Commissioning Structured Education

April 2017

I bought a tent! It arrived on Tuesday but I was working all five days last week, and had commitments on all five evenings so I didn't even open the box until Saturday. I had to mow the lawn before I could try it out, but it's looking good so far. The first test will come in July with a camping trip to Devon.

The extra day's work last week was a course all about advanced features of the Roche Bolus Advisor. This is the algorithm that is used in one particular blood glucose meter and insulin pump handset to try and suggest the right amount of insulin in any situation. It was a brilliant course but I don't have my notes with me at the moment, so that blog post will have to wait. In the meantime, I shall complain about a different meeting I went to on Wednesday.

The Clinical Commissioning Group (CCG) for the area where I work is a baffling organisation. Maybe all CCGs are baffling, but I couldn't say. Its role is to decide which health services should be provided to the local population and, as the name suggests, commission those services. Obviously I am affected by the commissioning of services relating to diabetes, but I couldn't tell you the mechanism by which commissioning is done, or how we are paid as a result. I think I know the names of one or two people in the whole chain of management that administers this process but I have no understanding of the process at all. No idea whatsoever. Not at all.

Recently there has been a national campaign to promote the provision and take-up of Structured Education for people with Type 1 or Type 2 Diabetes. Structured Education isn't just any old course, it has a definition within the national guidelines. It has to be evidence-based, have specific aims and learning objectives, have a curriculum that is written down with supporting materials, be delivered by trained educators, be quality assured by trained, competent, independent assessors who measure criteria that ensure consistency, and be audited.

Recently a pot of money was announced for Structured Education and bids encouraged from CCGs. The email from the CCG asking what we deliver in our area ended up with me, so I responded describing our courses as well as asking more about the bid in case I could provide some insight, given that I am actually delivering Structured Education to actual patients. "No thanks, we're fine" was the reply.

I heard no more, and then a colleague forwarded a message to me describing a workshop that the CCG were proposing to hold to discuss Structured Education. All sorts of people had been invited, but not me. They were happy to add my name to the list, though, and then a few days before the meeting was due to be held we received the documents that were going to form the basis of a discussion about what is delivered in our area, where the gaps might be, and how we could improve things.

That's all very admirable, but when we came to read the figures in the documents for the programmes that we were actually delivering, it became clear that they had spoken to nobody who was actually doing the job. The figures suggested that no courses at all for Type 1's were being run in one area, and that courses that were being run in the other area were completely inaccessible.

I try not to get annoyed about how the NHS is run, but this was very provoking. The CCG was convening a workshop to discuss a service that I personally deliver along with just four other people. Not only had they not spoken to any of us, but they hadn't bothered to even invite those who deliver the service that was to be discussed, and had circulated completely inaccurate data. My colleagues tend to assume conspiracy, but I generally believe it's either laziness, ignorance, or lack of time. The seeming inability to pick up the phone is particularly annoying though.

Anyway, we wrote a short rebuttal of the data and asked for this information to be circulated (it wasn't), and turned up at the meeting anyway. The person who presented the data did express doubt about its accuracy, but we weren't given an opportunity to clarify. We will be getting together with CCG representatives as a result of the meeting, but my confidence in their competence is pretty low. As for outcomes - there was a lot of the usual talk about how things could be better, but my experience is that nothing changes as a result of a meeting, especially if there is no new money. The CCG doesn't yet know the outcome of their bid.

By chance this has all coincided with a change in the administration of our course. I had long been dissatisfied with how patients were identified and notified about courses. We would set dates for courses a few months in advance, but when people were referred they were simply stuck on a waiting list. About a month before a course was to start (which might be a very long time since the referral was made) about twenty people on the waiting list were contacted in the expectation that we'd get about eight to turn up.

So the waiting list was full of people who, despite having presumably agreed to the referral, had no intention of attending. Many of those who had intended to come had forgotten what it was all about by the time they received an invitation. Although we wrote back to some referrers, most never found out whether their patient had attended or not. And we couldn't tell how long anyone might have to wait.

I got together with one of the other educators and our administrator and suggested how things might work better. I was taken aback by their resistance to any change at all, and it became clear that if I wanted improvements I was going to have to take over the admin myself, at least temporarily. So I fired up Excel and made a start, and so I had a good idea of how things stood in time for the CCG's meeting.

Last year we were struggling for staff with only two of us available to deliver the course. Now we are getting up to full strength with four (and soon five) of us, but at the same time referrals have increased dramatically. The waiting list stands at about ninety people, and there are virtually no referrals from GPs, so if this starts to happen (as it should) we will be properly overwhelmed.

