Providing practical tailored advice, and supporting staff in changing practice can improve service provision for patients with diabetes, as Lynne Nicholl and Sunny Russell explain

There is much evidence to show that patients with type 2 diabetes can be managed effectively in primary care, when care is delivered in a systematic way by GPs and practice nurses with a special interest in diabetes.

Research also shows that facilitators can help in improving diagnosis and management of patients with diabetes.1

The National Primary Care Facilitation Programme (NPCFP), now part of the Learning and Development Programme, based at the Public Health Resource Unit in Oxford, offered training and support to diabetes facilitators. A facilitator employed by the NPCFP worked with the diabetes facilitator of a PCT in Middlesex in an 18-month pilot study funded by the Department of Health to encourage practice staff to review and improve diabetes care in three local practices.

The Middlesex area was chosen for its large population of South Asian origin, who are at increased risk of insulin resistance and four to six times more likely to develop type 2 diabetes. These patients often have difficulty in gaining access to services, partly because of the language barrier.

The PCT was asked to select three practices with predominantly South Asian populations or, if possible, from the lowest quartile of known performance, so that the NPCFP could work towards reducing inequalities, in line with Department of Health aims.

At the start of the project, data held on computer were incomplete, and initial reviews were undertaken using both computerised and paper records.

By taking every other record, we selected 50% of each practice’s population of patients with type 2 diabetes and looked at those aged 20-79 years. No patients with type 2 diabetes under the age of 20 years were identified and many of those aged 80 years and over were in residential care and were considered separately.

The records were reviewed in full, including correspondence from hospital diabetes clinics, podiatrists and high street optometrists, so that all clinical care carried out both in the practice and by health professionals elsewhere was assessed.

Audit criteria and standards

Regular recall and review is one of the key interventions for improving quality of diabetes care.2 Patients who are not reviewed regularly have a significantly greater risk of developing complications because problems go undetected.3

The audit criteria were that all patients should have an annual diabetes review which included the investigations in Table 1 (below). Both the DoH and Diabetes UK have recommended that all diabetes patients are seen for an annual review.4-6

Table 1: Results of first and second audit* compared with standards and also averages based on published work showing percentage of patients undergoing respective investigations27

First audit
Second audit
Average taken27
from literature (%)
Annual review
85 92 100 85.5
68 87 100 72.5
Blood pressure
89 93 100 87.6
Body mass index (BMI)
74 88 100 52.5
Blood creatinine
69 84 100 49.0
Total cholesterol
67 84.5 100
Triglycerides 50 77.5 100
Urine dipstick for protein 68 77 100 65.8
Visual acuity
72 78 100 62.7
Fundoscopy 72 78 100 67.5
Feet examined visually/ sensation and pulses checked 66 89 100 67.7
Smoking status (last record) 89 96 100 71.45

*Averages of the three practices
† Only 1 patient was recorded as having fructosamine checked as an alternative

The investigations were agreed in February 2001 before the National Service Framework for Diabetes standards document4 and NICE guidelines for type 2 diabetes7-10 were published. Practices reached a consensus on the investigations based on evidence available at the time.11-25 HDL and LDL cholesterol levels, and whether or not the patients with type 2 diabetes had received dietary and exercise advice were not recorded; however, this has since been done.

The prevalence of type 2 diabetes in patients aged 20-79 years was calculated from practice registers.


Staff in the three practices were given detailed feedback on the initial audit and agreed on an implementation plan for their individual practices to ensure that all patients with type 2 diabetes were invited for an annual review and appropriate investigations.

As part of the implementation plan the practice staff agreed on which members of staff should take responsibility for undertaking aspects of the work and ensured that the staff were committed to carrying it out. In two practices the administrator coded the patients while in the third practice this was done by the practice nurse. The staff set themselves time limits for the completion of tasks. Training needs, for example IT skills, were identified.

The facilitators made sure that practices were working in accordance with local guidelines, i.e. those drawn up by their local diabetes service advisory group, and with Diabetes UK recommendations.5, 6

Staff also reviewed the results of investigations at the feedback sessions and decided on different approaches to treatment.


The first step in the implementation plan was to ensure that all patients with type 2 diabetes were correctly coded and to update the electronic register. An IT facilitator, who provided extra training, was invaluable at this stage. An up-to-date electronic register enabled the practice staff to develop a more effective system for recall.

During the 6-month implementation period, many patients with type 2 diabetes were recalled and attended an annual review which included the investigations listed in the audit criteria.

Despite letters and reminder phone calls conducted in the patients’ first language, two patients declined to attend for their annual review.

The practice staff made sure that patients were involved in joint goal setting and drew up care plans which were regularly reviewed. Both these approaches26, 27 have been shown to improve attendance as have patient-held records. The practices are considering the feasibility of introducing patient-held records.

The PCT facilitator taught nurses to carry out basic foot care and examinations. Interdisciplinary guidelines were drawn up based on the RCGP guidelines20 to ensure that referrals to podiatrists were timely and appropriate.

Second audit

The final stage of the facilitation process was the second audit. The results of the second audit showed an encouraging improvement in the percentage of patients with type 2 diabetes who received an annual review and had the appropriate investigations. Table 1 shows the results of the first and second audits, compared with the standard and also average results taken from the literature.28

Table 2 (below) shows an increase in recorded prevalence of type 2 diabetes in patients aged 20-79 years, resulting from an improvement in coding.

Table 2: Prevalence of patients with type 2 diabetes aged 20-79 years

First audit (%) Second audit (%)
Practice 1
2.7% 3.4%
Practice 2 3.2% 3.9%
Practice 3 1.1% 4.2%

Impact of the facilitation process

Staff from the three practices found face-to-face contact with the facilitator really motivated them to make improvements.

Facilitator involvement helped staff to set aside time to review their management of diabetes.

The staff felt that the success of the facilitation process was due to a good relationship with the facilitator and the fact that the help was practical and tailored to the individual practice.

Our experience shows that the input of diabetes facilitators was effective in implementing improvements in the service for type 2 diabetes patients included in this pilot study.

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Guidelines in Practice, May 2003, Volume 6(5)
© 2003 MGP Ltd
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