Unacceptable behaviour at annual review

[christi99]

What a bizarre thing to happen. My mind would have been reeling.

I'd suggest you have to do something, or this sort of interaction is the kind of thing that can eat away for ages, in the back of your mind, and potentially influence other parts of your diabetes care and interactions with HCPs. In your shoes, I might be inclined to either ask for another appointment, or write a letter. Whilst a face to face interaction can sometimes bring most satisfaction, writing a letter could allow you to make sure you cover all the points you want to raise, without the emotional rollercoaster that a face to face meeting would almost inevitably bring with it.

I think one of the main things I would want to understand would be why the referral was being made for bariartic surgery without any pre-consultation with yourself to ascertain how you felt about it and to help you understand what feels like a bewildering step on their part. There could, of course, be some great big misunderstanding going on here, whereby the person you met with thought you had requested it or that it had been discussed with you? I'm not saying that's what happened (how could I know?), just floating it as a potentially less destructive reason the situation could have arisen. Whilst many of us have had less than ideal interactions with medics over the years, I doubt the lady you met with was a callous, hurtful individual at heart. In my head, I can just imagine her thought process, thinking the appointment was a nightmare for a whole different set of reasons.

Once you understand the reason it might be felt appropriate for you to consider surgery, it will form a more reasonable foundation for any discussion that should take place. As others have said, for you to undergo any treatment or procedure, you are required, by law, to sign an informed consent, and it feels like you're a long way from being informed enough to consider any form of consent.

I'm not a great advocate of surgical weight loss, as I've observed one person for whom it spectacularly wasn't suitable, and she regained all the weight she lost after it. I'd say that she achieved nothing, aside from puting her body through several traumatic experiences - surgery, effective starvation, malnutrition (because of how she chose to eat post-surgery), and the the strain on her regaining the weight. That said, for many people it opens up a whole new, and healthier life. I've only added this paragraph in case you think I'm agreeing with your HCPs and their approach

I do hope you find a way forward with this, and very well done on the great HbA1c. It's such a shame you didn't get the credit you undoubtedly deserved during your appointment.

I think you have made so many good points here- because there is a possibility of a misunderstanding. However, the woman involved here may not "be a callous, cold hearted individual at heart"- but... for all intents and purposes, she behaved as if she was! When you work in healthcare, it can be very frustrating to deal with patients noncompliance or whatever, but you are also trained teaching strategies and communication styles to help a patient understand, be receptive and most of all comfortable with a plan of care. This visit could have gone very differently if it centered around the positives (HbA1C perfect!) and the positive feelings that accomplishment can create inside someone (and that really is a huge accomplishment!)- This helps build a foundation of positive self-esteem that will inevitably lead to greater ability to handle challenges, deal with anxiety, depression, and emotional eating.

 

[christi99]

That doesn't sound too bad for a young chap so tall. It's another example highlighting the fact that people assume (I nearly said naturally) that overweight people eat too much, even the NHS says so and I quote:-

"Obesity is generally caused by consuming more calories – particularly those in fatty and sugary foods – than you burn off through physical activity. The excess energy is then stored by the body as fat".

I notice that they have inserted the word generally since I last looked some months ago, covering their backsides because the fact is that it is only in a certain number of cases. Watching the video I posted and zand has reminded us of the link, explained things so well. Fat isn't the problem, carbs are, including sugar obviously.

Standard dietary advice shouldn't be the same for everybody, some people can handle carbs, lucky them, I can't.

I hope you can persuade your son to go to the gym or start swimming or walking, they're all good. You know what everyone else can do? Take a . . . . . . . . . . . . . (Not allowed to say that).

Yes, I agree! But seriously, this kid never eats sweets (but does not control his carbs- despite my nagging and does not eat more than his skinny 5'10' brother. Actually his skinny brother eats tons of fast food, whole pizzas, candy etc and no one is judging him (except for me because I want him to make healthier choices!) I have tried to encourage him in every way (he does have a physically demanding job too) but I guess I never realized the level of shame and discomfort he felt before. And he isn't that overweight- but it is how he sees himself more than anything. I guess my point is when a healthcare professional has the opportunity to impact someone's well being because of positive gains (like the great HbA1c), they should use it wisely. Mirroring back disapproval just doesn't help anyone after the age of 5!

