With diabetes patients numbering 8,000, and rising, in our region, the care for this illness, which can lead to complications requiring very expensive treatment, is hugely important in its own right.

However, beyond that, the caretaking approach now being promoted by the DHB has much broader ramifications for healthcare delivery in Hawke’s Bay, and we need to understand that context.

Diabetes made the front pages when controversy arose over the Hawke’s Bay District Health Board’s (DHB) decision not to renew the diabetes treatment contract of popular diabetes specialist Dr Janet Titchener.

Dr Janet Titchener

The contention was that, with Dr Titchener benched, Hawke’s Bay diabetes patients would be deprived of the best available care. But the DHB argued it was making a prudent, clinically-driven decision to use its limited resources to up-skill more doctors and nurse specialists to give equally high quality care to a substantially growing number of diabetes sufferers.

For now, the controversy has subsided into a not quite amicable divorce, with no clear ‘winner’.

More on the outcome and wider implications in a moment, but first the background, reflecting BayBuzz interviews with all the key players.

A diabetes Wonder Woman?

Dr Titchener has treated over 1,000 diabetes patients in Hawke’s Bay. And to say her patients are passionate about her is an understatement.

Many regard her contribution to their (or a family member) gaining control over their diabetes as having transformed their lives. Often they credit her with succeeding after other caretakers, notably clinicians at the DHB, have failed. To them she’s a diabetes Wonder Woman. When the DHB made its announcement, they became alarmed that her services might not be available to themselves, their families, and more broadly, the community. What in the world is the DHB thinking, they asked.

Speaking for herself, Dr Titchener confidently asserts that she in fact can document improvements in her patients’ diabetes status (as measured by decreased blood sugars) that are exceptional and persistent. She is especially proud of her successes with Mäori patients, given that diabetes is especially high in that community.

She challenges the DHB to document that they provide a better service.

Executives and clinicians at the DHB take a different view.

They generally, if begrudgingly, acknowledge Dr Titchener’s capabilities and track record. However, they insist that other ‘GPSI’s’ (General Practitioner with Specific Interest … in this case, diabetes) in the region show comparable results with equally satisfied patients.

And importantly, they are firmly confident that DHB now offers an excellent quality of service to many more patients, many with a challenging array of diabetes-related complications that must draw upon a wider range of clinicians operating as a team.

DHB CEO Kevin Snee emphasizes that providing the best medical care today is a “team game”. And indeed, patients using the hospital diabetes service may receive advice from the DHB’s psychologist services, nutrition and dietician input, clinical nurse specialists who have prescribing rights, and specialist doctors who are additionally specialists in internal medicine and endocrinology as well as diabetes.

DHB CEO Kevin Snee

Dr Titchener cites her Type 2 diabetes patients’ record of dropping their HbA1c levels by an average of 2% points (20 mmol/mol). She says research demonstrates that a 1% point drop reduces a person’s risk of heart attack or stroke by 27% per year, and healthcare costs by 37% per patient per year.

But simple comparisons of patient blood sugar reductions, DHB clinicians say, do not do justice to the more complicated cases that the DHB diabetes clinic must treat … to say nothing of the often lesser self-management motivation of many of those patients. Nor do local critics recognize the significant strides in improving diabetes care at the primary care level, particularly in the past two years since the adoption of a stakeholder-developed diabetes care strategy.

In short, according to DHB clinicians, for every ‘transformed’ and satisfied patient the Titchener camp can produce, the DHB can produce one as well. Tit for tat.

To the clinicians at DHB, as good as Dr Titchener is, the “extraordinary” resources that have been allocated to her practice can be better deployed to provide a high level of effective service to a diabetes population that will soon grow to 10,000. In 2012 and 2013, the annual allocated budget for the DHB’s diabetes service was $817,000. The diabetes service cares for a minimum of 1,408 patients at any one time. Therefore, the cost per patient to access specialist services through the diabetes service is approximately $580 per patient.

DHB parties say, Dr Titchener has been fully welcome to apply to participate in the DHB’s treatment scheme – focused at the GP and specialist nurse level, mainly in larger clinics around the region – but has elected not to do so. They say she has shown no inclination to work ‘within the system’, when offered opportunities to do so.

To which Titchener supporter Andy Lowe responds, referring to DHB’s Kevin Snee: “He said his staff will not work with her.”

Is this a simple matter of personalities – a ‘talented but vexatious’ square peg not fitting in a round hole? Or does one individual’s $150,000 contract dispute, almost insignificant in an institution with a $450 million budget, carry larger import?

A Mexican stand-off

Businessman Andy Lowe, responding to the alarm of several of his diabetes-afflicted employees who were satisfied Titchener patients, rallied to her cause. Dismayed by what he regards as the unresponsiveness of the DHB, he has come to the rescue of Dr Titchener, at least for the next twelve months.

He will subsidise a ‘pilot programme’ that allows Dr Titchener to provide diabetes educational services and training to 15 doctors and 17 nurses at Totara Health, and to Doctors Hastings, Doctors Waipawa, Gascoigne St Medical Centre and Te Taiwhenua o Heretaunga. Collectively, these practices serve 25% of diabetes patients in the region. Separately, she will provide clinical services to several practices and continue her private practice. “This education solution retains Dr Titchener’s talents in diabetes care and will help Hawkes’ Bay as it prepares to support and treat the growing number of people who will get diabetes,” said Totara’s managing director, Howard Dickson.

Motivating patient behavior change – patient centered care – is a key aspect of Dr Titchener’s approach, and her supporters regard her as peerless in this regard.

As Andy Lowe sees it, Dr Titchener has “shown them up” (referring to the DHB clinicians). He says the proof of Dr Titchener’s superior efficacy is shown by the number of GPs (and nurses) who are choosing to avail themselves of her training and/or refer diabetes patients to her … and will be further demonstrated by the patient outcomes these clinicians will produce.

