Dm
ROSTRUM
The Role of the General Practitioner in Diabetes Care 1. J. Benett The Alexandra Practice, Moss Side, Manchester, UK
KEY
WORDS Diabetes care
Introduction General practitioners (GPs) -began to take an increasing responsibility for the care of diabetes in the 1970s.’ The enthusiasm for general practice mini-clinics grew with the realization that metabolic control could be as good or as poor in this context as that found in hospital clinics.* Editorials began to appear in the British Medical journal and later in the journal of The Royal College of General practitioner^^,^ advocating a cautious move towards greater involvement of GPs in care of their patients with diabetes. This system of care was further encouraged by the provision of additional payments for clinics that came from the New C ~ n t r a c tIn . ~its document ‘The Health of the Nation’,6 the government also envisaged a greater role for GPs in diabetes care by ’encouraging increasing numbers to follow locally agreed protocols’. Alberti,’ commenting on this consultative document, pays scant attention to the role of the general practitioner and suggests that ‘there is a real danger that some patients will be kept in general practice and not receive optimal or even minimal care because of the new funding arrangements’. It is therefore time to examine the emerging role of GPs in the care of diabetes. There are two main approaches to the assessment and care of chronic disease. Firstly, there is the epidemiological approach. This seeks to measure clinically important outcomes at a population level, and by a process of intervention to improve the rates of those outcomes. The success or failure of interventions are tested by controlled, preferably double-blinded, clinical trials. The second approach is an individual, more holistic one. It recognizes that a disease is only one of the influences that contributes to illness. McWhinney suggests that illness is a very subjective experience and describes it as ‘all the sensations of the patient and all the ramifications of hidher disorder. It includes her symptoms, her feelings, her disabilities and discomforts, her defences and supports, her weaknesses, her attitudes to her condition and to the physician, and the effect of her disorder on relationships and her work’.8 Healing may involve curing the disease if that is possible, but for chronic diseases like diabetes, Correspondence to: Dr I. J . Benett, The Alexandra Practice, 2 Whitswood Close, Alexandra Park, Manchester M 1 6 7AW, UK.
0742-3071 /92/080769-04$07.00 0 1992 by John Wiley & Sons, Ltd.
General practice Mini-clinics
it means having a clearer understanding of what it is that
is making that particular individual ill. It therefore necessitates the understanding of that person at the emotional level, and understanding their beliefs about their illness. These two approaches can be reconciled, but are often in conflict. Interventions can make people ill by their side-effects but also by diminishing their independence and control. It i s therefore important that unless interventions have been shown to be of benefit, they should not be used. There is a further important point: even if an intervention has proven benefit at a population level, the costs to the individual also need to be assessed, and may be considered too high a price to pay for the potential benefit. These costs may be emotional, social, and psychological, as well as physical and financial.
