8th National Conference of the Primary Care Diabetes Society: Striving for gold standard diabetes care in the community

Martin Hadley-Brown, outgoing chair of the PCDS, and GP in Thetford, Norfolk, welcomed delegates to this 8th National Conference of the PCDS.

Driving and diabetes: What the new DVLA rules mean
Brian Frier, Honorary Professor of Diabetes, Edinburgh
In the opening talk of the morning session, Professor Frier, former Chair of the UK Honorary Advisory Panel on Driving and Diabetes, began by describing the effect of hypoglycaemia and nocturnal hypoglycaemia on cognitive function, illustrating cases in which hypoglycaemia has resulted in motor vehicle accidents on UK roads, stating that between three and five fatal accidents per year are thought to be attributable to hypoglycaemia. “There is an important correlation between a history of previous severe hypoglycaemia and driving mishaps” said Professor Frier, noting that self-declaration is mandatory. “For the HCP there are possible medico-legal consequences too,” for example, if a person receiving a sulphonylurea or insulin is refused blood-glucose monitoring strips and then goes on to have a serious accident. Professor Frier’s talk conveyed a balanced approach to driving with diabetes, taking into account the changes in EU regulations for licensing, and coupled with promoting safety on the roads. 

Focus on feet: Saving life and limb
Fran Game, Consultant Diabetologist, Derby
Dr Game focused on the diabetic foot, exploring the investigations and interventions that can improve outcomes and should form part of usual care. After describing the epidemiology of the disease – 6000 people every year in England undergo amputations, many of which are avoidable, and there is a 10-fold variation in amputation rates around the country – Dr Game framed her talk around the “stairway to amputation” (diabetes ’ neuropathy/peripheral arterial disease ’ ulceration ’ amputation ’ death), and described the various ways in which progression through these stages can be halted with appropriate intervention. Dr Game summed up by saying that the number of feet examined has increased but that the number of amputations has remained the same, and that a multidisciplinary approach “like that of an orchestra” is needed, and that access to specialties should be improved.

Mental health in diabetes
Richard Holt, Professor in Diabetes and Endocrinology, Southampton
“Depression has a two-fold increased prevalence in people with diabetes but is frequently ignored or missed.” Professor Holt opened his talk by describing the extent of the problem and looking at diabetes-specific risk factors for depression such as hypoglycaemia, drug treatment and complications such as sexual dysfunction and, in turn, how depression itself may also be a risk factor for diabetes. Professor Holt described how mortality and complications tend to be worse in people with co-existent diabetes and depression and how self-care parameters such as diet, exercise and self-monitoring of blood glucose tend to be poorer too. “It is important to identify those with depression in order to implement effective treatment” said Professor Holt, adding that treatment should be determined on an individual basis. Diabetes risk factors in people with depression should be assessed too and, in line with the common theme running through many of the presentations at the meeting, Professor Holt called for close collaboration between different specialties to ensure optimal management.

Early detection and prevention of diabetes: A pragmatic primary care approach to implementation of the NICE Guidance
Kamlesh Khunti, Professor of Primary Care Diabetes and Medicine, Leicester
“It used to be said that approximately half of people with diabetes were undiagnosed” said Professor Khunti. “Now this figure is believed to have fallen to around a third, so progress has been made”. Professor Khunti’s talk gave an update on the NICE guidance, approaches to primary prevention, identification of people at high risk and the key components of a successful intervention. He described the debate about screening for diabetes, saying that it has been shown that screening alone is not cost-effective, but that screening plus lifestyle interventions is cost-effective. Regarding thresholds for diagnosis, Professor Khunti said: “The overlap between HbA_1c and the oral glucose tolerance test is fairly small; only 30–50% of those diagnosed with diabetes according to one of the tests are also diagnosed according to the other test. If only HbA_1c were used, the prevalence of diabetes would be double.” Professor Khunti drew attention to the self-assessment and risk score tools, stating that use of these tools can reduce the overall cost of diabetes diagnostics.

Insulin Q & A and debate
Neil Munro, GP, Claygate, and Associate Specialist in Diabetes, London and Gwen Hall, Diabetes Specialist Nurse, Haslemere (now Portsmouth)
Opening this interactive discussion, Dr Munro began by describing insulin development and the characteristics of the various insulins available today. Gwen Hall offered her expertise in the practical aspects of insulin prescribing, highlighting the importance of taking a holistic, tailored approach, and involving the person with diabetes in optimising their treatment plan. The discussion was opened to the floor, with members of the audience asking questions and being asked by the presenters how they would tackle scenarios illustrated by case studies. “There is a place for all insulins, but they must be tailored to the individual,” concluded Gwen Hall.

Litigation and how to avoid it
Zafar Ali QC, Barrister, London
This presentation examined why HCPs get sued and how it can be avoided. “Litigation can occur when it is perceived that standards of care have fallen below those owed to the patient” said Zafar Ali. He highlighted that in some parts of the UK only 6% of people with diabetes get the regular checks recommended by NICE, and that one in three hospitals don’t have a specialist diabetes nurse, whereas one in six people in hospital have diabetes. In terms of avoiding litigation, he examined the importance of informed consent around a treatment’s risks, benefits and alternatives; good record keeping; scrutiny of medical history; and good communication and discharge instructions. The talk was illustrated with important legal cases.

Panel quiz: Would I lie to you?
Eugene Hughes, GP, Isle of Wight
The day’s scientific programme ended with this lively “true or false” quiz, hosted by Eugene Hughes, in which the audience could take part by using voting buttons on the keypads provided. Statements such as “giving people with type 2 diabetes vitamin D will improve their diabetes” was a lighthearted way to draw the audience’s attention to recent debate, research and facts and figures from the world of diabetes.

