Dr Matthew Lockyer argues that uncomplicated diabetes should be managed in primary care and complicated diabetes by shared care
Traditionally, GPs have thought of Type 1 diabetes as requiring hospital supervision and Type 2 diabetes as manageable in general practice to a level depending on the GP's confidence and expertise.
I believe we should stop thinking of Types 1 and 2 diabetes as having their care based primarily in hospital or primary care, but think of diabetes as uncomplicated or complicated. Uncomplicated cases should be manageable in primary care, and complicated cases with shared care. Exclusively hospital-based management could be reserved for special circumstances such as diabetic pregnancy and diabetes in younger children.
A recent Audit Commission report on diabetes services1 suggested this as a possible way forward for diabetes care: 'Hospital services are best placed to provide specialist care for patients with complications, support and training for staff working in the community and strategic direction for services across a district. Staff in primary care can deliver continuity of care close to home, and provide good routine support for people with uncomplicated diabetes.'
Cost examinations and investigations required for patients with diabetes are simple and readily available. GPs pride themselves on being expert in cardiovascular risk management. The management of many problems in Type 2 diabetes is an extension of this skill. Many younger Type 1 patients are free of complications and relatively stable. It is often the Type 2 patients who present management challenges.
If this model were accepted, primary care would need to provide clinical reviews for people with diabetes on an ordered basis. There is now so much to do routinely for each patient that opportunistic care in the context of a routine general practice consultation is no longer a realistic option.
Provision of staff and training to develop this style of care in all practices should be high on the agenda of most PCGs, as the latest Audit Commission report points out: 'If more people are to be cared for in primary care, a great deal of support and education will be needed to standardise good practice. The development of PCGs and LHGs could play a major role in this area ' 1
Good primary diabetes care depends on several simple clinical interventions being performed consistently and reliably. It is not high-tech, and should decrease rather than further stretch drug budgets.
Diabetes affects around 1.5 million adults in the UK and is increasing in prevalence. The lifetime probability of developing the condition is thought to be >10%. On average, patients stay in hospital >50% longer than age-matched non-diabetic controls and consume twice the health resources. This will inevitably increase pressure on hospital diabetes services unless we establish better patterns of care.
In 1989 the UK signed up to the St Vincent targets for improved diabetes care in the next 5 years. These were thought to be within our grasp. However, care in the UK has continued to be so lacking in organisation that we do not know whether we achieved the targets or not.
The Audit Commission has confirmed that diabetes care varies widely across the country, and that not all patients are getting the right treatment at the right time.1 The funding and expansion of primary care diabetes clinics with practice nurses and GPs will help to raise standards of care.
- Testing Times: a review of diabetes services in England and Wales. Abingdon, Oxon, Audit Commission Publications, 2000 (tel 0800 502030).