So the next thing to do is to get in touch with everyone on the waiting list to weed out those who can't or won't attend - that should reduce numbers significantly. Then I'll be offering actual course dates to fill up all the courses to the end of the year, and we'll see how many people are left over and if extra capacity is needed. We can't just put more people on a course, because (due to an error of the previous administrator) we had 12 attending the last course, and it didn't work very well at all.

The full course takes four days over three weeks - so what about those who can't spare the time for this? I am putting together a much shorter version which will be piloted in May over just four hours, and if successful we can at least offer something to people who can't commit to four days. But that won't be Structured Education.

When I started this job I was determined to keep my head down and have no bright ideas that would result in extra work. Nobody thanks you for extra hours, and I don't work with the sort of people who inspire any sort of innovation - as evidenced by their reluctance to consider admin change, even though they now see how much better it will be. I have started to hope that this job will be my last, if I can get an early retirement date. But I can't seem to help wanting to change things and making extra work for myself.

Blast from the past

Krakow street theatre, July 2016

I recently mentioned that Lola II brought me a pile of letters that I'd written in the early 1990's, and I was finding it difficult to read. Most of the content was fairly mundane and I was a bit disappointed to find very little that would be of interest today. In fact, one of the most interesting lines was from a letter of Lola II's that had found its way into the pile. In June 1991 she wrote (about me):

"She's really the official Lola since she was 'my assistant Lola' when we were cleaning the carpet."

So that's definitive evidence of the birth of the Lola, more than 25 years ago.

Another extract from the same period, again from Lola II rather than me, concerns a time when she volunteered for Hospital Radio in Manchester.

"Since I was there last (Hospital Radio) they've perfected a new system. Instead of asking for people to call in and then saying that no-one has called, they now ask people to call in and announce that we've had zillions of calls but no-one has got all 3 questions quite right. Occasionally I would shout out "Oh! the phone, Jenny" to give the impression we were inundated with calls."

The letters I wrote were tinged with anger and depression because of the job I was doing, although I seemed to have a pretty good social life at the same time. One extract that interests me reminds me that I've been an avid reader for a very long time.

"I've been reading a biography of Theodor Herzl, and boy! was he wacky. All those memorials to him in Israel and the general consensus that he was a visionary founding father of the modern state, and in truth he was a completely assimilated Hungarian-born "German" Jew living in Vienna and Paris, whose idea of a Jewish State was formulated as the answer to the problem of Jews not fitting in properly wherever they lived: all fair and good so far. Until you read that the first solution that he came up with was to have them all compulsorily baptized, because then there would be no Jewish religion and therefore no Jewish problem. The Jews would accept it gratefully because they would no longer be persecuted in the places where they were living. And then his negotiations with the Sultan of Turkey, offering to provide him with a nation of accountants in exchange for a tenancy agreement on a bit of land that he owned. Brings one down to earth a bit."

Of great interest to me is a throwaway comment about the terrible trouble I was having with eczema on my hands. This started at school and I had red, raw, itchy patches on my hands for many years. I went to the doctor about it in 1992:

"...he looked things up in his book and found that the steroid cream I'd been using before was based on 'parabens' which is in a special list of Things Which Are Likely To Irritate Sensitive Skin."

I now know that varieties of parabens are one of the two chemical types which definitely cause my problem, but I don't think I picked up on it at this point, or perhaps products didn't have their ingredients listed like they do now. I suffered several more years of painful itchy hands before the penny finally dropped.

This last extract is from a crazy time when PCs were in their infancy and I worked for the NHS in an old and dilapidated building that was regularly burgled. It was demolished not long after my time there. I've written about it before but this is from the letter I wrote home at the time.

"K started work about three weeks ago and is used to a word processor, but the equipment provided for her consisted of one typewriter which didn't work. There were all sorts of high-level and low-level negotiations: F talking to the "Care Group Manager" (whatever that is), D the other secretary talking to the admin manager and so on, all pestering them to supply us with something, if not a permanent machine then at least something on loan. K was going bonkers, and brought in her own personal typerwriter every day (obviously not leaving it on the premises overnight). Eventually I asked if I could join in and I was lucky enough to be the one to whom a computer was entrusted! So I had to go and pick it up (from the main psychiatry site) as a matter of honour, and made all sorts of promises about how of course it was only on loan, and yes we would eventually have to give it back, and yes we could lock it up at night, and other sorts of grovelling. And sure enough, when I passed on how very temporary this was to all the dudes back at Gaskell they smiled knowingly, and winked, and said of course we would give it back; just as soon as we have something to replace it.

