# NHS must hold CCGs accountable for poor diabetes care



## Northerner (Oct 21, 2015)

NHS England must say how it will hold clinical commissioning groups accountable for poor delivery of their local diabetes services, the National Audit Office stated this morning. In its latest report it said that although some progress has been made in tackling relatively high mortality and morbidity in people with diabetes, the rate of improvement in care has stalled – and in England about 22,000 unnecessary diabetes-related deaths still occur every year.

The NAO found that in 2012-13, only 60% of patients received all the care processes except eye screening; only 36% achieved all three treatment standards to control blood glucose, blood pressure and cholesterol levels; and fewer than 4% of people newly diagnosed with diabetes were recorded as having attended structured education to help them to manage their condition and reduce their risk of complications.

http://www.onmedica.com/newsArticle.aspx?id=9bf9eee3-d443-4c07-8556-a0e3047748e9


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## trophywench (Oct 21, 2015)

> ........... delivering the nine key care processes that the NHS has identified as essential for diabetes patients ..........



I think they meant 'that DUK identified and then beat the NHS into submission' didn't they?


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## trophywench (Oct 21, 2015)

Can anyone explain how CCGs can force any diabetic to turn up for these?

Or get the actual surgeries to not make people have to go to at least two if not three, different appointments with different people, to get this done?  (Vampire, nursie to have feet etc done, then GP if results warrant it)  Cos you have to do the same for your emphysema and the same again for anything else you might have - and NOOOOOO!!! they will NOT review all your health conditions at the same time.

If you are going to be stupid enough to get diabetes, then you have to pay for it by attending as many appointments as the NHS sees fit - even if you're doing alright thanks and in any case - your hospital diabetes clinic ALSO do all this !


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## KookyCat (Oct 21, 2015)

Well I wish DUK would change their approach then.  All the additional pressure will do to CCGs is make them pester even more and prescribe statins at the drop of a hat, push blood pressure medication, because that's the only way to meet the targets.  It will be less about individual care and more like a production line which in my opinion is precisely the wrong thing to do.  I am not interested in being a tick on their checklist, I want actual useful care.  The diabetes review at the GP was basically a paper exercise, so let's have more of those because they help, top it off with one of those incredibly innovative and useful information prescriptions and job done, we'll all be perfect standard diabetics and they can stop worrying about killing us off.  This makes me very angry as may be evident.  KPIs and targets are utterly useless if the purpose of them in the first place is lost amongst the effort of just ticking a box.


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## Northerner (Oct 21, 2015)

Agreed. At my last diabetes review, this time by the practice nurse, she insisted on ticking my feet, despite the fact that I told her I had been fully checked out by a fully-trained podiatrist less than a month before. She said 'I have to do it so I can tick the box... Well, I suppose it does mean that at least other diabetics are probably getting tests at the surgery they may not get elsewhere, and not all surgeries do that. I think the really appalling thing is that 'fewer than 4% of people newly diagnosed with diabetes were recorded as having attended structured education to help them to manage their condition and reduce their risk of complications' - no wonder we get so many newly-diagnosed people coming here floundering due to a complete lack of information about what they need to do, that's not care it's dereliction of duty


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## trophywench (Oct 21, 2015)

We wouldn't have a T1 course at UHCW - had those that wanted to do it, ie the two DSNs and the Dietician at Rugby - not part funded the training etc at BDEC out of their own pockets.  All the T1s from Coventry, Warwick and Rugby hospitals, go on the course now.  If they all left - who will pay for someone else to train?

The NHS are being ridiculous, aren't they?  They aren't prepared to pay for it - but you've got to do it !


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## KookyCat (Oct 22, 2015)

I spent 20 years of my working life managing contracts and KPIs.  I lost count of the times I said to clients (government departments mostly), "you do understand that we will do anything we need to to meet those targets, even if that means compromising customer focus don't you?"  I was like a broken record.  If you want to achieve your actual objectives and provide information that will allow people to help themselves, it requires engagement, personalised service, and not wasting people's time with some junior ministers prejudices about the education level of the general public.  The number of people we have on here who are very focused on control but can't get test strips, or a pump, or engagement about sometimes serious problems is very disturbing, they need time from medical professionals and tools and resources.  Instead the Government is intent on tying them all up in knots with more tick boxes and more standard checks.  They're dehumanising us at every turn by making us a series of checklists.  The language of compliance in the area of diabetes is already far too prominent, you can't force people to engage, but you can address the lack of engagement by making the experience better.  Those with their head in the sand are extremely unlikely to pop it out of the sand, when the language of diabetes is so negative and accusatory, they need to address and revise the model they have in place for self directed care because diabetes care has to be self directed.   Thing is though you can't say we won't actually provide you with any real help, or the tools to do your job, BUT we insist you come in for an annual appraisal so we can rip your management strategy to pieces and tell you what you're doing wrong, not if you want people to actually engage, rather than sit there planning their shopping list mentally whilst you prattle on.  If you're not engaged the person you're reviewing won't be either.  