 

[AndBreathe]

I think you have made so many good points here- because there is a possibility of a misunderstanding. However, the woman involved here may not "be a callous, cold hearted individual at heart"- but... for all intents and purposes, she behaved as if she was! When you work in healthcare, it can be very frustrating to deal with patients noncompliance or whatever, but you are also trained teaching strategies and communication styles to help a patient understand, be receptive and most of all comfortable with a plan of care. This visit could have gone very differently if it centered around the positives (HbA1C perfect!) and the positive feelings that accomplishment can create inside someone (and that really is a huge accomplishment!)- This helps build a foundation of positive self-esteem that will inevitably lead to greater ability to handle challenges, deal with anxiety, depression, and emotional eating.

I don't challenge anything you say here, or in your earlier post describing your son's struggle to drop weight. All I was trying to do was to urge the OP to try to get into a calmer place where he could open his mine to ask questions and try to understand better the rationale employed by the person he spoke to. Even those trained communicators (whether HCP or not) can be caught on the hop by a completely unexpected response to something they thought the listener was either expecting or would find helpful. At that point, it is possible a "brain freeze" took over and she just ploughed though her pre-prepared thoughts.

Regarding communication; I understand many HCPs are taught communication skills, but sadly, some people (not just medics!) are great communicators, and will always struggle, irrespective of the training they have. Sometimes these people are, frustratingly, also the most gifted.

As I said, I'm not supporting this experience as being acceptable, just trying to open minds to explanations are aren't completely unreasonable, if certainly undesirable.

On an aside, have you, or your son done any reading around links between insulin and weight gain? There's some fascinating stuff out there, and it certainly helped me understand my own T2 better. Obviously, T2 and T1s differ greatly, but the core issue is the amount of insulin we have on board at any time, and our bodies' ability to cope with that, metabolising food, without "instructing" our bodies to lay down fat. That's, of course, really very, very overly-simplistic, but a real read around might be good.

We see so many diabetics coming on here who struggle to lose weight, and many find the relationship between carb consumption and insulin can be more critical than calories in/out.

 

[christi99]

I don't challenge anything you say here, or in your earlier post describing your son's struggle to drop weight. All I was trying to do was to urge the OP to try to get into a calmer place where he could open his mine to ask questions and try to understand better the rationale employed by the person he spoke to. Even those trained communicators (whether HCP or not) can be caught on the hop by a completely unexpected response to something they thought the listener was either expecting or would find helpful. At that point, it is possible a "brain freeze" took over and she just ploughed though her pre-prepared thoughts.

Regarding communication; I understand many HCPs are taught communication skills, but sadly, some people (not just medics!) are great communicators, and will always struggle, irrespective of the training they have. Sometimes these people are, frustratingly, also the most gifted.

As I said, I'm not supporting this experience as being acceptable, just trying to open minds to explanations are aren't completely unreasonable, if certainly undesirable.

On an aside, have you, or your son done any reading around links between insulin and weight gain? There's some fascinating stuff out there, and it certainly helped me understand my own T2 better. Obviously, T2 and T1s differ greatly, but the core issue is the amount of insulin we have on board at any time, and our bodies' ability to cope with that, metabolising food, without "instructing" our bodies to lay down fat. That's, of course, really very, very overly-simplistic, but a real read around might be good.

We see so many diabetics coming on here who struggle to lose weight, and many find the relationship between carb consumption and insulin can be more critical than calories in/out.

Oh I so agree with you on your points made- especially the fact that some of the most gifted medically are not great communicators. And just people too at the end of the day. But also have such a potential impact on someone too, so maybe should be made aware of when they have offended as you pointed out earlier and to address it in a very constructive manner (that may benefit the offended person, the practitioner and potentially any other person they counsel.) Those were wise words!

As for the diet/weight gain/ insulin thing- ya- I do understand the physiology behind it and frankly - my son just doesn't seem to care or make any effort to restrict carbs (I mean outside of eating pretty much like an average guy his age). Sooo frustrating because i see how his choices are hurting every aspect of his life- but... yet it appears it is still not simply "what you choose to eat" - but why you choose to eat it. A very complex thing really, and that is why so many people struggle to lose weight or keep it off. But ya, I think by restricting carbs- like all those diets that ultilize this principle really do seem to work very well with those of us with altered glucose metabolism. It make sense to me biochemically and I think that is ultimately the only way to stabilize BG in Type2 (or T1).