Priorities for Diabetes Care in General Practice The role of the GP is to focus at the individual level within the context of the likely efficacy of interventions. The first priority should be to address the anxieties, fears, concerns, and beliefs of the patient. This requires a trusting relationship and highly developed consultation skills. McWhinney argues that empathy and love are also central to this process and to the ensuing process of healingg The patient’s agenda needs to be explored. Such questions as: why me?, why now?,’O questions of mortality and the prospect of disability are often raised. Deeper concerns, such as the contribution of sin and other health beliefs cannot be addressed unless uncovered. One patient wondered if his diabetes was a consequence of an extra-marital affair; another that her disease resulted from a road traffic accident. Others are concerned about such practical things as the higher premiums on life insurance and the supposed restrictions on driving. Examples of the emotional consequences of diabetes are the grieving over the loss of independence that comes with needing insulin injections, or the despair at becoming blind despite careful glycaemic control, or the anger towards God, society, and parents when newly diagnosed. The second priority is to reassert the patient‘s autonomy and self-esteem. This is the central aim of appropriate
769 DIABETIC MEDICINE, 1992; 9: 769-772
DrT7
ROSTRUM education, but it requires more than this alone. The doctor needs to show that the individual patient is valued as a person, that their feelings are identified with, and that there is a genuine concern for their well-being. People with diabetes are no longer diabetic patients, they are fellow humans with the right to be in control of their own illness, and to be able to make their own choices about their management and their future. They may well wish to share the decision-making with their doctor who in turn should be prepared to negotiate rather than dictate what should be done. It means a realignment of the power between doctor and patient so that interactions can be shared on an equal basis.” The third priority is to avoid harm. Avoiding hypoglycaemia and drug interactions are obvious. Much more subtly, doctors can engender feelings of guilt, failure or rejection. This can happen quite unintentionally, for example, when an overweight person is persistently told they must lose weight when they can not; or when it is implied that renal failure has been the result of careless blood glucose monitoring; or when insisting on giving up smoking when it is their only comfort. It may do less harm, occasionally, to give ‘permission’ to continue doing something ’bad’ for the time being, than to insist on unrealistic changes in lifestyle. These may need to be negotiated gently and tactfully, bearing in mind the realities of the individual’s circumstances. There is good evidence that early identification of microvascular complications prevents diability if acted upon promptly.12-14 The fourth priority must therefore be the regular review of people with diabetes for the development of such complications. The main cause of There is, however, mortality is coronary heart disease. l5 no evidence that any intervention improves coronary mortality in the population with diabetes. Risk markers have been identified l6but intervention trials have only been performed on the general population. Even these have been inconclusive and doubt has been cast upon their value. l7Only treatment of mild hypertension with and hypercholesterolaemiawith diuretics in the elderly, l8 diet l9have been shown to improve all-cause as well as coronary mortality. It may well be premature to conclude that more aggressive interventions are any more likely to be effective in people with diabetes. The case for meticulous metabolic control in diabetes, with its costs in diminished autonomy and risk of doing harm, is less persuasive. There seems to be a clear relationship between poor glycaemic control and the development of microvascular complications but not for macrovascular complications.20 However the only intervention trials that have demonstrated the possibility that complications can be prevented2’ have all been based on small numbers of Type I diabetic patients who have used continuous subcutaneous insulin infusion. The analysis of these results has been criticized. 22 The outcome of the large Diabetes Control and Complications Trial in the USA is keenly awaited. The cost of meticulous glycaemic control, particularly of the risk of 770
hypoglycaemia, for the potential benefit may be too high for those with Type I diabetes. Similarly, in Type II diabetes, euglycaemia may be an unachievable objective except for a few on diet management alone. The only randomized trial, exemplary in its methodology, and notwithstanding the ensuing controversy, suggested that tolbutamide resulted in more vascular deaths than placebo or insulin treatment.23The controversy remains to this day, but results of the United Kingdom Prospective Diabetes Study, due to finish by 1995, should help resolve which interventions are best able to prevent complications in these patients. The argument for early diagnosis of diabetes is supported by the evidence that prompt intervention in established complications can prevent or delay disability. Yet the process of case finding by screening carries its own costs. As well as the obvious financial and opportunity costs, inevitably false positive findings create illness; indeed the very process of screening can create anxiety irrespective of the results.24These costs need to be justified and balanced against the potential benefits of case finding. The most effective and efficient method of screening i s still to be established. There is little doubt that cessation of smoking is an effective intervention, but it is not without its costs. The evidence that a range of other lifestyle changes can either prevent the onset of diabetes or influence its course is far from proven. There is some support for the proposition that exercise may reduce the incidence of diabetes 2 5 but the evidence that weight loss, or dietary manipulation can do likewise is circumstantial. Some have suggested that obesity may yet be a consequence rather than a cause of insulin resistance.26Others point out that ’good diets’ are unaffordable by those on low incomes, and largely unavailable to those living in deprived, mainly inner city, areas.27Thus while these lifestyle changes may prove to be beneficial, the present evidence may not be sufficient to outweigh the costs of such changes to the individual.
