Treatment protocol - time to remove the GP?

[DeusXM]

Just been reading several threads on here and I'm starting to see something of a worryingly common theme.

In the last week alone I've seen threads about:

GPs refusing to prescribe bolus insulin to T1s
GPs refusing to prescribe medication to people with diabetes
GPs seeing results that are by NICE definitions 'diabetic' and taking no action
GPs refusing to prescribe test strips

And that's just a starter for 10.

Now, I know this site isn't representative of the whole experience of everyone with diabetes, and also that people only complain when things go wrong. But I'm starting to feel like there is something fundamentally broken with the way our health system works where GPs are expected to handle issues related to diabetes yet there seems to be a very large number of them who are, for want of a better word, utterly incompetent.

How many times have we read those stories about GPs assuming that anyone presenting with high blood sugars as an adult must be a T2, or for them to completely miss the diagnosis in children with sometimes fatal results?

I think there needs to be a radical rethink of how diabetes is managed within the NHS. This isn't good enough. We need to get out of this mindset that someone with a broad range of skills is sufficiently equipped to handle a serious, complex, chronic medical condition. What do we all think? I'd say a good start point would be anyone presenting with an A1C of >48 for the first time should be referred straight away to a proper endocrinologist on an immediate, emergency basis. I know we've had all these 'nice' campaigns about the 4Ts etc. but they're not working. Is this something that Diabetes UK could lobby for? We've tried the whole 'educating GPs' approach and it's clearly not working.

 

[Annette]

Where are you planning on finding all the extra endocrinologist appointments that would be needed from?
I dont disagree that its not working, but your solution wouldnt work either, in today's underfunded NHS.

 

[grovesy]

In my area a local surgery hit the national news as 4 partners resigned over cuts in funding. That surgery has now been taken over by Virgin Health.
My own surgery has cut back on services because of cuts, I have been with my surgery for over 30 years and had always provided a an emergency Saturday morning session, this has been axed, along with more recent early and late surgeries. They are also cutting back on phlebotomy services, trying to use one of the 2 surgeries as a hub!

 

[Ljc]

I think some of it is down to their training or rather lack of it, obviously some is down to cost cutting and I suppose their are some that just don't care.

TBH I've found the younger GPs at the practice I'm with now, less knowledgeable than the older ones at diabetes related things.
I had to explain to one younger GP ,that my insulin didn't come in different strengths it was the all done by injecting more or less units, he was very confused at this.
Another wanted me to drink a glass of cranberry juice everyday 😱 and yes he did know I was diabetic.

I too have read the same horror stories on here as DeusXM, it's dreadful to say the least.

 

[DeusXM]

Where are you planning on finding all the extra endocrinologist appointments that would be needed from?
I dont disagree that its not working, but your solution wouldnt work either, in today's underfunded NHS.

To some extent, I would argue 'that's not my problem'...the more sensible answer would be to research the overall impact that this poor performance from GPs has on patient outcomes, and posit that if people with diabetes were properly treated, the reduction in complications would result in fewer costs to the NHS, and that saving would therefore pay for the appointments.

 

[Pumper_Sue]

My GP is ACE with the capital letters intended, He has a far better understanding of my needs than and endo who I see once a year for 10 mins.

 

[Abi]

I agree with the above ( as a GP myself)
Understanding of the condition varies and much of it depends on the knowledge of nursing staff as much of the routine diabetic checks are carried out by nurses
Many primary health care staff are competent- or at lease sufficiently competent to know when/ and how urgenty they need to refer.
Unfortunately as the above posts show - some are not- to the point of being dangerous
Kooky's delayed diagnosis is an example
Failure of basic understanding re need for basal and bolus insulins and blanket bans on strips for non insulin users ( or over zealous rationing of quantities for insulin users) should not be occuring

 

[Abi]

As for referral of all with HbA1c of 48 or over- not going to happen any time soon!
Not unusual for 18 months or 2 years between hospital check ups in some places due to under resourcing. I think generally if you ask for help you will be accomodated but some people are not assertive enough or do not realised help is available
The other problem of course is if GP declines referral to secondary care believing that they can" manage" the condition when of course it is the patient who should be doing the management and may have not been given the optimum treatment regimen for their personal needs, in order to so so

 

[eggyg]

Just been reading several threads on here and I'm starting to see something of a worryingly common theme.

