Managing Diabetes In General Practice

Primary care has a pivotal role in ensuring that all people with diabetes receive effective diabetes care. This is recognised by the inclusion of clinical indicators for diabetes in the Quality and Outcomes Framework.¹ Many patients with diabetes are now managed solely or mainly in primary care. Some groups of patients are usually better followed up by a specialist team, including:

• Children and young people with diabetes
• Women with diabetes who are considering pregnancy or who are already pregnant
• Any person with diabetes for whom specialist advice is required for the management of metabolic control, cardiovascular risk factors or diabetic complications
• People with complex psychological problems, e.g. difficulty coping

• Each practice should have a named clinical lead for diabetes but everyone in the primary health care team, both clinical and non-clinical, has a key role in the management and support of patients who have diabetes.
• Patient care involves both organised reviews within designated diabetes clinics, often run by a lead practice nurse, and day to day care of patient needs, both directly related such as treatment issues or indirectly related such as the increased frequency and longer duration of infections.
• Practice registers:
  • Should ideally be computerised
  • Used to facilitate the call and recall of:
    • People at increased risk of developing diabetes, e.g. those with insulin resistance, so that they can be offered ongoing support to help them reduce this risk as well as appropriate surveillance for diabetes.
  • People with diagnosed diabetes for regular reviews
  • Practices should also have systems in place for following up non-attenders
• Practice guidelines should include:
  • Prevention of Type 2 diabetes: system for identifying people at increased risk of developing diabetes and offering them appropriate advice on how to reduce this risk, including increasing physical activity levels, promoting healthy eating and preventing and reducing overweight and obesity.
  • Identification and diagnosis of people with diabetes: a high index of suspicion is required for the early diagnosis of people with Type 2 diabetes.
  • Initial assessment and care at diagnosis
  • Initial and ongoing education, including dietary advice
  • Continuing care
• Individual patient care should include:²
  • Clear patient centred individualised care plans agreed with each person with diabetes
  • An agreed named health professional contact. The person with diabetes and their family or carer should know exactly who to contact for help and advice, including at any time out of surgery hours.
• Diabetes audit

There are separate articles discussing:

• The Diabetes Education and Self Management for Ongoing and Newly Diagnosed (DESMOND) project
• The Dose Adjustment For Normal Eating and Exercise (DAFNE) project

Members of the primary healthcare team involved in the provision of diabetes care need to be trained in:²

• Communication skills: including skills in behavioural change counselling to motivate change and to negotiate and agree goals.
• Provision of education, information and support: including the ability to impart the necessary knowledge, motivation and self-care skills to enable people with diabetes to take responsibility for their own healthcare.
• Diagnosis and examination: including the identification of the complications of diabetes
• Clinical management, including:
  • Assessment of the established patient with diabetes
  • Management of Type 1 diabetes
  • Management of Type 2 diabetes
  • Prevention of coronary heart disease in diabetes
  • Ongoing management, including diet and exercise, oral hypoglycaemics, insulin regimes and the management of diabetes during intercurrent illness.
  • Management of acute complications, e.g. hypoglycaemia, ketoacidosis
  • Management of long-term complications, e.g. eye complications
  • Associated conditions, cardiovascular risk factors; primary prevention and secondary prevention of cardiovascular disease
• Record keeping and administration, including the maintenance of personal diabetes records, a diabetes register and a call/recall system.