THE ORGANISATION AND DELIVERY OF OPTIMAL DIABETES CARE

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CHAPTER 7 THE ORGANISATION AND DELIVERY OF OPTIMAL DIABETES CARE

OVERVIEW

Although the focus of the primary health care team rests with its patients and local community, the delivery of good care is strongly influenced by a larger framework – government policy and the organisation in which the team works. A better understanding of this framework should help teams to organise the best possible delivery of diabetes care within the available resources.

BACKGROUND TO THE CHANGING ORGANISATION OF DIABETES SERVICES

INTRODUCTION

In October 1989, government health departments and patients’ organisations from across Europe, under the aegis of the World Health Organization (WHO) and the International Diabetes Federation (IDF), agreed upon a series of recommendations for diabetes care to be implemented. Called the St Vincent Declaration, this set out goals and targets for improved effective care (WHO/IDF 1990, Krans et al 1992). Subsequent initiatives in the UK have built upon this landmark declaration.

GOVERNMENT POLICIES AND NHS CHANGES

Current government health policy aims to deliver an improved quality of service to individual patients and to the whole population (DoH 1998). General practitioners’ (GPs) contracts with the National Health Service (NHS) now reflect the government’s intention to support and reward improved quality of care in various areas, including diabetes. In order to address the increasing prevalence of the condition, to take account of greater evidence for and availability for effective interventions, and to meet local patient needs, the organisation of diabetes services needs to adopt an integrated approach between primary, secondary and community care.

National Service Frameworks for Diabetes

Government policy to improve the delivery of care throughout the NHS to patients with diabetes is set out in the National Service Framework (NSF) for Diabetes. Its stated aim is to “make the best practice already offered in some places the norm”. This NSF was published in two stages:

• The first stage, published in 2001, listed 12 “standards” that define the areas of care that will need to be delivered (see Appendix 2), of which eight are relevant to type 2 diabetes management in primary care (DoH 2002). Text in this book that is specific to these standards is indicated by a box in the margin in which the numbers of the relevant standards are given.

• The second stage, published in 2003 set out a strategic framework on how the NHS would implement the NSF standards over a 10-year programme (uncosted) (DoH 2003).

Authoritative guidelines

The National Institute of Clinical Excellence (NICE) was established as an independent organisation (although government funded) in 1999 to provide guidance on new and existing technologies and to develop clinical guidelines and audit tools. In April 2005, NICE joined with the Health Development Agency to become the new National Institute for Health and Clinical Excellence (still known as NICE). NICE has published technology appraisals on medication (glitazones, long-acting insulin analogues), delivery systems (insulin pump therapy) and patient education models.

The National Clinical Guideline for type 2 diabetes consists of six inter-related guidelines, developed by a multi-professional, multi-agency collaboration with the support of NICE. These guidelines (with regular updating) aim to provide clinical practice recommendations (with the supporting evidence) for healthcare professionals in the following key areas:

• Foot care (Hutchinson et al 2000, McIntosh et al 2003).

• Retinopathy (NICE 2002a, Hutchinson et al 2001).

• Renal care (NICE 2002b, McIntosh et al 2002c). However, this is being superseded by the NSF for chronic kidney disease, part 2 published in 2005 (DH Renal NSF Team 2005).

• Lipids management (McIntosh et al 2002a), but now superseded by 2005 guidance from the Joint British Societies, which includes all relevant cardiovascular risk factors (Wood et al 2005) and the 2006 NICE technology appraisal on statins (NICE 2006).

• Blood pressure management (Hutchinson et al 2002). These were superseded by separate guidelines from NICE (North of England Hypertension Guideline Development Group 2004) and the British Hypertension Society (Williams et al 2004), updated by a single NICE/BHS guideline in 2006 (NICE 2006a).

• Blood glucose management (NICE 2002c, McIntosh et al 2002b).