The Place of Mini-clinics Diabetes mini-clinics provide an opportunity for protected time to address the priorities discussed above. There are also risks. The focused nature of the clinic means that there is a tendency to concentrate on the disease rather than on the illness which it creates. Furthermore, the encouragement of muItidisc ipl inary teams diminishes the opportunity for developing a relationship with a single carer and jeopardizes continuity of care. The aims and organization of mini-clinics must take into account these considerations if they are not to become simply community outposts of hospital clinics. For these reasons some practices may find it more appropriate to offer care within ordinary surgery times. However, for this to be as effective as mini-clinics, practices would have to overcome the tendency towards hurried consultations which do not lend themselves to I . I . BENETT
Dm dealing with emotional or psychological issues,28 or to the systematic detection of complications. There is also a tendency for patients to be lost to follow-up.29 It behoves those who choose such care, even if planned, to demonstrate that this method is as effective as miniclinics. In view of the stated priorities of care, there should be no restriction on the type of diabetic patient seen at mini-clinics. Where more technical help is necessary in treatment, education or investigation there is no reason why care should not be shared with the hospital. This may be more likely to apply to patients with Type I diabetes. However, care in General Practice should come to be seen as the natural first option; indeed care that does not include GP involvement should be considered less than ‘optimal or even minimal’.
Conclusions The effectiveness of GP care of diabetic patients is often judged by outsiders without experience of General Practice. Their criteria for good care are the same as used for hospital care, and are usually inappropriate. Priorities of care in General Practice are different: they involve addressing emotional issues, promoting autonomy, and avoiding harm. A shared priority is to identify and treat complications promptly as there is good evidence that this prevents disability. Other interventions are less efficacious and may even be harmful. General Practice care should be judged by how patients feel and on the level of disability, not on other spurious measures of activity or disease control. There are many questions still to be answered which will have a significant influence on diabetes care in general practice. It is important to continue to clarify which interventions are effective at primary, secondary, and tertiary prevention. The most efficient and effective method of early diagnosis is still to be established, and must bear in mind the costs of screening. The health beliefs of people who develop diabetes, particularly in our multicultural society, their main fears, concerns, and anxieties, and the most effective ways of enhancing autonomy and self-esteem are all questions of great importance if a better understanding of the illness is to be developed. Finally, do patients really want a different, holistic approach by their GP, or are GPs simply expected to fulfil the same role as specialists, but in the community? The answers to these questions will have profound implications for the delivery of care by GPs. For example, it may be that the fashion for mini-clinics is inappropriate as they focus too much on the disease rather than on the illness caused by diabetes. They tend to dilute both individual care and continuity of care by encouraging a multidisciplinary team approach. Mini-clinics are probably a good thing, but their aims should be to provide whole-person care, rather than just disease management. This is the challenge to which primary care must rise, or risk being regarded as second THE GENERAL PRACTITIONER IN DIABETES CARE
ROSTRUM rate to the hospital service. It is time for General Practice to assert its distinct identity and role in the care of chronic diseases generally, but specifically in diabetes care.
