SD Listens - The Successful Diabetes Blog

To attend clinic or not to attend it - but is that really the question?

2012-02-07T13:06:00.000Z

A short article, published in the latest issue of Diabetic Medicine (the professional journal of Diabetes UK), describes research into whether young adults in the UK choose to attend their clinic appointments or not. The authors looked at records of attendance and also interviewed 17 young people about what influenced whether they attended or not.

The results showed that, rather than might be expected, having ‘poor control’ (defined as having a high HbA1c level), made it less likely that people would attend, because of the fear of being judged by health professionals. Another major reason for not going to clinic was literally not being able to get there because of work or study commitments, including the attitudes of employers to taking time off for health-related appointments. The authors conclude that health professionals need to be more supportive and non judgemental, and also that reminders about appointments and flexible clinic hours are factors which will encourage people to attend more.

That sounds fairly straightforward, doesn’t it? Or does it? Sending a text or email reminder is a good idea and a very simple task, but does simply knowing about an appointment mean that people will attend it? The decision-making sounds much more complex than that, given the information about potentially feeling judged. In our experience, this complexity is not confined to young adults and whether to attend is often based on what the answers might be to questions such as these:

‘I already know my glucose levels have been high recently - will I hear bad news?’

‘Do I trust them enough to tell them how bad things are at home at the moment?’

‘Can I deal with MORE criticism right now?’

And even when things are going well, the questions or thoughts might include:

‘Is it a good use of my day off, to wait for ages, just to be told to come back in 6 months and keep up the good work?’

‘It’s a welcome break not to have to think about it all at the moment while things are going well’

On the other hand, health professionals pride themselves on being available to help people who are struggling and of course, know very well the potential negative outcomes of not attending clinic appointments or having longstanding raised glucose levels. Some health professionals, such as GPs, are actually paid higher amounts of money if people in their care have better diabetes (measured by HbA1c). They often genuinely worry about people who don’t attend and also become frustrated about empty appointments that could have been used for other people, and other upsets to the ‘system’. It’s no surprise in a way that a judgemental attitude can creep in, although most health professionals would be horrified to think they were being seen in that light.

So the real question is, How can we achieve success with lifelong attendance at clinic visits without damaging the delicate mix of emotions, self esteem and ‘having a life’ for both people with diabetes AND health professionals? Here are a few ideas of what could happen, which both people with diabetes and health professionals could influence:

· Start as you mean to go on, with a view that a consultation is a partnership, not a dictatorship. You are working together on the ‘diabetes project’ that is everyday life with diabetes for the person with it

· Build in a bit of preparation for the consultation, for example, the person with diabetes requesting or being offered the chance to see their test results before they attend, so that they can decide what aspects they want to discuss. Also, considering their own priorities and questions for the visit

· Starting every consultation with a discussion of how the person with diabetes is feeling and thinking and what questions they have, rather than with what the health professionals think. This way of doing things is known to increase satisfaction and attendance rates

· Thinking of the person with diabetes as a person rather than a patient, and a health professional as a supporter (and also a person!) rather than an authority figure. Terminology, as we explored in an earlier blog, can make a huge difference to attitude and relationships

· Finally, recognise that there is always a reason for the way people behave. Having some curiosity and care, and being brave enough to explore what is keeping people away from clinics, or why the relationship between health professional and person with diabetes doesn’t seem to be working, could make a vast difference to the future.

What do you think of these ideas – and how does all this fit with your experiences of either providing or receiving care in a diabetes clinic system?

Reference

Snow, R., Fulop, N. (2012). Understanding issues associated with attending a young adult diabetes clinic: a case study. Diabetic Medicine, 29,2, 257-259

Indecision about me, without me? A survival guide to the new NHS in England

2012-01-09T22:42:00.000Z

The UK government’s health reforms are edging ever closer to being enshrined in law. They represent a massive shake up of the structure and funding of health care in England, and the care people receive for long term conditions is right at the heart of the changes. But that doesn’t mean the NHS and diabetes care is safe – far from it. Read on…

We have followed the progress of the health reforms carefully since they were introduced in the White Paper ‘Equity and Excellence: Liberating the NHS’ in 2010. This paper lays out the plans to hand funding for local health care to groups of GP practices, to be called Clinical Commissioning Groups (CCGs). It also shows how public views of health services will be incorporated more effectively into planning, through an organisation called Healthwatch England. The CCGs will be able to commission, or in other words buy, care from any provider that meets the needs of their population. Some services will be centrally commissioned by a body called the NHS Commissioning Board.

Public health is also receiving a makeover, with Directors of Public Health being appointed for each locality. These posts will be closely linked with local authorities, and detailed plans for this service are being announced shortly.