 

[charon]

Had you discussed your weight before?
I would say deal with one thing at a time. I guess the most critical thing for you was BG control and you should be congratulated with dealing with that.

Maybe now it is time to look at your weight, you've shown that you can control your life so it should be possible without surgery - but you should be given the opportunity to concentrate on it to see if you can manage without impacting your BG.
I would have thought before considering surgery she should have had a discussion about whether you thought it would affect your BG control.

Being cynical it sounds like it might be to reach a target for numbers of overweight people dealt with.
I see nice bright out a draft guidance extending surgery to more people with diabetes - but only as a last resort after other serious attempts have failed. It also says it should be offered not forced.

When I was diagnosed I dealt with it by diet and exercise. By exercise I mean a short walk, about 10 - 15 mins. I lost about 3 stone. Even now if I test over 7 I will go for a stroll and it will drop to around 5. If not after a meal it will usually drop to the low 4's.

 

[carebear]

Can I just say that people are overweight for varying reasons and yes it doesn't help your diabetes. Some people are overweight and not diabetic, lucky them in some ways. I had bariatric surgery as I have diabetes but wasn't very overweight, it was for another reason.
When or if you attend the appointment for bariatric surgery, you should be assessed by a specialist nurse who WILL LISTEN to you and not dismiss you as someone who just eats. They understand that people are not the same and can advise you of what course of action to take. You won't just be operated on and left to get on with it. Please report what happened to you it was unacceptable behaviour from anyone Dr, nurse, or therapist. And make sure you have all the information so that you can make well informed choices about your care. I did, I have had a band in for 4 years, have slowly lost weight and I suppose look better, it has improved my diabetes but not my other chronic illnesses that make me disabled, like the Dr's said it would (funny that isn't it)!
So kick back at what happened to you, make your decisions and do what you feel is right for you. Things won't happen overnight but you will get there in the end. Take care.

 

[christi99]

IMO- I think practitioners recommend bariatric surgery waaaaaaaaay too casually these days- there are significant potential acute or life-long and irreversible consequences ( except for the lap band) that don't seem to be weighed too heavily (sorry, no pun intended) with the overall plan. When this surgery was 1st started, it was pretty much reserved for morbidly obese folks who had significant comorbidities (Type 2 DM, HTN, etc) that the benefits outweighed the risks. Now it is thrown out as "so you haven't lost weight- go get surgery" instead of the LAST option. They also now have much more data - more pts, more documentation of complications- G.I. malabsorption, "dumping syndrome", and other related sequelae. Also emotional or food addiction behaviors are not going to just go away because one cannot overeat. There is a time and place for this surgery, but I think it needs to be a very carefully thought out choice after all else has failed- AND the person really is committed to a lifestyle change- this is just "one tool in the toolbox"- not a magic fix-all.

 

[MarkE]

[snip]I
never asked nor do I want weight loss surgery. When explaining that I had mental health issues, acute depression, PTSD with anxiety and panic attacks and that I am not always able to deal with issues even if they are as acute as diabetes and the constant anxiety of injections etc. But she dismissed this with ''unless you are in a coma or someone has a power of attorney over you, then you are still able to make your own decisions about what you eat or do not eat'. So after this appointment I have no more idea about my diabetes and how it relates to me, no encouragement and now have a referral for bariatric operation that I didn't ask for nor will entertain.

Ye gods...

I truly feel for you- I'm an aspie myself, and handling any confrontation is quite simply near impossible, even when my diabetes is concerned. It can be truly horrendous when you are faced with someone in authority giving apparent orders- however wrong, however invalid- and you then have to "decide" based on such an approach what to do next.

Yes, complain: the only way that these tw*ts will learn is by challenging them- and yes, I do understand it is far, far easier for me to say this, than for you to do it...

