The focus of this issue of Diabetes & Primary Care is unashamedly on education. I see it as vital for all involved in diabetes – the person with diabetes, healthcare professionals and those working with them – so it grieves me to read the National Diabetes Audit (NDA) figures covering England and Wales.
The NDA (NHS Information Centre, 2011) is thought to be the largest clinical audit in the world. The NDA for 2009–10 covered four “core care” components of the National Service Framework (NSF) for Diabetes. These components are:
- Registration – is everyone with diabetes recorded on a practice register and is the diagnosis accurate?
- Care processes, of which nine are listed – weight, blood pressure (BP), HbA1c level, urine albumin:creatinine ratio, serum creatinine and serum cholesterol, as well as assessment of eyes, feet and smoking.
- Treatment targets – considering the NICE targets for HbA1c, BP and cholesterol (and remembering that these are funding targets and not necessarily the right target for the person in front of you).
- Rates of acute and long-term complications.
The figures are shattering. Only 10% of people with type 2 diabetes (aged 16–54) are in the normal or underweight bracket; 26.9% are overweight; 63% are obese (NHS Information Centre, 2011). The NDA shows that the vast majority of people with diabetes are having their weight recorded. But what are we doing about it? Education needs to start long before diabetes develops and long before primary care has to start to treat the condition.
The NICE-recommended HbA1c level of ≤59 mmol/mol (≤7.5%) was achieved in 66.5% of people with type 2 diabetes but only 28.2% of people with type 1 diabetes. That leaves a lot of people with sub-optimal glycaemic control and this is not accounting for the newly diagnosed and the younger person with type 2 diabetes, who should be achieving tighter control. Yet healthcare professionals up and down the land are telling me that access to high-quality education for themselves and people with diabetes is dwindling.
The story is no better on BP control. A total of 60.7% of those with type 2 diabetes achieved 140/80 mmHg. When the lower target of 130/80 mmHg was applied to people with eye, kidney or vascular disease, many more did not reach it. Heart attack and stroke are by far the biggest killers in people with type 2 diabetes; good BP helps to prevent them but treatment adherence is a significant problem (Donnan et al, 2002). We owe it to people with diabetes to help them understand why they are taking their medication when, often, it does not make them feel any better at the time.
During 2012, the NDA will be publishing the results of the 2010–11 core audit for individual Primary Care Trusts and Local Health Boards in a series of themed reports, culminating in a national report at the end of the year. The first of the themed reports will cover clinical processes and outcomes and will be published in June 2012.
Diabetes UK is encouraging involvement of people with diabetes in their own education by publishing information entitled The Care You Should Receive (available at: http://bit.ly/MgDEVv). This document firmly places the person with diabetes at the centre of his or her care and we would all do well to take heed of its advice. It lists 15 essential healthcare checks and services people with diabetes should receive. It goes beyond pure measurements. For example, number nine advises an agreed care plan and number 10, attendance at an education course (I’d like that one for me too!). I challenge you to give the checklist to your patients and live up to its expectations.
In the introduction to the NDA Dr Rowan Hillson says “We all know what to do, so why aren’t we doing it?” This issue of Diabetes & Primary Care shows that we have the motivation to provide high-quality diabetes care but we need the resources to do it and education is one key resource we ignore at our peril.