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State of the art lecture Primary care: the custodian of diabetes care? Azhar Farooqi Abstract General Practitioner and Honorary Professor, Type 2 diabetes is the disease of our times. With some 3 million cases in the UK, primary care University of Leicester, East Leicester Medical Practice, has a vital role in coordinating and delivering evidence-based care which includes the Leicester, UK prevention, detection and management of diabetes. However, primary care has not always been able to deliver such a role; up to the end of the 1980s, despite the drawbacks of busy hospital outpatient clinics, primary care could rarely Correspondence to: offer the systematic care and skills that people with diabetes require. Professor Azhar Farooqi OBE, East Leicester Medical Quality improvement and audit in the 1990s heralded the increased adoption of Practice, 131 Uppingham Rd, Leicester LE5 4BP, UK; email: [email protected] evidence-based practice in primary care. Many GP practices significantly improved the organisation and quality of care for diabetes as a result. The widespread adoption of IT Received: 30 July 2012 systems and the emergence of a more robust evidence base for care (for example, UKPDS) Accepted: 1 August 2012 accelerated this process. More lately, investment in general practice through the Quality and Outcomes Framework This paper was presented as the 2012 Mary and practice education programmes have helped deliver significant improvements in the Mackinnon lecture at the 2012 Diabetes UK Annual quality of primary care diabetes. Professional Conference held in Glasgow However, there is still much to do, with variation in care and health inequalities persisting. The development of clinical commissioning offers further opportunities to make the best use of available resources and target investment where it is most likely to benefit patients. A health care system where primary care in collaboration with other stakeholders coordinates the care of people with diabetes offers the best hope in addressing this modern epidemic that we face. Copyright © 2012 John Wiley & Sons. Practical Diabetes 2012; 29(7): 286–291 Key words primary care diabetes; quality improvement; clinical commissioning; education and diabetes Introduction Background: the burden and One of the cornerstones of the challenge of diabetes National Health Service in the Type 2 diabetes is the disease of our United Kingdom is a primary care times. The UK prevalence of this system where all citizens are able to chronic condition has increased register with a doctor-led service. from an estimated 1.4 million in This service not only holds the 1998 to almost 2.6 million in 2010; central patient record, but also this is predicted to rise to 4 million offers health care from conception by 2020.3 The numbers of people to the grave. It is ideally placed with impaired glucose tolerance and to coordinate and deliver the at risk of future diabetes is estimated life-long, holistic care required by at double those with confirmed dis- people with long-term conditions ease. The financial costs of diabetes, such as diabetes. which already consume >10% of Mary Mackinnon (whose consid- the health care budget,4 are set to erable contributions to diabetes are increase with the rising numbers of well described in Richard Holt’s patients, and with the increase in Mary Mackinnon lecture of 2011)1 expensive complications such as recognised this potential over three renal failure and cardiovascular decades ago. Mary spent much of disease. The human costs of this her early career improving commu- huge burden of poor health and lost nity services for people with dia- years of life are incalculable. betes; she subsequently went on The positive side of this dim to develop and deliver pioneering picture is that, unlike 30 years ago, diabetes education for primary care we now have a robust evidence base professionals.2 It is therefore fitting on prevention, early detection (in that in this lecture I consider the the case of type 2 disease) and progress of diabetes services in management of established dis- primary care, and whether primary ease.5,6 Appropriate interventions care is indeed achieving its potential can prevent or delay the complica- to be a fit custodian for the care of tions of diabetes, and we now have people with diabetes. technologies which allow many 286 PRACTICAL DIABETES VOL. 29 NO. 7 COPYRIGHT © 2012 JOHN WILEY & SONS State of the art lecture The 2012 Mary Mackinnon lecture complications, if detected early (for 11 12 example, diabetic retinopathy) to Hayes TM, Harries J. Cardiff, UK Singh B, et al. Wolverhampton, UK be treated effectively. GP patients vs OPD Structured GP mini-clinics vs OPD These developments, which apply to a large patient group with 200 patients, 100 discharged to GP Matched pair design, n=4222 patients lifelong disease, pose a real challenge on how best to organise 5-year follow up