In the last week alone I've seen threads about:

GPs refusing to prescribe bolus insulin to T1s
GPs refusing to prescribe medication to people with diabetes
GPs seeing results that are by NICE definitions 'diabetic' and taking no action
GPs refusing to prescribe test strips

And that's just a starter for 10.

Now, I know this site isn't representative of the whole experience of everyone with diabetes, and also that people only complain when things go wrong. But I'm starting to feel like there is something fundamentally broken with the way our health system works where GPs are expected to handle issues related to diabetes yet there seems to be a very large number of them who are, for want of a better word, utterly incompetent.

How many times have we read those stories about GPs assuming that anyone presenting with high blood sugars as an adult must be a T2, or for them to completely miss the diagnosis in children with sometimes fatal results?

I think there needs to be a radical rethink of how diabetes is managed within the NHS. This isn't good enough. We need to get out of this mindset that someone with a broad range of skills is sufficiently equipped to handle a serious, complex, chronic medical condition. What do we all think? I'd say a good start point would be anyone presenting with an A1C of >48 for the first time should be referred straight away to a proper endocrinologist on an immediate, emergency basis. I know we've had all these 'nice' campaigns about the 4Ts etc. but they're not working. Is this something that Diabetes UK could lobby for? We've tried the whole 'educating GPs' approach and it's clearly not working.

Interesting thread. I was diagnosed 6 years ago after having a partial pancreatectomy due to a tumour. I'm "an interesting case", "will never be normal" and "am a different animal" ( that last one from Cumbria's Head Diabetic Nurse Specialist whom I met on a Living with Diabetes Day last year). In the 8 years since my operation, I have NEVER seen an endocrinologist! My DSN once emailed one for advice! Luckily, I am a fairly intelligent person and with the help of the internet, books and the lovely people on this forum, I "muddle" through. I don't fit in any box so the system has all but forgotten me. My DSN nearly gets me but it's taken years, I always get the impression that she is relieved when I've had my review and I say everything is OK. But I'm with you on the fact that for all diabetes is costing the NHS billions of pounds a year, they are no better at treating it. We are basically just left to get on with it. I don't know the answer, more education perhaps? But there lies another debate! PS by the way I have always been able to get test strips etc. Never any argument there, small mercies eh?

 

[Diabeticliberty]

Deus you seem surprised as if the GP's sometimes letting some diabetics down is something new. Well as much as I don't wish to disappoint you it has been going on for decades and will continue to well beyond your lifetime. The fact of the matter is though it is the only NHS that we have so short of paying for private medical insurance and private prescriptions then it really is just a case of make the best of it. A few night school lessons at the Professor Google College Of Medicine unfortunately does not make you the next Alexander Fleming nor does it make me Marie Curie. We all know bits about of own condition and how it uniquely affects us as individuals. We do not know however how the condition uniquely affects other people. It is quite dangerous to make assumptions that it affects everybody the same because clearly it does not. Perhaps then this coupled with the extremely heavy workload of a whole medical book full of other conditions to deal with and treat we might want to cut our doctors just a little bit of slack. I thought that lobbying the NHS to try and re educate the more dogmatic GP's and DSN's as the most positive initial step and I still do. Unfortunately when I attempted to ask D-UK a couple of weeks ago on another thread regarding this subject I received what I can only describe as a lukewarm answer and that took longer than I felt was appropriate because surely it is one of the greatest challenges some diabetics face today. It does constantly appear to be he question that nobody really wants to answer fully. Until we can put together a united front and speak with a single unified voice and keep asking this question I fear it will never get answered and diabetics will continue to receive a service that may be detrimental to their best long term treatment regime. Before you start suggesting major rethinks which I do honestly commend you for suggesting it might be better to fully exhaust all current options presently on the table in front of us.

 

[Stitch147]

The surgery that I go to have 3 gp's out of 15 that specialise in diabetes one of those is actually certified in diabetes care, he is the only 1 that I will see for anything regarding my diabetes. He spotted the fact that I had a rare type of diabetes and he will actually listen to what I have to say when I go there. So I am more than happy seeing this particular gp about my diabetes.

