram Memorial Lecture. The first one was delivered by Dr James Shapiro from Toronto, an international expert on pancreatic islet transplantation for Type 1 diabetes. The lecture was a great success and they have continued more or less annually ever since. NNDT has been able to attract a series of distinguished speakers (see Appendix 1 below) and the large audiences have helped NNDT meet one of its charitable objectives – of providing a public benefit through increasing general knowledge and awareness of diabetes and its complications.
Chairmanship of NNDT
In 2010, after 23 years as chair of first NDA then NNDT, Dr Richard Greenwood stepped down and handed over to Nigel Bertram, one of Elsie’s two sons, who has personal experience of Type I diabetes. Nigel has extended the activities of the Trust to include the rest of the geography of Norfolk. To reflect this the Trust was renamed in 2010 ‘The Norfolk Diabetes Trust’ and new livery was produced. Engagement was made with the Queen Elizabeth Hospital in King’s Lynn, covering the west of the county, and the James Paget Hospital in Lowestoft covering the east of the county. A new and up-dated Trust Deed was produced reflecting the current status of the Trust and the number of Trustees who are now up to twelve.
In June 2012 the 100 years anniversary of Elsie’s birth and the joint 100 years of Nigel and his brother, Kip, having insulin dependent diabetes was commemorated in a short ceremony held at the Elsie Bertram Diabetes Centre at the NNUH. This attracted excellent press and radio publicity. Meanwhile funding of projects to improve the education and well-being of people with diabetes in Norfolk continued. In 2021, after 11 successful years as Chair of NDT, Nigel Bertram stepped down to become a Patron of the NDT, along with Kip Bertram and Dr Richard Greenwood, and Professor Mike Sampson, a local diabetes specialist, took over the Chairs role.
Acknowledgements
NDA/NNDT has been one of the most successful diabetes-related fundraising initiatives in the UK. It has achieved huge improvements in diabetes care for thousands of people with diabetes in Norfolk and beyond. This would not have been possible without the hard work of the members of the original NDA committee and subsequently the trustees of NNDT. The names of the NDA committee members are given in Appendix 2 and of NNDT Trustees in Appendix 3.
In addition to Elsie Bertram, MBE, the following individuals deserve special mention; Margaret Flatman, NNDT secretary (1990 – 2015), Joan Ford, Treasurer (1987 – 1992) and Joan Williams, Treasurer (2002 – 2017).
It goes without saying that numerous patients, relatives and supporters have made donations and given invaluable help with various fund-raising activities. They deserve our grateful thanks. Without them much of this would have been possible.
Appendix 1. Mrs Elsie Bertram MBE Memorial Lecturers.
Appendix 2. NDA Committee Members
Richard Greenwood (Chair)
Philip Heyburn (Vice-chair)
Janet Almond
Mike Baybutt
Elsie Bertram
Jenny Blyth
Ian Cripwell
Ray Fields
Joan Ford
Chris Freemantle
Martin Goreham
Brenda Grimes
John Harvey
Susan Panton
Linda Shingles
Henry Speer
Neil Wilson
Lynette Yaxley
Appendix 3. NNDT Trustees
Christopher Bertram*
Elsie Bertram
Nigel Bertram
Ketan Dhatariya*
Chris Dicker
Ray Fields
Margaret Flatman*
Joan Ford
Chris Freemantle
Richard Greenwood
Martin Hadley- Brown
Mark Halladay
Philip Heyburn
Lisa Jackson
Philip Norton
Rachel Orr-Dewing
Brendan Padfield
Mike Sampson*
Henry Speer
Joan Williams
(* = current)
