Mrs B had been watching Eastside Street on Freeview and was struck by the similarities in the storyline about the character, also in her late fifties who was having to get up to spend a penny frequently over night and was always feeling thirsty. From her Freeview she pressed the button and accessed information about diabetes. The side-bar offered her the opportunity to click for further advice on the “Your Health in Your Hands” page, available for £15, to be paid by credit or debit card. Mrs B was worried by now and paid immediately. The automated instructions appeared: press 1 to make own “diagnosis” press 1; to answer questions for third party press 2 etc…all information will be stored in NHS security bank. If you do not want carefully selected companies accessing information press 6… etc
Mrs B answered questions on the diabetes page, which advised her to make an appointment at the single access point “111”; this could have been done through the TV but that page was down; there was an alternative method by telephoning the Premium rate line “NHS-partners Phone”.
Mrs B phoned and was triaged by an outsourced overseas telephonic physician’s assistant (remote working from outside the EU in from a sweat shop) and advised to arrange batch 223a of available tests at pricing code Q. Next she duly printed out a blood test “Multi-script” and booked a test for Thursday week at 10.04 am at “Superco-pharma”, where she arrived on time with her daughter who had taken the morning off work as unpaid (but her’s by European law) “special-care leave”. They paid £6 for 1 hour’s parking. Her blood was taken by a kindly primary care assistant; on asking what the tests included was told very politely and apologetically that the assistant wasn’t sure but thinks they include a fasting blood test for sugar because of the “instructions to patient on Mrs Beattie’s tear-off slip” (in triplicate). Mrs Beattie and her daughter are concerned immediately that she had not spotted the instructions and ask for another appointment. The helpful primary care assistant is able to make a new appointment for the next morning at 9 am under “Advanced Access”; only the referral management database is closed for the day for a team building away-day; Mrs Beattie will leave with a news “script” for a blood test and the direct dial premium rate number on which to re-arrange for another convenient time. However, before leaving the NHS-partner health care assistant counselled her on alcohol, smoking, weight and exercise; which was strange as Mrs B rarely drank and had never smoked.
The test was re-arranged and her neighbour organised to drive her at 9 am. Mrs B has her blood tests in the fullness of time and is advised to receive the results from her Locality-based nurse practitioner in 5 working day’s time. A very professional and empathetic Southern consortium NHS-partner employed nurse practitioner advises her of her results and answers questions according to the computer –based, evidence-based protocol on possible meanings of raised blood sugar but advises her that another test must be done (to satisfy the underwriters of the multinational insurance company who in turn insure the high street name Professional Defence Union to whom her employer’s pay contributions). Once again Mrs B receives some rapidly delivered health promotion advice, however, she still hasn’t taken up drinking regularly so it doesn’t seem relevant to her and she wonders whether she’ll have a deduction made for it from her Personal Health Budget.
However, for Mrs B.’s convenience the next test can be arranged at a choice of five pharmacies, one of which is within 10 minutes travelling time of home, and four of which are more than an hour away but offer generous incentives such as free teddy bears and £2 off low carbohydrate meals in their health-cafes. There is no public transport to the “choices” commissioned by her Southern consortium and the post Bill NHS does not buy transport for any of these “choices” so her “choices” are less than the choices of patients with cars.
Three days later, at 6 am she receives an automated call to say that her result is ready and asking her to phone the usual premium rate line to make an appointment with a member of her “Locality Personal Health Care Team, free at the point of delivery.” Mrs B. makes an appointment for herself with an Advanced Nurse Practitioner (ANP) who is based in her Southern locality next to Superco. and checks the time-table for the Super-co eco-transport carrier that she can pay for to get to her 9 am appointment.
Mrs B. is seen by the locality ANP in Primary Care for the regulatory thirteen minute appointment, within the three star waiting times of 22 minutes who tells her that she has type 2 diabetes and asks her if she has any questions. Mrs B. and her locality based ANP complete a single-assessment personalised computer pro-forma, including the ageism/racism/income-ism document on page one of her care plan and print it off. The nurse practitioner begins to give her some health promotion but Mrs B says “It’s alright dear I don’t…” before she can be warned about smoking and alcohol again. Mrs B. gets to take the blue copy of her personalised care plan away at 09.13 and a “Script for the GP with a Special Interest in Diabetes (GPwSI) Trust locality referral management centre.
Mrs B. feels a bit confused by her new diagnosis so nips into the “Super-co Pharma Café” to spend a voucher from her loyalty programme on a cuppa and a doughnut while she reads and digests the information on her personalised computer printed information sheets, which she’s signed as having read and understood prior to accepting. Her information will now be carefully stored and only divulged to a limited number of selected companies.
Mrs B. decides to take her “Script” home on the Eco-transporter and make her appointment via the Referral Management Centre in the comfort of her own home; how thoughtful of the government, everyone agrees that home is the best place for everyone.
Mrs B. makes an appointment with the super-locality GPwSI Diabetes for three weeks time; she has been unlucky in missing a slot in between the doctor’s bi-monthly revalidation fortnights.
