Data from Partha Kar - Curated by EPG Health - Last updated 10 April 2017
In this article, I try to look at how the usual elephants in the room can be challenged as regards type 1 diabetes care. Should Type 1 diabetes sit with primary care? Who is actually trained to look at this populace nowadays tagged in with type 2 diabetes? Are all specialists trained either? and why do we always think that under specialist care has to mean based inside a hospital?
The time is perhaps right to look at all the audit data and stand up to say that the present system does need a change to improve care. the million dollar question however is whether we can do so beyond the politics and whether the appetite is there either.
It screams out at you, whether it be dry statistics from the National Diabetes Audit or the passionate views on social media, the present system of type 1 diabetes care isn't working. Wrapped in the paradigm of "diabetes" and subsumed by the mantra of exercise, healthy lifestyle aimed at type 2 diabetes, the pathology of type 1 diabetes and its different needs have indeed been forgotten.
Fundamentally, how does one attempt to change that? Let's tackle some elephants in the room first. Is primary care equipped or trained to look after type 1 diabetes? If one takes the heat out of that question, then perhaps the answer is no. Type 2 diabetes? For sure- with plenty of educational events, updates etc, type 2 diabetes is rightly too- in the majortiy looked after by primary care. Type 1 diabetes however- most people are not trained at any level- but still in this country, plenty are looked after by primary care- it begs the question- why. Is it politics- or is it because specialists forgot to make the distinction when the drive to move diabetes out of hospitals came along? You wouldn't have anyone untrained looking after your health needs and in many areas- such as antenatal diabetes, no primary care physician, rightly, even attempts to do so- but somehow, that distinction is lost in type 1 diabetes.
Then we come to the next big one..are all specialists trained to look after Type 1 diabetes? You would have thought so- but the answer is not quite what you would expect. An area is insulin pumps- if you think that most trainees have high standard training on insulin pumps, think again. But yet we expect all specialists to be able to look after type 1 diabetes, understand requirements of a pump, when to use it...any surprise the pump usage in the UK is so low?
Finally, the strange dichotomy of "under specialist = in the shiny hospital" does need to change. Its not about the building, but about the expertise. Type 1 patients should have the ability to choose who they see- and most importantly be able to see that the professional seeing them is trained in that particualr pathology. Can Type 1 diabetes be looked after completely by specialists? Yes- but do we need to change the model of finances to achieve that- yes of course
Why can't we think bigger and look at block contracts either held by a Trust or GP group with devolved responsibility of all type 1 diabetes patients in a locality to the specialist team? Of course we can- and the financial levers are there to do so. The 5 year forward view does offer an opportunity for primary and secondary care to work together for this population. By all means, primary care can hold the control- but use the specialists- and more specifically apropriately trained specialists to help this cohort of patients.
Present data suggests the system isn't doing anyone any favours and the age-old stand off between primary and specialist doctors is something that needs to be consigned to the bins. Do we have the willingness to do so? I certainly do...if you feel there is appetite amongst the wider community, then the time to change things is now. I strongly suggest we stop waiting for yet another audit and get going- and if you have a better idea than what I propose, bring that along too.
Only one request? Let us not keep the status quo. Type 1 diabetes patients deserve better