 

[trophywench]

Is he planning to retire within your lifetime? and if so, what are his plans for succession? LOL

Of course Deus - it IS your problem - and mine, and everyone else living here, who pays tax!

Let's have a look at the French equivalent of the NHS shall we? Fine if you have run of the mill stuff - but for anything more specialised it's different. Stayed in a Chambre d'hote in Normandy once. The lady went missing one day, she told us she wouldn't be there - her daughter had the ole 'sticky ear' thing - common enough in kids throughout, that one, yeah yeah - but the specialists for dealing with this once it got to the 'she needed a gromett' (the French for which, is 'YoYo' believe it or not!) stage - are in Paris! Daughter was due here check up so that's where mama was going. Another friend - English - lives 20 miles away from Montlucon - had bad migraines. All the investigations were done - and scans - very thorough - in Montlucon. Oh - you need to see the specialist - again in Paris. Off he goes to Paris - oooh yes - here's a 6 month prescription for the only drug that can possibly treat this. Nobody other than us is allowed to prescribe it, so you have to come back here. See you again in 6 months. Goes to pharmacy. Oh you don't live in Paris - you have to go to a pharmacy in Monlucon. Goes home and to the pharmacy. You can only have a month's worth of these. Oh OK - I'll come back in 25/6 days time for the next lat. Oh no you can't - not without a fresh scrip, not from this one because a Dr outside our area has prescribed it.

This can't be resolved - because Paris can't supply 28 day scrips for it and his Departement won't allow outside area scrips for longer than a month. These are the laws of the Departements, not Central Government laws and requests for exceptions - whoever makes them! - fall on stone deaf ears.

We are quite probably faced in future by similar mud wrestling.

All good fun!!

 

[Stitch147]

Is he planning to retire within your lifetime? and if so, what are his plans for succession? LOL

Thats the one bit that worries me!

 

[trophywench]

I was replying to Sue there, but you replied meanwhile and said much the same LOL

What I didn't say was - I think we might just be better off where we are - but successive Governments will have far better (!) ideas about it than we ever could, I'm certain!!

 

[Amigo]

Just been reading several threads on here and I'm starting to see something of a worryingly common theme.

In the last week alone I've seen threads about:

GPs refusing to prescribe bolus insulin to T1s
GPs refusing to prescribe medication to people with diabetes
GPs seeing results that are by NICE definitions 'diabetic' and taking no action
GPs refusing to prescribe test strips

And that's just a starter for 10.

Now, I know this site isn't representative of the whole experience of everyone with diabetes, and also that people only complain when things go wrong. But I'm starting to feel like there is something fundamentally broken with the way our health system works where GPs are expected to handle issues related to diabetes yet there seems to be a very large number of them who are, for want of a better word, utterly incompetent.

How many times have we read those stories about GPs assuming that anyone presenting with high blood sugars as an adult must be a T2, or for them to completely miss the diagnosis in children with sometimes fatal results?

I think there needs to be a radical rethink of how diabetes is managed within the NHS. This isn't good enough. We need to get out of this mindset that someone with a broad range of skills is sufficiently equipped to handle a serious, complex, chronic medical condition. What do we all think? I'd say a good start point would be anyone presenting with an A1C of >48 for the first time should be referred straight away to a proper endocrinologist on an immediate, emergency basis. I know we've had all these 'nice' campaigns about the 4Ts etc. but they're not working. Is this something that Diabetes UK could lobby for? We've tried the whole 'educating GPs' approach and it's clearly not working.

One of the best posts I've seen Deus and in the relatively short time I've been a diabetic, I've become dismayed and disturbed at some of the treatment diabetics receive and the inadequate level of understanding amongst medics at all levels. That isn't a doctor bashing point, it's merely a recognition that GP's are generalists and should be referring more complex or unresponsive cases to specialist endocrinologists much much earlier. From what I can see, the endocrinologists end up fire fighting routine treatment that has gone spectacularly wrong and serious symptoms have developed. That preventative role must be costed.

