What my PCT says

[hanadr]

This is it. It's not in line with NICE
Across the Thames Valley, the NHS spends approximately £4.4million each year on blood glucose testing reagents, more than that spent on oral antidiabetic drugs. The Thames Valley Priorities Committees have reviewed diabetes guidelines across the Thames Valley on Blood Glucose Testing Reagents and support the recommendations.
Key points were:
• There is little evidence to support self-monitoring of blood glucose in all people with diabetes, and especially those with type 2 disease, unless the purpose is clearly defined within an effective management plan for the patient.
• Self-monitoring is most likely to be most appropriate for patients with type 1 or type 2 diabetes, who use insulin and adjust their dose as a result of the test, or for all patients with diabetes who have inter-current illness.
• Blood testing is recommended for all patients with type 1 diabetes, and for those with type 2 diabetes who use insulin.
• There is no evidence that blood testing is effective at improving blood glucose control in people with type 2 diabetes who do not use insulin. Until further evidence is available from ongoing studies its use should be dictated by specific clinical need.
• Frequency and timing of self-monitoring should be determined individually by the clinical needs of the patient. This may vary from one test every 1-2 weeks, in patients with stable type 2 diabetes, to 3 times a day before meals and again at night for some patients on insulin where there are problems with control or hypoglycaemia.
Type 2 Diabetes Glucose testing guidelines (non insulin dependent)
Stability of Diabetes
Frequency
Suggested units of testing reagents/year
Stable control
Blood glucose 1-2 times a week at different times of the day
2 boxes of strips per year
Unstable control or Titration
Test once daily at different times of the day
7 boxes of strips per year
This statement will be reviewed in light of new evidence or further guidance by NICE (See full NICE guideline )

 

[IanD]

Frequency and timing of self-monitoring should be determined individually by the clinical needs of the patient.
Who determines "clinical need?" The Dr by an annual assessment?

This may vary from one test every 1-2 weeks, in patients with stable type 2 diabetes,
How do we know if we are stable? If I did one test a week at different times, I would get different results.

My Dr, who I would rate as "excellent" accepted my last HBA=6.7 as satisfactory control. Slightly higher than the recommended range of up to 6.5. I do about 3 tests a day.

to 3 times a day before meals and again at night for some patients on insulin where there are problems with control or hypoglycaemia.
What do we do with the "before meals" measurements, other than eat the meal? These readings will all be at the low range, unless the db is out of control.

By my arithmetic, 4 times a day = 1460 or 25 boxes of 50, NOT "7 boxes a year" which allows for only 1 test per day - for patients on insulin :evil: :!:

What about driving? Those tests for ID T2 will not give any indication of being safe to drive.

 

[sixfoot]

"There is little evidence to support self monitering in all people with diabetes, and especially those with T2 disease , unless the purpose is clearly defined within an effective management plan for the patient"

Well for T2s particularly if we hadnt tested and worked out what was what many of us wouldnt have achieved control by a particular diet regime,in addition most have accepted it is for life which makes it a managed programe.

The brick wall as i see it is that the regime " lo carb" dosnt comply with current NHS guidelines. Even though the evidence may be improved control, weight loss and general well being.

It would seem to say " We will only give you strips to test when you are actually in trouble", so what happened to prevention is better than cure??

Of course im not a highly paid medical proffessional so i may have it completely wrong

Dave P

 

[chocoholic]

No, I think you are spot on, sixfoot. Your wording is exactly what I used last week when I was told at my surgery I wouldn't be referred to a specialist "until I had ulcers or my toes turned blue". I said I felt preventative care was preferable to after-care.It's like we don't matter.

 

[DiabeticGeek]

The problem with self monitoring are that the NICE guidelines are really ambiguous for diabetics not on insulin. Any GP who doesn't want to prescribe strips could interpret them in such a way to support that decision. They could also salve their conscience with recent BMJ papers that argue that self-monitoring for newly diagnosed T2s is not cost-effective and of doubtful effectiveness. These papers are quite flawed, but on a superficial reading they could justify withholding strips. I have posted details of these papers in a previous thread.

 

[DiabeticGeek]

when I was told at my surgery I wouldn't be referred to a specialist "until I had ulcers or my toes turned blue".