 

[buckmr2]

Ask to be referred to a different clinc.
Re bariatric surgery.
I had Roux-en-Y surgery in November.(stomach reduction with titanium staples).
I wasn't bothered about my weight but was concerned over potential future insulin intolerance as I was injecting around 130 units a day (on insulin for 40 years).Post surgery it dropped to nearer 35 units a day....mission accomplished!
I've now hit the problem most type 1's' hit once they loose a lot of weight which is re-adjusting insulin to new weight/intake. Have been recording every carb/insulin/blood glucose results meticulously for when I see the Diabetic Nurse in a few weeks and patterns are there so hopefully will get sorted.Not easy to go against what i was doing when I was heavier but well controlled.
Good luck with your issues

 

[buckmr2]

Once referred for weight loss surgery you have to loose small amounts of weight at every stage during the 18 months or so before the op.I only had dumping syndrome once (frothy odourless vomit) and it's not a big deal.Main side effect I found was tiredness middle of the afternoon even though I was sleeping at night.So glad I had the op. Far more energy. Rarely if ever have to use my ventolin.
It's cost a fortune for new clothes.My waist was 48" now 36" and still falling and my feet have gone from a size 12 to a size 9.

 

[christi99]

I am happy to hear that you have had a good experience overall- I just feel I need to clarify the kind of dumping syndrome (there are 2 types: early and late- early being the rapid gastric emptying kind and the late being the hypoglycemic kind) I am referring to. The dumping syndrome I suffer from - both (not related to gastric bypass but another autoimmune dz) is the "dumping" of stomach contents into intestine rapidly and/or and the release of insulin into the bloodstream after the ingestion of usually simple carbs or sugars at a rate that is dysregulated from the amount you actually need, thus causing hypoglycemia, and related nausea, diarrhea, vomiting, confusion, sweating, weakness etc. from the effects of the rapid emptying food into intestines without the right digestive enzymes doing their job, shifting fluid into intestines. I have fainted from rapid blood pressure drops, tachycardia, and hypoglycemia - and boy, it isn't pleasant or a great thing to experience out on a date! Very imbarrassing Dumping syndrome isn't unique to bariatric surgery but is usually related to G.I. surgery of many kinds. Additionally, research has found that persons can develop it at anytime after surgery, I read a research study identifying gastric bypass population findings that the gastric cells are no longer in good synch with the pancreatic release if insulin- sometimes symptoms starting years after initial surgery. Malabsorption syndromes can also result. It's usually managed best by avoiding high starch, sugar or carb intake or (high fat too). And if hypoglycemic, treat like any other kind- glucose. Not trying to tell you how you are feeling, because obviously it has not been a problem for you- (because you are T1 you won't have the hypoglycemic problems from this type of dysregulation)-just that dumping syndrome is a more complex physical/digestive or endocrine reaction - by definition anyway.

But,more importantly, it sounds like you are a really positive example of the good outcomes in bariatric surgery and that it is a valuable treatment option- but people should know the risks and sequelae associated with it short and long term. Also, congrats on sticking to a program that has helped you achieve a healthy and steady weight loss!! Good point you make as well about the period prior to surgery, where one usually has to engage in counseling, weight loss and an exercise regimen before they deem you a potentially successful candidate and ready to go. This is really something they did right, because it help folks deal with what will be happening after the surgery and address overeating issues before they will not be able to overeat.

 

[Scardoc]

IMO- I think practitioners recommend bariatric surgery waaaaaaaaay too casually these days- there are significant potential acute or life-long and irreversible consequences ( except for the lap band) that don't seem to be weighed too heavily (sorry, no pun intended) with the overall plan. When this surgery was 1st started, it was pretty much reserved for morbidly obese folks who had significant comorbidities (Type 2 DM, HTN, etc) that the benefits outweighed the risks. Now it is thrown out as "so you haven't lost weight- go get surgery" instead of the LAST option. They also now have much more data - more pts, more documentation of complications- G.I. malabsorption, "dumping syndrome", and other related sequelae. Also emotional or food addiction behaviors are not going to just go away because one cannot overeat. There is a time and place for this surgery, but I think it needs to be a very carefully thought out choice after all else has failed- AND the person really is committed to a lifestyle change- this is just "one tool in the toolbox"- not a magic fix-all.

Unfortunately, there is probably less emphasis on the bit of paper which is home to the "Advantage/Disadvantage" table and far more emphasis on the balance sheet. Bariatric surgery has become a routine operation and as such the short term financial cost of doing it is proving to be worth it. Will it remain economic long term? It may or it may not. But for now, assume that those in charge are wearing suits as opposed to scrubs and are looking at the pounds and pennies.

