Managing wheezy infants and toddlers
Dr Azhar Farooqi explains how a systematic approach to offering diabetes care can pay off for both practices and their patients
a systematic approach to offering diabetes care can pay
off for both practices and their patients
One of the welcome aspects of the new contract is that general practice will, for the first time, be rewarded for delivery of evidence-based care. The care of people with diabetes is one of the highest-scoring areas of the quality and outcomes framework, with 99 points available (see box 1 overleaf).
It is important for patient care that different sets of national guidelines are consistent. Although some of the Q&O clinical indicators may differ in their detail from the national service framework and NICE guidance, the new contract does in essence reinforce and enhance these documents.
Much of the evidence base to support all these sets of guidance comes from the United Kingdom Prospective Diabetes Study (UKPDS) which showed serious complications are not an inevitable consequence of type 2 diabetes. The UKPDS highlighted how structured care aimed at reducing risk factors for complications can have a big impact on outcome. Specifically it found that:
lBetter blood glucose control can cut the risk of major diabetic eye disease by a quarter and of early kidney damage by a third.
lBetter BP control in hypertensive diabetic patients can reduce the risk of death from long-term complications by a third; and of stroke and serious visual deterioration by more than a third.
There is significant audit data to suggest the performance of primary care against such indicators has been patchy up until now. While there is some excellent practice, the majority of GPs probably have significant room to improve.
An audit of the performance of more than 90 Leicestershire practices against criteria similar to the Q&O indicators was conducted between 1997 and 2000. The results (table 2 overleaf) show how the average practice will need to improve significantly to achieve a high level of quality points under the new contract.
The audit group that undertook this study also conducted further research2 to identify the practice characteristics that were associated with improvements in care as a result of the audit. The practices that showed the greatest improvement in audit performance over a 12-month period had common features that included:
lgood organisation of care
la strong degree of teamwork between GP and practice nurse taking the lead roles in diabetes care
lthe development by the practice team of systematic plans for quality improvement and
la positive attitude among GPs and practice nurses to the value of repeat audit.
Such characteristics of effective practice organisation will be displayed by those primary care teams that make a success of the contract.
Good organisation of care
It is now accepted that well-organised and structured care results in improved management of diseases in primary care3. To achieve maximum or near-maximum quality points, practices will need to deliver such care. Key elements include:
la practice protocol for diabetes Clinical protocols and guidelines are widely available both nationally (eg NICE/SIGN guideline) and locally at regional/PCO level. These will need to be modified or adapted to match the clinical indicators for the Q&O. All relevant staff in the practice (GPs, nurses, health care assistants etc) will need to be aware of the practice protocol.
ldiabetes register Accurate coding of patients with diabetes will allow the automatic generation of a diabetes register on most GP clinical systems. But the practice will need a robust policy for identification and coding of new patients (eg from screening activity and hospital letters) and the deletion of deceased patients or those who have left the list. Practice prevalence will vary between
2 and 10 per cent depending on the demography and ethnicity of the population.
lcomputerised data capture The use of clinical software templates, such as those developed for use with the new contract, will allow relevant data to be captured as well as prompting appropriate assessment and intervention in consultations. Practices will also need a systematic approach to the recording of information from secondary care and intermediate care providers to help ensure they reach Q&O targets.
ldedicated time for diabetes care Most practices – particularly larger ones – will find it essential to undertake diabetes care in a systematic way using trained clinical staff in the relatively protected environment of a formal clinic. The broad nature of general practice means the systematic care that is reserved for chronic diseases is difficult to achieve in routine surgeries and clinics.
lcall, recall and audit An organised call/recall system will be needed to ensure as many patients as possible are adequately reviewed and those not achieving targets (eg for HbA1c and BP) are followed up. Such a system will also allow patients who are eligible for exception reporting (eg those on maximal therapy, persistent defaulters) to be excluded from targets. Persistent defaulters, however, should not be left to opt out of care. There is evidence that different models of care, such as home visits for the housebound, telephone consultations and drop-in clinics, may help to engage such patients.
Improved training of GPs and practice nurses involved in diabetes care is also needed to help meet some of the stringent clinical indicators in the Q&O. A range of local, national and distance-learning courses is available and practices should explore these as part of practice and personal development plans.
The annual review is the cornerstone of diabetes care. It should ensure:
lall process elements of the Q&O indicators have been performed
ltherapy has been tailored to meet targets
lpatient education has been addressed and
la follow-up appointment has been made.
The annual review should be performed in an extended clinic appointment (typically 30 minutes). Blood tests will usually need to be taken one to two weeks beforehand so up-to-date results are available. The review will often be conducted by a trained nurse, with the GP providing clinical support for prescribing decisions and risk-factor assessment. In future, a growing number of practices may have a diabetes-trained 'nurse practitioner' who has prescribing powers and can undertake the review without significant GP support.
Workload and resources
There are undoubtedly significant resource barriers to improved diabetes care, including:
lstaff shortages (both nurse and doctor)
llack of training and
ldifficulties accessing specialist support services such as dietetics and podiatry.
