Primary diabetes care: yesterday, today and tomorrow

Yesterday

General practitioners (GPs) in the United Kingdom were among the first to see that they could manage many aspects of diabetes care in their own practices. The pace for providing this care was initially slow, but eventually many innovative schemes were described and initiated. The 1965 GPs' Charter was to prove a watershed for general practice. The Charter recommended better education, reimbursement for staff and premises, and pay that reflected workload, skills and responsibilities. Following this, GPs began to work in health centres or purpose built premises. They also recognised the importance of working in partnerships and with nurses who were initially ‘attached’ to practices but went on to develop a role as practice nurses. This relationship was later to prove very important for the primary care management of diabetes.

There was very little evidence of organised diabetes care in general practice throughout the first 25 years of the National Health Service (NHS). In 1973, Wilkes described how he ran a diabetes clinic in his own practice. In his conclusion he suggested that ‘diabetes could be looked after by the family doctor’.1 Also in 1973, Thorn and Russell described 14 general practice diabetes clinics in the Wolverhampton area, and introduced the concept of mini clinics in general practice.2 Like Wilkes, they proposed that ‘general practice seemed the proper place to look after many diabetics, allowing the GP to become increasingly competent in diabetes care’. From the perspective of the hospital diabetes clinics at the time, there was also a realisation that a full service could not be provided in overcrowded clinics.3

In 1989, the St Vincent Declaration4 inspired many primary care workers, and led on to the development of Primary Care Diabetes UK, which became a full section of the then British Diabetic Association.5 If the 1965 GP Charter was a watershed for GPs, then the 1990 General Practice Contract, and the NHS health reforms a year later, saw a fundamental change for primary care in the UK.6

This contract was further modified in 1993, with the introduction of financial incentives for health promotion and chronic disease management of diabetes. By the mid 1990s most GPs were working in partnerships, in collaboration with practice nurses, health visitors, district nurses, and practice and fund managers, and were supported by large numbers of ancillary staff. An enhanced role for nurse practitioners was actively promoted and many practices now have direct access to a variety of community and hospital based services, including specialist nurses.7

Around this time the importance of critically appraising the evidence for practice diabetes activity was realised and Kinmonth and Greenhalgh reviewed schemes that had been reported suggesting ways in which primary diabetes care could be enhanced.8, 9

Primary care was developed further in December 1997 when the Government published a White Paper entitled The new NHS modern and dependable.10 This set primary care groups at the centre of a reformed NHS, but by publishing separate white papers for each region of the UK,11-13 may also have signalled the fragmentation of the NHS.

Today

In the years around the millennium, as the responsibility for the routine recall and review of people with diabetes shifted to primary care, the debate about ways of providing diabetes care moved on from primary versus secondary diabetes care to examining aspects of quality of care and raising standards in primary care. These discussions took place against a background of rising numbers of people with diabetes.

Contemporary surveys have established that GPs are now providing a significant amount of care for up to 75% of their patients with diabetes.14, 15 These surveys showed that whilst chronic disease management had been a catalyst for change it had brought only a minimum of investment or support, which was not uniform. They also established the important role for practice nurses in running diabetes clinics and organising diabetes care in practice.

The United Kingdom Prospective Diabetes Study (UKPDS) remains the most important study, the evidence and cost-effectiveness of which changed GPs' practice16, 17 and underlined that people with diabetes, especially in areas of socio-economic deprivation or with large ethnic minorities, were not dying from the metabolic consequences of diabetes but from heart attacks and strokes. With type 2 diabetes being redefined as ‘a state of premature cardiovascular death’, the emphasis of care moved to aggressive treatment of blood pressure and other risk factors.18

Evidence is increasing that control of hyperglycaemia, hypertension and dyslipidaemia may postpone the development of diabetic complications in patients with type 2 diabetes. There is also good evidence for antiplatelet treatment, for coronary artery bypass grafting – rather than percutaneous transluminal coronary angioplasty – and for lipid regulating therapy. In a Dutch study in primary care, structured individualised personal care with educational and surveillance support for GPs reduced levels of risk factors in type 2 patients after six years.19

This growing body of evidence has in turn helped to inform evidence-based guidelines for the management of diabetes. The Scottish Intercollegiate Guideline Network (SIGN), National Institute for Clinical Excellence (NICE) and American Diabetes Association (ADA) guidelines have helped GPs to understand aspects of patient management. Although published separately, they have widely concurred on patient management – especially in the prevention of cardiovascular complications.

In the 1997 contract, national service frameworks (NSFs) were to be a fundamental part of the modernisation agenda for the NHS. It was intended that these NSFs would, through the evidence-based standard setting, identify cost-effective interventions as well as a timetable for action, thereby reducing variations in care that occur between different geographical areas or sections of the population.