 

[diabeticguy]

Very interesting reading all of your responses. I have an appointment with the CPN on Friday so will feel able to off-load to her. I spoke to a guy at PALS at Eastbourne hospital who suggested that he would approach the head of dept. I felt at this stage that was all that needed to be done, a discussion with the GP confirms that he, as a diabetic specialist will be able to perform the annual review and that retinopathy screening is dealt with by a third party I won't need to attend the hospital again.

I am still astounded that a diabetic consultant would be so aggressive in suggesting that I get butchered in order to get me to a weight that pleases her without any consideration of my wishes, thoughts or intentions. In fact in retrospect her whole demeanour was that of a person who was blaming me for the condition I was in and she just couldn't disguise her disgust/displeasure at my failure to control my weight; even though there was a serious mental condition that makes it very difficult for me to balance all of the ailments in a consistent manner.

 

[christi99]

Very interesting reading all of your responses. I have an appointment with the CPN on Friday so will feel able to off-load to her. I spoke to a guy at PALS at Eastbourne hospital who suggested that he would approach the head of dept. I felt at this stage that was all that needed to be done, a discussion with the GP confirms that he, as a diabetic specialist will be able to perform the annual review and that retinopathy screening is dealt with by a third party I won't need to attend the hospital again.

I am still astounded that a diabetic consultant would be so aggressive in suggesting that I get butchered in order to get me to a weight that pleases her without any consideration of my wishes, thoughts or intentions. In fact in retrospect her whole demeanour was that of a person who was blaming me for the condition I was in and she just couldn't disguise her disgust/displeasure at my failure to control my weight; even though there was a serious mental condition that makes it very difficult for me to balance all of the ailments in a consistent manner.

Good for you- sounds like you found a good solution to this. As for the comment you make about her not being able to hide disgust etc and the blame issue- boy, do I know what you are talking about. My son is maybe 40 lbs overweight, diabetic and eats no differently then his thin siblings (who, btw- eat whatever they want and have no blood sugar issues). I have been with him and he has consistently been treated just as you describe - and it is so callus, mean and frankly, not a simple problem to fix- even without the psychiatric struggles you describe. I have also struggled with Type 2 (or probably 1.5- they now call) since I was young- I have always been thin, even underweight and guess what? No one blamed me ! Weight loss is not an easy thing, particularly when you may be taking medications that also can cause people to gain weight. But because of the very real prejudice against obesity, what you describe is all too common and as you said- TOTALLY UNACCEPTABLE. I know they are just people, but perhaps they should choose a different profession than to interact with human beings who have health issues. It is already a stressful situation. They are not helping anyone by compounding the shame, anger, or whatever one may be feeling already. We all have our own struggles inside and no one has the right to judge how well we are coping or what we may look like on the outside. Best of luck to you and just know you do not have to do ANYTHING that doesn't feel right to you. Only you have to live with the benefits and the risks- and therefore, your decision.

And on the aside... a handful of nutritionists I know personally have struggled with anorexia or bulimia their whole lives, hence why they went into nutrition (they tell me it helped them manage their obsessive issues with food by letting them manage someone else's intake ! But seriously - may possibly explain the extreme behavior we have experienced. Any eating disorder is as unhealthy as another- the closet bulimic just isn't being judged.

 

[christi99]

Unfortunately, there is probably less emphasis on the bit of paper which is home to the "Advantage/Disadvantage" table and far more emphasis on the balance sheet. Bariatric surgery has become a routine operation and as such the short term financial cost of doing it is proving to be worth it. Will it remain economic long term? It may or it may not. But for now, assume that those in charge are wearing suits as opposed to scrubs and are looking at the pounds and pennies.

Bariatric surgery has become routine and it can be a great tool for many, but having just come from a funeral last week for a 30 y.o. young man, who had a 6 mo. old child, and wanted to "get healthy" for his baby - brings sobering reality to any surgery in a higher risk population. ( He happened to have had a pulmonary embolism while sitting in a chair in the hospital post-op). My best friend for 25 yrs had gastric bypass 15 yrs ago- she has chronic, severe iron deficiency for which she has iron infusions monthly, and a host of other malabsorption issues, severe dumping syndrome (that just developed in the last couple years), gastric ulcers they believe are related- and to top it off - she didn't even lose all the weight she wanted to because she says she could not stop overeating even with a surgery and it only took a short time to basically stretch her stomach to hold a good amount (in her words). She lost weight, but in her opinion when I asked her, she would recommend it to no one unless they are fully aware of the potential issues that can be life-long. At the time she had it- they were just starting and she was one of the 1st cases at the hospital she was at.

