Do I work for the NHS or the DVLA? This is what I found myself wondering about in my last clinic.

It’s rare in medicine that your duty to act as the patient’s advocate is not the over-riding factor in all clinical decision-making. However, if you are fortunate enough to be a diabetologist, then several times a month you will find yourself in the professionally invidious position of doing the DVLA’s bidding, potentially not putting the patient’s concerns centre stage.

Allow me to furnish you with a hypothetical scenario. A 42-year-old patient with a 20 year history of diabetes consults you for their routine annual review and during the appointment also requests that you complete a medical questionnaire for the DVLA. They have the form with them and plonk it in front of you. You are working your way through the questions fairly well until you get to the one that asks if you have inspected a written record of their recent blood glucose monitoring results.

You are happy that day-to-day glycaemic control is not a major problem for this patient, their HbA1c is 59 mmol/mol, the hospital notes bear witness that they have never been seen in A&E with a major hypo - nor trauma from a road traffic collision caused by hypoglycaemia for that matter. They verbally report no major hypos and good hypoglycaemic awareness and your clinical instincts tell you that you have no reason to disbelieve this account of things.

You have previously scrutinised their glucometer and recorded in the notes “glucometer readings mainly single figures/low teens”. However, they do not have either glucometer or glucose monitoring diary with them today. You would not be making an issue of this minor point were it not for the DVLA form, after all, have you never, not even once, arrived at work without your hospital ID badge? We are all human.

But now the pressure’s on, the patient’s driving license is about to expire, they need it for their livelihood, they have to get the form back to the DVLA in the next three days or the license expires. Do you just tick the box saying you’ve inspected the glucose monitoring diary? No, better not do that, what if that one in a million chance comes to fruition and they have a huge hypo on the way home and plough in to a crocodile of school children on a zebra crossing?

OK, plan B, politely explain to the patient that it will not be possible to complete the form today even though your professional instincts are telling you that to do so would be quite OK? You explain, the remonstration starts, the pleading, the imperative to keep driving with which you so completely empathise. Now, from being kind, sympathetic, benevolent, you are cast as cruel, heartless and callous.

Not only has this consultation gone badly wrong, but the entire therapeutic relationship has been seriously injured, perhaps forever by a third party who was never invited to this consultation in the first place. Oh dear, how did it ever come to this? Did you ask to be both policeman and doctor at the same time? I suspect not, I know I certainly didn’t.

Click HERE for guidance on diabetes diagnosis and management.

A letter from the Drug and Therapeutics Bulletin to the Daily Telegraph deplores the axing by Novo Nordisk of an insulin product, currently used by an estimated 90,000 diabetics in the UK.

The letter, which has the backing of several leading specialists and the Insulin Dependent Diabetes Trust, calls on manufacturer Novo Nordisk to reverse its decision to withdraw Mixtard 30 from sale by the end of this year.

Here’s the letter in full:

Dear Sir,

The drug company Novo Nordisk plans to withdraw its insulin product Mixtard 30 from the UK at the end of this year – a move that we believe will adversely affect the wellbeing of many people with diabetes and add millions to NHS costs.

Mixtard 30 is a biphasic human insulin, currently used by an estimated 90,000 people in the UK. It is recommended by the National Institute for Health and Clinical Excellence (NICE) as a treatment of choice. And, crucially, scientific evidence indicates that alternative ‘analogue’ forms of insulin, promoted by the company, such as NovoMix 30, are neither more effective nor safer.

But they are much more expensive, with one estimate suggesting that a straight switch to NovoMix 30 for patients in England alone would add around £9 million to the NHS drugs bill. And this figure takes no account of other added cost pressures. These include the need to review many thousands of patients to switch treatment, some of whom will need many months to become established on an alternative insulin.

The withdrawal of Mixtard 30 also signals the end to the availability of a biphasic insulin in an ergonomically designed device, and this could leave many users with eyesight and manual dexterity problems dependent on others to help them take their insulin.

Of note, Mixtard 30 has never been available in the UK (unlike in Germany) in the FlexPen, an injecting device very popular among people with diabetes. If it had, perhaps the decline in sales of Mixtard 30 in recent years, cited by the company as a reason to discontinue it, might have been avoided.

Like over 1,000 signatories to the ‘Don’t Drop Mixtard 30’ campaign petition, we are alarmed by Novo Nordisk’s attitude to people with diabetes who rely on Mixtard 30. We urge the company to reverse a decision that is simply not in the interests of patients, healthcare professionals or the NHS.

Yours faithfully,

Dr Ike Iheanacho, editor of Drug and Therapeutics Bulletin; Edwin Gale, emeritus professor of Diabetic Medicine at the University of Bristol; Geoff Gill, professor of international medicine at the University of Liverpool; Jenny Hirst, co-chair of Insulin Dependent Diabetes Trust; Harry Keen, emeritus professor of human metabolism at Guy’s Hospital; and John Yudkin, emeritus professor of medicine at University College London.

Sign their petition.