The first NSF document to appear was the Scottish Diabetes Framework published in November 2001.20 This was followed by the NSF for Diabetes in England, which was published in two stages: the standards document was published in December 2001,21 followed by a delivery strategy containing milestones for implementation in January 2003.22 Subsequently, the Welsh Diabetes Framework Committee published similar implementation guidelines.23 In Northern Ireland, the Northern Ireland Taskforce for Diabetes published in broadly similar joint Clinical Resource Efficiency Support Team/Diabetes UK (CREST/DUK) guidelines in November 2002.24

Six years on from the publication of the NHS white papers10-13 there has been a lot of activity in terms of the acceptance of a growing diabetes evidence base, recognition of the developing epidemic of diabetes and the setting of standards, with local and national variations within the NHS. There is, however, some recognition that, in spite of the wide dissemination of standards and the acceptance of guidelines, it is much harder in practice to implement these guidelines in both primary and secondary care.25

In June 2003, GPs voted for a new GP General Medical Services (GMS) contract. It is hoped that over the next two years this contract may deliver many of these quality indictors by rewarding recording of data and thereby enhancing standards following an audit cycle of continuous improvement.

Tomorrow

In referring to the influence of information technology William Gibson has said that ‘the future is here already, it is just not widely distributed’.26 This was certainly the case for the early general practice diabetes clinics described in the 1970s. Many in primary care are hoping that the new GP GMS contract will be the catalyst to deliver the uniform quality agenda, which is needed in primary diabetes care.27 Practice nurses will remain the cornerstone of these diabetes reviews, supported, especially in prescribing and clinic management, by GPs who may have increasing knowledge and expertise in diabetes.

The epidemic of obesity seen in the United States is increasing in the UK and in many other countries. Concurrent with this epidemic is an increase in the incidence of type 2 diabetes and this trend is likely to continue and develop. This will make metabolic diseases an important part of the work of hospital and primary care health care professional alike.

It is likely that examination of the human genome will allow scientists to define more types of diabetes, as well as subtypes within type 1 and type 2 diabetes. Examination of the individual's genetic profile at birth, coupled with evidence for earlier intervention in diabetes, may lead to much earlier treatment or active prevention of diabetes.

As the burden of diabetes care develops it would be hoped that many more active interventions would become available in primary care. The late 1990s saw the introduction of the thiazolidinediones, the metaglinides and the much wider use of insulin in type 2 diabetes. These trends in therapeutic interventions are set to continue with new delivery mechanisms for insulin, and more varied thiazolidinediones. Also it would be hoped that there would be a mechanism for the wider dissemination of drugs for addressing cardiovascular risk such as newer antihypertensives and ‘superstatins’, as the epidemic of diabetes will also bring many cardiovascular problems. In type 1 diabetes it is to be hoped that islet cell transplantation and stem cell research will bear useful fruit in the management of type 2 diabetes.

Health care professionals in the early decades of this century may wonder why we did not do more to implement the already clear evidence of the importance of lifestyle interventions in diabetes. This is particularly so for increased physical activity in the prevention and treatment of diabetes. As the evidence for prevention grows, so does the case for screening for diabetes. This is likely to be undertaken in primary care, but will need to be carefully considered and adequately funded to make the exercise worthwhile. Perhaps governments will move on from the successful tax on tobacco to a tax on fatty and sugary foods as a way of both preventing excess consumption of these foods, and giving financial support to those trying to prevent and deal with the diabetes and obesity epidemic.

The debate, which began in the 1990s, as to who should follow up people with diabetes, and where they should be cared for, is bound to continue as numbers escalate and people with diabetes live longer. The increasingly frail and national diversified structures of the NHS may weaken it further. It is difficult to see universal free health care continuing far into this century, but it is to be hoped that care for people with diabetes will continue free at the point of delivery in the UK as many people with diabetes will be old or very old. Diabetes UK will have an increasingly important role as a patient advocate group and it should also become more active in patient information and management. The threat of type 2 diabetes being seen as a lifestyle disease will remain.

Information technology and technological advances have had less impact on metabolic disorders than other medical disciplines such as cardiology or radiology. This may change with more sophisticated delivery mechanisms for insulin and other drugs becoming available. Follow up of large numbers of patients will be a problem. More sophisticated ways of storing patient data on databases may become available although, due to data protection law, this is likely to remain local to practices rather than becoming available as national diabetes registers. The wide dissemination of mobile telephones in the last decades was not expected or predicted, nor was the popularity of sending text messages. Follow up of patients has not kept pace with these developments. Sheer numbers of patients may make follow up by telephone technology more widely acceptable as it is disseminated through all age groups in society.

This raises the question of what are the key skills needed for patient empowerment. In primary care we feel that the ability to empower patients through a skilled consultation is our fundamental skill. In future, people with diabetes may be much better informed as evidence becomes widely disseminated and available. In turn, this may empower them to share decision making on their diabetes care with their health care professional – and hopefully thereby improve patient concordance with an increasingly complex drug and or physical activity regimen.