"Work is looking decidedly good now that things are moving on my project, and there's nothing proper left to steal that will affect my project (except the computer in my room, which may conceivably disappear one day). The actual conditions of work have been utterly chaotic for as long as I can remember, though. At last we've had the BT men in to remove the system of plastic cups and string that called itself a switchboard and put in something less antique. I wrote about when the video camera was taken and nothing else, and that they cut some wires at the same time: well, one whole corridor had no electricity for over a week. They were conducting their patient appointments by candlelight.

"On another day, there were BT men swarming over the place as usual, including one little red-faced man called A who's worked for BT for 30 years. S the receptionist lost her voice through stress or laryngitis, so we had a temp in to answer the phones. The first thing was when the temp told S about a funny phone call she'd just taken, from the main psychiatry department over the road asking us if we were on fire. Then two fire engines arrived, complete with oxygen gear and the works, and swarms of interested busybodies from psychiatry who'd heard we were on fire and had come over to watch us burn, and security men, and workmen, and all sorts. We told them that as far as we knew we weren't on fire at all, though they were very welcome to check. Meanwhile, little BT A was getting redder and redder, and had to admit that he had a suspicion that he'd caused a short and triggered the alarm. Amid all the confusion and excitement, poor A was on the phone to his boss, saying "Norman? Norman, I'm having a bit of a day..."

"Then last Monday we actually had a working phone system, so there were all the usual BT men (including poor A, who's become almost one of the family now), and two extra sales support ladies here to train us how to use the new system, and of course the glaziers and the maintenance men and the security men and some new unfamiliar faces - some cleaners. This time, the burglars had worked out that unless they broke into the corridor the alarms don't go off, since most of the downstairs rooms don't have movement sensors in them, only the corridors. So they broke three windows, and had a good time in Dr S's room rifling through papers and notes and throwing pot plants about, and a special bonus: loads of blood everywhere because they'd cut themselves getting in. The alarm wasn't triggered at all, so it was discovered late on Sunday when the cleaning supervisor came over to look at the state of the cleaning because of a separate long-running feud with the cleaning department over the way we aren't cleaned. We had a fingerprint man in later too: such interesting visitors."

This is certainly wilder than the situation in the NHS today, but in other letters from the bundle I described meetings that were no different from the one I had this week - no agenda, no minutes, nobody leading, many talking and few listening, and virtually no progress in two hours of directionless discussion full of pointless digression. The main difference is that now I sit quietly and care a lot less about the frustration and futility of it all. In between piping up with "and Dietitians!" every time we aren't mentioned in the context of service delivery, I try and work out how I can write about it here without breaching confidentiality or getting myself into trouble.

Krakow Botanic Gardens, July 2016

Ten things

Greece, June 2014

This post is pretty close to a rant. It's true that I have been feeling a bit stressed and the four-day weekend for Easter was very welcome. Normal service should be resumed very soon with calm, considered blogs of an informational and entertaining nature. I hope so, anyway.

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1. Sensational media reports based on a flawed interpretation of a journal article or on something made up by a journalist or a celebrity

"Did you see the TV programme last week about how eating saturated fat is good for you? I've switched back to butter."

"I read in a magazine about how you will lose weight if you eat nothing at all after 5 p.m."

"I cut this article out of the newspaper about kale smoothies reversing diabetes."

"This website says that chia seeds will melt fat."

"The Daily Mail says that eating blackberries brings your blood glucose down."

"It says there's a new cure for diabetes."

FACT: It's all rubbish, ignore it. If you are overweight and want to reduce your blood glucose and improve your diabetes control, then eat less carbohydrate and lose weight. If you want to lose weight, you need to eat less, and ideally move more. The dietitian's job is to help you find a successful way to do all this, not spend half a consultation explaining how journalists are perfectly free to MAKE STUFF UP and are paid handsomely for it.

2. I can't possibly eat any less

The patient declares that there's no way they can eat any less than they already do. "I don't have any appetite," they say. "I eat like a bird. My two-year old grandson eats more than I do." The account they give of their daily diet consists of a small bowl of cereal for breakfast, half a tin of soup for lunch, and one slice of toast and a tin of sardines for supper. Between meals: black tea and coffee with sweetener. "I can't understand it," they say.

FACT: You are eating more than this, and you know it. Or maybe you don't know it. Either way, you're eating more than this or you wouldn't weigh 20 stone.

3. Artificial sweeteners

"Aren't they as bad as sugar? I read they cause cancer. They're full of chemicals, really bad for you. I wouldn't touch them."