This really surprises me. I thought that you had a right to demand to be referred to a specialist if you are unhappy with a GPs treatment. Do any NHS rules experts here know exactly what a patients rights to see a specialist are?

 

[chocoholic]

Don't worry, since then, I have seen my D.N. again and INSISTED she refer me. She said a letter would be sent off and I'd get a phone call to book an appointment. I'm still waiting at the mo'......but I'll not be fobbed off this time.

 

[hanadr]

I rang my local paper today. the journalist who has health issues as his brief will be back from Holiday on Tuesday and will get in touch. This morning, I also heard on the "Today" programme that PCTs are not following NICE guidelines on in vitro fertilisation. That leaves me with some questions:
1. What is NICE for if PCTs can chose to ignore its guidelines?
2. What does NICE cost, just to be ignored?
3. How is it that some PCTs follow NICE guidelines?
4. Who are these PCT people and what are their qualifications?

 

[DiabeticGeek]

some questions:
1. What is NICE for if PCTs can chose to ignore its guidelines?
2. What does NICE cost, just to be ignored?
3. How is it that some PCTs follow NICE guidelines?

All very good questions. The only one I can hazard a guess at is:

4. Who are these PCT people and what are their qualifications?

I think they are the mythical "great and good" :wink: They may well have professional members (I hope that they do), but they are primarily lay political bodies. I have a relative who is a trustee on a PCT (not mine, he is in a different part of the country). His background is that he is effectively a professional politician (an agent for an MEP, a Councillor of many years standing, a JP and generally an all purpose New Labour man). He is most certainly not a medic - his main qualification is a history degree from Oxford. He told me that if any practice in his patch was found to be deliberately ignoring NICE, that would be cause for serious trouble. However, he did agree that the guidelines are often open to various interpretations.

 

[Nellie]

I don't know if you've already found it but this links to the individual areas of the PCTs in the Thames Valley. http://www.tvpca.nhs.uk/page.asp?fldArea=17&fldMenu=0&fldSubMenu=0&fldKey=415

I had a quick look at the Oxfordshire link and the first thing on the homepage is a survey on diabetes care

And a few more links,names and sometimes biographies
oxfordshire : http://www.oxfordshirepct.nhs.uk/about-us/how-the-pct-works/trust-board/membership.aspx
Bucks: http://www.buckspct.nhs.uk/yourPCT/sub.aspx?id=123
Milton Keynes :http://www.miltonkeynes.nhs.uk/default.asp?ContentID=44
Berkshire West: http://www.berkshirewest-pct.nhs.uk/page.asp?fldArea=1&fldMenu=2&fldSubMenu=0&fldKey=456
Berkshire East : http://www.berkshireeast-pct.nhs.uk/about.asp?fldID=192&fldSubAreaNum=2

 

[Buachaille]

Guidelines are just that "guidelines". They are not rules and/or regulations. As such they can be accepted, or considered and under whatever circumstances rejected/ignored.

Against, farting and thunder come to mind. They will consider the "guidelines" within the constraints and or priorities (financial or otherwise) that they (have) to operate.

Such is life.

The alternative to 'guidelines' would be 'directives' .

Look for snowballs in hell.

 

[martinbuchan]

Having listened in on a diabetologists' forum, we do seem to have sympathetic ears to self testing from our consultants. However, the interpretation of the big studies (ACCORD, ADVANCE etc) are still argued about. It seems logical to achieve good control of A1C which will reduced microvascular complictions. The jury is out regarding actual mortality in Type 2 diabetes. These same diabetologists do get frustrated at the multitude of type 2s who are non-compliant. These big aforementioned studies are populated by the same non-compliant patients (I just think of my late wee grannie). Exercise and diet are not looked at in these studies, which , as we all know, are the cornerstone of diabetes care.

I just don't see how a GP can sit there and refuse to help a motivated diabetic desperate to sort themselves out. It must be a revelation for them to find a type 2 who wants to get the best control possible.

 

[ally5555]

martin - I cannot understand it either!

I had a very heated debate in the surgery this week as a few gps do not think type 2s should test - their argument is that an HBA is a better guide! I dont agree and have got patients machines - their point is that just testing now and again doesnt tell you anything. It may be a cost issue but how can u make a diabetic wait 3 months to find out what is going on?