References 1. Thorn PA, Russell RG. Diabetic Clinics Today and Tomorrow: Mini-clinics in General Practice. Br Med I 1973; 2: 534-536. 2. Singh BM, Holland MR, Thorn PA. Metabolic control of diabetes in general practice clinics: comparison with a hospital clinic. Br Med / 1984; 289: 726-728 3. Home P, Walford S. Diabetes care: Whose responsibility? Br Med I 1984; 289: 713-71 4. 4. Nabarro JDN. Diabetes and the general practitioner. / R Coll Gen Pract 1987; 37: 389. 5. Department of Health and Welsh office. General Practice in the National Health Service: a New Contract. London: HMSO, 1989. 6. Secretary of State for Health. The Health of the Nation. London: HMSO, 1991. 7. Alberti KGMM. The Health of the Nation: responses: Role of diabetes. Br Med / 1991; 303: 769-772. 8. McWhinney IR. An lntroduction to Family Medicine. Oxford; Oxford University Press, 1981. 9. McWhinney IR. A textbook of Family Medicine. Oxford: Oxford University Press, 1989. 10. Hellman CG. Diseases versus illness in general practice. J R Coil Cen Pract 1981; 31: 548-552. 11. Metcalfe D. The crucible (William Pickles lecture 1986). I R Coll Gen Pract 1986; 36: 349-354. 12. British Multicentre Group. Photocoagulationfor proliferative diabetic retinopathy: a randomised controlled trial using the xenon laser. Diabetologia 1984; 26: 109-1 15. 13. Thompson FJ, Veves A, Ashe H, Knowles EA, Gem J, Walker MG, et a/. A Team approach to diabetic foot c a r e t h e Manchester experience. The Foot 1991; 3: 75-82. 14. Bjorck S, Mulec H, Johnsen SA, Norden G, Aurell M. Renal protective effective of enalapril in diabetic nephropathy. Br Med I 1992; 304: 339-343. 15. Morrish J, Stevens LK, Head J, Fuller JH, Jarrett RJ, Keen H. A prospective study of mortality among middle-aged diabetic patients (The London Cohort of the WHO Multinational Study of Vascular Disease in Diabetics) I: causes and death rates. Diabetologia 1990; 33: 538-541. 16. Morrish NJ, Stevens LK, Head J, Fuller JH, Jarrett RJ, Keen H. A prospective study of mortality among middle-aged diabetic patients (The London Cohort of the WHO Multinational Study of Vascular Disease in Diabetics) It: associated risk factors. Diabetologia 1990; 33: 542-548. 17. Oliver MF. Doubts about preventing coronary heart disease. Br M e d l 1992; 304: 393-394. 18. MRC Working Party. Medical Research Council trial of treatment of hypertension in older adults: principle results. Br Med / 1992: 304: 405-41 2. 19. Trusswell AS. The cholesterol controversy (correspondence) Br Med / 1992; 304: 91 2-91 3. 20. Pirart J. Diabetes mellitus and its degenerative complication: prospective study of 4400 patients observed between 1947-1 973. Diabetes Care 1978; 1: 168-1 88. 21. Hanssen KF, Dahl-Jorgensen K, Lauritzen T, Feldt-Rasmussen B, Brinchmann-Hansen 0, Deckert T. Diabetic control and microvascular complications; the near-normoglycaemic experience. Diabetologia 1986; 29: 677-684. 22. Wolff SP. Blood Glucose Concentrations and Progression
771
Drn
ROSTRUM 23.
24. 25.
772
of Diabetic Retinopathy (Correspondence) Br Med 1992; 304: 505-506. The University Group Diabetes Program: A study of the effects of hypoglycaemic agents on vascular complications in patients with adult-onset diabetes. Diabetes 1970; 19: 74 7-830. Nathoo V. Investigation of non-responders at a cervical cancer screening clinic. Br Med I 1988; 296: 1041-1 042. Manson JE, Rimm ES, Stampfer MJ, Coltitz GA, Willett WC, Krolewski IS, et a / . Regular vigorous exercise and incidence of NlDDM in prospective cohort of 87253 US women aged 34-59. Lancet 1991; 338: 774-778.
26.
27.
28.
29.
King H, Dowd JE. Primary prevention of Type II (noninsulin dependent) diabetes mellitus. Diabetologia 1990; 33: 3-8. Lang T, Andrews H, Bedale C, Hannon E. lam Tomorrow. The Food Policy Unit, Manchester Polytechnic. ISBN 0-947866-01 9, 1984. Ridsdale L, Carruthers M, Morris R, Ridsdale J. Study of the effect of time availability on the consultation. / R Coll Cen Pract 1989; 39: 488-491. Hayes TM, Harries J. Randomized controlled trial of routine hospital clinic care versus routine general practice care for type II diabetics. Br Med I 1984; 289: 728-730.
