Monday, August 31, 2015

Not quite NICE enough

It's an interesting you set the principles first before attempting to achieve it? Now normally that seems to be the perfect approach- how do you know where to go if you haven't set your destination first? That clearly makes sense in a normal world but unless we have all been living under a rock, you may have noticed the NHS isn't quite in normal back to the it the principle that needs to be set first- or more a question as to what is affordable/needs investment/needs working differently...take your pick depending on your inherent belief

The problem also is that as soon as you raise a question...its because you are against it. Well, not quite- sometimes questions are asked to raise the validity of what can be achieved, not necessarily questioning the principle. Let me give you an example- recently, lots of media attention was drawn towards how lack of senior cover was compromising patient safety on weekends- beyond even the debate about the accuracy, when I raised the question whether what is being asked is achievable, many a patient safety advocate felt I was against it. Well, not quite - just want to know how those extra bits are going to be funded. Leaders of all hues have a responsibility- to aspire to quality care- but also to be realistic and more importantly stop raising false hopes- as for those who have pinned their hopes based on promises made...not achieving it causes angst, hurt and frustration.

Let me give you another example- whats new in town? Ah yes, the latest NICE type 1 diabetes guidelines. Now before the world and its dog descends on me after reading this- let me make2 things crystal clear. Firstly, I am one of the biggest supporters for high quality care for type 1 diabetes patients and secondly, the committee who have come up with the guideline are comprised of folks I genuinely respect. It's led by Stephanie Ariel, one of the few folks in the whole world to whom I would bow anyway based on her prowess- not to mention some others on the list. For a change, its a committee comprised of folks who garner respect- which is light years away from what the type 2 guidelines committee are- making a pigs ear of a guideline, wasting valuable tax payers money...but that's a different story altogether.

So back to the NICE guidelines- whats good about it? Well, pretty much most things- as something to aim to- simply fantastic- it has most things which all Type 1 diabetes patients should be able to have. There are new bits added to the 2004 guidelines and on face value, its not too far away from utopian type 1 diabetes care. Just one snag- it doesn't appear to be grounded in reality..or to put it politely, it seems like the principles are set- but without any wherewithal as to how to achieve it.
I know some will say its all about working differently, efficiently, using consultants differently...and without putting too much fine a point on are speaking to the converted. Efficiency is what our care model is about- many an area spend many an hours trying to emulate what we do- so yes, I know. The problem...its just not stacking up anymore.

One small example- CGMS or Continuous Glucose monitoring system- approximately 4K. Flip it- thats about 40 outpatient appointments. OR care of 3 pregnant women. OR review of many a foot ulcer. Did we say priorities? Heres another one- blood glucose monitoring- it says 4 times/ day - if not 10/day. This in the face of an NHS where some type 1 patients have their strips rationed due to cost. Access to walk in clinics and phone what tariff- built into job plans? Or not? So many questions, eh?
Do I think patients need what is said in the guidelines? Absolutely- do I, as a provider and a CCG board member think its achievable? No- it isn't- unless we have one of the 3 options:
a) An investment to create headroom- to allow new models to flourish, technology to ramp up- and thus give the savings in long term-as advocated by the think tanks
b) A debate about prioritisation- lets not broaden it too much- we could just start with diabetes as a whole
c) Increase investment overall in the NHS

I know its boring- I know its the same record...but on behalf of many a patient with type 1 diabetes, all I can say is that don't raise false hopes, unless there is a plan to implement. Otherwise discussions will be about patients, rightly expecting to have CGMS based on NICE guidelines...grinding to a halt with providers having to make business cases in a choked financial climate. Cue frustration and misunderstanding that the professional hasn't tried hard enough...the truth could be they did- and got turned down as something else took priority in the bigger NHS schemes. Here's something to ponder about. The last type 1 NICE guidelines from 2004...we achieved little of what was there- in times when finances were better- what gives us hope that 2015 will be different?

However, I will finish on a positive note. The NICE guidelines is achievable- to do that, it needs some big bold steps, steps that will upset some, steps that will not be palatable for many, steps that will need some serious leadership.The billion dollar question? If the present lot haven't been able to deliver over the last 10 years, in times of need, what faith do I have that a NICE guideline will impact much?
To end- my final view of the NICE Type 1 guidelines? Good but not bold enough. Positive but not revolutionary enough. In a delicious twist of irony...a bit more boldness could have opened up the way to achieve much in there. Have a think what that could be..won't you?


  1. Thanks for this Partha. I do think it was a positive that the Guidelines actually said we should be supported to do 4-10 tests per day, I've heard horror stories of t1s being "diagnosed" (and yes stuff probably being put in their notes) for wanting to test more than once a day!
    There definitely needs to be a recognition of the difference between an aspiration and something that is currently achievable. I worry about the judgement and repercussions for the vast majority of t1s who visit GPs etc and who will be seen as non-compliant/delinquent/very sick will be denied drivers licences etc because they have an A1c of 7.

    1. when I said "diagnosed" I neglected to add "with an anxiety disorder", doesn't really make much sense without that.