It is arguable that NICE guidance has not always been set out clearly and that some recommendations are inconsistent with its own stated targets, other current authoritative guidance and the results of research. Professionals need to consider this information, but should be prepared to exercise their best clinical judgement to act in the patient’s best interests.

Other authoritative guidelines for the management of diabetes are now readily available from:

• The American Diabetes Association (ADA) publishes comprehensive and referenced clinical practice recommendations, updated annually and available on its website (ADA 2007).

• The Scottish Intercollegiate Guidelines Network (SIGN) published its own excellent authoritative guidelines in 2001, reviewed in 2005 (SIGN 2005).

AIMS

NSF

The delivery of high-quality care to type 2 diabetic patients in primary care requires that their needs are identified clearly and correctly, and that the available resources are used optimally to address these needs. Better outcomes are more likely to result if the delivery of care respects and complements the goals chosen by the patient. Patients should be regarded as the main managers of their disease. Diabetics who understand their disease are more likely to have similar aims to those of a caring professional. Table 7.1 summarises a professional’s perspective of suitable aims for the care of individual patients with diabetes.

Ensure the earliest possible detection of the disease

Abolish symptoms of the disease

Achieve optimal blood glucose control, avoiding extremes of hypoglycaemia and hyperglycaemia

Prevent or delay, and provide early treatment of diabetes complications

Minimise the risk and impact of cardiovascular disease

Enable patients to play the fullest possible role in the management of their disease, by providing suitable education and psychological support, maximising self-reliance

COMPONENTS OF OPTIMAL ORGANISATION WITHIN PRIMARY CARE

Effective delivery of care to diabetics has relied traditionally upon the three Rs of chronic disease management: Registration, Recall and regular Review. “Multifaceted” interventions (such as individualised goal-setting with patients and suitable education) improve the performance of both the practitioners and the organisation, with better outcome measurements of such parameters as blood pressure and glycated haemoglobin (Olivarus et al 2001, Renders et al 2001). A successful “recipe” for diabetes care needs to contain the appropriate “ingredients”:

ACTIVE PARTICIPATION OF DIABETIC PATIENTS IN THEIR CARE

NSF

If professionals respect their patients’ autonomy, then patients are more likely to be able to act as the main managers of their chronic disease.

Attention to the following guiding principles should enhance this autonomy:

• Type 2 diabetes is a progressive disease that requires regular and staged changes in therapy. Patients must not be made to feel guilty or at fault when these changes occur.

• Treatment plans should be “negotiated” and attempt to incorporate the patient’s own chosen goals. Other issues in a patient’s life may affect the priority given to these diabetes-related goals.

• Interventions should aim to promote and maintain improved self-care behaviour and to maximise freedom and flexibility in the patient’s life.

• Where possible, patients should be encouraged to adjust their treatment and be supported in this. Patients will need to know the actual values and the significance of any tests. This requires the professional to identify and address each patient’s educational needs. If patients are allowed to make decisions, then they should be allowed, without stigmatisation, to make mistakes from which each patient and the professional can learn.

• The professional should aim to earn and maintain each patient’s respect. Solid evidence, where available, should support any guidance given.

• A balance needs to be struck between keeping things as simple as possible and recognising that diabetes is not a simple disease.

• Patients have the right to make choices that may ultimately cause them harm.

PRIMARY HEALTHCARE TEAM PERSONNEL

QOF

Education 8

The delivery of diabetes care is a “team effort” with the different members of the primary healthcare team each playing an important role. In most practices, GPs and practice nurses will deliver most of the first-line clinical care with administrative and/or reception staff providing the organisational back-up. However, an increasing number of practices have employed or access other professionals:

• Podiatrists

• Dieticians

• Psychologists

• Pharmacists, particularly for medicines management, which may reduce HbA1c results (Choe et al 2005)

• Informatics staff

• Opticians

• Diabetes specialist nurses.

The following points may inform how members of the primary healthcare team can deliver diabetes care more effectively:

• The active leadership of a GP or a practice nurse with a particular interest in diabetes is likely to provide the necessary driving force within the team.