I. 1. B E N E l l
ROSTRUM
The Role of the General Practitioner in Diabetes Care 1. J. Benett The Alexandra Practice, Moss Side, Manchester, UK
KEY
WORDS Diabetes care
Introduction General practitioners (GPs) -began to take an increasing responsibility for the care of diabetes in the 1970s.’ The enthusiasm for general practice mini-clinics grew with the realization that metabolic control could be as good or as poor in this context as that found in hospital clinics.* Editorials began to appear in the British Medical journal and later in the journal of The Royal College of General practitioner^^,^ advocating a cautious move towards greater involvement of GPs in care of their patients with diabetes. This system of care was further encouraged by the provision of additional payments for clinics that came from the New C ~ n t r a c tIn . ~its document ‘The Health of the Nation’,6 the government also envisaged a greater role for GPs in diabetes care by ’encouraging increasing numbers to follow locally agreed protocols’. Alberti,’ commenting on this consultative document, pays scant attention to the role of the general practitioner and suggests that ‘there is a real danger that some patients will be kept in general practice and not receive optimal or even minimal care because of the new funding arrangements’. It is therefore time to examine the emerging role of GPs in the care of diabetes. There are two main approaches to the assessment and care of chronic disease. Firstly, there is the epidemiological approach. This seeks to measure clinically important outcomes at a population level, and by a process of intervention to improve the rates of those outcomes. The success or failure of interventions are tested by controlled, preferably double-blinded, clinical trials. The second approach is an individual, more holistic one. It recognizes that a disease is only one of the influences that contributes to illness. McWhinney suggests that illness is a very subjective experience and describes it as ‘all the sensations of the patient and all the ramifications of hidher disorder. It includes her symptoms, her feelings, her disabilities and discomforts, her defences and supports, her weaknesses, her attitudes to her condition and to the physician, and the effect of her disorder on relationships and her work’.8 Healing may involve curing the disease if that is possible, but for chronic diseases like diabetes, Correspondence to: Dr I. J . Benett, The Alexandra Practice, 2 Whitswood Close, Alexandra Park, Manchester M 1 6 7AW, UK.
0742-3071 /92/080769-04$07.00 0 1992 by John Wiley & Sons, Ltd.
General practice Mini-clinics
it means having a clearer understanding of what it is that
is making that particular individual ill. It therefore necessitates the understanding of that person at the emotional level, and understanding their beliefs about their illness. These two approaches can be reconciled, but are often in conflict. Interventions can make people ill by their side-effects but also by diminishing their independence and control. It i s therefore important that unless interventions have been shown to be of benefit, they should not be used. There is a further important point: even if an intervention has proven benefit at a population level, the costs to the individual also need to be assessed, and may be considered too high a price to pay for the potential benefit. These costs may be emotional, social, and psychological, as well as physical and financial.