Meeting people’s health needs more locally and more effectively is one of the main promises of the reforms. The aim of making sure that people are much more involved in decisions that are made about their condition and treatment is also emphasised. The phrase ‘no decision about me, without me’ is used to describe this, and indicates the ambitious nature of the proposed changes. More choice is envisaged too, with, for example, the chance to choose a GP away from the area where you live (for example, nearer to your workplace), and also the ability to change your GP more frequently and easily.

Some of these ideas sound pretty good – more choice, and having more of a say in your consultations, can be a good thing. So too giving more purchasing power to local GPs who well know the needs of people using their services. However, it’s one thing to commission economic and prompt services for procedures such as cataract surgery or hip replacements, but quite another to ensure that diabetes is looked after properly. This includes a lifetime of screening for complications, the provision of regular and accurate prescriptions, occasional unpredictable acute episodes that might require hospital stays, plus an ongoing structured education programme being in place and monitored.

The changes proposed above have yet to become law. The Health and Social Care Bill is still going through parliament, and there is still a huge amount of detail being argued about. There have been a number of amendments already and may be more, as those who are against the current format try to curb its more extreme measures and protect the NHS as a national organisation by ensuring the Secretary of State for Health retains overall accountability for its performance.

There is so much to consider, and so much associated politics, it would be easy to patiently await the ‘brave new world’ when the Bill becomes law. On the other hand, there is much at stake. The last decade has seen unprecedented advances in diabetes care in terms of treatments which are inevitably more expensive, as well as more structured care and an increased emphasis on the availability of structured education. It has resulted in more people than ever receiving systematic appointments for annual review, which in turn results in less complications or at least the complications being detected and treated earlier. It’s possible that ignoring the impending NHS changes might mean sleepwalking into a minefield of disorganisation and fragmentation of all this good work. Another huge ‘but’ is that the changes are already starting and they have to be delivered at the same time as 20 billion pounds worth of savings have to be found by the NHS, on the Government’s orders, to help deal with the ongoing economic crisis in the country as a whole.

Everyone knows that reorganisation is costly, even thought it is meant to save money in the long run, and it’s also said that ‘the best way to predict the future is to invent it’. Since the consequences of any changes made will affect people with diabetes themselves, we have created a mini ‘survival guide’ to the new NHS so that you can look after yourself or your loved one with diabetes, and you come out of it with your diabetes care intact, even if there is chaos in the system during the changeover period.

The SD Survival Guide to the New NHS:

Find out what’s going to happen locally – via your diabetes service, your GP or your Primary Care Trust website – find the contact details via www.dh.gov.uk or www.nhs.uk. You don’t always have to make an appointment in person, you can phone or email them and ask them to update you regularly, and some websites allow you to sign up to be informed of the latest developments
Read about the NHS reforms in relation to diabetes, for example via NHS Diabetes (www.diabetes.nhs.uk) or Diabetes UK (www.diabetes.org.uk)
Keep track of the changes and the Health bill’s progress towards law, via its pages on the UK parliament website, at www.parliament.uk (search Health and Social Care Bill, 2010-11) and sign up for automatic updates
Spend a bit of time thinking ‘what if’ in relation to your own diabetes care. For example, ‘what if my GP decides to buy care from a different hospital than the one I go to at present?’; ‘what if I decide to change my GP?’ ‘what if I don’t’ receive the recommended level of care from a new provider?’ etc. The issue for you will be individual, but from this you can create questions to put to your local services
Contact your MP and ask about the changes and how they will provide for diabetes services in your area. Again, you can email or tweet as well as attend their surgery in person. If you don’t know who your MP is, now is the time to find out! There’s a complete list of MPs at www.parliament.uk/mps-lords-and-offices/mps/
Be aware when your annual review for diabetes is due, and ensure you have an appointment for it as the time approaches. If your appointments are postponed or changed, ensure you have a new date rather than an open invitation to attend
Be proactive: if there are changes to your local service, don’t assume you will be given information or a new service will understand exactly what you need – ensure you have a contact number and remind yourself to check regularly what is happening.
Ask questions: you or your loved one with diabetes are the ones who will be affected by changes, especially as a new system is put in place. Keep a list of questions and don’t be afraid to ask them!

We want the new NHS to be even better than before, and also to provide the very best diabetes care. The proposed changes offer a lot of potential – but it can’t be realised alone. We all have to do our bit as architects, building the system that creates the reality of ‘no decision about me, without me’.

What’s your view of the NHS changes? Are you worried what might happen to your diabetes care or confident that your needs will be met? The discussion is open!