 

[DiabeticGeek]

Having listened in on a diabetologists' forum, we do seem to have sympathetic ears to self testing from our consultants.

Interesting. Was this a real life meeting, or an online forum? If the latter, is it still active? This is something that I would be very interested in earwigging!

 

[DiabeticGeek]

I had a very heated debate in the surgery this week as a few gps do not think type 2s should test - their argument is that an HBA is a better guide!

My GP and two nurses at that practice have all been adamant that they consider testing to be a "bad thing" for T2s. The cynic in me is convinced that cost is at the root of this. However, the reason that they gave was that in their experience many people test without doing anything useful with the results. I, and I think most T2s on here, consider testing to be a vital tool to learn what is going on in your body and to allow you to "fine tune" a diet. However, to be fair to my GP, I guess that there are some people (maybe a lot of people) for whom his view is true. They either don't understand how to design a sensible testing strategy, or how to interpret the results, or possibly most likely they just view diabetes fatalistically and use testing as a kind of score keeping. It is sad because not only are these people putting their own health at risk, but they are bolstering the view in the medical establishment that for T2s testing is, at best, not cost effective.

I have yet to get a single strip on prescription, and that is something I find irritating. Worse, it isn't so bad for me, because I can afford to buy strips. I get absolutely livid when I think of all of the people who must be out there who can't.

 

[hanadr]

I'm very fond of my doctor. I've been his patient for 30 years and I do manage to cadge strip prescriptions rom him.He doesn't think testing is necessary (I think that's genuine) and I know he worries about costs. He told me I'm "worried Well". that's with a condition that our sainted government is using to "scare" people into losing weight :?
I'd like to know how several accountants, one nurse and a vet( our PCT) can make the clinical decisions on his behalf. I plan to go to their September meeting. I just mised july and there's none in August.

 

[ally5555]

diabetic geek!

The gps maybe right for some pts - I have loads who it would be a waste of time . And some never act on high results - but that is life - its almost like those who choose to smoke!

 

[DiabeticGeek]

The gps maybe right for some pts - I have loads who it would be a waste of time.

Oh I don't doubt you for a moment. It is just sad that so many people are either unwilling or incapable of helping themselves. What is worse than sad is that the attitudes of such people make life more difficult for those of us who are willing and indeed eager to do whatever it takes.

its almost like those who choose to smoke!

That is actually a very interesting thought. There are a number of parallels between the public health issues relating to smoking and diabetes. The health problems of both smoking and diabetes are largely avoidable (pretty much totally in the case of smoking - you can always quit; also totally in the case of T2 - at least if control is established before permanent damage is done; and to a very considerable extent in the case of T1). Despite this, many people smoke and many diabetics suffer from the most serious complications. The reasons for both are, no doubt, a complex mixture of educational cultural and social problems. However, the really interesting parallel is that for smoking most scientists who worked in the field and many medics were well aware of the health implications for decades before it started to have an impact upon public health policy. There was a combination of complacency and fatalism - too many people new healthy 90 year old smokers, and there was a prevailing attitude of "people can't be expected to give up smoking en masse, so why try to make them". This is exactly where we are with diabetes today. As far as I can see, in some of the medical establishment and amongst most of their political masters diabetics are seen as a lost cause. Just as in the 1950s it was generally assumed that people would always smoke, regardless of the impact upon their health, today it is generally assumed that most diabetics won't ever be able to maintain tight control of the disease. The emphasis is thus on slowing their decline as cost-effectively as possible.

It took almost 40 years from when the smoking-lung cancer link was first discovered to the public health campaigns of the late 1960s, and then nearly another 40 years until the situation we are in today when smokers are finally becoming quite a small minority. I only hope that it doesn't take 40 years until public health policy catches up with diabetes. Sadly, though, history does have a horrible habit of repeating itself.

 

[hanadr]

I got an email from the PCT diabetes educator, who offered to call my GP andsee if she could get me more strips, Because sometimes there are !"administrative reasons" for this. I din't like to think I could end up on the wrong side of my doctor and DSN, so I have stalled a bit. I definitely don't want to upset them
Hana