FACT: Artificial sweeteners are safe. They're calorie-free. They're carb-free. THEY ARE FINE, STOP BEING STUPID.

4. Exercise

"I would lose all this weight if I could exercise, but I can't."

"I'd love to go out for a walk, but my back/hip/knees are too painful."

"My dog died and I put on 10 pounds."

FACT: exercise is incredibly good for us - it brings down high blood glucose levels, makes us feel good, strengthens muscles and helps stabilise joints - but the amount of calories burned by ordinary people who increase their activity level is about equivalent to a sandwich. If you're a typical overweight person you won't lose weight by exercise alone, and you'll probably reward yourself with more calories than you used up. But go out for a walk anyway, because the other benefits of activity are so worth it. And then start eating less.

5. Honey

"I've cut out all sugar, I don't have any now. I put honey in my tea and on my porridge instead."

"Honey's natural so it must be better than sugar."

FACT: Sugar is processed from plants by people; honey is processed from plants by bees and then people. Honey will have the same effect on your blood glucose and your waistline as sugar. Sorry to disappoint you, but YOU ARE DELUDING YOURSELF.

6. Fruit and fruit juice

"Fruit juice is healthy, isn't it? It's natural."

"I buy the fruit juice labelled 'no added sugar.'"

"I've stopped snacking on biscuits, and I'm having lots and lots of fruit instead."

FACT: fruit juice has more sugar in it than lemonade, and nearly as much as Coke or Pepsi. Why would a manufacturer need to add more sugar to a product that's already 10% sugar? Yes, whole fruit is better, but you're not helping your blood glucose levels if you have more than a handful at a time. And the 'five-a-day' message? Well, it's perfectly OK to have five portions of vegetables and no fruit at all.

7. 'Full of sugar'

"I stopped having ketchup on my chips - it's full of sugar."

"Those pasta sauces are full of sugar."

"I don't eat grapes or bananas any more; the nurse told me they are full of sugar."

"I have muesli now - cornflakes are full of sugar."

FACT: There's far more 'sugar' in your chips than in your dollop of ketchup, more in your large bowl of pasta than in the couple of tablespoons of pasta sauce, and no less in your bowl of muesli than there was in your cornflakes. It's all about the carbs. Grapes and bananas are fine, but have a handful of grapes or a small banana, not the whole punnet or a banana the size of a baseball bat.

8. The Menu Plan

"Just tell me what to eat."

"Can you just give me a menu plan?"

The lifestyle magazines are always printing "a menu plan for a week". We love them. I love them. If only we could just follow the plan to the letter, it would be so easy and we'd reap the promised benefit. But then we look through them - one muffin? Half a grapefruit? 300g kale? What do we do with the five other muffins that came in the pack of six, or the other half grapefruit, and I'm not allowed grapefruit anyway, and kale comes in 500g packs, and I don't like kale, and it's too expensive to eat all that fish, and I don't like fish except tinned tuna. What do I do in week 2 - just repeat week 1? My wife does all the cooking and we eat curry and chapatti not sausages and potatoes...

FACT: Menu plans are useless, and I don't have one for you. You'll have to work it out for yourself. Sorry.

9. "You're telling me I can't have..."

Honey. Rice. Sugar puffs. Fruit juice. Potatoes.

NO, I'M NOT TELLING YOU WHAT YOU CAN AND CAN'T HAVE. What I'm telling you is the effect that it will have on your weight, or your blood glucose. You can have whatever you like, whenever you like, because it isn't me that will put on weight or need to inject insulin, it's you. If you want to start the day with a Pepsi, that's fine, but if I were you, I wouldn't do it, like I wouldn't walk into the road without looking, or swim in the sea when there's a red flag flying. But if you want to, you go ahead.

9a. 'Good' and 'Bad' food

There is no such thing as good or bad food - nothing is forbidden. It's good to eat a lot of some foods and a little of others, and hey! it's bad to eat a lot of some foods and a little of others. Eat what you like, it's your decision and you will have to live with the consequences. My job includes making sure you are aware of what those consequences might be.

10. Low blood sugar

"I had to have a sandwich because my blood sugar was low."

"I can't sleep unless I have a glass of milk and a biscuit before bedtime."

"I need a snack to keep me going."

FACT: if you 'need' a regular snack then your insulin needs adjusting down. If you're not on insulin (or gliclazide or another insulin-stimulating medication) then you don't 'need' a snack, you just want one - you will never have low blood sugar. Grow up, you're not a toddler any more.