Diabetes Care Progress Report: Shows Promise, Could Do Better The importance of diabetes as a health problem has been recognized nationally and internationally: the Saint Vincent Declaration of 1989' established both general goals for people with diabetes and five-year targets, and the problem of diabetes has been highlighted in the recent government publication 'The Health of the Nation'.2 There have been major improvements in diabetes care in the last 10-20 years, especially in the management of chronic complications: for example, patient education, more effective use of antibiotics, and improved surgical management have reduced the need for major amputation^;^ because of the availability of chronic ambulatory peritoneal dialysis and renal transplantation, people with diabetes need no longer die is largely preventable of chronic renal f a i l ~ r e blindness ;~ with appropriate use of laser treatment5 and a teamwork approach has changed the outlook in diabetic pregnancy.6 Large sums of money have been invested in the teamwork approach to diabetes which i s increasingly focused upon diabetes specialist nurses, dietitians, and chiropodists as educators, while doctors have generally found themselves concentrating on medical aspects of management. General practitioners in association with practice nurses, have been encouraged to become much more involved in diabetes and many GPs now run their own diabetes mini-clinics. There appears to be increasing pressure to shift responsibility for 'routine' management of people with diabetes to the primary care system. At the same time, there has been major capital investment in diabetes centres most of which are located in or near hospitals and which provide open access for patients and are aimed at prevention of problems through education and self care. But, has all this investment in manpower, new technology for the treatment of complications, and changed approach to management shown any signs of benefit and where should we focus our attention in the future? There is now good evidence that mortality from Type 1 (insulin-dependent)diabetes i s declining.' This, in part, is a consequence of a reduction in the incidence of nephropathy.8 However, the fall in mortality is not simply a consequence of fewer deaths due to chronic renal failure but is partly related to reduction in mortality due to ischaemic heart disease: in people with Type 1 diabetes and proteinuria up to 40 % of deaths under the ~ age of 50 are due to cardiovascular d i ~ e a s e . The
Correspondence to: Professor S. Tornlinson, Manchester Diabetes Centre, 130 Hathersage Road, Manchester, M13 OHZ, UK.
relationship between proteinuria and coronary artery disease is not clear; it may be related to dyslipidaemia or changes in mechanisms of blood coagulation and/or thrombolysis. Data from death certificates mentioning diabetes in the UK during 1985-86 compared with 1975-76 have shown a 3.5 % increase in men over 45 and an 11.5 % decrease in women. In contrast, in men under 45, deaths from diabetes appeared to fall by 30.7 % and in women less than 45, by 26.7 %. This fall may be a result of increased acceptance of people with diabetes onto renal replacement programmes but it may also reflect the decline (18.4 % in men and 23.5 % in women) in cardiovascular deaths in this age group. In contrast, in the over 45 age group mortality from ischaemic heart disease associated with diabetes increased by 15 % in men, and changed little in women. l o Thus, direct and indirect evidence suggests that although life expectancy is still reduced, mortality from Type 1 diabetes has declined. In Type 2 (noninsulin-dependent) diabetes, on the other hand, there has been a lack of improvement in the average reduction in life expectancy; this remained between 7 and 8 years for people diagnosed between the ages of 40 and 59 and between 3 and 6 years for those diagnosed over the age of 60 between the years 1975 and 1988.'' As with Type 1, the causes of coronary artery disease in Type 2 diabetes have not yet been defined but they may be multifactorial and include obesity, dyslipidaemia, and hypertension, as well as the hyperglycaemiaof diabetes.12 There is, therefore, still a great deal to do, especially to improve the outlook for people with Type 2 diabetes. The task is daunting: up to 40 % of people with Type 2 present with complications and there may be as many people with undiagnosed Type 2 diabetes in the population as there are with diagnosed Type 2 diabetes. The increasing emphasis on the management of Type 2 diabetes in general practice and the encouragement of health promotion clinics which involve screening for cardiovascular risk factors such as dyslipidaemia, obesity, and hypertension, as well as diabetes, has resulted in a very large increase in the number of people referred with diagnosed Type 2 diabetes; for example, at The Manchester Diabetes Centre, the number of people with Type 2 diabetes on the register has increased by almost 20 % (306 patients) in the last year (of whom 40 % are from ethnic minorities) compared with just over 10 % for people with Type 1 diabetes (107 patients). The average number of new referrals with Type 2 diabetes is now 40 per month and it is becoming increasingly difficult to provide high quality care, especially in relation
@ 1992 by John Wiley & Sons, Ltd.
DIABETIC MEDICINE, 1992; 9 : 590-591
DT17 to education and dietetic support. Many patients are disadvantaged because they are from social classes 4 and 5 or from ethnic minorities, or because they are elderly and frail. If we are going to aim for a complicationfree life, more active and more preventional care than has been traditional for people with Type 2 diabetes in the past is essential. There is also a need for careful thought about the respective roles of primary care and hospital clinics or diabetes centres. More effective integration, especially with regard to definition of responsibility is essential. As we look towards a more integrated approach to the delivery of care for people with diabetes, especially those with Type 2 diabetes, we must begin to develop a more organized and structured approach to diabetes education for health care professionals. Increasing specialization and the concentration of diabetes care by specialists in diabetes centres can reduce opportunities for education for undergraduate medical students, junior doctors, nurses, dietitians, and chiropodists; moreover, as GPs and practice nurses become more involved in a variety of health promotion clinics there is a risk of professional isolation and the time available for GPs to undertake clinical assistanceships in diabetic clinics becomes less. But many of these problems present us with opportunities; the concentration of diabetes services in a diabetes centre, for example, might allow undergraduate medical students and junior hospital doctors greater flexibility to attend sessions than the traditional once- or twice-weekly diabetic clinic. Likewise, study days for nurses, dietitians, and chiropodists are relatively easy to organize from a diabetes centre and are much in demand. Throughout the country there has been increasing effort to provide education for practice nurses; at The Manchester Diabetes Centre we began to provide weekend courses for practice nurses almost 2 years ago and expected to have perhaps three or four in the first year, but we are now running one a month. Many Family Health Services Authorities (FHSAs) are very keen to encourage practice ‘nurses to attend such courses. However, one-off courses are not enough; nurses want continuing education and we are now planning regular workshops as well as putting together a distance learning package which will complement a package for GPs which is currently being piloted. Many GPs are becoming increasingly enthusiastic about diabetes care and are happy to become involved in audit. The Manchester Medical Audit Advisory Group has developed a diabetes audit programme called ‘Diabetes 2000’ and in less than a year almost half the
EDITORIAL Manchester GPs have ‘come on board’. Thus there is an enormous amount of activity, commitment, and enthusiasm. However, the quality of these educational initiatives may vary and there is undoubtedly a need for some kind of monitoring process, perhaps even endorsement or validation of courses. The British Diabetic Association is well placed to undertake this task.
S. Tomlinson Manchester Diabetes Centre, Manchester, UK References 1.
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