• Members of the practice involved in any activity require sufficient and updated knowledge and skills to undertake these tasks. Training needs should be identified by appraisals, audit, questionnaires and patient feedback. Training may be obtained from a variety of sources, such as attendance at specific courses, observation of specialist colleagues or clinics, distance learning, self-directed reading, or in-house. Current educational practice suggests all team members should have a personal learning plan.

• Non-medical members of the team play an important role. With adequate training and safeguards, nurses should be able to prescribe changes in therapy according to an agreed protocol; this enables a prompt and more effective response to problems and a greater likelihood that the individual patient’s goals will be achieved.

• Good working relationships with others involved in diabetes care outside the practice, both in health and in other services (e.g. social), will facilitate each patient’s access to and a more seamless movement between the available agencies that best address each particular need.

• All team members should be committed to ensuring equitable access and care to patients of all ethnic and cultural backgrounds.

Chapter 6 of the Diabetes NSF Delivery Strategy (DoH 2002) outlines issues that relate to workforce planning and development. Although directed more at a district level, the document and its references may be relevant to how individual practices might manage their own personnel.

ADMINISTRATIVE STRUCTURES AND PROCESSES

NSF

QOF

DM19

The following should enhance the delivery of quality diabetes care in practices:

1. An accurate up-to-date diabetic register for recall, management and audit, with a named person responsible for maintaining it. All team members should notify the register when made aware of a newly diagnosed or registered diabetic. Practices should also consider setting up a parallel register of those at higher risk of developing diabetes (in particular those with IGT), for recall to be screened regularly.

2. An evidenced-based protocol to cover all the key areas of diabetes care within the practice. As a minimum, the protocol needs to provide the framework and details of how the practice will attempt to achieve the maximum points for the various indicators found in the QOF of the GMS contract. The evidence for each component of the protocol may come from various authoritative sources: the latest NICE guidelines and technology appraisals, Diabetes UK recommendations (including Diabetes UK 2000), guidelines from the Joint British Societies (Wood et al 2005) and the British Hypertension Society, ADA (ADA 2007), and SIGN (SIGN 2001). There may be other sources for ideas, such as locally produced guidelines. Regular audit and reviews of medical literature should enable the protocol to be revised in accordance with best current practice.

3. An effective call and recall system should be in place. Administrative and clinical members need to agree upon the precise protocol (including standard recall letters) for contacting diabetic patients when and after their periodic review is due.

4. Contact details (telephone and fax numbers, and e-mail addresses) of and good working relationships with outside professionals, such as diabetes specialist nurses, podiatrists and hospital diabetic, renal and eye clinics.

5. The framework for undertaking both full and interim diabetes reviews should be agreed. Adequate time must be set aside within the framework to carry out properly the activities set out in the diabetic protocol. Mini-clinics are regular sessions set aside for diabetes care by the primary healthcare team, with regular participation from other professionals. If blood tests are taken prior to the mini-clinic, relevant information is available at the time of review. Figure 7.1 shows a possible model of how patients might “travel” through a practice framework for diabetes care.

6. Practices may wish to look imaginatively at alternatives to the standard appointment in the surgery or a home visit, particularly in lifestyle interventions. Examples include telephone prompting, group sessions, electronic and written educational packages, and the involvement of professionals from outside the primary healthcare team.

7. Outside of planned reviews, diabetics should have adequate access to diabetes care at other times. Nonwhite ethnicity and socio-economic deprivation may affect both needs and access to care. Women with diabetes reported greater difficulties than men in accessing suitable care in practice (Hippisley-Cox et al 2006).

8. The practice should be capable of and willing to undertake regular quality control and audit, and to implement changes.

9. The practice must ensure that adequate resources are available for the relevant team members to carry out the entire range of tasks required to provide a high-quality service, without detriment to other professional activities.

