Dr. W. Edwards Deming’s, the father of quality improvement, most famous quotation is: “Every system is perfectly designed to achieve the results it achieves.”  If the British (and virtually every other) healthcare system achieves poor marks in diabetes care, it is the system’s fault, not the individual players in the system.  We have bright physicians and dozens of ancillary health professional that are perfectly capable of delivering excellent diabetes care.  We also have dozens of studies that demonstrate how successful diabetes care can be delivered.  The question then as raised in this and several other posts over the past few months is: “Why do we do such a shabby job of diabetes care?”

Let’s start with the purpose and design of the current health care system.  Its basic design evolved in the 19^th and early 20^th centuries to treat the most common health problems in its day: acute illness, mostly infectious in nature and injuries.  In such a system the patient is mostly passive: “Hold still while I give you a penicillin shot.” or “Hold still while I cast your leg.”  The system was perfectly designed for the active physician and the passive patient.  Over the years we have gotten really good at treating acute illnesses.

If fact, we have gotten so good that they account for fewer that 40% of primary care visits.  What has replaced them for the other 60% of primary care visits are chronic diseases like diabetes, the case under discussion and its cardiovascular risk factors.  So health professionals in general and physicians in particular are trained to treat acute illnesses in a passive patient model and practice in an environment designed to treat acute illnesses that fosters that passive patient model.  If you do not believe me, look yourself in the mirror tomorrow morning and ask yourself how much self-care education can you provide in a 10-minute consultation?

So what do virtually all of the studies in diabetes care (and in the care of any chronic illness that involves significant self-care) demonstrate?  Quite simply they demonstrate that it is the patient who needs to be the active partner and the health professionals’ role is to provide the patients with the appropriate knowledge, skills, means and motivation to accomplish their necessary self-care and monitoring to achieve control of their disease or, in most cases, diseases.  I have posted elsewhere about the new join ADA/EASD statement. 

http://doc2doc.bmj.com/blogs/diabetes/_new-bible-diabetes-care  that discusses in greater detail the importance of patient activation in diabetes self-management.  I have also reviewed recent studies demonstrating the successful role of patient education and self-management in improving diabetes outcomes.

http://doc2doc.bmj.com/blogs/diabetes/_big-week-diabetes-patient-education-bmj

My bottom line is to stop beating each other up about the poor results achieved in diabetes care by a system poorly designed to deliver such care and start talking about how to change that system to treat the diseases we see in primary care in the 21^st century, not the 19^th.