But to address your point- I wonder if it is saving money in the long term? I am sure that is the ultimate hope anyway, as you said as it related to short term savings. It will probably take a much longer history to look at this population across time versus those who have elected not to have surgery but have the same comorbidities in addition to morbid obesity. Western medicine tends to look at short term gains and "hoped for" long-term potential- than actual realities of someone's life. And I do know they often mean well and want to help people but often get tunnel vision in their quest for medical progress.

I also know they have developed a new type of bariatric surgery that is somewhat different (and may avoid some of the malabsorption issues and dumping they have seen in long term pts). So it is possible that it may be less risky and cause less secondary problems than the 1st bariatric surgeries are associated with. In my experience and opinion, many doctors really are not in touch with what a PERSON is actually experiencing, and instead are just looking at numbers and objective data, instead of asking... "how are you feeling"? And...listening to the answer. Treating a whole person will not only save money but will result in long term health objectives.

 

[Fayefaye1429]

Very interesting reading all of your responses. I have an appointment with the CPN on Friday so will feel able to off-load to her. I spoke to a guy at PALS at Eastbourne hospital who suggested that he would approach the head of dept. I felt at this stage that was all that needed to be done, a discussion with the GP confirms that he, as a diabetic specialist will be able to perform the annual review and that retinopathy screening is dealt with by a third party I won't need to attend the hospital again.

I am still astounded that a diabetic consultant would be so aggressive in suggesting that I get butchered in order to get me to a weight that pleases her without any consideration of my wishes, thoughts or intentions. In fact in retrospect her whole demeanour was that of a person who was blaming me for the condition I was in and she just couldn't disguise her disgust/displeasure at my failure to control my weight; even though there was a serious mental condition that makes it very difficult for me to balance all of the ailments in a consistent manner.

Hi diabetic guy I sorry to hear your experience. I experienced similar I was 20 given a pump and told eat anything as long as you carb count. Well is been on a struck diet for 5 years and for two of those years where I worked next door was a teasing bakery, so I went nuts. I put on a load of weight but got good control at last with my diabetes. I went in to the hospital a nurse and dietitian said you have done well reading wise but your a big fat cow now so you must loose weight. A mixture of tears and anger I got up stormed out and never returned and was referred to another hospital. Weight wise I thought hard about I was personally unhappy about my weight rather than the hospital enforcing their stuff on me so I lost 5 stone via gym and weight watchers. Years later a professional told me that often people in hospitals have to justify the appointments with some kind of goal and often just pick on anything to push the paperwork through. This could be true maybe not but as far as I am concerned no one should speak to anyone in a disrespectful manor generally is a wish but especially with health

 

[robertconroy]

That's because doctors believe being overweight is the cause of most all chronic diseases. Well being obese is a chronic disease. You're overweight because you have high insulin. If your insulin is high, your body stores all carbs as fat. If you lower your insulin, you can lose a pound a day. Just learn the glycemic loads of foods to lower blood sugar and insulin, and watch the kilos roll off you!

 

[donnellysdogs]

Be careful of GP's that are supposedly the "diabetic" GP.
Our Practice when our last "diabetic" GP left just selected another GP to take over the "diabetes" patients. GP selected has no specialist knowledge in diabetes care at all.

 

[donnellysdogs]

Its the same as allocating a named GP's to all patients now... If you have "A to E" as the first letter to your surname you get allocated "xx" GP; F to M you get "xx" as your named GP.

Diabetic GP's can be just given the role of looking after diabetics... Mine knows next to nothing and a complete waste of time.

 

[masonbason63]

Our GP has a designated diabetic nurse practitioner who I use to see every 6 months or so. I've lived in THURROCK for 11 years now when I first moved here the practitioner wasn't aware of pumps so I was their first so when I said I'd like them to apply for full funding which they did and got but when it came to ordering a new pump a couple of years later it was left till later and later In fact till a week of expiry countdown date on pump so getting totally worried I went above the surgery and found out the name address etc of where they applied for it and told them my situation and two days later pump and plenty of consumables turned up at my door. Needless to say it's a diabetic clinic 12 miles away that now deals with my Type1 and not GP surgery 1 mile away only for blood tests it's worth the distsance