‘In nature, there are neither rewards nor punishments; there are consequences.’ – Robert G. Ingersoll
Some people feel that the future of diabetes care rests with polypills and polyclinics. Personally, that idea makes me want to think about personal pension plans and purchasing holiday homes in the sun. Joseph Stalin was a big fan of polyclinics and they continue to thrive today in modern Russia. Unfortunately, the continued dependence on this system is associated with an average life expectancy for a male Muscovite of 54 years. As for polypills, when this idea was first being banded about, the expectation was that they should contain a glitazone in addition to a statin, metformin and an ACE inhibitor. Given recent events, I am glad that I did not invest in that one!
As mentioned in a previous editorial (Diabetes Digest 5:140), the management of type 2 diabetes is going to become mind-bogglingly complex with the introduction of incretin mimetics (with short, intermediate, long and extremely long duration of actions to choose from), DPP-4 inhibitors, glucagon antagonists and the rest. The plan still seems to be to leave this to primary care. For specialist diabetes teams, the pressing need is to beef up what is on offer for people with type 1 diabetes.
Although there continues to be ongoing political shenanigans related to ‘my education programme is better than yours’, it is still a shame that as a national health service, we are unable to produce long-term meaningful evidence of our efforts on a regular basis in terms of outcomes that matter. Accepting that it is notoriously difficult to get groups of specialists to agree core data parameters, it is noteworthy that our primary care colleagues have managed it relatively easily with their Quality and Outcomes Framework (QOF). There does not seem to be any reason why this idea could not be exported into other aspects of chronic disease management. To open the debate, Diabetes Digest would like to suggest the following QOF outcomes on which to judge the quality of a specialist centre:
- proportion of people with diabetes using multiple daily injections
- proportion of people with diabetes offered a structured group education programme
- availability of insulin pump therapy and glucose sensing
- annual frequency of severe hypoglycaemic events
- frequency of ketoacidosis in diabetes
- pregnancy in diabetes outcomes.
While there may be others and not everyone will agree first time, nevertheless, perhaps the idea of specialist centres for type 1 diabetes will finally take hold and free other centres less interested in this area to develop in other aspects of diabetes and endocrinology. Telemedicine in health care is in its infancy, but could be a major contributor to developing such a system, allowing individuals to be looked after from geographically disparate areas. Who knows, maybe the government will put some money into this and start rewarding QOF points for type 1 diabetes care or use them as markers for awarding diabetes centres additional resources. The concept of awards for good outcomes could also be applied to other areas, such as inpatient diabetes care (just a thought!).
Vinod Patel highlights the growing evidence base that lifestyle interventions are effective, and encourages persistence even though they can be difficult.
25 May 2023