Exploring a reluctance to change

Shortly before the GP Contract, I sat, as a practice nurse, in my ivory tower and gave my full attention to the people with diabetes who turned up at our clinic in response to our invitation. I diligently checked their clinical parameters; their blood pressure, their height and weight, their urine and their feet. I gave them sage advice. And sometimes someone would take it on board. I felt we were doing a good job. We even won national recognition for doing so (Department of Health [DH], 2001).

But I’m referring to the GP Contract of 1990. So why, oh why, do I still find that to be the norm for diabetes care today in many practices? At least we, in those far off days, had the excuse that we were breaking new ground by inviting all people with diabetes to have a review in the practice, but it was, and is, inefficient. The people providing the service – I hesitate to call it care – may have changed but sadly the system may not. 

Why are we reluctant to embrace new ways of working? The University of Notre Dame (2008) comes up with eight common reasons (Box 1). We can recognise some of these traits not only in ourselves but in people with diabetes too.

The barriers are not just within ourselves. A Briefing Paper for the NHS (DH, NHS Service Delivery and Organisation Research and Development Programme, 2006) identifies barriers to change brought about, at least in part, by system reform. Imposing targets to be met by healthcare professionals may be at the expense of improving the service to meet individuals’ needs. Let’s consider the Quality and Outcomes Framework: highly successful in improving diabetes clinical investigations but makes no attempt at evaluating self-care, skills and education on behalf of people who actually manage the condition most of the time – the people with diabetes themselves. Try a simple exercise: ask people with diabetes to tell you how their medication works, using open questions, and try not to be surprised when someone does know. 

In this supplement Simon Eaton provides clarity on effective systems that do promote “care” and insights from the Year of Care projects. We need to embrace change, but we should also have access to the time and resources to carry it out.