Whenever I see people criticising the concept of "integrated care" I point them towards type 1 diabetes care and say - so that does not need integration? https://twitter.com/HPIAndyCowper/status/1276468603374747649

Remember T1D is a specialist service (transfer it to GPs and I will use A&E as my diabetes healthcare, seriously, GP "advice" on my T1 diabetes has almost forced A&E on me). But thru QoF GPs have to be involved

So literally one week I can have a HbA1c test for the consultant (which I am happy to have) and the next week the GP could demand I MUST have another for them. Integration?

Remember ALL diabetes care is done by the individual. We see Drs just to get reassurance and some advice, and at that point we become "patients". For LTCs its important that we are not patients. The NHS should be turning patients into individuals managing their conditions

The hospital used to check my feet and urine, then that became something for GPs to do. But the consultant has to ask me if its done because often the GP doesn't do it. There's no QoF on checking urine but that's no excuse not to do it

Then there are prescriptions. Some T1Ds find they are rationed insulin by their GP. Seriously. They put in a prescription and get told "you aren't due another until next week". When I hear of this I say "go to A&E, get them to write to the GP, they'll soon learn"

GPs treat type 1 diabetics as a waste of money. It is serious. Some have GPs rationing blood sticks ("you cannot need that many"), some refuse to allow people to use the sticks they are comfortable using. And the same with needles.

T1Ds cannot live without injecting and the insulin dose is not optimal without blood testing. If you make blood testing and injecting difficult then the patient just won't do it. Saving a few pennies will cost the system thousands in future care needs.

The blood stick stuff is serious in this pandemic. T1Ds are badly affected by covid because it causes a rapid raise in ketones which could be fatal without prompt action. When ill, you need to test for ketones regularly and act appropriately and promptly.

I cannot test my blood ketones because my GP (without talking to diabetics or hospital) moved me to a cheaper meter that does not do ketone testing. All to save money. When I enquired, I got urine sticks which means I cannot test my blood ketones *now*, just what it was hours ago

Then there's records. I tried to get my CCG to have a single diabetes record, and give every patient an "annual report". The hospital is happy to do this, but the CCG said that the GPs would not want their data used. Some might but not all would. No integration killed a good idea

I could relate the saga of Freestyle Libre (which the consultants said would be transformational - it is - but GPs at the CCG refused outright) but the thread is getting too long, and it needs to be related over a few pints.

My T1 diabetes is diabetes specialist, GP and eye specialist. The only way they "talk" is through me.

Hospital commissioned by CCG, GPs 'commission themselves' (CCG). eye screening commissioned by PHE. If there was just one commissioner then there could be just one service /end