Mind your language – Oz Style!

2011-12-19T14:09:00.000Z

Anyone who followed the recent debate about the actor Ricky Gervais’s use in tweets of the word ‘mong’ will be in no doubt that the terminology we use is under scrutiny everywhere, and people can be touched personally by terms even though they may have been given a new meaning by a new generation. It’s the same with diabetes – do you shudder at the word ‘diabetic’, shout aloud at the television when presenters talk about ‘non compliant patients’ or simply shrug your shoulders and say “they’re just words, get over it”?

Whatever your view, there are some strong feelings about language and diabetes. One in particular is that the language we use reflects the views we hold and these can slip over into how we treat people – for example in hospital, someone being referred to as ‘the diabetic in bed 5’, or in a clinic as ‘the patient’, suggests they are talking about objects rather than actual individuals. We once heard someone describe this experience in a clinic as “they might as well ask for the ‘next pancreas’ please”!

Now Diabetes Australia have published ‘A new language for diabetes’, a position statement that aims to improve communications with and about people with diabetes. Its 10 summary recommendations include:

Avoid jargon
Avoid judgemental terms
Be holistic – don’t just consider the medical aspects
Focus on what’s achievable
Use language that is positive and supportive, and forward rather than backward-looking

Pretty straightforward stuff you might think, but for anyone remaining in any doubt, the report also includes some helpful examples to show exactly what words and expressions could be used as alternatives to those which don't. For example:

instead of: use this:

diabetic/sufferer/patient person living with diabetes

diabetes control diabetes management

failed to / failure has not, did not

blood testing self monitoring or checking

There’s nothing not to like about this document – with the possible exception of the sadness that it needs to exist at all. It seems such a shame that people need to be reminded of the very personal nature of diabetes and the efforts that people make day in day out to keep on top of a condition that most definitely does not keep to the ‘rules’ - as a lady with type 2 diabetes once put it to a health professional “I’m afraid my body hasn’t read your text book!”

We welcome this statement with open arms, particularly as it is so consistent with our own philosophy of personal, individual care and attention, which we apply to all our own writing and publications.

Our Australian colleagues have given an example to all other countries and we hope many others will adopt this idea. Diabetes Australia - in the plainest possible language - thank you!

The full statement is available to download FREE from the ‘SD Focus’ section of our website home page. For your copy, simply go to www.successfuldiabetes.com and log in or register and log in.

Reference

Diabetes Australia. A new language for diabetes: improving communications with and about people with diabetes.

How much does the language people use in relation to diabetes matter to you? We'd love to know, so feel free to share your thoughts in the discussion below…

Can having ‘virtual diabetes’ teach doctors anything?

2011-11-29T10:09:00.000Z

When you attend for a consultation for your diabetes, do you ever feel it would help if the health professional also had diabetes? Or if you’re a health professional, what do you say when you are asked “do you have diabetes?” or someone says “it’s alright for you, you don’t have to live with it every day like I do?”

A study presented at a recent meeting of diabetes specialist doctors told of 10 trainee specialists being asked to live with Type 1 diabetes for a week, incorporating it into their usual lives. Their ‘diabetes life’ involved giving mock injections, taking regular blood glucose measurements, recording how much carbohydrate they ate and being prepared for hypos.

How did they get on? Perhaps not surprisingly, they forgot some tests and injections during the week, many did not record carbs and half of them did not carry a hypo kit. Most found injections and tests and the routine harder than they expected. So far, so normal – what a relief! Importantly, 9 of the 10 doctors said that their attitude in their clinics had changed as a result of taking part in this experiment.

Sadly, the short report did not reveal exactly how they had changed their practice (we are trying to find out), but we could perhaps guess that it was to have a lot more understanding of the demands of living with diabetes and the realisation that it is not easy to do boring, repetitive tasks every day on top of everything else.

Having more understanding is certain to be really helpful in making conversations in consultations more shared and realistic. We only hope that the 10^th doctor in the survey - who said their attitude had not changed - already understood what having diabetes meant – or perhaps even had it themselves!

There are plenty of health professionals who do have diabetes or live with it in some way, for example having partners, children or other family members with it. For many, it is the reason they specialised in diabetes in the first place. In our experience, health professionals have different attitudes to revealing their diabetes. Some seem to expect everyone to do what they do; some find it stressful, feel that they have to act as an example and may be judged on how they are managing their own diabetes; others choose not to tell anyone, to avoid their diabetes becoming the focus of the consultation rather than the person they are seeing. In short, just like anyone with diabetes, they cope with it in different ways and make choices about how much to incorporate it into their working lives.

