‘May you live in interesting times’ – Ancient Chinese curse
Two dramatic things have happened in the last 10 years in diabetes care in this country: the progressive movement of care for the majority of people with diabetes from hospitals to the community and the phenomenal increase in the number of people living with the condition.
Despite clear government policy (Secretary of State, 2000; DoH, 2006) the evidence for the benefit of transferring services to the community from secondary care is largely lacking. Furthermore, intermediate care teams are popping up all over the place, comprising GPSIs, DSNs, podiatrists and dietitians – almost always with support and encouragement from diabetologists who were previously hospital-based. As the White Paper Our health, our care, our say: a new direction for community services notes, much of Europe does not use hospital-based outpatient clinics. Instead care is provided in multidisciplinary clinics in the community.
In this country, community-based teams are looking after people with both types of diabetes, initiating and adjusting insulin regimens and providing support and training to local practices. Data from our own clinics and around the country suggest such clinics are safe, effective and well-liked by people with diabetes.
The expansion of practice-based commissioning has speeded up this process. Community care for people with diabetes is seen by commissioners as a means of delivering high-quality care in a convenient location for the person with diabetes.
Unfortunately, in some areas, rather than a planned transition of care from hospitals – perceived as having overcrowded clinics, high staff turnover and poor access – the care of people with complex needs has been dumped on inadequately prepared and poorly trained primary care teams. Unable or unwilling to be part of the change mechanism, secondary care teams have felt uncomfortable and threatened by such moves, even invoking Diabetes UK in a plaintive plea (Diabetes UK and Association of British Clinical Diabetologists, 2005). This view, while seemingly justified if community clinics are inadequately planned and supported, should not and has not prevented many diabetologists from wholeheartedly engaging in this move to community-based care.
Which brings me to the numbers game. Even the most bullish projection of diabetes prevalence from a few years ago seems to be wildly under the mark. In suburban Bradford we estimate the number of people with diabetes on our register will double in the next 7 years. With better care, earlier and more effective risk factor reduction and more timely and dynamic treatment of complications, many more people with diabetes in our area will live long enough to trouble the health service in unprecedented ways.
So diabetologists and GPSIs are not going to become unemployed. They must, however, be proactive in designing, supporting and monitoring community-based services and providing education. Crucially, no accreditation process can take place without the support of experienced colleagues. Traditional secondary care skills will be still needed to provide expert care for specific groups (such as pre- and antenatal women) as well as technical support in an area of rapid development and to undertake and coordinate research to support our decisions.
The following article by David Kerr clearly shows that balanced and enlightened views from secondary care are not endangered. As Confucius said: ‘If you do not change the direction in which you are going, you will end up where you are headed.’