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Ask the experts: diabetes commissioning

Five GP diabetes experts and CCG leads offer advice on typical dilemmas facing commissioners tackling diabetes care

Patients from south Asian backgrounds are often diagnosed late with diabetes and their health is overlooked, which results in worse outcomes and more hospital admissions than in other patient groups. How can awareness and outcomes for diabetes in this and other at-risk communities be improved?

Dr Ken Aswani, NHS Alliance  diabetes lead, medical director of NHS North East London and the City and a GP in Leytonstone

Diabetes remains a common condition with rising prevalence across all communities, and especially in certain groups such as south Asian populations. A strategic and targeted approach with nominated leadership in every CCG is needed to make a difference to overall outcomes.

The complications of diabetes, such as coronary heart disease, eye and renal complications, are occurring at an earlier stage, especially within the high-risk groups and not unusually under the age of 50. The issues are not only for the individual, but the high costs of managing renal dialysis and other specialist interventions.

On the preventive side, CCGs should influence health and wellbeing boards to publicise awareness of the condition and offer general advice on prevention, such as maximising information on diet and local exercise initiatives. Engaging the community leaders of particular groups such as the south Asian population has also been shown to be effective.

Professor Kamlesh Khunti, professor of primary care diabetes and vascular medicine at the University of Leicester, and a part-time GP in the city

Because of increased awareness, nowadays south Asians are diagnosed earlier than they used to be. However, the outlook for them in terms of cardiovascular events and mortality is still worse.

The new NICE guidance on early detection has done some health economics analysis that shows earlier diagnosis by screening and then a prevention programme would save money in the longer term. Every patient with diabetes should be referred for structured education programmes such as Diabetes Education and Self Management for Ongoing and Diagnosed (DESMOND).1 There is some evidence that community workers and nurses specifically trained to look after south Asians have improved intermediate outcomes.

Dr Mike Knapton, associate medical director for the British Heart Foundation and a GP in Cambridge

We have just done a small YouGov survey on an African-Caribbean population – the sample size was 200. We asked what their awareness was of risk factors for heart disease, especially diabetes. Around one in four African-Caribbean adults in the UK don’t realise their ethnicity increases their risk of high blood pressure and diabetes – major risk factors for stroke. African-Caribbean communities are more than twice as likely to develop diabetes compared with the general UK population. We’re using the survey this month as a hook to raise awareness through Asian and other BME media outlets, such as radio stations and community papers.

Patients must act before health problems escalate. The NHS is doing what it can with the Health Checks programme but given this only kicks in for patients aged 40 and over, for some it comes too late.

The challenge is that now the split between local authorities, commissioners and public health means diabetes care can fall between the gaps – with commissioners on all sides assuming it’s someone else’s job to tackle.

Can you suggest any innovative incentive schemes, pathways or models of diabetes control?

Dr Patrick Holmes, diabetes lead for Darlington CCG

Robust systems need to be developed that reduce variation in care while making it as cost effective as possible. General practice is incentivised through QOF to hit ‘audit’ standards of care for the majority of our patients. However, this leaves many patients with sub-optimal care, and a minority with very poor care. This is potentially harmful, particularly to at-risk minorities, and could expose future budgets to the costly complications of amputation and dialysis.

Some areas have simply commissioned intermediate care services from local foundation trusts or other providers. One great strength of this model is that prescribing and care variation can be kept to a minimum because it can be specified in the contracting process. However, some patients don’t want to be managed outside their practice and potentially this approach could lead to the de-skilling of care staff working within primary care. The results of a randomised controlled trial on this model of care due out soon2 will shed more light.

Incentive schemes designed to reward practices providing enhanced care are superficially attractive. However, they must reward outcomes, not processes (for example, HbA1c attainment rather than insulin initiation). Impact on prescribing costs also needs to be considered, as typically more expensive agents are often favoured.  Quality of provision is key if hidden costs and morbidity increased through hypoglycaemia and weight gain are to be avoided.