Reaching a shared understanding in a consultation of what’s important to someone with diabetes plays a crucial role in creating a useful plan of action and making attending worthwhile. The lived experience of what it takes to really put instructions into practice is a welcome step towards this. The authors of the report recommend that it should be incorporated into specialist training for doctors. We wonder why this should not be the case for ALL diabetes specialist staff?

Tell us what you think – do health professionals ‘get it’ better if they have diabetes or experienced living with it like these doctors? Should 'virtual' diabetes be an essential part of training for people working in the field of diabetes? the floor is open for your comments!

Reference:

Pokrajac, A. et al (2011). Insight into life with diabetes mellitus improves consultation skills in diabetes trainees: Association of British Clinical Diabetologists Spring Meeting 2011 Abstracts. Practical Diabetes, 28, 8, 362.

Brittle or just individual?

2011-11-13T00:36:00.001Z

A chilling report in a diabetes journal this month has revealed that of 33 women diagnosed 20 years ago with ‘brittle diabetes’, only 20 could be traced and of these, 10 had died.

The term ‘brittle diabetes’ is used to describe very unstable diabetes, typically in young women with Type 1. Its features include frequent, lengthy hospital admissions, often for diabetic ketoacidosis. The term has been in use since the 1930s, (shortly after insulin was first discovered and used as a life-saving treatment) and in the last 2 decades of the 20^th century, there was a great deal of interest and reporting of the condition. One common conclusion of studies that could not identify a physical reason for the problem was that the people affected must be bringing it on themselves by ‘interfering’ with their treatment, through not giving themselves any or enough insulin. Such assumed behaviour is described as ‘manipulation’.

20 years on, this current report focuses on interviews with the 10 women who were traced. What is striking is that, when asked whether they had manipulated their treatment, 8 of the 10 were adamant that they had not and some still felt extremely angry to have been accused of this. The authors seemed to disregard the claims of these women, citing the fact that some had had relatives present when they were interviewed, whereas those who admitted manipulation were interviewed alone.

What has happened to these still-young women (their average age now is only 42 years) is clearly very serious. They have poor social lives, some have mental health problems, and some still have diabetes that is really difficult to manage. Tragically, some were advised not to have children at the time of their ‘brittle diabetes’, advice which was never revisited as they grew older, resulting in 7 of them not having had a family. Most tragic of all are the 10 who lost their lives, presumably as a result of diabetes itself. There is also the question of those who cannot be traced – what happened to them?

What are we to make of all this? Regardless of the terminology, the research really highlights that some people have more of a struggle than others with their diabetes and so need more support. This study was confined to women because in the 1980s and 90s brittle diabetes was thought to be exclusively an issue for them. Nowadays, it’s known that men often suffer unstable and hard-to-manage diabetes, too – which at least shows some positive change in attitudes about gender differences in our health services. Despite the effort it takes to keep in touch, to keep records and above all be empathic, the outcomes of this example group give a clear message that diabetes services need to invest, perhaps heavily, in the small group of people who experience such difficulties with their diabetes, to literally save their lives. It’s true that there are much better systems and ways of keeping in contact today than there were 20 years ago, which serves to make this task easier – but the commitment to its importance is the most vital ingredient.

Perhaps this sort of research also illuminates, with the advantage of looking back over time, that periods of real difficulty can be overcome and can pass, even though their legacy can bring its own troubles and the need for ongoing support to help with managing these.

However, the main message from this work could be that health professionals must always beware of assumptions and attributions that label and blame people unnecessarily just because what is happening to them and their diabetes defies a medical diagnosis.

Does any of this ring true for you and your experience? Why not add your views to the discussion…

Reference

Cartwright, A. et al (2011). Life quality and experience among long term survivors of brittle type 1 diabetes mellitus. Practical Diabetes, 28, 8, 332-335.

Checklists - the way forward for diabetes care?

2011-10-14T17:21:00.000+01:00

A new checklist for people with diabetes to monitor whether they are receiving the essential care they require has been launched by Diabetes UK as part of its ‘Diabetes Watch’ campaign. Diabetes Watch aims to hold health services to account for the care they provide for people with diabetes.

It’s an admirable aim and one that Diabetes UK will pursue with its usual vigour and clarity. The idea of ensuring that people receive standard aspects of care that has been shown to make a difference, and raising their awareness of what they should receive would seem to be a logical step. It also made us think about how having a checklist sits alongside the personalised approach to health that is, happily, currently being recommended.

A closer look at the 15 measure checklist shows that it focuses most on the medical aspects of care, for example having measurements such as blood glucose, blood pressure and blood fat levels, weight, feet and eye checks. It also defines where specialist care is required, such as for children and young people and those who are pregnant.

