Sunday, June 9, 2013

A lesson from history

Let me say this at the very outset. As regards diabetes care, so called leaders of the GP world about 7-8 years ago  let down their colleagues.Massively. Misrepresented what the grass-roots wanted, misrepresented what was needed. Massively dealt their colleagues a poor hand..leaving them now, understaffed, under resourced to delver good quality diabetes care. I have no idea of other specialities so can't comment for certain but as regards diabetes care? Without a shadow of a doubt. you ask? Well, you know what...about 8-years ago, I still recall attending, nay sitting in a national meeting where diabetes care was being discussed. It was the time when "move in the community" became the clarion call and as usual, diabetes was picked as one of the disease areas to look into.  And I sat with utter bemusement to hear 3 senior GP leaders, one after another, stand up and explain why ALL diabetes care could move into the community, one even said there was no need for a diabetes base within a hospital, no need for diabetes specialists, quote unquote.."there is nothing a Consultant in diabetes does what a GP couldn't." I was bemused and dismayed at this...but those were the days when you listened, rather than piped up.The problem was that the Consultants in that meeting said little to counter, I even asked one of them why..their response..."ah don't bother responding to silly people".

Problem was those "silly people" had the ear of policy makers and a significant chunk of diabetes care moved to the community, without any planning. Problem? It didn't move with the resources necessarily...but hey, if all followed QoF targets, it would be fine, right? Many years later, the national diabetes audits show the folly of it...huge variation, some poor outcomes, admissions up....just asking the "GPs to take it over" doesn't work. Many reasons for that, including a non evidence based, blanket QoF but in the main, a policy shift driven by a few, but not supported by the many.

So here are some  tips to GP leaders (are they called CCG leads now?) from a specialist who worries other specialisms heading this way...with GP colleagues being asked to absorb the extra work

1. When you come up with ideas, please make sure it's not just your own prejudiced view, but that of the grass-roots. Please get a consensus view as that stops a lot of angst or resistance with the tag line "I never agreed to it". Maybe even borrow ideas from areas where primary and specialist care may ACTUALLY be working together.
2. Don't come out with statements like "we don't need specialists". That's a statement borne out of arrogance or a lack of respect. An example from the diabetes world? No you cannot do antenatal diabetes or pump diabetes. You haven't been trained for it, I have. Straight talking isn't arrogance- its stating the obvious which otherwise harms patients.Your level of patient care for those sort of groups of patients would be comparable to me providing GP care for a day, It's called "suboptimal". So try and define what bits is not appropriate for patients to be handled solely by primary care.
3. Think of the resource implications and also the impact on your practice nurse. Type 2 diabetes care, in the main, is delivered by practice nurses in this country...ask them whether the more complex patients is appropriate to be managed solely by primary care.
4.  If you want to have resources, then have a think whether simply increasing GPs or practice nurses will do. Do, please understand there are some areas in each speciality where you need a specialist opinion. They have been trained for that at the expense of the taxpayer...use them for that.There is a need for specialists to work differently too but it can only happen when there is acceptance they have a role, rather than none at all.
5. If you want to use Consultants, then see what educator role they can have. Asking them to do an intermediate clinic on their own serves little educational purpose. All that has been achieved is moving the patient from one building to another. You have dropped the revenue for the local hospital that year, but not allocated that money to the educational content which would help the GP to stop sending a similar patient for review.
6. There are some GPs who can "do it all" but in the main, most are stretched beyond breaking point. The one who shouts loudest that he can do all isn't necessarily representing the majority.

I could go on a bit more but in the main, the above ideas and views are not mine. They are grass roots GPs and practice nurses....collected after being part of a model whereby I and my colleagues have been part of each individual local GP surgery...visiting them twice a year discussing diabetes care, understanding the frustrations...and believe me, that frustration is widespread...the angst of more and more complex patients being sent out if hospital without any resource, point of contact etc.

So take it as an ode from a specialist. As regards diabetes locally, as mentioned before, we have been fortunate to have CCG leads who have listened and supported the above concepts, but the frustration in areas I visit is palpable. Forgetting even that, without an educational and support content for primary care, where specialists can have a big role,  there's very little help of us battling the ever increasing demand with a capped, maybe even reduced, finances.

This no longer is the time to score political points, it is genuinely time to work with specialists, understand their roles, respect they have plenty to offer (as it needs to happen the other way too) and hopefully, we can do some good for patients. Together. Side by side. Not jostling to see who is the big dog in the healthcare system.We keep talking about "working together", "care without walls" ....Let me quote you something from the "Tragedy of Hamlet"... "Suit the action to the word..and the word to the action". 


  1. As a type 1 diabetic of 37 years, let me give you my history of diabetes. When I was first diagnosed, at 11, it was quite clear that my GP did not know about diabetes. This didn't matter because I was under the care of the diabetes department at the local hospital, however, my GP did one of the most important things that she could do: she gave my mother the address of a local family who had a boy my age with type 1 diabetes. We learned far more from them about how to live with diabetes than we did from any clinician. Diabetes is a 24 hour condition and only someone who lives with it will be able to tell you how to manage it all the time.

    I was under a hospital consultant from when I was 11 until I was 29. At that point I moved house and my GP practice was one of these new-fangled things called "fundholders". I registered with my GP and at the first appointment I asked to be seen at the local hospital. The GP said that they ran their own clinics, so that is where I would be seen (in those days there was no concept at all of patient choice). At the first diabetic appointment the GP told me "I've just been on a course about diabetes, but since you've had it for 17 years I think you know more about it than me". Oh dear. I was, however, referred to the retinopathy clinic at the local hospital, which was a good thing since I was starting to get bleeds in my eyes.

    After two years I moved house again and this time I was at a non-fundholding GP (again - no patient choice, the practice just happened not to be a fundholder). At the first appointment with my GP I was firm: I wanted to be seen by the hospital consultant. My GP was happy to refer me, but suggested that I had "split care" and so for the last 18 years I have been seen by both the hospital consultant and the GP diabetic clinic.

    At this hospital I am *always* seen by a consultant, never a junior doctor. The hospital also has diabetic nurses and I have their number and can call them when I want (office hours). I find this helpful because there are some aspects of living with diabetes where a nurse is more understanding and practicable.

    Initially at the GP I was seen by the practice nurse for tests and then have a double appointment with my GP. My GP had an interest in diabetes, however, when she retired I was told that no other GP in the practice had a special interest in diabetes and so the GP clinic changed to an appointment with the practice nurse, twice a year. Last year I was told that because of staff shortages I would only be seen once a year by the GP practice nurse.

    I have seen, perhaps, 6 different GPs at that practice and all say that they do not have experience with type 1 diabetics. Is this a surprise? I think not. Going on the proportions of diabetics in the population I reckon my GP has about 60 type 1 diabetics, most of whom will be healthy and managing their condition well, so for a practice with 10 GPs a single GP is unlikely to see a type 1 diabetic.

    I have raised the issue of diabetes care with the local CCG who admit to me personally that there is an issue in the area, with a wide variation across the GP practices. At the moment I am reassured that I am seen by my hospital consultant (who also manages my hypothyroidism). I will resist any policy that removes that entitlement from me.

    1. Well put indeed. We MUST learn from history, and hear those for whom we do this. Otherwise its all a waste of time.

  2. As a nurse who cares for diabetic patients, I have to admit it is very much a struggle. For over 5 years I have dealt with monitoring their glucose levels and ensuring that they are keeping up with their insulin injections using the proper syringes. Even though it is hard work, I wouldn't change my profession.