The prevalence of obesity is increasing in the UK, and with it the number of people with diabetes continues to grow. Coupled with the rising complexity of treatment for people with type 2 diabetes, the burden in primary care becomes greater. Effective management of this condition requires a team approach in which all members of the primary healthcare team must have the requisite skills.
Updated guideline from NICE
The updated guideline from NICE on the management of type 2 diabetes1 combines the content from previous NICE guidance published in the past 6 years into one document. As well as including information from previous technology appraisals, the guideline updates and replaces published advice on:
- management of blood glucose
- management of blood pressure and lipids
- management of type 2 diabetes: prevention and early management of renal disease in patients with type 2 diabetes
- screening and early management of retinopathy.
The patient (service user) guide, Understanding NICE guidance, is available from the NICE website (www.nice.org.uk) and healthcare professionals should encourage all patients with type 2 diabetes to read it.2 It is clear, fairly easy to read, and sets out the relevant targets and aims of treatment. The guide is not, however, intended to be a complete manual on diabetes.
The first key priority for implementation in the guideline is that structured education should be offered to every patient and carer, particularly for those people who are newly diagnosed with diabetes. The emphasis of this guideline is on having an informed, educated patient, who is able to self-manage their condition.
Engaging with the patient effectively is clearly an art, but the process demands reproducibility and structure. The traditional chat with the patient about diabetes is no longer sufficient. It is necessary to address the patient using learning methods suited to the individual and through both verbal and written communication. Information should also be accessible to people with additional needs such as physical, sensory, learning disabilities, and people who do not speak or read English.1
The healthcare professional should encourage the patient to make notes or to use a patient-held worksheet, rather than merely distributing a few leaflets. Learning in groups promotes better understanding for most people and the guideline recommends offering group education programmes as the preferred option.
It is not enough for the healthcare professional to think they have covered everything. They need to ensure that, not only has information been made available, but that the patient grasps the implications. The person with diabetes should come away with a clear understanding of their condition and an agreed plan of how they can manage it.
Quality-assured education does not stop after diagnosis, but should continue when patients are initiated on insulin therapy. Often in primary care the healthcare professional is hard pressed to give all the facts in the time available; information can be missed, and the patient may struggle to take it all in. This guidance goes some way to turning this around and ensuring that the patient has all the knowledge and information they require.
As well as involving patients in new ways, the healthcare professional also has additional targets to meet. While the quality and outcomes framework (QOF) indicators continue to be the standards for measuring practice achievements, clinicians must recognise that targets need to be set on an individual basis; this will usually exceed those in the QOF. Clinicians should aim for:
- a specified target level for glycated haemaglobin (HbA1c)—this is generally 6.5% in patients with type 2 diabetes, but intensive reduction to levels less than this should be avoided and the actual level for some individuals may be >6.5%
- blood pressure <140/80 mmHg or <130/80 mmHg if there is kidney, eye, or cerebrovascular damage
- total cholesterol level <4.0 mmol/litre.
The steps to be taken to achieve each of these targets are clearly laid out in the algorithms in the NICE guideline. Clinicians will want to review their current clinical practices in light of the updated recommendations.
Blood glucose monitoring
There is a strong emphasis in the guideline on understanding the reasons for aspects of diabetes management. The use of plasma glucose monitoring is discussed and encouraged so long as its use is defined and rational. Its implementation should, however, be as part of a larger learning package. The implication is that most people with diabetes should not only know how to test their plasma glucose, but they should also be able to describe why they are doing it and what they will do with the results. This will be welcomed by many patients, but may antagonise pharmacy advisers keen to keep costs down.
Renal disease and retinopathy
The renal disease section of the guideline also stresses the importance of involving the person with diabetes in the discussion of their results, while the retinal screening guideline promotes quality assurance.
Multidisciplinary team approach
Few healthcare professionals will read the NICE guideline on type 2 diabetes without finding new and challenging objectives. A team approach is required, which includes the GP, practice nurse, healthcare assistant, and other healthcare professionals, such as dieticians, as required. To implement the recommendations in this guideline, it is important that all clinicians remain highly skilled and do not just delegate diabetes care to the practice nurse alone.
Implementation of the updated NICE guideline on type 2 diabetes will represent a challenge for PCTs and practice-based commissioners in finding sufficient resources. In some areas, there will need to be additional funding for group education and high-quality educational materials appropriate to patients, as well as higher expenditure on therapies to achieve new targets. Other areas have already invested heavily in diabetes education and educational resources and sanction the use of more expensive treatments.
However, NICE remains very aware of the cost and seeks to promote use of the most cost-effective medicine available. This includes, for example, neutral protamine Hagedorn insulin as first-line treatment for type 2 diabetes and simvastatin as the statin of choice.
Recently there has been a trend among some pharmacy advisers to play down the role of glucose control, suggesting it is of limited importance compared to the management of blood pressure and lipid levels. The NICE guideline provides a more balanced view, which should not be distorted by local antagonists. The guidance will also promote further discussion about how diabetes care should be structured and delivered within the community.
The updated NICE guideline on the management of type 2 diabetes is of the highest standard and sets a benchmark for diabetes care that no healthcare professional or PCT can afford to ignore. The guidance must be seen as a whole and not taken only in parts. To do this will require a major change for many practices in the way in which they engage with patients. If implemented correctly, the guideline will result in patients viewing their health in a new light, encompassing understanding of their condition, their own test results, as well as participating in discussions and implementation of the management of their condition.
This will be good not only for diabetes care, but as a model for management of all long-term conditions. It will lay to rest the old paternalistic approach, and patients will see themselves as partners in their own care.
- National Institute for Health and Care Excellence. Type 2 diabetes—the management of type 2 diabetes (update). Clinical Guideline 66. London: NICE, 2008.
- National Institute for Health and Care Excellence. Understanding NICE guidance: information for people who use NHS services. Type 2 diabetes. London: NICE, 2008. G