Fig. 7.1 Pathway of patients through a practice diabetes care framework

INFORMATION MANAGEMENT

Optimal information management is an essential ingredient in achieving improved quality in any area of health care. Strategic planning in this area needs to look at what is recorded and how information is handled. Practices may wish to refer to the DoH’s documents Diabetes Information Strategy (DoH Diabetes Information Strategy 2003) and Information for Health (NHS Executive 1998).

Manual records now have only an archive role. The National Programme for Information Technology (NPfIT) is an ambitious national programme to develop an IT system in the NHS. Among its elements that will be relevant to the delivery of care to patients with diabetes are patient records (National Care Records Service), electronic transfer of prescriptions (Electronic Prescription Service) and referrals (Choose & Book). The aims are ambitious, but implementation may prove problematic and the track record of national government-funded IT programmes has been poor.

Content

The data recorded by each practice are determined by clinical, administrative and medico-legal requirements. Any data recorded must have a clear purpose and should not be only “for information’s sake”. QOF indicators and the components of the periodic review could provide the basis for the data that practices wish to record. Precise definitions of all recorded data need to be agreed and understood by all users. All current UK electronic systems use Clinical Terms, known as Read Codes, which are produced and maintained by the NHS Information Authority (NHSIA online). Read Codes for the QOF have been agreed and the relevant documents available from the General Practice Committee of the BMA (West Midlands Local Medical Committee online). Where multiple codes are available for single or similar terms, practices should agree a unique code for each item of data to be recorded and ensure that it will be counted in the QOF.

System design

The design of any information system must address:

• Recording of data

• Data storage

• Data retrieval.

Recording of data

Data recording needs to be accurate, efficient and facilitate retrieval. Diabetic data are best recorded onto agreed specific templates, which facilitate data collection and accessibility. With the new GMS contract, the accredited GP software companies now incorporate templates for recording data required to assess performance of the indicators in the QOF. Protocols need to be developed as to who actually enters data onto the computer. It is also necessary to devise a practical and accurate system for recording data produced from outside the practice (e.g. hospital clinics) onto the practice database.

Data storage

Electronic records should be stored automatically on the practice computer’s hard drive, but regular back-up stored off site is required in the event of crashes or other disasters.

Many patients and professionals support the creation of patient-held records to facilitate patient self-management and communication between different centres of care. However, it is necessary that all involved professionals have continuous access to the data. Electronic systems should minimise the time and effort devoted to duplicate data entry onto the practice database.

Data retrieval

It is essential that all relevant data are readily available both to the patient and to the involved healthcare professional. With the increasing use of audit for administrative (e.g. contracts) and clinical purposes, the speed and accuracy of retrieving data for analysis on an electronic system is seen to far outweigh the initial extra effort of data entry. The storage and retrieval of patient data must respect all the relevant legal requirements, in particular the Data Protection Acts. This is a minefield, and any practice is well advised to have in place clear policies and suitable training for all involved staff.

PHYSICAL PREMISES AND EQUIPMENT

Practices that carry out diabetes care have a need for the following (which may have “resource implications”):

• Adequate space: including access to a darkened room for retinal screening, by whatever method (ophthalmoscope, slit-lamp or retinal camera).

• For clinical examination: a sphygmomanometer (with standard and large cuffs), an ophthalmoscope, mydriatic drops (tropicamide 0.5% and 1.0%), tape measure, weighing scales, height measure, cotton wool, patella hammer, tuning fork (128 Hz), sterile needles, 10 g (5.07) monofilaments or Neurotips (if available), Snellen chart for visual acuity hung at the correct distance, pinhole for correction of refractive errors.

• For testing: laboratory sample equipment (tourniquet, needles, syringes, blood and urine sample bottles, sharps container, disposable gloves and swabs), urine test strips (for protein, glucose and ketones), blood glucose meter and appropriate test strips (ensure proper quality control) and finger-pricking devices.

• For therapeutic indications: glucose for OGTT, and access to insulin and glucagon.

• For recording and management: a networked computer terminal with access to a printer for prescriptions and health education literature.