An interesting alternative model is one undertaken in and around Derby.3 A new organisation was specifically developed, with co-ownership by the local foundation trust and primary care. It aimed to develop integrated care, based on the premise that patients often move from one care environment to another with their condition. The organisation is responsible for assessing and developing clinicians’ competence as well as patients’ education, thereby reducing variation across the patch.  Early results are encouraging, with improvement of the traditional risk factors and a reduction in referrals from primary to secondary care.

How can the CCG be persuaded to use new diabetes therapies and are there any third parties, such as pharmaceutical companies or charities, who could help to support their use?

Dr Tom Humphries, GP clinical lead for diabetes and long-term conditions at NHS Derbyshire County, and a GP in Rampton Hospital

In general, new therapies do not have long-term outcome data and therefore it can be hard to make the case for trying them and for considering them cost-effective. From experience, quite often medicines management teams will try to suggest drugs should not be used in a locality.

However in practice, we find that gradually these medications creep in through a few GPs. I try to make the case that the introduction of these new drugs is inevitable and therefore we are much better off if we can identify who is most likely to benefit and to focus usage on those particular groups. For example, a treatment that can be given once per week by injection may be preferable to daily injections, particularly when someone else has to give the injections – for example, to elderly frail patients, or patients in secure environments where there are concerns about needle usage.

Clearly drugs that help weight loss will be looked upon more favourably than those that cause weight gain, and it is useful to highlight those particular issues. However that does not guarantee that there will not be unforeseen long-term undesirable effects. New drugs can also be better promoted if there is a trade-off by reducing costs in other areas.

References

1 The DESMOND programme. desmond-project.org.uk/

2 A Wilson et al. A cluster randomised controlled trial of the effectiveness and cost-effectiveness of intermediate care clinics for diabetes. BMC Trials (in press).

3 RD Rea, S Gregory, M Browne et al. Integrated diabetes care in Derby: new NHS organisations for new NHS challenges. Practical Diabetes 2011:7;312-3

Readers' comments (8)

  • Can someone please explain? Diet is always quoted as an important factor in Diabetes control. Why therefore do the NHS and Diabetes u.k. give wholly unsuitable diet advice by recommending the ingestion of excessive quantities of Carbohydrates. Would you quench or control a fire by feeding it petrol. Who in the Medical Profession has the guts to stand up and declare the present dietary advice erroneous and extremely harmful.

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  • This is a fallacy that dieticians across the board appear to approve ( unlike dietary advice offered in the USA). Excessive carbohydrates leads to weight gain. I agree that wheneverI advice my patients to reduce the carbohydrate content, the dietician tells me off. Limiting carbohydrates is the key to losing weight increasing vegetables and fruits and salads is what we should be advocating.

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  • You are correct. In insulin resistance whilst new therapies can be helpful the correct diet is even more important and that means reduced carbohydrate intake & when they are used they should be unrefined complex long acting carbohydrates.

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  • It is good to see the recognition that carbohydrates are a significant factor in control. Now let's be really controversial ! Carbs should be minimal ..No farinacious products no root vegetables no fruits(fructose) occasional raspberries/strawberries(low fructose) plenty of leaf vegetables.. meats cheeses cream eggs, small amounts of bran crispbread. O. K. fat intake is increased and that is not good we are lead to believe!
    Maybe somebody will quote the clinical or scientific research papers proving this point conclusively. I can't find any!!

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  • Read 'the diet delusion' by Gary Taubes. Plenty of references in there.

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  • Thanks, I have read it and it rather proves the problem of excessive carbs. Can I suggest isbn 978-1-905140-22-0
    How "Healthy" eating is making us ill- by Barry Groves, an equally thought provoking tome!

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  • ,quote.cream eggs, Anonymous | 21 October 2012 8:19am
    Would that be cadbury cream eggs? :)

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  • Anonymous (31-10-12:19.15)
    Only if a Fruit & Nut case! Apologies, I consider myself thoroughly punctuated.

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