Thursday, 29 January 2015
Information Prescriptions for Diabetes - Backward or Forward Step?
At first glance, the information prescriptions for diabetes, launched this week, seem like a great idea. Take someone who attends their GP with blood glucose/cholesterol/blood pressure levels that don’t match the recommended targets and give them a takeaway - a bright, shiny A4 sheet describing how they can do better. Simple! And very quick, the all-important consideration for many hard pressed primary care professionals. So that’s that problem solved, then. The trouble is, as many of us know only too well, that a fix like this is highly unlikely to make much of a difference to the underlying reasons why someone might have these high levels – whether it’s because of the stresses of coping with difficult family or work circumstances (supporting your sister who’s ill with cancer, or looking after your grandchildren 3 days a week so your son can make ends meet with 3 jobs) or by actual choice (the schoolteacher of a class of 5 year olds who needs to make sure he doesn’t have a hypo during lessons). We also know that ‘one size doesn’t fit all’. For some, the written word is easy and a pleasure, for others, torture and incomprehensible. And in any case, with all the other bits of paper that often accompany a medical appointment, will it see the light of day again from the pocket or bag it’s been placed in, once the person exits the building? For many, information prescriptions will be offered after discussion and in response to specific questions that might be raised, and that is of course, the intention. However, for equally many others, they may be seen as a convenient way of ‘solving’ a clinical problem and ticking a box that flashes up on the computer screen – ‘this person needs an information prescription. Tick here when completed’. We hear that information prescriptions have been well received by people with diabetes and health professionals in the areas where the scheme was piloted. This is welcome news, but as is well-known, finding people to approve a development in a research situation and in ‘real life’, are not the same thing. The medical model is one where people are told what to do by health professionals and expected to do it. This works really well for acute conditions, where there is relief in sight in quite a short time and / or the immediate consequences may be dire if instructions are not followed. For example, taking antibiotics for a severe infection that might otherwise result in hospital care being needed. To use a diabetes example, taking increased amounts of insulin with very high blood glucose levels during illness, to avoid life-threatening ketoacidosis in Type 1 diabetes. The medical model is no good at all for helping someone live with a long term condition like diabetes, that depends mostly on self management, day in, day out. People with it need to make multiple daily decisions, choices and act accordingly, without a doctor or nurse’s say-so, or even in sight. The skills people need to make these decisions are usually not included in the ‘top down’ approach the medical model embraces. Information prescriptions smack far too much of the medical model. What happens if people still have less than desirable (from the health professionals’ point of view) numbers next time, post-information prescription? Will they simply be issued with another, and another until they finally ‘obey’? or will they be cast out of the door, not to return until they have sorted themselves out to the satisfaction of the health professionals? Equally, what about those who would like the information contained in the prescriptions, but are ‘well controlled’? do they miss out on having their questions answered because they are not deemed ‘bad enough’ to qualify for an information prescription? A way forward is not to medicalise even further, the encounter between someone living with diabetes and their health professional, when it comes to meeting the challenges of daily life. Rather, it’s to personalise things more. A really quick start to this, using the information prescription model, might be to have a message flashing up on the health professionals’ computer screen that incites them to congratulate a person who has achieved the recommended targets and discuss their success and how they might maintain it. Thankfully, there is a model, which is gradually achieving recognition and implementation support in NHS circles. It’s known as personalised care planning, or PCP, which we’ve talked about and promoted on many occasions, as a system-wide solution to appreciating that people themselves are in charge of their condition and the choices they make each day are the only ones that will make a difference to the resulting ‘numbers’. The job of the health professional in PCP is not to pontificate, order, tell, force or even cajole the person into submission to their will, but to share their ‘numbers’ with them and invite them to identify their own problem areas, goals and ways they wish to address them. Only through this process can they get anywhere close to addressing what, on the surface may look like a ‘non compliant diabetic’. Information is everywhere and people can choose what works for them best. What’s needed is not a prescription, but a menu and support to explore it, and continued discussions of what’s worked in subsequent consultations. Fortunately, the idea of a local ‘menu’ is included in personalised care planning guidance recently published by NHS England, and is already being used in some areas. In the meantime, our own ‘SD Signposts’ is available for anyone to download and start to use, according, if they wish, to their personal learning style. Health professionals may find more benefit from moving from information ‘prescribing’ to people with diabetes, to information ‘sharing’, which will be much more effective, not only for reducing the clinical ‘numbers’, but also frustration and time spent ‘telling’ – that’s our prescription for guaranteed satisfaction!