• For reference: BNF, BMI chart, and important telephone numbers.

PATIENT INFORMATION AND SUPPORT

A wide range of information is currently available in several formats. Effective health education should ensure that patients have ready access to appropriate up-to-date information as a means of “empowering” them to better self-manage their condition.

Patient information may include:

• Educational materials (leaflets, posters and videos) in appropriate languages for nonEnglish-speaking patients, if required.

• Information on local services, including optician, dietician, podiatrist and social services.

• Lists of useful websites for patients with access to the internet. Some excellent patient information websites include:

• Diabetes UK: (www.diabetes.org.uk)

• the NHS: www.patient.co.uk – then enter “diabetes mellitus” in search

• Clinical Evidence: http://www.besttreatments.co.uk/btuk/conditions/6537.jsp

• The National Institutes of Health (in the USA): http://health.nih.gov/result.asp/187.

Patients and their families may also benefit from support beyond that offered by their professionals. Patients (and families) who join Diabetes UK gain access to a confidential helpline, useful publications and various insurance and financial “products”; there are also better opportunities to meet other people with diabetes.

As discussed above in this section, ready access to professional help (outside the periodic review) is essential for managing various medical problems. During out of hours, patients may find it useful to telephone NHS Direct on 0845 46 47.

DELIVERING HIGH-QUALITY CARE TO OLDER PATIENTS WITH TYPE 2 DIABETES

Type 2 diabetes in the elderly may pose both clinical and logistical problems. With the growing number of older individuals, the prevalence of older diabetics will also increase significantly. Older diabetics are also more likely to request out-of-hours consultations and to need acute hospital admission (Tattersall & Page 1998).

Guidelines for the care of older diabetics have been published by the American Geriatric Society (Brown et al 2003) and the European Diabetes Working Party for Older People (Sinclair et al 2006). The latter suggests that “areas of clinical importance and targets for concerted action” in older diabetics should include:

• functional and vascular risk assessment

• detection of cognitive impairment and depression

• management of specific major complications

• ethical and moral aspects of treatment

and

• “Care Home” diabetes.

OLDER POPULATION

The prevalence of diabetes is higher in an older than in a younger population. Both clinically and functionally older diabetics are not a homogeneous population. Many will have a variety of co-existing morbidities and more complex medication regimens (with the attendant risks of polypharmacy) than younger people. Older diabetics are more likely to have cognitive impairment and/or depression, and to be more prone to falls, incontinence and chronic pain.

Due to the increasing prevalence of diabetes with increasing age and to frequent asymptomatic presentation, clinicians need to have a lower threshold for considering the diagnosis and arranging appropriate screening. Although the OGTT is the ideal diagnostic test, a fasting plasma glucose may be a more feasible test, and an HbA1c greater than 7.5% may be useful if the individual is frail, demented or confined to a residential home (Greci et al 2003).

ASSESSMENTS

In addition to assessing the components of the periodic review, older patients with diabetes may benefit from an evaluation of:

• Global/physical function, such as looking at basic activities of daily living (ADL) (Katz et al 1963)

• Cognitive function, such as assessing memory and orientation using the Mini Mental State Examination score (MMSE) (Folstein et al 1975)

• Nutritional status, using some agreed checklist or inventory.

TREATMENT AIMS

It remains important that, irrespective of age, all patients are treated with respect and according to their needs, and with full information and access to all appropriate services. There is less evidence for the benefits of tight glycaemic control, blood pressure, and lipid control in individuals over 65 years of age than for the younger population. The recommended targets may need to be reviewed, particularly if there are present other co-morbidities and/or high dependency and/or advanced dementia.

Although glycaemic control is important in older diabetics, the greatest reduction in morbidity and mortality may result from some improvement in all modifiable cardiovascular risk factors. Treating hypertension in the elderly has been shown to be beneficial. There is less evidence for benefits of lipid modification and aspirin therapy; nevertheless, since all diabetics (especially the elderly) are at increased risk for developing CVD, these interventions are worth considering, unless contraindicated or in the very frail with limited life expectancy. Older diabetics who “are active, cognitively intact, and willing to undertake the responsibility of self-management should be encouraged to do so and be treated using the stated goals for younger adults with diabetes” (ADA 2007).