Masterclasses
A series of eight interactive masterclasses was available during the conference. Delegates could chose to attend the two sessions that were of most relevance to them.

Ramadan and fasting
Alia Gilani, Health Inequalities Pharmacist, Glasgow
“It is estimated that there are 325 000 Muslims in the UK who have diabetes” said Alia Gilani. This masterclass provided a comprehensive overview of the cultural significance and benefits of Ramadan, examining what it entails, which individuals may be exempt from fasting, what risks are involved for people with diabetes, and issues such as what medicines can and cannot be used during fasting. “As the fasting period will occur in the summer months in the UK over the next few years, meaning that fasts will be up to 20 hours, it is vital that HCPs are equipped with the correct knowledge on Ramadan and its implications, thus being able to offer their patients advice in allowing them to make an informed decision whether to fast or not.”

Keeping safe with coughs and colds
Debbie Hicks, Nurse Consultant – Diabetes
The purpose of Debbie’s presentation was to explore some of the myths associated with intercurrent illness, and provide general advice on how to manage hyperglycaemia and hypoglycaemia should they occur. “As healthcare professionals, we are looking for people to be able to self-manage during intercurrent illness” said Debbie. “Generally, no adjustment to dosages of oral medication is required during intercurrent illness” she explained, but went on to describe situations where changes are really important, for example, glucagon-like peptide-1 agonists or metformin should be stopped where there is severe nausea and vomiting, or where an increased dose of a sulphonylurea can be used temporarily to bring blood glucose levels down during illness.

Diabetes, exercise and sport
Rob Andrews, Consultant Senior Lecturer, Bristol
“Exercise induces an increase in cardiac output, respiration and fuel mobilisation” opened Dr Andrews. He looked at the physiological effects of various types of exercise, and strategies that people with diabetes may be able to use to undertake sport and exercise safely. Dr Andrews presented four case studies, including a keen runner, an individual embarking on training for a marathon, an elite athlete and a university runner, to illustrate approaches that may be used
to avoid episodes of hypoglycaemia during training.

Saving life and limb: Systems of care
Paul Chadwick, Principal Podiatrist, Salford
The masterclass on “saving life and limb” began with a series of challenging questions on foot care, which gave delegates an opportunity to test their learning from Dr Game’s plenary session on the diabetic foot. Dr Chadwick continued the interactive format by leading attendees through a series of discussions on various aspects of performing foot assessments in the primary care arena, which included looking for “red flags”, being alert to ulceration risk factors, choosing the optimal number and location of monofilament test sites, and going beyond the Quality and Outcomes Framework.

End-of-life care and care homes
Su Down, Nurse Consultant – Diabetes, Somerset Partnership NHS Foundation Trust
This masterclass explored the potential challenges to providing high-quality care in the care home setting. “Hypoglycaemia in the frail elderly population is an area of great concern and growing recognition” said Su, adding that the problem can be compounded by a lack of awareness of risk factors such as going to bed early without eating and forgetting to take medications. An overarching theme of this masterclass was that there is currently an issue with regimens in frail elderly people being selected to suit the “science” rather than being tailored to suit the individual. “There is a need for individualised care plans” said Su.

Fitness to drive
David Millar-Jones, GP, Gwent
Dr Millar-Jones built on Professor Frier’s earlier plenary session in taking delegates at this masterclass through a series of thought-provoking case examples that raised key issues concerning driving. The discussion covered the potential impact of – among other topics – retinopathy, cerebrovascular disease, dementia, sleep apnoea, ischaemic heart disease, neuropathy, cardiac complications, and joint conditions. Delegates were offered many sage words based on the presenter’s personal experiences. These included the importance of raising the topic of driving, voicing concerns, and having full discussions that should include advising patients of their legal responsibility to inform the Driver and Vehicle Licensing Agency and their insurance company. “Driving against medical advice is a crime,” warned Dr Millar-Jones. Also stressed was the importance of documenting the advice given, and how this is made easier by providing the patient with something written, such as the Diabetes: Safe driving and the DVLA leaflet. In addition, Dr Millar-Jones helped attendees to clarify any remaining uncertainty they had about recent changes to driving regulations for both Group 1 and Group 2 drivers.

Sleep apnoea – the practicalities
Shahrad Taheri, Consultant Physician and Senior Lecturer in Medicine, Birmingham
The objective of this masterclass was to discuss the evidence linking obstructive sleep apnoea with diabetes and its complications. “If I have a patient of say 60 years of age with a BMI of 50 kg/m², diabetes, sleep apnoea and other co-morbidities, they could be biologically 80 years old,” said Dr Taheri. He talked about the diagnosis of sleep apnoea, stating that self-assessment questionnaires may not be useful, particularly where questions are linked to driving and people may be in fear of losing their licence. Dr Taheri emphasised that diabetes specialists need to contribute more to the diagnosis and management of sleep apnoea in their patients as part of more “holistic” care because diabetes HCPs are best placed to put the sleep apnoea into the context of their diabetes. During the session, a continuous positive airway pressure (CPAP) machine was demonstrated, which is currently the most common way of managing sleep apnoea.

Safe use of insulin
June James, Nurse Consultant – Diabetes, Leicester and Gwen Hall, Diabetes Specialist Nurse, Haslemere (now Portsmouth)
In this masterclass exploring the safe use of insulin, June James described resources such as the free NHS e-learning module, the National Patient Safety Association’s insulin passport and the NHS Diabetes booklet, which is now available in different languages. Gwen Hall’s part of the workshop described the various devices and pens available, sharing out a selection of pens amongst the audience and describing practical considerations such as the characteristics of the insulins, needle length and weight of the person with diabetes. Gwen recommended that, given the increasing amount of choice available, the choice of pen should rest with the person with diabetes. The take-home message of this masterclass was the importance of tailoring the treatment to best suit the individual.