More diabetologists and specialist nurses are needed if we are to achieve clinical targets, says Dr Matthew Lockyer
Dr Roger Gadsby's article on the National Service Framework for Diabetes (Guidelines in Practice, Vol 5(1): 18) was a fair analysis. I wonder how many other professionals share our frustration with this document and with the delay in announcing the details of how the services will be implemented?
When I read the NSF summary I was struck by the many similarities to the St Vincent Declaration of 1989. The UK was a signatory to this WHO mission statement for diabetes care, which encompassed a belief in patient-centred care and also measurable clinical targets to improve outcomes for patients with diabetes.
Our databases for these patients are still not comprehensive enough for us to know if we have achieved the St Vincent targets. The 5-year period for improving these outcomes is long past, but we have concrete evidence from surveys such as Testing Times from the Audit Commission1 that diabetes care in the UK is still variable and chronically underfunded.
We know that diabetes, especially type 2 diabetes, is rapidly increasing in prevalence. The current number of diabetes patients is predicted to double by 2010, when there will be 3 million sufferers. The cost of this burden to the NHS and to society will be enormous. The Code-22 and the T2ardis3 studies estimated the cost of type 2 diabetes care at 4.7% of the total NHS spend. Cancer care accounts for less than 3%.
Most of these costs arise from the increased care needed to treat complications of diabetes. Every passing year will increase the burden on diabetes services and make it harder to achieve good standards of care.
While I understand the problems inherent in population screening, diabetes seems to fulfil all the criteria for a successful screening programme. Such a programme might reduce the early incidence of diabetes complications. I share Dr Gadsby's surprise that a decision on this aspect of diabetes care is being deferred for so long.
The impressive SIGN guidelines for diabetes (see 'SIGN diabetes guideline receives warm welcome' Guidelines in Practice Vol 4(12): 20 and 'New SIGN guideline addresses seven major areas of diabetes care' Guidelines in Practice Vol 5(1): 23-31) show how the growing evidence base for diabetes care can be applied clinically.
Many of the difficulties in applying clinical guidelines and in encouraging patient-centred care come down to shortages of professional staff. The Audit Commission found staffing by diabetologists and diabetes nurses to be almost universally below recommended levels. Dietetics and podiatry services were even more sparse.
The SIGN guidelines and the NSF agree that depression and maladapted coping mechanisms are often significant barriers to good diabetic outcomes. This means that clinical psychologists will be increasingly important members of the diabetes team, with further manpower implications.
Whatever the final NSF instalment holds it seems clear that a recruitment drive for trained diabetes nurses, diabetes specialist registrars, podiatrists and dieticians will be needed. It is hard to see how any improvement could be delivered without this.
Many diabetes teams already know where they are failing to meet targets or to provide good patient-centred care and could sensibly use extra funding in areas already validated by other authoritative guidelines.
After the problems that have arisen with the funding of the NSF for Coronary Heart Disease it is tempting to conclude that some of the delay in implementing the NSF for Diabetes is driven by a political agenda.
- Audit Commission. Testing Times: A Review of Diabetes Services in England and Wales. London: TSO, 2000.
- Bottomley J. Lawlar D, Baxter H. CODE-2*UK: The Current Costs of Type 2 Diabetes in the UK. ISPOR, Edinburgh, November 1999 (poster).
- T2ARDIS. Implications for Seamless Care Provision in Type 2 Diabetes in the UK. Satellite Symposium, BDA Annual Conference, March 2000.
Matthew Lockyer, GP, Suffolk and clinical assistant in adult diabetes medicine