These aspects are really important in diabetes care, and emphasis on them has driven up standards in recent years, so it is absolutely right for them to be included in the list. However, they all also imply a certain passivity – that someone else will weigh, measure, take your blood and deliver your baby, for example. There is rather less on the list about active involvement by the person in their own care, an approach known to to help people live successfully day to day with their condition. ‘Receiving care planning to give you an equal say about your individual needs’, ‘attending education courses to learn how to manage your diabetes yourself’, and ‘getting psychological and emotional support’ are all included in the list, and are important. But there is a massive amount of other evidence about the effects of people being more involved in consultations, and in decision making about their own needs. This leads to a greater satisfaction with consultations as well as effective self-management of the condition. Like some medical evidence about what works, this knowledge is not always translated into practice in consultations and so perhaps should also be included in a checklist for monitoring a service for diabetes?

So, we’ve come up with our own ‘supporting self care’ checklist – some ideas for aspects that could be used to measure the ‘way’ care is provided, to complement the ‘what’ of the items in the Diabetes UK checklist. Here are the ideas we had:

SD ‘Supporting Self Care’ Checklist

You are given the chance to receive your test and investigation results in advance of the consultation where you discuss them
You are invited in advance to think about what you most want to discuss in your consultation
In the consultation, you are asked what you want to achieve in relation to your health
You get the chance to ask questions at the beginning of, and throughout, your consultation
You are able to change your appointment easily if you are unable to attend
You are asked if you would like a reminder to attend your appointment and the most convenient way to receive this
Your thoughts and ideas about your treatment options are listened to and discussed
You are asked about how you feel - emotionally as well as physically
You are offered relevant information about what is available to help you, in a format that is useful to you
At the end of a consultation you are clear about what you are going to do and what your health professional is going to do and when you will next be in touch with each other
You are able to get in touch with your health professional easily and quickly between appointments

Let us know what you think of checklists in general – and what would you add to either of these checklists, from your experience?

Is 'designer insulin' an expense too far?

2011-09-27T01:13:00.000+01:00

A report on BBC news last week caught our eye. It was about some new research from Cardiff University that showed that the amount the NHS spends on insulin has risen massively in recent years. The researchers put this down to the use of more expensive, modern insulins that they dubbed ‘designer insulins’. These insulins are more commonly known as analogues, where their structure has been altered to provide a more even absorption or a shorter or longer length of action. The study reported that possible savings of £625m could have been made by the NHS if these insulins were not so widely used in Type 2 diabetes, and more traditional human insulin prescribed instead. This report raised several questions in our mind:

Firstly, how many people with any type of diabetes on analogue insulin would consider themselves to be the recipient of a designer product? They should be so lucky! Our experience is that most people think that if they have to be on insulin, then an insulin that causes them the least amount of hassle in their daily life might be preferable. It’s true that no insulin is perfect, but analogue insulins are a huge step forward in diabetes management. They are much easier to use in terms of timing, and also have got some track record in making both hypos and weight gain– two well known and hated side effects of insulin treatment – less likely.

Secondly – how does the idea of wholesale changing of insulin prescriptions fit with the health policy rhetoric of ‘no decision about me, without me’? We would be the first to support this statement and whilst we admit that collaboration in consultations is not always all it might be, the thought of researchers telling prescribers how to cut back on their bills, leaving the person taking the medicine with no say in the matter and no chance to weigh up the pros and cons of a change, does not quite seem to be the way forward.

Thirdly, and maybe most importantly, the huge ongoing expense, in both physical and emotional terms, of the consequences of undiagnosed type 2 diabetes, the frequent delay in starting any kind of insulin (designer or otherwise), and the lack among many services of fundamental annual check ups (revealed by the most recently published national diabetes audit) and support for self management, would easily swallow up any savings that a purge on insulin prescriptions would make. These are the real health challenges in diabetes, not the type of insulin prescribed. In a way, it’s an easy win for the NHS to focus on prescribing costs, rather than investing in changing what happens within diabetes clinics. Designer insulin? What we really need is designer diabetes services.

Specialist Diabetes Care at Your Doctor's?

2011-09-15T00:49:00.000+01:00

A recent diabetes journal for health professionals discussed the issue of increasing demands on the NHS and on diabetes services in particular. These discussions highlighted the changing NHS and the proposals now going through Parliament, for services to be provided in general practice where possible, rather than people being referred to specialist services in hospitals.

The journal highlighted four different models that had been developed in different areas of England. They all have commonalities, for example they all emphasise working in partnership with other health professionals to ensure services are integrated, and they all recognise that up until now, services have mainly been organised around the hospital-based system.

