Intended for healthcare professionals

Views And Reviews Taking Stock

Rammya Mathew: Where are we letting our patients down?

BMJ 2020; 371 doi: (Published 20 October 2020) Cite this as: BMJ 2020;371:m3980
  1. Rammya Mathew, GP
  1. London
  1. rammya.mathew{at}
    Follow Rammya on Twitter: @RammyaMathew

A recent consultation has stayed with me. In many respects it was a run of the mill general practice consultation, but it made me reflect on health inequalities and why the care we provide for people with low levels of health literacy can be woefully lacking.

He was a patient with type 2 diabetes taking long term insulin, who had developed acute symptoms in the previous 24 hours. He had broken English, but he was able to communicate his history without too much difficulty, so I persevered without an interpreter. In response to some very direct questioning, it became apparent that he hadn’t had anything to eat or drink that morning, he hadn’t checked his blood sugar levels, and he hadn’t thought about adjusting his insulin dose. How was it feasible that a patient taking insulin for so many years had no idea about type 2 diabetes sick day rules? Could it really be that no one had ever taken the time to counsel him about this?

I looked online for a patient information leaflet that might be of use, but I abandoned the idea quite quickly, as I was unsure whether he’d be able to read it—and even if he could, I was worried that the information might be too complex for him to follow. I decided that giving him the minimum information to avert a crisis was the best course of action. So, I encouraged him to drink more, to check his blood sugar every four hours, and to call a health professional if it was over a certain threshold. I was firefighting, and it didn’t feel good to be in that position.

His lack of knowledge about type 2 diabetes sick day rules, however, probably reflected his overall understanding of the condition. It made me wonder where we’d let this man down. At diagnosis, was he enrolled onto a structured education programme? Even if he was, could he attend it around his shift work? And if so, was he able to take anything away from it, given his limited English?

Patients with long term conditions such as type 2 diabetes are meant to have annual reviews with their GP or practice nurse. Was anything meaningful happening at these reviews, or was his medication just being continuously titrated up? A significant part of these reviews is meant to focus on helping patients to set goals and take control of the aspects of their health that matter most to them. But, if you don’t understand your condition and your role in managing it, you can very quickly become a passive spectator in managing your health, and well intentioned tasks such as goal setting just become yet another meaningless, tick box exercise.

That single consultation and the patient journey behind it capture many of the gaps in our system, and they explain at least partly the stark health inequalities that have become so painfully visible in recent times. There’s a tendency to think that some patients can’t be helped, but the reality is that the system has let them down. We have to stop laying the blame on disadvantaged patients and, instead, focus on redesigning healthcare to better meet their needs.


  • Competing interests: I co-lead Islington GP Federation’s Quality Improvement Team.

  • Patient consent not needed (patients anonymised, dead, or hypothetical).

  • Provenance and peer review: Commissioned; not externally peer reviewed.