Zohra Ismail-Panju, Tamara Al-Jabary and Safiya Virji are NHS GPs and medical educators with a shared commitment to improving long-term condition management and the systems that support it.
Mrs Patel’s diabetes is “…managed.” The word sits there in her record – innocuous, orderly, and utterly detached from the reality of her care. In practice, it means a carousel of appointments, letters, and care plans, none of which connect. Each review adds a note, an adjustment, another referral. Yet despite everyone’s involvement, no one seems to own her care. Her HbA1c fluctuates, her motivation wanes, and her story gets lost in the system.*
This is what fragmented care looks like.
This is what fragmented care looks like.
Few conditions reveal the strength of a health system as clearly as diabetes – common, costly, and responsible for around £10 billion of NHS spending each year, 80% of it on complications.1 And this matters now more than ever: prevalence is rising while primary care capacity contracts.
To meet demand, nurses now lead most diabetes reviews, while GPs remain accountable but increasingly distant from routine care. As complexity grows, care shifts to community or specialist teams. As patients move between services, messages are lost, tests repeated, and reviews duplicated – leaving care scattered and patients caught in the confusion. For many GPs, this model feels “impossible”, carrying a quiet but heavy price: duplication, delays, and the erosion of professional confidence.2 The visible financial burden is matched by hidden costs in morale, time, and trust.
Major studies such as UKPDS and DCCT show that early good glycaemic control prevents long-term harm – the ‘legacy effect’3 – but the opportunity to achieve this is often lost amid system constraints. Patients spend only a few hours each year with healthcare professionals; the rest of the time they manage their condition alone, navigating advice and medication changes that can be inconsistent or confusing. GPs report feeling deskilled; nurses overstretched; and specialists in community or hospital settings often feel remote from the realities of general practice.4
Fragmentation doesn’t just affect outcomes; it drains energy from the very people trying to hold the system together – a hidden cost rarely captured in audits or budgets.
If fragmentation is harmful, is the opposite beneficial?
There are examples that show what integration could look like in practice. In Portsmouth, the Super Six model brought specialist diabetologists into regular contact with GP practices – running joint clinics, offering real-time advice on complex cases, and providing ongoing education for practice teams.5 The Derby model went further, with shared electronic records and joint governance across hospital and community teams. In both cases, care felt integrated because clinicians knew each other, communicated regularly, and worked towards shared goals rather than separate targets.6
If general practice is to remain the cornerstone of chronic disease management, we need to be part of efforts to reconnect care – not by taking on more work, but by having a clearer voice in how systems are designed around our patients. We must reclaim ownership through visibility in the design of local pathways and using our daily insight into patients’ lives to shape how pathways link together:
• IT systems that effectively talk to one another, so information follows the patient rather than the referral.
• Time and space for shared case discussions, so teams can solve problems together instead of in parallel.
• Commissioning and funding models that value continuity, not just activity.
• Support for stable teams – through protected time and consistent working relationships – recognising that relationships, not just protocols, deliver safer care.
These are modest, practical ambitions, but they matter.
We offer a call to act.
These are modest, practical ambitions, but they matter.
Within Primary Care Networks and Integrated Care Boards, GPs can help keep continuity and connection on the agenda – asking how information flows, who holds oversight, and how time for joint discussion can be built in. In our own practices, we can start small: reviewing pathways together, aligning recall systems, and ensuring that no patient becomes invisible in the spaces between services.
Recognising and addressing these hidden costs – wasted time, duplication, and demoralisation – is as important as managing financial budgets. Mrs Patel deserves more than a string of disconnected consultations. She deserves a team that knows her story and speaks with a unified voice. Until we rebuild that voice, we’ll keep mistaking activity for care – and that may be the most expensive mistake of all.
*Deputy Editor’s note: Mrs Patel is a fictional patient based on the authors’ experience and not any specific patient.
References
- Baxter MA. The new NHS and diabetes care. British Journal of Diabetes. 2014;14:3:87-94. doi.org/10.15277/bjdvd.2014.026
- Dambha-Miller H, Griffin S, Kinmonth A, Burt J. Provision of services in primary care for type 2 diabetes: a qualitative study with patients, GPs, and nurses in the East of England. Br J Gen Pract. 2020;70:698:668-675. doi: 10.3399/bjgp20X710945
- Murray P, Chune G, Raghavan V. Legacy Effects from DCCT and UKPDS: What They Mean and Implications for Future Diabetes Trials Curr Atheroscler Rep. 2010;12:432–439 doi: 10.1007/s11883-010-0128-1
- Pierce M, Agarwal G, Ridout D. A survey of diabetes care in general practice in England and Wales. Br J Gen Pract. 2000 Jul;50:456:542-5. PMID: 10954934; PMCID: PMC1313748.
- Kar P, Meekin D, Cummings M, Cranston I. The Super Six model of diabetes care: Two years on. Diabetes Prim Care. 2013;15:4:211-15.
- Rea R, Gregory S, Browne M, Iqbal M, Holloway S, Munir M, et al. Integrated diabetes care in Derby: new NHS organisations for new NHS challenges. Practical Diabetes. 2011;28:7:312-3. doi:
Photo by Bruno Figueiredo on Unsplash
