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Patient-initiated clinics: pros and cons

Daniel Flanagan
Daniel Flanagan asks whether patient-initiated clinics, as opposed to regular scheduled follow-up, is the future of type 1 diabetes care.

A lot has happened in the past two years. Healthcare has had to change, and the change has occurred much faster than it would otherwise have done. The lightning speed means that this change was not carefully planned and, at times, was very uncomfortable. Some of it may have degraded the quality of care delivered but there are also many positive aspects that we will want to keep and build on.

At the end of 2019, the majority of specialist diabetes services were comfortable offering the same sort of delivery that they had for many years. Although there were discussions and debates about the pros and cons of patient-initiated follow-up, most clinics were offering routine visits to review diabetes care at fixed time intervals of perhaps 6 or 12 months. When giving feedback, many people with diabetes were happy with that model as it was what they had always done. Having said that, they need to be able to contact the service in a timely way when they have a problem and not potentially wait for weeks or months for a solution. Equally, the prospect of giving up a morning to travel to a hospital, battle for a parking place and then sit in a waiting room for an hour before being told that no changes were required is not something that most people would choose.

The COVID health crisis is ongoing and is certainly not behind us, but now is the time to consider what is good about the change that has been enforced and what practices we would like to keep and develop in the future. The wide use of video and telephone clinics together with improvements in remote monitoring, with cloud-based sharing of diabetes information, have been positive developments. However, the inability to deliver regular training in many aspects of diabetes management has been a major problem. There is also the risk that changing the current paradigm will provide a more responsive service for some but will leave other groups of people behind.

Patient-initiated follow-up, as described in the present article by Ryg and colleagues, may be a significant part of the future model of diabetes care. Seeing people with diabetes when they need to be seen but monitoring the quality of care remotely at other times has been successfully implemented in a number of other long-term conditions. That said, the specific issues with diabetes management are not the same as the management of, for example, chronic lung disease or rheumatoid arthritis. Diabetes treatments have rapidly progressed in recent years, and with this the understanding that ongoing patient education is crucial. Simply maintaining the current standard of care may not be good enough if the alternative would have been a slow but steady improvement in adjustable risk factors. If done properly, patient-initiated follow-up will require more clinical time, not less. Otherwise, there is a risk that a group of people with diabetes will be left behind and health inequality will get worse, not better. Thought needs to be given how to engage with those where there is clinical concern, with perhaps a different care system being used.

We have seen that we can do things better but that change requires careful thought. The problem in the middle of a pandemic is finding the time to work this through.

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