The new NICE guideline puts GPs at the forefront of care for adult patients with type 1 diabetes, says Dr Alan Begg
The practice-based diabetes team will play an increasingly important role in the management of all adult diabetes patients. Of the disease specific categories of the new GMS quality and outcomes framework,1 diabetes has the largest number of indicators and offers almost as many points as coronary heart disease.
These evidence-based indicators have been influenced by previous NICE publications, and the recently published guideline on type 1 diabetes will be able to inform the contract review, planned for 2006. The indicators currently reflect risk factor management, glycaemic and blood pressure control as well as identification and management of microvascular disease.
There are now no separate Joint British Societies Coronary Risk Prediction Charts for diabetes.2 The cardiovascular risk of a type 2 diabetes patient is regarded as equivalent to a patient without diabetes who has had a coronary event.
The previous charts underestimated the risk in type 1 diabetes patients because elevated HDL cholesterol levels are not associated with the same cardioprotective effect in these patients as in those without diabetes.
The NICE guideline suggests an annual assessment of risk factors and recommends – at a low grade of recommendation – that those with microalbuminuria or two or more features of the metabolic syndrome should be managed as the highest risk category, as though they had type 2 diabetes or declared arterial disease.
There is a clear, important recommendation that diabetic care should be provided by a multidisciplinary team, and it is essential that team members have the necessary training and competencies to perform their individual roles. These skills are much easier to obtain with the excellent national training courses for diabetes with many outreach schemes being developed.
The guideline accepts that the paediatric diabetes care team, rather than the practice diabetes team, will care for children and young people with type 1 diabetes. However, the guideline states that a home-based programme for initial management and education is as safe and effective as one based in hospital.
Screening for retinopathy, microalbuminuria and raised blood pressure should commence from the age of 12 and, importantly for primary care, there should be a clear programme of transition to adult care.
GPs providing nonscheduled emergency care for children and young people with diabetes will need to ensure that they are competent to treat hypoglycaemia and diabetic ketoacidosis.
There is good evidence that structured diabetes care in general practice can provide better control and lead to fewer complications.3
The quick reference guide is being widely disseminated to aid implementation of the guideline. Local health communities in England and Wales are encouraged to review their current practice and consider the timescale, as well as the financial and human resources, necessary for full implementation. The latter two clearly form the greatest barrier to successful implementation.
Type 1 diabetes: diagnosis and management of type 1 diabetes in children, young people and adults. Clinical Guideline 15, can be downloaded from the NICE website: www.nice.org.uk.
- Investing in General Practice:The New General Medical Services Contract. The NHS Confederation/BMA, 2003. http://www.nhsconfed.org
- Williams B, Poulter NR, Brown MJ. Guidelines for management of hypertension: report of the fourth working party of the British Hypertension Society, 2004-BHS IV. J Hum Hypertens 2004; 18: 139-85.
- Griffin S. Diabetes care in general practice: metaanalysis of randomised control trials. Br Med J 1998; 317: 390-6.