At her first appointment with a doctor she sees a charming GPwSI with a delightful chaperone who confirmed the diagnosis and explained the importance of her diagnosis in the context of her existing medical history, although he could not put it into the context of her social history as that screen was down and the doctor had never met her before. The GPwSI had full access to all patient and pharmacist entries but failed to make eye-contact because of the wealth of boxes to complete on the computer screen. The consultation was digitally recorded and a recording handed to Mrs B. for safe-keeping at a voluntary cost of £10; if she didn’t want a recording her rights to later take the Trust to court over a medical error were waived.
Mrs B was referred to a choice of English-speaking Basel, Carlisle, Great Yarmouth, Kyser-Care or her geographically convenient Southern locality diabetic clinic with a waiting time of 16 weeks. Mrs B. was tempted to go to Kyser 0’Care (the Irish theme Health Maintenance Organisation) as she had heard good things about it but unfortunately there was no Eco-transport there and the appointments were all in the day, and her daughter had used up her allocation of government directed “special-care leave”.
At the Trust entrance Mrs B. passed the convenient boutiques and Solicitors advertising no win-no fee contracts if anyone at the Trust made Mrs. B feel worse than on her arrival. From there she found her way to the Clinic waiting room with a state of the art and easy-to-use machine to repeat her blood tests. Mrs B. could have followed the multilingual instructions and inserted her electronic patient record card which she had remembered to bring with her; but unfortunately she had forgotten to bring her reading glasses. Luckily, Biopharm, (co-incidentally and little known to either the general public or what used to be called the medical profession were a subsidiary of Superco), the generous suppliers of the machine had used large print writing to display the latest long-acting medicine skin patches and tasty perfectly balanced diabetic (but rather dear) ready meals. (Perhaps she ought to buy some even though they’re expensive as they’re recommended by an unnamed Diabetologist).
Mrs B. successfully used the electronic height, weight and BP machines in the waiting room, but got in a bit of a muddle with the new Euro-units; fortunately a stranger accessed her personal medical records for her using her card and inputted the details for her.
Mrs B. was seen in the clinic with her results by a very pleasant GPwSI, who looked a little familiar, and may have been that young GP Registrar who had seen her years ago at her old GP’s surgery. The GPwSI gave her some patient empowerment lifestyle advice which was similar but differed here and there, because of differing scientific opinions and something called “p” values from the information she already had. Mrs B. would have like to ask the nice doctor “You’re the doctor, what would you do?” but she was conscious of her reduction in Council taxes, related to her rights and responsibilities as a patient and didn’t like to.
Mrs B. was helpfully informed of local “Expert patient” support groups and told she might be able to get travel insurance if she attended eight out of ten sessions a year. She was referred to a choice of the locality dietician (who had the maximum nationally acceptable waiting list or some other dieticians in places which she was unsure of where they were) and a Private finance initiated podiatrist. Mrs B. was given a follow-up “Script” for a Consultant Nurse member of the Locality team. Mrs B. signed to say that she fully understood her mutually agreed individual patient management plan, which included an automated referral for retinal screening at a Locality optician. Unfortunately the Locality Local Delivery Plan had only commissioned 100 of these for the year and they had all been used; but, if she phoned in on April 1st next year’s allocation would be made on a first come first served basis. Alternatively Mrs B.’s family if they cared for her might like to send her to the convenient Superco. Diagnostics Centre next week.
A member of the 90-strong Locality team phones most weeks to ask how Mrs B’s sugars are matching her plan and to refer back to the Community Matron for long term conditions if the result is outside the national reference range. A more sophisticated computer programme is being developed to take into account local laboratory reference values but has been delayed.
The team member may not pick up on Mrs B.’s little queries because they often fall outside of the questions the team member has to ask for the form. However, Mrs B always gets some helpful health promotion advice on her weight, exercise and alcohol consumption and they are always keen to check whether she has taken up smoking yet.
Mrs B. has the telephone number for the 24 hour Superco answering service if there are any problems and they will contact a member of the 90-strong team. If she is achieving her mutually agreed quality targets she will remain under the care of locality Community Matron and if she has poor control she will be referred to a GPwSI at whichever centre is offering the best deal to the commissioning consortia that year. There are lots of different hospitals and treatment centres for her to explore in the years to come for her kidney, vascular or ophthalmology care too.
Mrs B’s Personalised Care Plan for her Long Term Condition
- A salaried GP based at the Locality super-surgery will retain responsibility with respect to future illness, at £x pa.
- A member of the Primary Care team will see Mrs B. periodically with respect to future screening, health and possibly triage e.g. minor illness, at £x pa.
- Patient develops further chronic disease e.g. coronary heart disease – Community Matron will coordinate care and tailor personal management plan for individual patient, at £x pa, until Mrs B’s personal health budget is spent.
By Helena McKeown 29.1.11
(With apologies to Dr J P Marshall who inspired me with his original “Diabetes vignette -best case scenario” in 2004)
