Whose blood is it anyway?

“If a person is treated like a patient, they are apt to act like one.” – Frances Farmer

Much of diabetes care is routine, repetitive and dull but demanding for those living with the condition. People with diabetes also face the regular prospect of twice yearly face-to-face visits with their clinical teams, the majority of which occur in primary care. An invariable part of the ritual of attending “the clinic” wherever it is located is to have a blood test performed, usually before the visit. This can be a hassle as the availability of NHS phlebotomy services is variable with some primary care teams completely opting out of routine venesection, while some hospitals still have archaic systems with all potential donors being offered appointments at the same time, leading to prolonged waits. Even if an NHS service has a more holistic approach to blood testing in terms of scheduling, the appointments are usually during standard weekday hours with very infrequent early morning, late evening or weekend offerings.

Another common feature of the NHS’s approach to routine blood testing is that the results are only made available during the actual appointment with the doctor or nurse. For some this can lead to unnecessary anxiety as they await judgement from their medical advisors as to whether they are “failing” (based on their prevailing HbA_1c test) or whether nasty diabetes complications, such as kidney problems, are looming. 

Unlike the United States’ system, most people with diabetes are kept in total darkness about the cost of their blood tests and few have access to serial records of data. Furthermore, individual choice of which blood test to have is virtually unknown in the UK. A quick check on the internet shows that one private provider is offering diabetes blood testing ranging from a simple HbA_1c for around £100 to nearly double that for an annual blood “screen” (www.privatebloodtests.com), although this does “include GP referral and all fees”. On checking, one local private provider in Bournemouth, UK, is currently charging £55 for the same HbA_1c test provided a GP completes the appropriate blood test form.

Here on the west coast of America, where patients increasingly see themselves more as consumers, the mindset is somewhat different. It is now possible to have any laboratory test without first being required to obtain a healthcare provider’s request or approval by a health insurance company. All costs for the tests are considered to be out-of-pocket rather than paid for by an insurer although the interpretation of the results is left to the patient/consumer. The perception from one company providing this service seems to be that this will “change the healthcare paradigm to one in which early detection and prevention become reality”. To support this there are now “Wellness Centers at convenient hours” with prices that are 50–80% below the standard reimbursement rates. As an example, I could have an HbA_1c test done (and more or less painlessly) in California today for $6.67. The advantages of direct-access testing include convenience, lower cost, privacy, more rapid access and being prepared for a forthcoming visit to the doctor or nurse. The flip side is that there is no requirement to review results with physicians or nurses, nor any assurance that tests requested are appropriate or that the results are reliably interpreted. 

Is the NHS ready to adopt a similar system where low-cost blood testing is made generally available to people with diabetes, as often as they desire and, also, with the opportunity to have other tests performed? It may also be helpful for patients/consumers to be given information about the real costs of laboratory investigations, rather than them being thought of as “free”. Whatever else, this new approach to blood testing would mean a shake-up of current NHS laboratory and phlebotomy services, which some may perceive as no bad thing.