Caught between a (diabetic) hard rock and a (patient charter) hard place

Copperfield laments the workload paradox that NHS England’s new patient charter and NICE’s diabetes draft guidance has generated

If you ever feel that demand’s being stoked while supply’s being choked, then I have two news stories for you.

The first is the release of the patient charter laying out the rules by which practices must abide.

The second is new draft NICE guidance on T2DM.

Predictably, the charter highlights to the public exactly what we are contractually meant to do for them. Which is, absorb patient requests via every conceivable channel, at every available hour, with no fobbing off and a mandated 24-hour response time, or else… Well, here the charter helpfully goes on to outline the complaint mechanism. Up to this moment in time, GP pragmatists might have viewed this as aspirational. Patients certainly won’t, at least not now.

So pressure is cranked up at precisely the same time that available appointment and head space is cranked down – assuming the draft diabetes guidance gets the rubber stamp. Sure, putting loads more diabetics on loads more drugs will probably improve some outcomes, but appointment waits won’t be one of them. Polypharmacology gobbles up consultation slots, especially if you have to warn about side effects such as urinary disturbance, DKA, and in male patients, the penis falling off. That last one doesn’t happen too often, but once is enough, right?

One of the problems with NICE guidance (and there are many) is that it invariably tells us to do more. And to do more, we either have to work harder or stop other things. And as there are no things we can stop (if we did they would circle back to us anyway), we are crushed to the point of professional asphyxiation.  

So the inconvenient truth is that NICE is asking us to deliver the undeliverable, and the patient charter demands we do it yesterday.

Look, I can remember when diabetes care was just diet, or metformin if you got really fancy. And when cardiac failure was diuretics and sit up at night. And when COPD was salbutamol and stop smoking. Now we’re expected to provide specialist level, multi-drug, intensively monitored, chronic disease perfection, while still doing the core job.

It’s just not possible. The solution, of course, is either: we GPs just refer all this stuff back to secondary care to deal with, assuming we can fend off the inevitable bounce backs; or for the Government to fund community teams to take chronic disease management off our hands.

I don’t mind. But something must be done. It says so on the charter.

Dr Copperfield is a GP in Essex. Read more of his blogs here