Day 1: ‘A patient is lost in a maze of bureaucracy’
I get to the hospital at 8.30am for a multidisciplinary team meeting, at which consultants and specialist nurses get together to discuss complex diabetes cases. Today, we’re focused on patients who have severe mental health conditions in addition to their diabetes. We find that when things go wrong in people’s lives, their diabetes care is one of the first things to suffer. People with eating disorders, personality disorders and other problems often find management of the disease much harder, and it’s our job to find solutions.
After the meeting, my morning is spent doing admin and calling patients who have missed appointments. I speak to one patient who is severely disabled and blind as a result of his diabetes. He can’t afford access to the internet, so he is unable to upload his blood sugar data to me via an app. While apps can be useful in helping patients manage their condition, they don’t account for the fact that not everyone has the ability or means to use these tools. There used to be diabetes clinics in the community for marginalised patients, but many have closed due to a lack of funding, which has increased the pressure on our services.
At 11.30am, I grab a sandwich before heading into my face-to-face afternoon clinic, which is constantly overbooked. Newly diagnosed patients have to be seen urgently, but there’s no spare capacity in the system to account for this. For example, the inpatient diabetes services used to have between four and six nurses every day, but this was reduced to just one or two earlier this year. It means our outpatient team has to try to support hospital patients as well as running overbooked clinics and we’re increasingly overstretched as a result.
In the afternoon, I see a patient who hasn’t had a face-to-face appointment in four years because she had fallen out of the system. Like many others, she became lost in a maze of bureaucracy. I spend some time trying to make sure she is referred to the right places so this can’t happen again.
Another patient I see has had their appointment delayed – most likely because the clinician was so overworked that they had forgotten to send the required letter. I resolve the situation, but it makes me anxious. It’s the biggest worry for all of us: that we are so busy we don’t even recognise when we are dropping the ball.
Day 2: ‘One of my colleagues wants to quit nursing’
Today I’m working from home, which means I can spend time with my baby in the morning. My virtual clinic runs all morning and I see my patients via telephone and video calls. It’s a helpful service, because I’ve got patients based across a wide area, including those who move away and want to continue their specialist care with us.
One of my first patients is a recovered alcoholic who has recently suffered a bereavement and is finding it hard to manage her diabetes care. She tells me this is only the second time she has seen the same nurse or doctor. This kind of continuity of care means a lot to people.
Later I see a young woman who has recently been diagnosed with type 1 diabetes. She really needs help from a dietician, but there’s a shortage of them at the moment. A lot of dieticians come from abroad and recruitment has been affected by Covid and Brexit.
One of the nicest parts of my day is when I refer an older man to the charity Diabetes UK to be given a medal for living well with diabetes for 50 years. We’re now seeing the first generation of diabetes patients living into their 80s, which is a significant milestone.
While I’m busy seeing patients, senior managers have a meeting to discuss further cuts to some of our services. I’m told we may be closing a couple of specialist clinics, including one for people who live with diabetes and cystic fibrosis, which is really worrying, as these are vital services. One of my colleagues is so appalled that she tells me she wants to quit nursing.
I spend the afternoon writing outpatient letters to GPs. I also phone a patient who missed her morning appointment. Once again, it turns out she’d called to rebook but nobody had passed on the message. Without enough admin staff, these inefficiencies are becoming increasingly common, which just adds to the pressure on us as nurses. Sometimes we miss people calling with medical emergencies, such as a broken insulin pump.
Day 3: ‘It feels as though we’re failing on all levels’
Today is Friday, which is when the pressures of the week reach a climax. At any one time, 20% of hospital patients have diabetes and there aren’t enough staff to run a weekend service. It’s our job to safeguard people who will be in over the weekend, making sure they’re stable and have their diabetes-related needs met. My pager, which tells me about urgent cases we need to attend, starts going off the moment I step through the clinic door. The majority of these cases are handled remotely, by communicating with the ward staff, because we don’t have the resources to go and see every patient. It’s stressful, because there are so many people who need help, and we simply aren’t able to give them the time and care they deserve.
My next task is to follow up with a patient who’s started using a glucose sensor. This is a really useful piece of wearable technology that helps people to manage their sugar levels 24 hours a day, but there’s a lot of box-ticking and bureaucracy needed to get one prescribed long-term. All the admin is slowing our services down and making it harder for us to give patients the treatment they need. I also have a virtual morning clinic, at which I see lots of patients who are juggling their appointments around work. Employers should give people time off for vital medical checks, but many don’t.