A recent audit in Eastern Leicester PCT highlighted great variation in the level of practice nurse support available in different practices (table 3). Lack of clinical resources is not easy to address but many practices and PCTs have adopted interesting strategies such as:
lrecruitment of health care assistants and phlebotomists to undertake routine duties
luse of external nurse support (PCT nurses and pharma-funded nurses) to improve practices' care
lincreased use of district nurses and health visitors to monitor patients (eg the housebound)
ldevelopment of intermediate care and group patient education to deliver a greater volume of care.
Better management of diabetes in primary care will mean better outcomes for patients, but it will also mean more referrals to secondary care as detection of disease complications improves. Many practices will remain unable to provide services such as care of complex cases, insulin initiation and group education. More specialist diabetes care will increasingly be provided locally via 'intermediate care' services led by GPs with a special interest or diabetes specialist nurses as well as consultants.
Will all the effort be worth it? For patients – certainly. For GPs, there will be the personal satisfaction of providing good care as well as the financial pay-off from the Q&O. The average three-partner practice can earn a maximum of £7,425 for the diabetes clinical indicators in 2004/5, rising to £11,880 in 2005/6. Inevitably, some of this will be swallowed by increased expenses – but it does mean GPs will have a little less to complain about over resource allocation.
Leicestershire PCAG diabetes audit report 20001
audit report 20001
Aggregated results of the
Glycated haemoglobin checked
in past year 80
Results within normal limits;
Normal HbA1c range (<7%)>7%)>
Moderately raised (7-10%) 35.5
Poor HbA1c (>10%) 13.7
Feet checked in past year 64.2
Urine checked in past year 63.9
Fundi checked in past year 62.4
Smoking checked in past year 66.4
BP checked in past year 84.3
1 Farooqi A et al. Does clinical audit improve care? Lessons from a multi-practice audit. Journal of Clinical Governance 2000; 8:152-156
2 Stevenson K et al. Features of primary health care teams associated with successful quality improvement of diabetes care: a qualitative study. Fam Pract 2001; 18:21-26
3 Griffin S. Diabetes care in general practice: meta-analysis of randomised control trials; Commentary: Meta-analysis is a blunt and potentially misleading instrument for analysing models of service delivery, BMJ Aug 1998; 317:390-396
4 Farooqi A, Dodd L, et al. Diabetes Service Provision in Primary Care: a baseline survey in a city PCT.
Practical Diabetes International 2004
Azhar Farooqi is a GP in Leicester, diabetes clinical lead for Eastern Leicester PCT and a member of the professional executive council of Diabetes UK
Blueprint from a 'model' practice
Diabetes tsar Dr Sue Roberts has praised Haslemere Health Centre in Surrey as a model of good practice for annual diabetes reviews – senior partner Dr Chris Taylor explains how the system works
We have a relatively low prevalence of diabetes at our practice - currently 400 patients out of a list size of 17,500. This reflects the fact that our west Surrey location means our list is mainly made up of white middle-class patients.
We hold a weekly clinic to conduct annual diabetes reviews (see box). We set this up after we realised a gulf was developing in the quality of care we were offering to patients who were getting their annual review at our existing diabetes clinic – and those who, for various reasons, were not.
Our practice nurse Gwen Hall has taken the University of Warwick's Certificate in Diabetes Care and is now a trainer on the course. She was therefore able to train up district nurses and health visitors to identify patients who needed an annual review and so expand the practice's outreach, particularly in nursing homes. Those needing to see a GP are then referred to the practice.
We have developed an annual review template on our computer system so results can be updated on screen. A copy is then printed out for the patient, allowing us to achieve the NSF recommendation for wider use of patient-held records without laborious form-filling.
The advantage of training up the whole practice team is that we, as GPs, can deal with the more problematic patients and spend more time with them. Our overall diabetes workload as a practice has gone up because we are managing more diabetes patients in the surgery and referring fewer to hospital – but it's much more satisfying for us as we have all become more skilled.
Some time ago I decided to do the Warwick course myself, and found myself being taught by Gwen! I had no problem with this – she has more knowledge of diabetes than I do.
We expect our integrated approach to diabetes care to pay off under the quality and outcomes framework. We have changed the template on our computer to bring it in line with the Q&O indicators and hope to achieve 90 per cent of the diabetes points. Our biggest problem has been the recording of data – a lot of the information is there somewhere but we're having to make sure we are using the right Read codes.
How our clinic works
lHealth care assistant telephones each patient to remind them of their appointment; ensures they have correct forms for blood tests
lBlood and other tests are done a fortnight before the annual review clinic
lPractice nurse interprets blood results with the patient, answers queries, gives advice, checks blood monitoring, checks injection sites and provides general education
lUpdated results are entered on to an annual review template along with therapy recommendations and other advice; a copy is printed off for the patient
lA 20-minute slot is available with the clinic GP to address concerns and complete the physical examination if necessary
lA community chiropodist and dietitian attend the clinic every fortnight