We are frequently reminded that diabeties is probably one of the biggest financial threats this country faces over the next decade but at a basic level it's simply not functioning well. I'm forever haunted by an elderly friend of my mum's, a newly diagnosed type 2, absolutely denied the right to test, spiralling into trouble with serious symptoms and a GP who kept telling her she was ok. She was utterly clueless and had decided to take a well meaning friend's advice to keep sucking sugary sweets 'because that's what diabetics do' to stop them collapsing! I took the time to explain to her what it was all about and she sat open mouthed because nobody else had bothered. And the sweets had to go!

Sadly it's not an uncommon story and in a very busy GP's surgery, if someone is 'functioning' and not in immediate danger, the temptation must be to accept far too little for them. It's why I insist on becoming my own advocate especially where my cancer is concerned and I have a condition some GP's never encounter. There's times I'm convinced it's saved my life.

 

[Flower]

To some extent, I would argue 'that's not my problem'...the more sensible answer would be to research the overall impact that this poor performance from GPs has on patient outcomes, and posit that if people with diabetes were properly treated, the reduction in complications would result in fewer costs to the NHS, and that saving would therefore pay for the appointments.

Would a reduction in diabetic complications result in any savings being directed towards endocrinology or GPs with a specialist interest in diabetes? I doubt it. The clinics I attend for complications are not with an endocrinologist, I fill up ophthalmology, cardiology, orthopaedics, neurology, renal clinics. With the NHS so over stretched and under funded any savings would be eaten up by the deficit not in appointing endocrinologists to see to us all. My pump appointment was moved back from 4 months to 17 months due to the sheer demand of new patients, I can't imagine there is any slack in any of the systems to divert care.

Good care and support along with access to sufficient treatment and tools to control our diabetes is absolutely vital wherever that comes from. It is obvious from posts on here that this just doesn't happen and the consequences can be dire. The massive imbalance between up front treatments versus the ballooning costs of complications has to somehow be addressed but this requires a long term outlook and investment in the future and in 38 years of diabetes I haven't seen it happening yet.

 

[grovesy]

Whilst out walking the dog I remembered seeing a tweet on Twitter this morning, where a group from US had written a letter to CEO of an insurance company, that were funding only one type of pump from July. I have also seen posts from people in the US who are seeing endocrinologist and still not happy with care. Also that insurance companies dictate what meters they will fund.

 

[Martin Canty]

Well, there is a diabetes crisis going on in the world, here in the US, the rate is about 1 in 9 being T2, let's not even mention pre-diabetic.

This is a serious, life threatening, chronic condition that's only going to increase in prevalence before we start to see some changes in healthcare; placing an increased burden on an already overtaxed system. Imagine, as a Dr. 1 in 10 of your patients (in any given day) is diabetic.... That's a lot of exposure so please don't tell me that it's something that a medical professional isn't concerned about & wants to at least learn more.

Added to which, "guidelines", are these about treatment or something more insidious like budgets? It strikes me that the most cost-effective approach is to empower diabetics to control their own destiny. We, on this forum, have already done this & the medical profession need to take note of the benefits of what we are doing (and the reasons for doing so) rather than dismissing us as mavericks...

 

[trophywench]

Well certain of us only came onto the internet to Google Diabetes when the NHS didn't offer any help and I was struggling. This forum didn't even exist in those days!

I got the help I needed. I have regular pump clinic appointments - but quite honestly get absolutely nothing from them. If the NHS had some other way of communicating test results to me - I wouldn't need to bother going!

If they ever had anything different to say then it would be worthwhile, but as they don't - it's a complete waste of time for all of us!

But - it is a security blanket - that people who are experts are actually keeping an eye on me. There is no other way of getting that security as things stand.

 

[Copepod]

Interesting line of thought. I've been dealt with 4 different GP practices in 4 different cities, plus lived temporarily in 2 other cities, since diagnosis (which occured overseas) 20 years ago. All have been excellent, co-ordinating referrals to diabetes clinic at hospitals / retinal screening. Plus, they've looked after my other health issues - 1 knee injury, 1 frozen shoulder and some symptoms of menopause - as well as providing flu and pneumonia immunisations and arranging start of breast cancer screening. I would not be happy to rely only on hospital clinics, and lose the co-ordinating and delivery roles of GPs and practice nurses.