All too familiar? : QiC Awards 2012 Guest post

I was invited to write a blog post or two for the Quality in Care (QiC) awards 2012. QiC highlights and recognises outstanding practice and initiatives of healthcare professionals, NHS trusts and other organisations in the care of long-term conditions including diabetes that meet the values of QIPP (Quality, Innovation, Productivity and Prevention). This second post does a bit of moaning about decentralised care.

Familiarity breeds contempt they say, and I suppose that is true of those with chronic conditions. We have attended so many appointments, check-ups and dealt with so many prescription requests over the years that we can become quickly frustrated by any perceived administrative inefficiency.

We are already devoting quite a considerable amount of time and effort to this ‘playing at being a pancreas’ project and have little enthusiasm for repeat appointments and any apparent lack of communication between different parts of our care team. For example, I needed to make some changes to my repeat prescription recently as suggested by the DSN at the hospital. It took at least four attempts to get it right at my surgery. This is about average. I’m not sure how I could have made the requests any clearer. In the end it took two handwritten notes, one typewritten, one from the DSN herself and three visits to the GP’s reception.

At no point was I called or emailed with a query or to request any clarification, I just had to keep going back and asking for the same thing over and over until the repeat prescription form eventually came out right. And this is a surgery that I know handles their aspects of my care brilliantly. Compared to other people’s experiences that I read on various forums, I know I am very lucky.

There seems to be another push for the decentralisation of care at the moment. I can remember when what I used to refer to as my 30,000-Jab Service (annual diabetic review) took place with two visits. I would get some bloods taken a week or two before my appointment, then go along to clinic and spend the inevitable hour waiting to be seen before being variously poked and prodded until everyone was satisfied that I was OK to be released for another 12 months. All in all, including the blood tests, it probably took about two or three hours.

Change 1: The arrival of eye screening units. The traditional scary-pupil-enlargement-and-bright-light-combo was taken out of the review and began to involve snazzy photography by a mobile unit at the GP surgery rather than being peered at by someone clutching an ophthalmoscope and holding their breath. Not a bad change – but it did involve an extra appointment and thus a bit more waiting room drudgery.

Change 2: The next thing that happened was that a practice nurse and GP at my surgery went on a short course, and they began to run a diabetes clinic. Since I’m on their books I was not-very-gently encouraged to attend (I always assumed there was a financial incentive). Up to that point my care had always been at the hospital, and for a year or two I endured double appointment ‘fun’. Twice the appointments, twice the blood tests, twice the reviews, more hours spent in waiting rooms, more time away from work – no actual benefit.

Since the surgery was not taking no for an answer I ended up signing myself off at the hospital and kept going to my GPs for a few years. This was all well and good for some things, but after drifting for a while with a not-disastrous-but-not-great HbA1c I had a peculiar hypo one night that shook me up a bit and ended up with a precautionary, though looking back largely unnecessary, trip to A&E.

Some of the long-standing frustrations and/or peculiarities in the micro-management of T1 became more pressing. But when I went for an appointment first with the practice nurse, then with the practice GP ‘with interest’ both looked a little rabbit-in-the-headlights when I started asking pointy questions about changing insulins. I think the GP said ‘It’s a bit out of my league really’. So I was referred back to the hospital again. Approximately 18 months later I am going through that same loop again – ‘review overdue’ is appearing on my repeat prescription request form. I’m booked in to the GP clinic again. Even though I had an ‘annual’ review six months ago.

Now that doesn’t sound too troublesome as a story – but coming from a point of feeling ‘well cared for’ for about 10 or 15 years with one or two appointments a year the number of appointments has risen exponentially. And often the appointments can be 2 minute affairs just to say that someone doesn’t know and I’d have to go and see someone else.

I am extremely lucky in that my working hours are quite flexible, but in previous jobs this would have been extremely difficult to manage. I can understand the logic in trying to free up time in hospitals by getting some of the checks and tests (weight, blood pressure, eye squinting, toe tickling and so on) done in a local GP surgery, but the problem seems to be that the various parts of the now widespread team are not sharing their bits of information effectively.

Additionally if you break down one appointment into four or five different slices it becomes a lot more troublesome and time consuming for the patient. From the surgery point of view I can see the QoF* incentive to get good results from all the people with diabetes on your books – after all we are expensive to keep – but surely a result is a result? A test and/or notes taken at hospital clinic should not need to be repeated a month or two later at the surgery unless there is a compelling clinical reason for doing so.

*The Quality and Outcomes Framework allocates 'points' for GP surgeries where patients with long-term conditions are meeting certain criteria and/or have all the relevant records up to date. The points then equate to additional budget for the surgery.