GPwSIs in diabetes: Beacons of light?

An ambitious title you may think, but this is the first in a series of ambitious supplements to Diabetes and Primary Care devoted to supporting the development and progression of General Practitioners with a Special Interest (GPwSIs) in diabetes.

The way that diabetes care is being delivered in the UK is changing dramatically. In England and Wales, the National Service Framework for diabetes (Department of Health [DoH], 2001) signalled a shift in the delivery of diabetes care from secondary care to primary care. This has been further promoted by the new General Medical Services contract and its associated Quality and Outcomes Framework (QOF; DoH, 2004), which provides GPs with a significant amount of additional resources for delivering quality process components of diabetes care. At the same time, GPwSIs have emerged as part of the NHS Plan of 2000 (DoH, 2000) as a means of delivering improved access to services for primary care organisations (PCOs).

The need for GPwSIs in diabetes
The UK Prospective Diabetes Study (Turner et al, 1998) has removed all doubt now that improved glycaemic control leads to better outcomes, and Steno-2 has shown that multifactorial interventions improve cardiovascular outcomes (Gaede et al, 2003). (It’s interesting that 57 % of the intervention group in the latter trial received statins, 60 % aspirin, and 90 % an angiotensin-converting enzyme inhibitor – figures that would be regarded as no more than average for diabetes care under the QOF.) In addition, previous studies of diabetes care in general practice have shown that well-organised, register-based systems in primary care can deliver care as good as or better than that delivered in secondary care (Griffin, 1998).

Primary care trusts (PCTs) have not been slow to appreciate the benefits of primary care-delivered diabetes care, and practice-based commissioning and the uneconomic tariffs imposed on secondary care will accelerate this move, I feel. PCTs have appreciated that the service will not evolve beyond the process-driven aspects of the QOF – valuable as they are – without a higher level of expertise in the community: the GPwSI in diabetes.

The needs of GPwSIs in diabetes
Good care of people with diabetes, I believe, needs robust systems for call and recall, as well as mechanisms for identifying suboptimal care. In addition, the early identification and addressing of dilemmas and treatment of complications needs not just high levels of organised care within primary care, but the clarification of pathways to other specialities.

GPwSIs will have a pivotal role not just in providing aspects of more complex care but in organising services that include education, for both professionals and patients, and community-based prevention and screening initiatives.

Alongside all this – and probably more importantly for the sustainability of the model, I feel – GPwSIs have a duty to support themselves. Training and the acquisition of core competencies need to be standardised and GPwSIs need to help to develop a respected accreditation and revalidation system, which must include  measuring the impact and outcomes of this model of diabetes care. GPwSIs also need the support of the Government, PCOs and consultants. Finally, they require a coherent voice.

The Primary Care Diabetes Society has agreed to host a GPwSI subsection, and a GPwSI internet chat room is being constructed to get and share views from existing and aspiring GPwSIs in diabetes. I believe that this series of supplements in Diabetes and Primary Care will also play a major role in the support and development of GPwSIs in diabetes.