The possible reasons for poor concordance with or refusal of treatment include depression, cognitive impairment, loneliness, adverse socio-economic circumstances and the presence of malignancy. The decision to offer an intervention should take into account the likely benefit/risk ratio. In the elderly, limited life expectancy and increased vulnerability to adverse and other effects may alter the calculation. Health education in the elderly remains as important as any age group, but the content and delivery of the educational package may be altered by sensory and/or cognitive impairment, and other physical frailties.

CARE HOMES

With increasing age, individuals are more likely to be house-bound or live in some form of residential or nursing home. The nature and quality of provision of diabetes care within residential care homes is variable. Among the potential or existing problems that may be encountered in these institutions are:

• Increasing numbers of “clients”

• Lack of access to the full range of healthcare professionals, including specialists

• Inadequate dietary care and advice

• Lack of education and training plans for staff

• Lack of individualised care plans

• Poor monitoring of quality.

Staff in homes or other carers can feel isolated and, with numerous other demands upon their time, may not invariably monitor diabetic control and other problems optimally. Practices will need to organise the provision of domiciliary diabetes care for some individuals, in collaboration with other professionals, such as diabetes specialist nurses, podiatrists and opticians, and with the carer(s), who may require education and other support from the practice team. It is crucial that the management protocols are appropriate (not too complex or inflexible) and agreed by all those involved. Ideally, one motivated knowledgeable person should take overall responsibility.

THE NEWLY DIAGNOSED PATIENT

ESSENTIAL QUESTIONS TO BE ADDRESSED AT THE INITIAL CONTACT

When the diagnosis of diabetes is made, three questions need to be answered by the clinician by the end of that initial consultation:

1. Is the patient severely ill?

If yes, then an intercurrent illness may also be present in addition to type 2 diabetes, and the patient should be admitted urgently to hospital, irrespective of the blood glucose level.

2. Can this patient be managed in a primary care setting?

Type 2 diabetics, who have treatable complications should be referred promptly to the appropriate specialist department. However, it is likely that the practice team will become involved in the subsequent management of these problems and of the diabetes.

3. What treatment is required to correct the blood glucose level?

Correction of elevated blood glucose begins at diagnosis. Using the “step-up” recommendations outlined in Table 3.3, the initial choice of diet alone, oral hypoglycaemic agents or insulin (if ketonuria is present) is based upon the following:

• Current blood glucose level

• Presence or absence of ketones in the urine

• Presence of hyperglycaemic symptoms, such as polydipsia and polyuria

• Patient’s weight

• Patient’s general well-being, hepatic and renal function.

IMPORTANT AREAS TO ADDRESS FROM DIAGNOSIS

At or soon after diagnosis, three further areas will require attention:

1. Involving the patient in the self-management of his or her disease

2. Minimising cardiovascular risk

and

3. Carrying out essential administrative tasks.

INVOLVING THE PATIENT IN SELF-MANAGEMENT

From the first consultation, healthcare professionals need to educate patients about their condition, and allow the patients to make informed choices, wherever possible, about their management.

MINIMISING CARDIOVASCULAR RISK

An early assessment of overall vascular risk, followed by interventions to reduce or eliminate treatable risk factors, such as blood pressure, smoking and lipid profile, should be an integral part of the management of type 2 diabetes.

IMMEDIATE ADMINISTRATIVE TASKS

The urgency of addressing these needs depends upon the patient’s circumstances and clinical status.