At lunchtime, I grab a sandwich and eat at my desk. There’s nowhere to sit down and eat in our department, and we just have a kettle and a microwave. At 1pm, I quickly change into my nurse’s uniform – in the toilets, because we don’t have a changing room – before heading on to the ward.
I see a patient in his 90s who is being kept in hospital, despite being medically fit for discharge. There are no social care services to support him, so it’s not safe for him to leave. But it’s also not safe for him to stay in hospital, because his mental wellbeing might deteriorate.
Afterwards, I speak with a type 2 diabetes patient who is starting to take insulin because he is struggling to manage his blood sugar. In 10 years, he’s never had a proper education session, so we go back to square one, which will hopefully help him to better manage his diet.
I stop for a two-minute chat with one of the ward managers, who tells me they’ve had mice in the kitchen this week and are still waiting for management to do something about it. They’ve had to clear up droppings from the corridor each morning. It’s incredibly dangerous from an infection control point of view.
The rest of the afternoon is a mad dash to deal with referrals before the clinic closes at 5.30pm. In the NHS, even when preventive medicine hasn’t been what it should be, we’ve always done “rescue services” well. Now it feels as though we’re failing on all levels, and we can’t even help all the people in crisis. I leave work feeling absolutely shattered and stressed out. As a nurse, it’s a horrible feeling knowing that patient care is unsatisfactory. When I get home, I grab a beer and try to wind down with my partner and our baby.
Day 4: ‘Even urgent referrals take three months’
My day starts with another multidisciplinary team meeting. We talk about the challenges people face in getting the right technology to manage their diabetes – patients are waiting six to 12 months for specialist services, and even urgent referrals take three months. Things feel as if they’re sliding and we’re losing the ability to believe it will get better.
My first patient is very late, but when he eventually turns up I’m glad, because he’s so vulnerable. He doesn’t speak English well, and I’m not sure whether he has a good understanding of his disease. I soon discover he’s been taking too much insulin, so I adjust the dose.
I also see a homeless, alcoholic man, who lives with diabetes and emotionally unstable personality disorder (also known as borderline personality disorder). He tells me his diabetes is the least of his health concerns. He hasn’t seen a diabetes specialist for 12 months, but he does have a good understanding of his condition and its triggers.
Later, an older woman comes in. She wants to talk about the challenges she is facing getting social care. She can’t afford to pay for it herself, and the stress is exacerbating a previous mental health condition. I contact her GP to recommend a referral for additional services.
After work, I come home and take over the childcare so my partner can go for a run, before joining a video call with team members to talk about the forthcoming strikes. The goal is to ensure that patient safety isn’t compromised any more than it already has been by funding cuts. We will run a Christmas-style service, where wards are partly staffed and outpatient units are closed.
Day 5: ‘As usual, I’m exhausted when I finish’
I am awake with the baby from 2am to 3am, so I start my day with a very large coffee. I’m doing an online clinic from home today, which runs all morning. My first patient was meant to be an elderly man with complex problems. I discover that he had attempted to rebook his appointment, but a lack of admin staff meant the messages never came through. It’s so frustrating, because we could have fitted in another patient in his place – especially since there’s a six-month waiting list.
My next patient is a woman in her 50s who is prioritising work over her condition, and struggling with her health as a result. She speaks to me from her home, wrapped up in a blanket. She has a huge predicted energy bill and her finances are very stretched, which is why she is taking on so much extra work. She’s a professional who wouldn’t consider herself vulnerable, but the cost of living crisis has increased the pressure on everyone. It’s a challenging time, but I have to warn her of the health risks associated with her poorly managed diabetes, which include heart attacks, strokes and blindness.
Another patient I’m really concerned about is a young woman who crash-landed into our services after an emergency. She has severe mental health challenges and diabetes “burnout” – where people simply can’t cope with the demands of the disease any more. It’s a common problem for people with diabetes, because they have to spend so much time and energy managing it every day. I refer her to a specialist psychologist and suggest some local support groups she can join while she’s waiting. At lunchtime, I cook some fish fingers with peas and take care of the baby so my partner can have a break.
Like everyone in my team, I’m really behind on writing my outpatient letters to GPs, so I spend the afternoon catching up. I join a weekly diabetes team meeting, at which we talk about some of the problems we’re facing, such as recruitment challenges and a shortage of nurses. We also discuss some of the forthcoming service cuts. My boss says he is going to fight for the cystic fibrosis service because it’s so desperately needed. As usual, I’m exhausted when I finish work. I spend the evening chilling out and watching football. I just want to spend some time with my family before there’s a new crisis for me to deal with.
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