Priorities for Diabetes Care in General Practice The role of the GP is to focus at the individual level within the context of the likely efficacy of interventions. The first priority should be to address the anxieties, fears, concerns, and beliefs of the patient. This requires a trusting relationship and highly developed consultation skills. McWhinney argues that empathy and love are also central to this process and to the ensuing process of healingg The patient’s agenda needs to be explored. Such questions as: why me?, why now?,’O questions of mortality and the prospect of disability are often raised. Deeper concerns, such as the contribution of sin and other health beliefs cannot be addressed unless uncovered. One patient wondered if his diabetes was a consequence of an extra-marital affair; another that her disease resulted from a road traffic accident. Others are concerned about such practical things as the higher premiums on life insurance and the supposed restrictions on driving. Examples of the emotional consequences of diabetes are the grieving over the loss of independence that comes with needing insulin injections, or the despair at becoming blind despite careful glycaemic control, or the anger towards God, society, and parents when newly diagnosed. The second priority is to reassert the patient‘s autonomy and self-esteem. This is the central aim of appropriate
769 DIABETIC MEDICINE, 1992; 9: 769-772
DrT7
ROSTRUM education, but it requires more than this alone. The doctor needs to show that the individual patient is valued as a person, that their feelings are identified with, and that there is a genuine concern for their well-being. People with diabetes are no longer diabetic patients, they are fellow humans with the right to be in control of their own illness, and to be able to make their own choices about their management and their future. They may well wish to share the decision-making with their doctor who in turn should be prepared to negotiate rather than dictate what should be done. It means a realignment of the power between doctor and patient so that interactions can be shared on an equal basis.” The third priority is to avoid harm. Avoiding hypoglycaemia and drug interactions are obvious. Much more subtly, doctors can engender feelings of guilt, failure or rejection. This can happen quite unintentionally, for example, when an overweight person is persistently told they must lose weight when they can not; or when it is implied that renal failure has been the result of careless blood glucose monitoring; or when insisting on giving up smoking when it is their only comfort. It may do less harm, occasionally, to give ‘permission’ to continue doing something ’bad’ for the time being, than to insist on unrealistic changes in lifestyle. These may need to be negotiated gently and tactfully, bearing in mind the realities of the individual’s circumstances. There is good evidence that early identification of microvascular complications prevents diability if acted upon promptly.12-14 The fourth priority must therefore be the regular review of people with diabetes for the development of such complications. The main cause of There is, however, mortality is coronary heart disease. l5 no evidence that any intervention improves coronary mortality in the population with diabetes. Risk markers have been identified l6but intervention trials have only been performed on the general population. Even these have been inconclusive and doubt has been cast upon their value. l7Only treatment of mild hypertension with and hypercholesterolaemiawith diuretics in the elderly, l8 diet l9have been shown to improve all-cause as well as coronary mortality. It may well be premature to conclude that more aggressive interventions are any more likely to be effective in people with diabetes. The case for meticulous metabolic control in diabetes, with its costs in diminished autonomy and risk of doing harm, is less persuasive. There seems to be a clear relationship between poor glycaemic control and the development of microvascular complications but not for macrovascular complications.20 However the only intervention trials that have demonstrated the possibility that complications can be prevented2’ have all been based on small numbers of Type I diabetic patients who have used continuous subcutaneous insulin infusion. The analysis of these results has been criticized. 22 The outcome of the large Diabetes Control and Complications Trial in the USA is keenly awaited. The cost of meticulous glycaemic control, particularly of the risk of 770
hypoglycaemia, for the potential benefit may be too high for those with Type I diabetes. Similarly, in Type II diabetes, euglycaemia may be an unachievable objective except for a few on diet management alone. The only randomized trial, exemplary in its methodology, and notwithstanding the ensuing controversy, suggested that tolbutamide resulted in more vascular deaths than placebo or insulin treatment.23The controversy remains to this day, but results of the United Kingdom Prospective Diabetes Study, due to finish by 1995, should help resolve which interventions are best able to prevent complications in these patients. The argument for early diagnosis of diabetes is supported by the evidence that prompt intervention in established complications can prevent or delay disability. Yet the process of case finding by screening carries its own costs. As well as the obvious financial and opportunity costs, inevitably false positive findings create illness; indeed the very process of screening can create anxiety irrespective of the results.24These costs need to be justified and balanced against the potential benefits of case finding. The most effective and efficient method of screening i s still to be established. There is little doubt that cessation of smoking is an effective intervention, but it is not without its costs. The evidence that a range of other lifestyle changes can either prevent the onset of diabetes or influence its course is far from proven. There is some support for the proposition that exercise may reduce the incidence of diabetes 2 5 but the evidence that weight loss, or dietary manipulation can do likewise is circumstantial. Some have suggested that obesity may yet be a consequence rather than a cause of insulin resistance.26Others point out that ’good diets’ are unaffordable by those on low incomes, and largely unavailable to those living in deprived, mainly inner city, areas.27Thus while these lifestyle changes may prove to be beneficial, the present evidence may not be sufficient to outweigh the costs of such changes to the individual.