Where the models differ is in their approaches. For example, one of them offers a ‘top-down’ approach that talks about key services that should always be provided by a specialist team, and thereafter focuses on the relationship and support services that their specialist diabetes team provide to primary care colleagues.

Another is presented from the point of view of people with diabetes, who found that their care providers were too authoritarian, and that the model of care did not support self-care or shared decision making.

A third is written from the perspective of a limited company of general practitioners (GPs) providing an integrated diabetes service for their local population.

A fourth and final model is written from the hospital specialist team’s perspective but based on the local vision of ensuring that care is of good quality and equally available to all people with diabetes.

So which is the right approach? How diabetes services are organised has been debated for at least 20 years, mainly among health professionals, and mainly from an ‘opposite sides’ point of view, with both specialist services and general practice both arguing that no-one else can provide care in the way that they do. The result has been that within these services, people with diabetes have at times been bewildered and left with very little explanation about their local system of care, or why they see who they see.

The last decade or more has seen the Government’s health policy firmly pointed towards greater accessibility of services locally, alongside holding managers and commissioners to account for how money is spent on services and how best value for money can be achieved without reducing quality of care.

Assuming there is no one model that fits everywhere – and the NHS has consistently failed to provide a single system of care which works throughout the country – how can you tell if your local diabetes service is delivering what it should? We believe you should be able to get the answers locally, whichever country in the UK you live in, to the following questions:

í What objective information can you be provided with to tell you why you are being seen by the specific health professionals that provide your care?

í Can your diabetes service explain exactly what their model is?

í Are there additional diabetes-related services on offer that you could take advantage of?

í Where can you find information about the design of your local diabetes service, with information about when or where you might expect to need expertise from outside your ‘usual’ diabetes team?

í How are decisions made about the design of your local diabetes services, and how can you have a say in those decisions?

í How well are people with diabetes, their families and carers represented in the decision-making system – for example is there a token ‘person with diabetes’ among a vast panel of health professionals and managers, or is a more equal voice apparent, such as a representation group or discussion forum for people living with diabetes?

The answers to these questions may of course lead you to want to know even more of course, as the answers may be complex and potentially difficult to find. But you have the right to know not only what care you should expect, but what your local healthcare managers are doing to make sure you get it. The government has vowed that we all experience an NHS where there is ‘no decision about me, without me’ and in our view, this applies as much to the design of services as to their delivery.

Professional development in diabetes care – How to make good choices

2011-09-05T19:49:00.000+01:00

As we enter the new academic year, how’s your professional development portfolio looking? We’ve noticed that every diabetes journal holds at least a few, if not a rainforest full, of flyers showing the exciting number of educational opportunities for people working in the field of diabetes care.

In our experience, attendance at courses and conferences often provides gems of information that are really helpful in practice and make a huge difference. Equally, we’ve found it is possible to attend a conference and come away feeling dissatisfied that the one thing you hoped to get out of it wasn’t covered. So although it is fantastic that there are so many opportunities available, the sheer variety of choice and opportunities can be overwhelming. It can raise feelings of ‘how on earth could I go to all of the ones that interest me?’ – followed by ‘how on earth do I choose which will be of most use to me?’ And there is usually a £ sign attached, if only for travel and subsistence, so these thoughts come alongside the perennial ‘how do I spend the money I have available for education wisely?’

The question seems to be: how can we ensure that the conferences, workshops or other educational opportunities that are attended are the ones that will be most useful to us? We’ve put together some considerations to help get through this tricky dilemma.

First, take a moment to jot down some ideas of what kind of training you actually want at the moment – where are the gaps in your knowledge or skills? What do you struggle to get your head around? What topics make your heart sink when someone asks you a question in a consultation?

The next question to ask yourself is: what kind of learning do you want to experience? Are you happy to sit in front of a series of lectures, taking notes and having a quiet ‘aha!’ moment? Perhaps you prefer something a bit more interactive, where you can share your ‘ahas’ and learn about everyone else’s? Also consider if you like to be able to ask questions throughout the sessions or are happy to wait until question time after a presentation. Do you get frustrated if you don’t get a chance to comment on or debate the information you are being given? Perhaps the thought of having to contribute fills you with dread and sitting quietly at the back is more your thing?

A final deliberation is about money. Are you looking to take advantage of free or sponsored events only, or are you able to pay or have funds for a certain amount? Perhaps you’re in a position to choose the most appropriate event, regardless of the cost?