services for diabetes. A conservative estimate based on just four reviews HbA1c 9.5% (hospital) vs 10.5% (GP) 9.6% (hospital) vs 9.7% (GP) OHA or follow ups a year, means that in the UK a minimum of 12 million Higher mortality in primary care 10.6% (hospital) vs 10.8% (GP) BD insulin consultations per year are required for people with proven diabetes. Only 13% in GP seen annually Only small % of all practices ran mini-clinics While some of these patients will have complex disease or complica- Hospital care superior No difference in HbA1c after 2 years tions which require hospital-based between hospital and GP patients specialist care, it is clear that for the vast majority of patients care can GP = general practice; OPD = outpatient diabetes clinic; OHA = oral hypoglycaemic agents; only realistically be met in primary BD = twice-daily care, where general practices already deliver a doctor-led service Table 1. Should type 2 diabetes be managed in hospital or general practice? Summary of 2 papers providing 330 million face-to-face published in the British Medical Journal in 198411,12 patient consultations per year.7 The challenges for primary care, primary care. Eric Wilkes10 explored the hospital service had better gly- however, are considerable. These some of these issues further when a caemic control and lower mortality include ensuring staff have the large cohort of patients was dis- compared to those followed up in appropriate skills, support and time charged from the Sheffield hospital general practice. The study showed to deliver consistent and high service in the late 1970s. Wilkes, in a that only 13% of patients in the gen- quality diabetes services. These prospective study, demonstrated that eral practice arm attended regular challenges have increased over the many practices did not have the follow up. In contrast, a study by last three decades as diabetes has infrastructure to adequately follow Singh, Holland and Thorn,12 pub- become more common, and the up such patients. In his perceptive lished in the same journal, demon- evidence base for treatment more summary of this study, Wilkes articu- strated that patients discharged to clear. I will explore how primary lates the dilemma patients faced: selected practices which provided care has evolved to try and ensure it ‘...deaf, anxious partially sighted organised diabetes care (diabetes can deliver the services people with patients not accustomed to rapid learning mini-clinics) had outcomes which diabetes deserve. in strange hospital environments absorb were as good as hospital-based little of what they are told, but busy follow up. Interestingly, these The 1980s, the decade of GPs attuned to contractual requirements practices included those which realisation and herculean tasks in the 5-minute Thorn had worked with in the 1970s The debate as to whether diabetes consultation may not seek out extra to develop mini-clinics.9 (in particular type 2 disease) should work; even if they do, they will have to Both the Hayes and the Singh be managed in hospital by specialists pay for the detection and pursuit of studies show that the glycaemic con- or by GPs in primary care is not a non-attenders themselves.’ trol for hospital and general practice new one. Even in the 1970s when the In the 1980s, a common view patients was by today’s standard prevalence of diabetes was much (particularly among specialists) was poor, with the average HbA1c lower, questions were being asked as that general practice simply could achieved >10% (86mmol/mol). to where care was best undertaken. not be trusted to look after diabetes These and other studies provide Pioneers such as Professor John and, however imperfect, large-scale objective evidence that most general Malins recognised as far back as the hospital outpatient care was the practices at this time had neither the 1960s that crowded hospital outpa- only solution. structure, nor the organisation, to tient clinics were not best placed to In 1984 two papers, published in look after patients with diabetes provide care for many patients. the British Medical Journal, con- effectively. However, well-organised Malins in Birmingham and Thorn in tributed further to this debate practices (although still a minority) Wolverhampton did some of the (Table 1). Hayes and Harries11 pub- could deliver care equivalent to that early work to enhance the capability lished the results of a study in which provided in hospital diabetes clinics. and expertise of general practice, patients attending a hospital dia- This conclusion is further con- including assisting practices to set betes clinic were randomly allocated firmed in a meta-analysis by Griffin et up structured mini-clinics.8,9 either to continue attending hospi- al. (Figure 1).13 The difficulties of oversubscribed tal, or to receive follow-up care in The time up to and including the diabetes clinics prompted some hos- general practice.

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