The Place of Mini-clinics Diabetes mini-clinics provide an opportunity for protected time to address the priorities discussed above. There are also risks. The focused nature of the clinic means that there is a tendency to concentrate on the disease rather than on the illness which it creates. Furthermore, the encouragement of muItidisc ipl inary teams diminishes the opportunity for developing a relationship with a single carer and jeopardizes continuity of care. The aims and organization of mini-clinics must take into account these considerations if they are not to become simply community outposts of hospital clinics. For these reasons some practices may find it more appropriate to offer care within ordinary surgery times. However, for this to be as effective as mini-clinics, practices would have to overcome the tendency towards hurried consultations which do not lend themselves to I . I . BENETT
Dm dealing with emotional or psychological issues,28 or to the systematic detection of complications. There is also a tendency for patients to be lost to follow-up.29 It behoves those who choose such care, even if planned, to demonstrate that this method is as effective as miniclinics. In view of the stated priorities of care, there should be no restriction on the type of diabetic patient seen at mini-clinics. Where more technical help is necessary in treatment, education or investigation there is no reason why care should not be shared with the hospital. This may be more likely to apply to patients with Type I diabetes. However, care in General Practice should come to be seen as the natural first option; indeed care that does not include GP involvement should be considered less than ‘optimal or even minimal’.
Conclusions The effectiveness of GP care of diabetic patients is often judged by outsiders without experience of General Practice. Their criteria for good care are the same as used for hospital care, and are usually inappropriate. Priorities of care in General Practice are different: they involve addressing emotional issues, promoting autonomy, and avoiding harm. A shared priority is to identify and treat complications promptly as there is good evidence that this prevents disability. Other interventions are less efficacious and may even be harmful. General Practice care should be judged by how patients feel and on the level of disability, not on other spurious measures of activity or disease control. There are many questions still to be answered which will have a significant influence on diabetes care in general practice. It is important to continue to clarify which interventions are effective at primary, secondary, and tertiary prevention. The most efficient and effective method of early diagnosis is still to be established, and must bear in mind the costs of screening. The health beliefs of people who develop diabetes, particularly in our multicultural society, their main fears, concerns, and anxieties, and the most effective ways of enhancing autonomy and self-esteem are all questions of great importance if a better understanding of the illness is to be developed. Finally, do patients really want a different, holistic approach by their GP, or are GPs simply expected to fulfil the same role as specialists, but in the community? The answers to these questions will have profound implications for the delivery of care by GPs. For example, it may be that the fashion for mini-clinics is inappropriate as they focus too much on the disease rather than on the illness caused by diabetes. They tend to dilute both individual care and continuity of care by encouraging a multidisciplinary team approach. Mini-clinics are probably a good thing, but their aims should be to provide whole-person care, rather than just disease management. This is the challenge to which primary care must rise, or risk being regarded as second THE GENERAL PRACTITIONER IN DIABETES CARE
ROSTRUM rate to the hospital service. It is time for General Practice to assert its distinct identity and role in the care of chronic diseases generally, but specifically in diabetes care.