You're right TW we want it but we won't pay for it, and we want it but we can't be bothered to work out how to get it doesn't make sense.

Incidentally I seem to have inadvertently recommended either the thread or my post....no idea how I did that but it's probably th universe telling me to stop ranting


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## Northerner (Oct 22, 2015)

Don't stop ranting KookyCat! That's something the Powers-That-Be need to be hearing!  Well said!  What's a KPI?


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## trophywench (Oct 22, 2015)

Key Performance Indicator, Alan.  (Not peanuts LOL)


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## TheClockworkDodo (Oct 22, 2015)

KookyCat said:


> they need to address and revise the model they have in place for self directed care because diabetes care has to be self directed.   Thing is though you can't say we won't actually provide you with any real help, or the tools to do your job, BUT we insist you come in for an annual appraisal so we can rip your management strategy to pieces and tell you what you're doing wrong, not if you want people to actually engage, rather than sit there planning their shopping list mentally whilst you prattle on.


So right, KookyCat, and so frustrating!  I am still at the arguing with the consultant stage, haven't yet reached the planning shopping list stage, but can see it arriving any time soon, because yes - the appointments (aside from all the ridiculous box-ticking) are all about telling us what we're doing wrong (while looking at a tiny snapshot of what we're doing rather than the whole picture) when they should be about them asking us what we would like them to do for us and how they can help.


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## KookyCat (Oct 22, 2015)

Northerner said:


> Don't stop ranting KookyCat! That's something the Powers-That-Be need to be hearing!  Well said!  What's a KPI?



Yes Key Performance Indicators, or core quality measures in some instances....I'm all over the Government speak, it's ingrained in my vocabulary


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## trophywench (Oct 22, 2015)

We had KPIs where I worked - in the insurance industry - from about 1980 !  Mind you, our parent co at the time was American!


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## KookyCat (Oct 23, 2015)

trophywench said:


> We had KPIs where I worked - in the insurance industry - from about 1980 !  Mind you, our parent co at the time was American!



The Americans love them, although they have started to move away from them more recently because they recognised that they can actually be disruptive in contractual terms, because the KPI becomes the objective, rather than a measure of your performance whilst trying to achieve the objective.  I saw this happen constantly working with Government departments.  Their sole focus was to prove they were achieving value for money.  The key thing they forgot was, if the service you design is useless to the public, then your contract might be water tight against the press in terms of efficiency and the best price per interaction BUT the headline in the Sun would still be "bumbling idiot pays 5 million for a service telling public how to tie shoelaces".  It's only good value if it meets its core objective.

The NHS is a perfect example of this happening before our very eyes.  They are losing sight of the actual objective of providing good, useful care, and chasing quality indicators that doom them to failure.  I'm a focused patient but my GPsurgery is pressing my last nerve at the minute regarding a number of issues.  I had 15 phone calls about a diabetic review that's useless to me (because already had one, several actually at the diabetes clinic).  I say that again, 15.  I am a compliant patient but was forced to state that if they didn't stop ringing I would consider it harassment and would be lodging a formal and very persistent complaint (they wouldn't want me to go all vengeance on them trust me).  Despite my stroppy cow skills it's actually hard to get me to use them, but they've succeeded at least twice.  They are not policing my health, I am not a child, and I take full responsibility for every last thing I do.  They are not interested in my health, they are interested in "proving" they are making people comply.  All of their energy time and resource is being pumped into harassing folk to attend, then when you need an appointment you can't get one!  They're latest harassment topic is a type 1 education course, that requires me to take three days off work, and consists of one day of presentations on how the pancreas works, a day on complications, a talk from the meter companies, and 1 hour on insulin adjustment.  This is the only option available, they want me to do it so they can meet their target not because it's useful for me.  The word "mandatory" has been used, and the term "failure to comply" is now being banded around.  When I said I'd be more than happy to consider the Daphne or expert insulin course (because they'd be useful), they said "we'll decide what's useful".  There is the rub.  No you won't, I will.  That's not bravado it's the gods honest truth, and expending energy trying to bully people into useless interactions undermines their relationship with their patients.  That is what KPIs and core quality measures do.  The quality measure becomes the objective.  This is why there were so many press pieces about five years ago where suppliers had failed to provide a service but we're still being paid, because they might have provided a useless service but they'll have met every contractual KPI so legally they have to be paid.  The system was actually skewed so the supplier didn't need to provide a useful service they just needed to meet the targets.  In the real world now contracts are changing.  If the NHS wasn't so hampered by the Government those 15 checks wouldn't be quality indicators with bonuses attached they'd be mandatory contractual basics, don't make them available, don't keep the contract, and the quality indicators would be client satisfaction, measures to attract disengaged clients, treatment outcomes that show an improvement in the long term quality of life.  You can't force disengaged patients to engage with constant threatening letters and phone calls, or with language that's meant to intimate they'll be set adrift without medication if they don't comply.  They aren't actually allowed to hold you down and stab you with a needle, or wilfully cause your death.  It's a cycle, you hack off the people who are complying and trying their damnedest to keep control, you make the ostriches bury their head further into the sand because you're frightening the bejeesus out of them, and the people who just don't care still just don't care.  The medical professionals in the middle of it all are spending less and less time doing the thing they're actually trained to do, and more time "pretending" they're in an episode of the apprentice.