EARLY ASSESSMENT AND MANAGEMENT

The newly diagnosed type 2 patient requires an early full assessment to detect diabetes complications and cardiovascular risk factors, to identify any specific needs and to tailor management to these findings. This can be done either in the next available diabetic clinic session (if held regularly) or over a series of appointments. The components of the full periodic review are the basis of this assessment, which does need to be more comprehensive to establish a baseline. Additional information gathering will be dictated by the clinical situation. The structure of this assessment involves history, examination, investigations and administrative tasks (see Table 7.2), and will form the basis of the patient’s management plan. Optimal outcomes are more likely if the patient understands and agrees with the aims and methods. The familiar acronym RAPRIO (reassurance, advice, prescription, referral, investigations, observation) provides a useful framework to organise management interventions.

TABLE 7.2 Components of a full assessment of a newly diagnosed patient with type 2 diabetes

History

Symptoms that may be related to diabetes complications: visual disturbance, angina, foot problems, sensory disturbances, diarrhoea, infections (balanitis, candidiasis) and male impotence

History and treatment of any other conditions

Lifestyle (i.e. smoking, alcohol consumption, exercise, diet, other substance use)

Family history of diabetes and/or vascular disease

Social circumstances (e.g. occupation, others at home, cultural factors, health beliefs)

Mental status (e.g. cognitive function, affect – including any features of depression)

Examination

Height and weight to give BMI (kg/m²) and/or record waist circumference

Blood pressure: sitting and standing

Feet: sensation, pulses, skin lesions

Eyes: visual acuity, lens, fundus via dilated pupils

Oral examination

Thyroid palpation

Cardiac examination and peripheral pulses

Abdominal examination (e.g. for hepatomegaly and arterial bruits)

Neurological examination (e.g. for neuropathy)

Investigations

Serum biochemistry: urea and electrolytes (including eGFR), liver function

Serum total cholesterol, lipoprotein fractions and triglycerides

Thyroid function tests

Urinary albumin–creatinine ratio (ACR)

Administrative tasks

Add to diabetic and annual influenza immunisation registers

Invite for pneumococcal immunisation if never administered before or for repeat immunisation either if with another immuno-comprising problem (see BNF) or if over 64 years of age and had previous immunisation more than 5 years previously

Sign the FP92A form, available from chemists, for free prescriptions (patients on insulin or an oral hypoglycaemic are eligible). This is sent to the Health Authority, which issues the patient with an exemption certificate

Advise any drivers that they must notify the DVLA in Swansea that they are now a diabetic and document this advice in their notes. Drivers should also be advised to notify their motor insurance company

Recommend joining Diabetes UK, which can advise on various issues

For patients who are started on hypoglycaemic medication, ensure that they always carry instant sugar and a card to indicate that they are diabetic, what treatment they are on and instructions for dealing with hypoglycaemia

Update repeat prescription and medication review data

THE PERIODIC REVIEW: WHAT SHOULD IT CONTAIN?

Although each professional encounter with a diabetic patient provides an opportunity to address any current or potential problems related to lifestyle, glycaemic control, cardiovascular risk, diabetes complications or living with the disease, a systematic regular review ensures that no important aspect of diabetes care is overlooked for all recalled patients on a practice’s diabetes register.

Deciding what to include in the periodic review needs to take into account the following:

• Components that will contribute to achieving the most important aims of diabetes care for all patients with diabetes: optimising glycaemic control, minimising cardiovascular risk, minimising diabetes complications and enabling the patient to live with and better self-manage his disease.

• What will enable practices to achieve their maximum QOF points?

• What can be delivered effectively using the current resources of the practices, without detriment to other aspects of patient care?

A suggested list of the essential components for a periodic review is given in Table 7.3. Accurate recording of what is measured is essential.

It is essential, if attempting to achieve optimal outcomes for diabetics, that patient-centred care is both delivered by appropriate members of the team and based upon a “structured, protocol-driven, multi-factorial approach” (Marshall & Flyvbjerg 2006). To avoid fragmenting care by focussing upon specific risk factors and/or complications to the exclusion of all relevant components, it is useful to remember the “Alphabet Strategy” (Lee et al 2004):

• Advice (patient education)

• Blood pressure reduction

• Cholesterol (total and LDL-C)

• Diabetes control

• Eye care

• Feet care

• “Guardian drugs” for CVD prevention: aspirin (in most), statin (in most), ACE/ARB (in many), unless contraindicated.