Once you have considered all these questions, you can look again at the adverts and flyers for educational events. Armed with exactly what you are looking for, you’ll be able to focus on the topics, the method of presentation and the cost and quickly narrow down your options. When you sign up, you can feel confident that what you choose will be of real benefit and a good use of your valuable time.

Good luck and happy learning!

Does having diabetes make you ordinary or extraordinary?

2011-08-23T19:00:00.000+01:00

An eye-catching news item about disabled people has made us stop and think. It discusses why disabled people might undertake dangerous or gruelling (or both) activities, such as trekking to the Arctic or running a marathon.

Diabetes magazines and websites often feature people with diabetes doing extraordinary things, like climbing Everest, trekking in a rainforest for weeks or – yes, you’ve heard of this one – winning many gold medals at the Olympics. You could almost be forgiven for thinking it was obligatory to ‘overcome’ the condition by proving that you are somehow extraordinary. Leaving aside the obvious question about whether these activities do have a life-enhancing, diabetes-defeating effect, the fact is that in reality, doing these things is off most people’s radar screens, whether they have diabetes or not.

So do you have to prove yourself somehow ‘normal’ if you have a condition like diabetes? Our thinking about this is that having diabetes doesn’t make you any more or less able to do ANYTHING, and nor does it mean that you have to prove anything.

There will always be people who enjoy and succeed at ‘super ventures’. Having or developing diabetes might uncover your desire for these, or if that desire is already present, it will not stop you, and for this we salute you. But there are many more less adventurous souls who are happy just to get through each day and count its successes and blessings – this seems to us equally worthy of celebration and it would be great to hear a bit more about the ordinary life achievements, as well as the extraordinary!

What’s your view? Are you an adventurer or a get-through-the-day-er? Has diabetes made a difference to how you view life? The discussion is open!

There's a nudge coming your way very soon!

2011-08-15T23:20:00.000+01:00

How would you respond if you were told that an aspect of your behaviour was different from that of most people, for example that most people were taking more physical activity than you each day, buying more fruit and vegetables each week, or even paying their tax bill more quickly than you?

This may or may not concern you, but whether it does or not, you will be seeing more of these kinds of messages in supermarkets, letters from the tax office or at work very soon, because these ‘nudges’ are firmly built into health and social policy ideas for the next few years.

Where does nudge come from?

The idea of behavioural nudges was developed by two American professors and published in a book, unsurprisingly called ‘Nudge’. It describes how we might be prompted to change our behaviour by our environment, but without restricting our right to choose. And the UK Government has taken up this message in a very big way. One of its first actions when coming into office was to set up a ‘behavioural insight group’ to look at ways health and social behaviour could be influenced, and the authors of Nudge are said to be advisors to the group.

So far, the group have raised several nudges that will come into regular use in the near future. These include a change to the wording of an overdue tax letter and an automatic opt-in to pension schemes. Other ideas being discussed are working with supermarkets to reorganise products and messages on their shelves to make it easier to buy healthier products, and inviting you to make a charity donation when you are withdrawing cash from a hole in the wall.

How do nudges work?

The theory is quite straightforward. As humans, we behave in certain ways, for example:

1. It’s known that our choices are influenced by what’s immediately available in the environment

2. We tend not to opt in to something, but once in, we tend not to opt out

3. We respond to rewards

4. We like to feel similar to other people, rather than different

So, putting this evidence into practice may result in strategies that help us successfully change our behaviour.

If you’re thinking ‘so what’s new?’, you are not alone. We already know the effect of peer pressure, and in recent years we have all seen desirable or special offer products being positioned near checkouts to tempt us. We have also all got a purse or wallet full of reward cards. So in commercial terms, we are often ‘nudged’. However, nudge theory has not yet been applied to creating national health related policies.

In pursuit of this, the aforementioned behavioural insight group have recently published a document discussing how nudging could be applied to health, using examples from many areas, including diabetes. It cites one pharmaceutical company’s blood glucose testing product, which offers points on popular computer games for each test completed. Apparently, as a result, more tests are done because the user feels less pain and forgets about the experience more quickly when it is coupled with playing the game, which is a distracting and enjoyable activity.

Is nudging a good thing?

Although it’s important for people to make choices that are right for them personally, nudging could be a useful way to make people aware of options they hadn’t yet thought of, and so there would definitely be some value in ‘moderate nudges’. There’s no doubt that there’s a big need for change in some areas of our lives, particularly health related – you only need to look at the growing size of the nation (literally!), concerns over the livers of teenagers, and the lack of physical activity in the population to know that. We also know that conventional ‘telling people what to do’ doesn’t work in the long term, and many of our good and healthy intentions only last a few months before we relapse back into our old ways. Anyone who’s tried to lose weight more than once will know this so well! So maybe a well-placed reminder or two to do the right thing will really help and there’s a fair bit of evidence for that. Also, nudging focuses on providing only choices that result in a positive outcome. Applied to health, where often only the negative aspects of taking certain actions are presented, nudges could be a particularly welcome development.