References 1. Thorn PA, Russell RG. Diabetic Clinics Today and Tomorrow: Mini-clinics in General Practice. Br Med I 1973; 2: 534-536. 2. Singh BM, Holland MR, Thorn PA. Metabolic control of diabetes in general practice clinics: comparison with a hospital clinic. Br Med / 1984; 289: 726-728 3. Home P, Walford S. Diabetes care: Whose responsibility? Br Med I 1984; 289: 713-71 4. 4. Nabarro JDN. Diabetes and the general practitioner. / R Coll Gen Pract 1987; 37: 389. 5. Department of Health and Welsh office. General Practice in the National Health Service: a New Contract. London: HMSO, 1989. 6. Secretary of State for Health. The Health of the Nation. London: HMSO, 1991. 7. Alberti KGMM. The Health of the Nation: responses: Role of diabetes. Br Med / 1991; 303: 769-772. 8. McWhinney IR. An lntroduction to Family Medicine. Oxford; Oxford University Press, 1981. 9. McWhinney IR. A textbook of Family Medicine. Oxford: Oxford University Press, 1989. 10. Hellman CG. Diseases versus illness in general practice. J R Coil Cen Pract 1981; 31: 548-552. 11. Metcalfe D. The crucible (William Pickles lecture 1986). I R Coll Gen Pract 1986; 36: 349-354. 12. British Multicentre Group. Photocoagulationfor proliferative diabetic retinopathy: a randomised controlled trial using the xenon laser. Diabetologia 1984; 26: 109-1 15. 13. Thompson FJ, Veves A, Ashe H, Knowles EA, Gem J, Walker MG, et a/. A Team approach to diabetic foot c a r e t h e Manchester experience. The Foot 1991; 3: 75-82. 14. Bjorck S, Mulec H, Johnsen SA, Norden G, Aurell M. Renal protective effective of enalapril in diabetic nephropathy. Br Med I 1992; 304: 339-343. 15. Morrish J, Stevens LK, Head J, Fuller JH, Jarrett RJ, Keen H. A prospective study of mortality among middle-aged diabetic patients (The London Cohort of the WHO Multinational Study of Vascular Disease in Diabetics) I: causes and death rates. Diabetologia 1990; 33: 538-541. 16. Morrish NJ, Stevens LK, Head J, Fuller JH, Jarrett RJ, Keen H. A prospective study of mortality among middle-aged diabetic patients (The London Cohort of the WHO Multinational Study of Vascular Disease in Diabetics) It: associated risk factors. Diabetologia 1990; 33: 542-548. 17. Oliver MF. Doubts about preventing coronary heart disease. Br M e d l 1992; 304: 393-394. 18. MRC Working Party. Medical Research Council trial of treatment of hypertension in older adults: principle results. Br Med / 1992: 304: 405-41 2. 19. Trusswell AS. The cholesterol controversy (correspondence) Br Med / 1992; 304: 91 2-91 3. 20. Pirart J. Diabetes mellitus and its degenerative complication: prospective study of 4400 patients observed between 1947-1 973. Diabetes Care 1978; 1: 168-1 88. 21. Hanssen KF, Dahl-Jorgensen K, Lauritzen T, Feldt-Rasmussen B, Brinchmann-Hansen 0, Deckert T. Diabetic control and microvascular complications; the near-normoglycaemic experience. Diabetologia 1986; 29: 677-684. 22. Wolff SP. Blood Glucose Concentrations and Progression
771
Drn
ROSTRUM 23.
24. 25.
772
of Diabetic Retinopathy (Correspondence) Br Med 1992; 304: 505-506. The University Group Diabetes Program: A study of the effects of hypoglycaemic agents on vascular complications in patients with adult-onset diabetes. Diabetes 1970; 19: 74 7-830. Nathoo V. Investigation of non-responders at a cervical cancer screening clinic. Br Med I 1988; 296: 1041-1 042. Manson JE, Rimm ES, Stampfer MJ, Coltitz GA, Willett WC, Krolewski IS, et a / . Regular vigorous exercise and incidence of NlDDM in prospective cohort of 87253 US women aged 34-59. Lancet 1991; 338: 774-778.
26.
27.
28.
29.
King H, Dowd JE. Primary prevention of Type II (noninsulin dependent) diabetes mellitus. Diabetologia 1990; 33: 3-8. Lang T, Andrews H, Bedale C, Hannon E. lam Tomorrow. The Food Policy Unit, Manchester Polytechnic. ISBN 0-947866-01 9, 1984. Ridsdale L, Carruthers M, Morris R, Ridsdale J. Study of the effect of time availability on the consultation. / R Coll Cen Pract 1989; 39: 488-491. Hayes TM, Harries J. Randomized controlled trial of routine hospital clinic care versus routine general practice care for type II diabetics. Br Med I 1984; 289: 728-730.
I. 1. B E N E l l