At the DHB, clinicians insist their diabetes service, independently evaluated, staffed by doctors and specialist nurses with decades of diabetes experience, ranks as one of the best in New Zealand. They bristle at the suggestion that their service is anything less. Moreover, they argue, the training programme the DHB is now providing doctors and nurses throughout the region, focusing first on larger-scale practices that see the most patients, will yield better health outcomes for a much larger portion of the population.

Setting aside the personalities, it appears that neither side disagrees on the fundamental strategy:

Patient self-care or self-management is pivotal to successfully addressing this disease; and,

The best opportunity to educating patients and motivating the needed behavior change (and providing additional intervention if needed) for the thousands of patients involved is at the GP primary care level.

So now diabetes patients in Hawke’s Bay will have a choice between two competing services. The question that remains on the table is whether one service or the other will deliver better outcomes over the coming year.

Like it or not, fairly or unfairly, Team Titchener/Lowe has thrown the competitive gauntlet down to the DHB and Health Hawke’s Bay (the region’s Primary Health Organisation), effectively saying ‘we can do better’. In so doing, they call into question the efficacy of the DHB’s approach.

Andy Lowe and supporters of Dr Titchener

Team DHB may regard that as totally unjustified and, in fact, a disservice if the claim wrongly undermines public confidence in the DHB-led service. But that’s the reality they will need to deal with over the coming year.

The ball is in the court of the DHB and Health Hawke’s Bay to establish what they — and independent observers — regard as the appropriate metrics for evaluating the two competing services.

Our community will be very poorly served if mutual anger prevails, and the metrics and processes are not in place to make a proper evaluation when the time comes. And when the comparison is made, it must be made with full transparency.

Maybe there will be an outright ‘winner’. Maybe both will demonstrate excellent outcomes. Maybe the competition will drive each to lift the other’s game. And perhaps, that’s the upside to this dispute.

As one on-looking GP observes, it’s unfortunate that irreconcilable personalities are involved, but hopefully this rocky path will benefit patients, which is where the focus should be.

And that brings us to the broader implications of the diabetes care controversy.

Changing health care

The diabetes controversy highlights several important trends in healthcare.

First is a consumer dynamic. Patients/consumers will no longer simply follow any ‘voice of authority’ out of sheer deference or passivity. Wisely or otherwise, patients increasingly seek out choices and alternatives. For many, the internet is their ‘adviser’ on health issues, including treatment options. They are more demanding – and this reaches to proof of performance – and will become ever more so. They want more control over their bodies and their treatment.

Second, healthcare funding is getting tighter and tighter, and with Hawke’s Bay’s stagnant population size, the DHB’s budget simply will not grow, as urban areas of NZ, with increasing populations, get a correspondingly increasing share of the pie.

Faced with what amounts to a costly diabetes epidemic, the DHB must intervene early and more effectively with diabetes patients, shifting as much care as possible from the hospital, where it is most expensive, to well-trained primary care providers … and better still to patients themselves, motivated and educated to self-manage their condition.

No one disputes the thrust of Dr Titchener’s ‘business case’ – lowering a patient’s blood sugar through better self-management can yield substantial savings … with a 1% point (HbA1c) decrease reducing inpatient costs by 36% per patient per year, according to the studies she cites. There is a 20% increase in lifetime medical costs of diabetes for every 10 years older a person is at diagnosis.

Third, if for no reason other than cost, ‘treatment’ of much illness – heart and kidney disease through diabetes – must move from the bottom of the cliff, coping with the consequences of unhealthy lifestyles (including smoking and excessive drinking), to prevention. And prevention requires behavior change … by motivated patients.

By the time a patient appears before their GP with high blood pressure or high blood sugar, they are already in need of behavior change … they are highly likely to be obese and sedentary. Unhealthy situations over which virtually all patients have some control.

To the physician, this means that ‘treatment’ should become less a matter of prescribing medications and more a matter of educating and motivating their patients to change their lifestyles.

In other words, ‘treatment’ by a GP becomes more a matter of facilitating self-care by the patient. Inter-personal skills and relationships on the part of the care-provider are crucial. The approach is ‘patient centered’.

One might think the patient’s increasing demand for information and choice might lead him or her naturally to better and sustained self-care. And for the highly motivated, it probably does.

But then there’s the rest of us! And for us, a properly trained, facilitating physician, or nurse, can make all the difference between self-managing an affliction like diabetes, or sliding slowly into worsening health.

Not every doctor or nurse is naturally skilled at being the ‘counselor’ that patient centred care requires. That seems to be an outstanding quality of Dr Titchener.

And that’s why the training offered by Dr Titchener – and the DHB – to primary care practices throughout the Bay is so crucial.

DHB Diabetes Clinic

Getting the doctor-patient relationship ‘right’ – leading to self-management – is not just important for diabetes. It’s the model for management of other chronic disease. Otherwise, as our population ages, and as poor living habits transform into chronic illnesses and infirmities that we’ve failed to prevent or manage at the patient level, our healthcare resources will be swamped.

At a recent meeting between Titchener advocates and DHB representatives, someone commented: Why did the DHB pick a problem as complicated as diabetes to launch into such a major change … the GP-based, patient centred approach?

Given the prevalence of diabetes in Hawke’s Bay, and the long-term costs of its complications to both patient wellbeing and the financially stretched health board, it’s not clear the DHB had any choice.

Hopefully, if all the participants ‘get it right’ on diabetes, and a patient centred approach is implanted and embraced, the benefits will be quickly seen … and the approach will become the foundation of all healthcare.

Hawke’s Bay should see some evidence in a year.

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