Primary care has a pivotal role in ensuring that all people with diabetes mellitus receive effective diabetes care. This is recognised by the inclusion of clinical indicators for diabetes in the Quality and Outcomes Framework (QOF).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.

Organisation

• Each practice should have a named clinical lead for diabetes but everyone in the primary healthcare 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 be computerised and 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 prevention or reduction of 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 (see The Newly Diagnosed Diabetic record).
  • Initial and ongoing education, including dietary advice.
  • Continuing care (see separate record Assessment of the Established Diabetic).
• 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 whom to contact for help and advice, including at any time out of surgery hours.
• Diabetes audit.

Education, training, personal and practice development

See separate article: Diabetes Education and Self-management Programmes.

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 patient with established diabetes.
  • See separate record: Management of Type 1 Diabetes.
  • See separate record: Management of Type 2 Diabetes.
  • Prevention of coronary heart disease in diabetes; attention to all cardiovascular risk factors.
  • 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.
• Record keeping and administration, including the maintenance of personal diabetes records, a diabetes register and a call/recall system.

Quality and Outcomes Framework 2009/2010³

Records

The practice can produce a register of all patients aged 17 years and over with diabetes mellitus, which specifies whether the patient has type 1 or type 2 diabetes: 6 points.

Ongoing management

The percentage of patients with diabetes:

• Whose notes record BMI in the previous 15 months: 3 points (payment stages 40-90%).
• Who have a record of HbA1c or equivalent in the previous 15 months: 3 points (payment stages 40-90%).
• In whom the last HbA1c is 7 or less (or equivalent test/reference range depending on local laboratory) in the previous 15 months: 17 points (payment stages 40-50%).
• In whom the last HbA1c is 8 or less (or equivalent test/reference range depending on local laboratory) in the previous 15 months: 8 points (payment stages 40-70%).
• In whom the last HbA1c is 9 or less (or equivalent test/reference range depending on local laboratory) in the previous 15 months: 10 points (payment stages 40-90%).
• Who have a record of retinal screening in the previous 15 months: 5 points (payment stages 40-90%).
• With a record of the presence or absence of peripheral pulses in the previous 15 months: 3 points (payment stages 40-90%).
• With a record of neuropathy testing in the previous 15 months: 3 points (payment stages 40-90%).
• Who have a record of the blood pressure in the previous 15 months: 3 points (payment stages 40-90%).
• In whom the last blood pressure is 145/85 or less: 18 points (payment stages 40-60%).
• Who have a record of microalbuminuria testing in the previous 15 months (exception reporting for patients with proteinuria): 3 points (payment stages 40-90%).
• Who have a record of estimated glomerular filtration rate (eGFR) or serum creatinine testing in the previous 15 months: 3 points (payment stages 40-90%).
• With a diagnosis of proteinuria or microalbuminuria who are treated with ACE inhibitors (or A2 antagonists): 3 points (payment stages 40-80%).
• Who have a record of total cholesterol in the previous 15 months: 3 points (payment stages 40-90%).
• Whose last measured total cholesterol within the previous 15 months is 5 mmol/l or less: 6 points (payment stages 40-70%).
• Who have had influenza immunisation in the preceding period 1 September to 31 March: 3 points (payment stages 40-85%).

Document references

1. Department of Health; Quality and Outcomes Framework (QOF)
2. Care recommendations - The provision of services in primary care, Diabetes UK
3. British Medical Association; Quality and Outcomes Framework guidance; March 2009.

Internet and further reading

• Diabetes guidelines, NICE; various dates
• Diabetes, National service frameworks and strategies, NHS Choices

Acknowledgements