On the other hand, what about our right to choose and not to have our behaviour psychologically manipulated? Where will it end? The cash machine telling me to spend my money on attending Weight Watchers instead of buying wine? My driving licence only being issued if I agree to donate my organs if I die in a car crash? My doctor’s surgery restricting my appointments because I haven’t performed as well as other people with the same condition as me? Obviously these are extreme examples, but then nudge is based on the fact that human behaviour is somewhat irrational, and also that we tend not to opt out if we are automatically opted in… so perhaps we need to be aware of these possibilities and be alert for that ‘nudge too far’?

A more intriguing question for us and one which is consistent with our philosophy of enabling people to make the right choices for themselves, is ‘could people nudge themselves?’ Knowing a bit more about nudging and knowing what our priorities for change are, could we arrange things in our own lives to make it easier for us to make different choices? For example, making ourselves more aware of our unhealthy behaviours by counting the number of our friends who don’t smoke, or who do eat 5 a day, or who have successfully lost weight? Setting a mobile device to regularly ask us about the amount of physical activity we have undertaken? Even reorganising the shelves in our cupboards or fridge so the healthy options are easier to reach? Then again, if it was that easy, perhaps we would already be doing these things - so perhaps we DO need the bony elbow of the health ministry to help us!

What’s your view about nudging? What would ‘nudge’ you - or are you un-nudgeable? This topic is now open for discussion…

Blood Glucose Testing Savings...or not?

2011-08-05T18:07:00.000+01:00

An article in a diabetes nursing journal last month described how a PCT was able to reduce its costs by £500,000 over 2 years by cutting back on the number of blood glucose meters offered to people with diabetes and thereby the amount of blood glucose testing strips being prescribed. This is extremely impressive and hopefully the money saved will be ploughed back directly into diabetes self management education. The article did not state whether this would be the case, but did say that blood glucose monitoring should ‘only be used as part of self management education’.

This begs the question for us ‘What parts of diabetes care should not be used as part of self management education?’ Hospital and GP practice based consultations? Diabetes specialist nurse consultations? Foot clinics? Dietitians? Retinal screening? Pharmacy prescriptions and medicines reviews? If we are going to pick and choose who should and who shouldn’t do blood glucose monitoring on the basis of self management education, perhaps we should also start limiting many of other aspects of diabetes care which very often do not promote self management? That would save as much money if not more, plus the incalculable cost of time, stress and wasted journeys.

More than once we have heard about consultations where someone is told off or given limited information to help them self manage their condition. Many times the attitude of ‘patients don’t do as they are told, they are simply non compliant’ comes through the stories of health professionals. It’s particularly hard for people with diabetes who have attended diabetes structured education and learned so much about managing their condition in all its carb counting, insulin adjusting, hypo treating, correction bolusing glory, who then visit a clinician who simply tells them off for having an HbA1c outside the recommended range and accuses them of not sticking to their diet!

Obviously if we simply applied the cost-cutting principle to all these other aspects, we may end up with fewer services all round. But what if the money saved were redirected to investment in services which were truly self management orientated? That would really be something. There are welcome suggestions of this in the current health reform aspirations, but we have yet to see which ‘babies’ are thrown out and which survive the metaphorical bathwater that is the Health Bill.

So, back to our question: why should it only be blood glucose monitoring that is offered in the context of self management education? Surely every single aspect of diabetes care should ‘only be offered’ in this aspiration? Blood glucose monitoring limitations can bring eye-catching savings in the short term, but without a proper, self management focused strategy alongside this decision, the real costs of doing so will start to become evident in the long term. We also need to bring more accountability into the ‘people’ cost of diabetes care provision, and make sure that we are investing our money to provide real self management support and services.

Welcome to the SD blog!

2011-07-29T11:02:00.001+01:00

Hi Everyone

SD has joined the blogging world, so we can share our thoughts and bring you the latest news and comment, and also give you the chance to share yours with us in a really easy way. We've called it SD Listens because the art of listening is something really important to us - whether it's listening to you through your comments here or on our website, encouraging and demonstrating listening skills in all our workshops or writing about the value of listening in our books and publications. One of our favourite tips for participants in our workshops to develop skills in working with people with long term conditions like diabetes is "give people 'a good listening to' as opposed to 'a good talking to"!

That's all for now - look forward to hearing your thoughts soon!
The Successful Diabetes Team