REFERRALS OUTSIDE THE PRIMARY HEALTHCARE TEAM

Although indications and mechanisms of referral to specialists (mainly secondary care) are discussed throughout the previous sections, a quick reference summary (not exhaustive) is provided in Table 7.4. Patient safety must remain paramount: clinicians should recognise the limits of their own competence and act accordingly.

TABLE 7.4 Summary of possible indications for referral to specialist care

MEASURING PERFORMANCE: AUDIT

WHAT IS AUDIT?

NSF

“Audit is the process of looking critically and systematically at our own professional activities with a view to improving personal/practice performance and the quality and/or cost effectiveness of patient care” (Fraser 1982). Guidance for undertaking clinical audit has been set out in Principles for Best Practice in Clinical Audit, published in March 2002 (NICE QUIDS 2002). Quality Indicators for Diabetes Services (QUIDS) has developed an audit methodology “appropriate for measuring the clinical quality performance of population based (primary and secondary care) routine, continuing diabetes care”. The final report commissioned by NICE, Diabetes UK and the NHS Executive Northwest, is now available (NICE CHI 2002) and complements the Diabetes Information Strategy.

STAGES OF CLINICAL AUDIT, AS APPLIED TO DIABETES CARE

The process is divided into five stages, although not all of the steps in each stage are needed in every audit:

1. Prepare for audit

The steps involved include:

• Involve users (staff, patients) in the process.

• Topic selection, influenced by the team’s interests and requirements, and by clinical governance considerations (local and NSF). Table 7.5 suggests aspects of diabetes care that may be suitable for audit, alongside the periodic review.

• Define the purpose of the audit (“to improve, to enhance, to ensure or to change”).

• Provide the necessary structures so that audit is an integral part of the team’s work.

• Identify and provide the skills, people (including training) and resources required.

TABLE 7.5 Aspects of diabetes care suitable for audit (Griffin & Kinmouth 1997)

Criteria group	Suitable examples
1. Structures (resources required)

Availability of specific items (e.g. a large sphygmomanometer cuff, protocol)

Availability of specific facilities (e.g. dark room for fundoscopy, educational resources, protected time for reviews)

Practice diabetic register: does the practice’s prevalence equal the local estimate? What is the ethnicity of the diabetic population?

Training for team members

2. Processes (actions and decisions taken by practitioners together with users)

Appointments – waiting times and default rate

Record in the notes of checks of parameters for periodic review agreed in the practice protocol

Uptake of influenza and pneumonia vaccination in type 2 patients

Information given to patients as part of their education

3. Outcomes (measures of the physical or behavioural response to an intervention, reported health status or level of knowledge and satisfaction); some of these can be used as performance indicators to measure progress in:

• medication and diet

• implementing the NSF

• meeting the St. Vincent Task

Force objectives

Results of parameters checked

Complications, e.g. registrable blindness, renal failure, lower limb amputations

Significant events (e.g. referrals, emergency hospital admissions, deaths, incidence of myocardial infarction)

Levels of patient knowledge about self-monitoring

Days off work

Quality of life

2. Select criteria

A criterion (plural criteria) is an explicit statement that defines the element of care that is being measured. “Valid” criteria should be based upon evidence and related to aspects of care important to the team and/or patient. Criteria can be classified into three groups:

1. Structure (what is needed)

2. Process (what is done)

3. Outcome of care (what is to be expected).

Standards are the percentage of events that should comply with the criterion (Baker 1995). If standards are set, they need to be agreed by the team, based upon relevant high-quality research evidence (if available) and realistic (current targets for glycaemic control, lipids and blood pressure are not always attainable). As the aim of the audit is to improve care, standards may be reset just above the predicted level of performance.