Monday, 9 December 2013

Commissioning diabetes services

Great Horned Owl
Cotswold Falconry Centre, April 2013
At this very moment, right now this instant, I should be getting on with my admin. After a triumph last weekend when I finally, FINALLY managed to switch energy companies, I thought I would keep up the momentum and finish the deal with sorting all the bits of paper heaped up in an enormous pile.

So far this weekend, I have been obliged to go to two, count 'em, TWO Christmas dinners, as well as having my hair cut and going to the greengrocer and making two cakes. Because I am leaving work and there is only one weekend left before my leaving 'party' and I want to stuff vine leaves next weekend and that takes ages. So cakes must be baked this weekend, but I can't do another one because I have run out of cinnamon, so I have to do my admin. Except for the small matter of blogging.

Christmas dinners: one was on Friday night in a local pub/restaurant with my home badminton club that I haven't played with for six months, and the other was on Saturday night in a posh hotel with the Dietitians from the hospital where I used to work a year ago. On balance I probably liked the second one better, because there was a live band and lots of dancing. But the first was very good too.

Cakes: one spiced with fruit, one lemon drizzle.

My leaving 'party': this is taking place after work in a couple of weeks, when a modest buffet will celebrate two people leaving and one going on maternity leave.

Work is a bit strange because I will be leaving in less than a month, so I have much less patience for all the annoying things that happen on a daily basis. Colleagues are constantly complaining about all sorts of things, some of which are genuinely troublesome, but a lot of which are just giving them the pleasurable sensation of feeling put upon. Nothing much has changed in my world, except that I have at last finished the Carbohydrate Reference Tables and sent them for approval by the Trust communications police via the approved route, and have heard nothing at all for two weeks.

The main complaint at the moment concerns a plan by the Clinical Commissioning Group (CCG) to improve the service given to people with stable Type 1 diabetes who are registered with City GPs. The CCG is the official body now authorised to commission services and spend the NHS's money, and it wishes to discharge these patients from care within the city hospitals to be seen in an 'intermediate' service in the community instead. The advantage to the patients is that clinics should be easier to get to and there will be some evening and weekend appointments. There is no change planned for patients who live further afield in the catchment area served by the Trust. People with Type 2 diabetes under the care of the City CCG have already been discharged in this way, but they are back under the care of their GPs rather than being seen in a specialist diabetes service.

In itself, this plan is a good thing. The difficulty lies with the bitter internecine conflict between staff in the Diabetes service based in the two hospitals within the Trust. I may have written long ago about the attempts being made to bring the two locations together somehow, but we have not only remained as two separate units, but the divisions between the two seem to have increased. All this is helped not at all by feuding Consultants and an extreme lack of nurses that is due to become worse when three nurses reduce their hours and one goes on maternity leave in January. Despite the lack of consensus and the lack of staffing, the CCG continues to press forward with the plan.

Some of the difficulty was brought into the open recently because we offer two completely different types of Structured Education, which NICE says should be offered to people diagnosed with diabetes soon after diagnosis. Quite a lot of information, knowledge and skill is needed to manage diabetes in the best possible way, and there are many courses available, some of which are based on a national curriculum and others developed locally. Suitable courses must be evidence-based, and must demonstrate that participants have better outcomes in their diabetes management after they have been on the course.

The two hospitals in the Trust currently offer different Structured Education packages, one developed locally and one licensed nationally. The CCG wishes to offer just one type of Structured Education in the new service, and it is proving difficult and divisive to decide which one this will be. Emotions are running high, as various people have a deep commitment to one or other of the courses, and not only seem unable to decide which to choose, but also seem unable to settle upon a method by which the choice should be made.

The decision to discharge these patients into the intermediate service has also been made seemingly without adequate consideration of the practicalities. How will appointments be made, and by whom? Who exactly will be seeing the patients, and what level of qualifications should they have? Where will they be seeing the patients? What data will need to be recorded, and where and how will it be kept and made available to people who need to see it? How will patients contact the key doctors, nurses and dietitians? A date has been circulated for when the new service will start, without any reassurance that these questions have been considered.

The more forcefully that the new service is pushed, the more resistance is developing, and where I sit and have my lunch all goodwill has evaporated towards the instigators and supporters of the scheme. It is unusual for a day to go by without someone starting up some sort of complaint about the whole situation, and all and sundry chime in, and my pleasant relaxing lunch break is over.

I am very much looking forward to the new job, and it was very useful chatting at the Dietitians' Christmas do. A colleague asked how many days I would be working, and I was able to turn to the manager (who was sitting next to me) and ask, "How many days a week will I be working?" Her answer was "At least four," so that's a bit clearer now. I'm not exactly sure what I will be doing, but another colleague said that she had trained my predecessor for a renal clinic (kidney damage is one of the complications of poorly-controlled diabetes). I was also told that the Diabetes Dietitians in the Trust who are based in a couple of other locations have regular meetings as a team, so I should be able to draw on the expertise of more experienced colleagues for support and for clinical supervision.

Stop Press: my Carbohydrate Reference Tables have been returned by the official people who approve such publications, and who now want us to get written feedback from five service users before approval will be given. And so it goes on...


  1. Mmmmmm, lemon drizzle cake...

  2. "The main complaint" to "break is over" is a very clear description of the difficulties that lead in due course to NHS scandals about patients being lost from the system. How brave are you feeling? Is the CCG aware of these tensions, and has it called any sort of Reconciliation Tribunal meeting? Maybe they should call in a mediator?

    1. I am not feeling brave, and I know very little about what the CCG does and doesn't know. For all I know, everything is very well thought out and will succeed without a hitch, since I am not included in any of the decision-making groups. I simply report what I see, which may or may not reflect the truth of the matter. Some people whom I respect and trust are involved in the process (well, one person) so I hold my tongue and hope.


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