All that talk of prescribing medicine that isn't needed is also interesting, I'd like to see how much of that medication is prescribed because it ticks a box on a quality measure.  we're prescribing 40% of our patients stains, tick, never mind that 39% of those are ending up in the bin.  It appears I just can't stop ranting about this one so apologies in advance for more future ranting.  It just makes me so damned angry.  It also makes me angry that other organisations like DUK are spending time pontificating about waist measurements, and the last time you had yours measured.  Sweet mother, I have diabetes, that doesn't make me incapable of measuring my own ruddy waist.  When people are losing limbs, dying in hospital because we can't manage to educate healthcare professionals about insulin, and being denied access to basic tools a waist measurement is somewhat indulgent.  I'm going to stop now because the rant is gaining momentum with every key stroke


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## Northerner (Oct 23, 2015)

I can confirm that you have met your objective of producing a rant of the highest quality KookyCat, these targets are dehumanising things and actually decreasing efficiency and quality of care  The NHS budget needs taking outside of political control.


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## KookyCat (Oct 24, 2015)

I'm considering writing an open letter to the Guardian, or more likely becoming a lay member who gives them hell at the next CCG meeting, but then the pressure is applied in the wrong place.  Mr Cameron it is then, just need to think on that one.


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## TheClockworkDodo (Oct 24, 2015)

Start a 38Degrees campaign? - https://you.38degrees.org.uk/petition/new?source=38homepage


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## trophywench (Oct 24, 2015)

Who is your MP Kooky?  (rhet Q - I don't need to know LOL) Could we not ALL write to our MPs about this and basically say what you said there?


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## Northerner (Oct 24, 2015)

Here's a link to the full report from the National Audit Office:

https://www.diabetes.org.uk/Global/Homepage/News/Management of adult diabetes.pdf


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## trophywench (Oct 24, 2015)

Oh incidentally - nobody - but NOBODY ! - medical has ever ever in my whole life, measured my waist.  What the hell is the POINT of it?  It's over 30 inches now but I've never had a waist even when I was in size 10s - oh shit, have I been liable to get T2 for the last 40+ years then?

What rubbish !


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## Worcester_Matt (Oct 25, 2015)

I measured my waist a while ago. I wear 34" jeans, but according to the NHS measurement location I have a 40 inch waist. That seems illogical to me.


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## KookyCat (Oct 25, 2015)

My MP is a shambles, so she's best avoided. I'm going to think about the best way to approach this and report back.  First step read the entire report (thanks for the link Northerner), I'll also have a look at setting up a petition.  I've also been looking at becoming a patient representative for the CCG but that's unlikely to really help since it's a national framework.  I've been doing a bit of digging regarding the structure within the government departments, the politicians are just the front men the real power is the civil service.  

On the waist size front, the DSN at the GP whipped out her tape measure and proceeded to measure an area that is most definitely not my waist.  I'm guessing it's actually to measure fat around your internal organs.  Slight problem with that in my case is I have a bit of loose skin in that area, it was muscle before the DKA it's now less muscle more slightly deflated balloon!  Still only measures 25 inches but oh what fun we had with that 10 minutes.  Followed by another ten minutes of her telling me I was overweight (if you could see me you'd know how exasperating that ten minutes were).  Once I'd shown her how to use the BMI chart for a woman of my height we discovered I am not overweight.  I only mention that because it shows how little they're using their actual brains, eyes and common sense.  Another random figure that they don't understand, that really just allows them to increase the number of people in the at risk group.


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## trophywench (Oct 25, 2015)

When my husband was walking 10km every day (reading meters) with a 30" waist, and gorgeous arse cheeks (oh I do love a nice bum on a bloke ! LOL) I could grasp in one hand and OMG he was FIT  LOL - according to the surgery nurse's chart he was a stone overweight and obese.

They discussed possibly amputating a leg, cos she actually does have a brain and realised it was barking  ......  I dunno what she recorded it as!


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