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My solution for type 1 diabetes workload dump

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So in a sign of things to come, or things that are actually happening, or things that have actually happened, depending on your particular neck of the woods, NHS Dorset CCG is intending to ‘discharge from specialist management’ 50% of type one diabetic patients. And as we all know, discharge from specialist management = dump on GPs.

In a war, there are always going to be casualties

Well, bring it on. For my next trick I’ll start giving IV chemotherapy, performing peritoneal dialysis in my treatment room and repairing aortic aneurysms with my teeth and a rolled up copy of the BJGP. Oh, no, wait, actually I won’t - on account of not having the skills, time, energy, funding etc (apart from maybe a minor surgery fee for the AAA, but I’m still not doing it).

I’m being a bit ridiculous, but then so’s NHS Dorset CCG by the sound of things. True, I probably could look after patients with T1DM, or my nurses who know one end of an insulin needle from the other, could, because there aren’t that many and they aren’t actually that difficult. But that’s not the point. The thing is, and I’m surprised that anyone has to point this out to any CCG, we GPs are at saturation point. We are Monty Python’s Mr Creosote, and the first type 1 diabetic to walk through our doors with the words ‘They’ve discharged me from the hospital’ is our wafer-thin-mint.

It is our responsibility to avoid exploding over our patients, and therefore I’m going to share with you a plan I have been cooking up in my practice. I devised it even before I heard about this latest work dump fandango and, with delicious irony, it exactly mirrors the CCGs tactic. It’s fighting fire with fire, or rather fighting T1DM with T2DM.

What you do is, first, recognise the fact that, for some time now, you and your nurses have been running, completely unfunded, a very resource and time-consuming diabetes clinic. It’s the sort of clinic which used to be the remit of the hospital, given that, back in the day, primary care level T2DM care used to involve precisely two drugs. Next, you acknowledge that you don’t have to do this at all. And finally you agree that, because you need to do lots of other things, and so do your nurses, these T2DM patients should, as of now, in a glorious reverse-dump manoeuvre, all be referred to the hospital clinic.

Bye bye type two diabetics. Hello time and space. I feel sorry for these patients being caught in a game of interprofessional diabetennis. But in a war, there are always going to be casualties.

Dr Tony Copperfield is a GP in Essex. You can follow him on Twitter @DocCopperfield 

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Readers' comments (8)

  • Although I understand the sentiment.

    This is the wrong approach, GP's should be actively looking to take over clinical territory in relatively easy clinical areas.

    The strategic thing is to actively dump work and refer more. not how you want to practice but some real strategic thinking is required here

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  • Peter Swinyard

    Oh dear. Jo Smit seems to think that we are idealists with unlimited resources. We are not. We are chronically underfunded, underdoctored and overstretched. No doubt we could do all the things that Copperfield was suggesting (perhaps not the AAA though, thanks. Too messy) but we are struggling to do the basics just now. When we are 25% of doctors short of establishment as we are in Swindon, we are working silly hours to manage demand. And this is one condition in which patients are actually much safer in a hospital clinic if they suffer from a condition which is the prime cause of young people going blind or having renal failure.
    No, this is one where Dorset have it wrong and the LMC should be fighting hard to say NO NO NO NO NO

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  • Peter Swinyard is 100% right on this one!

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  • Doctors and commissioners are going about this the wrong way.

    The only people well-placed to manage T1 diabetes are T1 diabetics themselves. Do do this well, what they need is:

    1) Complete access to all their information - no withholding of data by GPs and specialists.

    2) Access to specialist online educational sessions (many people can't afford to take a week off for DAFNE).

    3) or alternatively, on diagnosis, keep the T1 diabetic in hospital for a week and train them up properly - a 1/2 hour session with a DSN before being let loose with insulin is totally inadequate.

    4) Access to online/telephone support services from a specialist team 24/7. I don't need my GP to contact someone on my behalf I need to communicate with specialists myself.

    5) Access to technology that will help monitor blood sugars constantly like Freestyle libre or CGM. You can't make accurate insulin adjustments with limited data.

    6) Access to psychological counselling to deal with the major lifestyle impairments that diabetes causes.

    7) No restrictions from GPs on test strips. Testing is life saving.

    8) More peer-provided support and education. The only people who really understand insulin dosing are other T1 diabetics. Many professionals are clueless.

    9) Better official NHS dietary advice for all diabetics. It's not okay to eat normally if you want near-normal blood sugar levels. Carbs will always spike your sugar levels.

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  • You're a fool if you think treating T1DM is easy. Yes we all know they just need a bit of insulin, but as the patient above suggest (perhaps a little impolitely, most of us are genuinely just trying to help you, not deliberately withholding information) they do know a lot more about their condition than the average GP or practice nurse, and need access to a proper specialist team when they need support or advice. I presume Dorset CCG thinks GPs can assess patients for insulin pump therapy, CGMS, psychological support, meter downloads, driving and transplant assessments etc etc Because otherwise this is postcode rationing...

    It is a pity that specialist services aren't supported more to give the kind of service this patient wants. Instead all investment goes to the Vainguard Futility Projects and the expertise is lost forever

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  • Anonymous | Other healthcare professional28 Jun 2016 4:30pm

    Totally agree.

    One extra thing, keep practice nurses who are not specialists in this area away from people who have diabetes, they are no help at all and in fact add to the problem and waste my time and theirs.

    All I ask for is ten minutes with a GP when I need it who listens and responds and says when he doesn't know what to do rather than bluffs. Then I pay to go and see a specialist myself, the £150 he charges is far better value to me than all the nonsense the NHS would try to put me through at one of their hospital clinics.

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  • I think Dr Copperfield is absolutely correct. In a few years time, we WILL be required to do chemotherapy. We're we required to do T1DM management 10 years ago? So, look forward to chemo!
    As I keep saying, the problem is the our contract wording. If the. GPMC and the BMA and the LMCs started fighting for our contract, on the basis of the ICD ( international classification of diseases list), all GPs would know what to learn. If they start now there may be a change within the next 100 years. The other option is, implement ICD or we will all resign. The wording " all GPs are expected to provide GM services, as provided by all other GPs, is like " an albatross around our necks".
    Retired GP

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  • Once again: is it GMS? No? Then not primary care's responsibility and the Dorset CCG, who supposedly are 'GP-led' need to think about who they work for.

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From: Copperfield

Dr Tony Copperfield is a jobbing GP in Essex with more than a few chips on his shoulder