Making best use of primary care resources: Focusing on ticking time (not boxes)

Time’s arrow flies on and brings a new year, 2014, which is one in which we mark significant anniversaries.

The Primary Care Diabetes Society (PCDS) will hold its 10th annual national conference (in Birmingham on 20–21 November). We will be celebrating the work of the Society as the year progresses, as well as recognising a decade of the Quality and Outcomes Framework (QOF), approximately 10% of which is devoted to diabetes clinical indicators (http://bma.org.uk/practical-support-at-work/contracts/independent-contractors/qof-guidance [accessed 28.01.14]).

Another milestone being reached is that of the Clinical Practice Research Datalink (formerly the General Practice Research Database; www.cprd.com [accessed 28.01.14]). The organisation, initiated in 1994, now marks its 20th anniversary. Important data on the utility of antidiabetes agents in large primary care cohorts have been published from this bank of information. As the data are essentially extracted from primary care, we will continue to publish analyses performed using the database in this Journal. Also in 1994, David Sackett moved to Oxford and began the evidence-based medicine (EBM) movement there (Trinder, 2000). EBM has gone on to be very influential, particularly in underpinning the drawing-up of our guidelines.

Diabetes UK at 80: Links between this edition’s content and current campaigns
Few organisations have represented people with diabetes more proactively than Diabetes UK, which is celebrating its 80th anniversary this year. Two areas of focus for the charity in recent years have been the dangers of hypoglycaemia unawareness (www.diabetes.org.uk/Guide-to-diabetes/Complications/Hypos-Hypers [accessed 28.01.14]) and the need for better diagnosis and management in children and young people (e.g. www.diabetes.org.uk/About_us/What-we-say/Improving-diabetes-healthcare/High-Quality-Care-for-Children-and-Young-People-with-Type-1-Diabetes-in-the-UK [accessed 28.01.14]). In this edition of the Journal, we feature contributions relevant to these facets of the condition.

The real and common issue of hypoglycaemia unawareness is highlighted in an informative comment piece (on page 9), while a group from Portsmouth outlines an approach to the problem of hypoglycaemia that it has adopted in primary care, using a telephone hotline (in an article starting on page 26).

Diabetes UK (2012) has also recently championed a campaign designed to promote an early diagnosis in children and young people by highlighting that type 1 diabetes in younger life often presents as the “4 Ts”:

• Toilet – going to the toilet a lot, bed wetting by a previously dry child or heavier nappies in babies.
• Thirsty – being really thirsty and not being able to quench the thirst.
• Tired – feeling more tired than usual.
• Thinner – losing weight or looking thinner than usual.

Underpinning this campaign is the relatively high prevalence of type 1 diabetes in the UK, which is currently the fifth highest in the world and is largely unexplained (The Guardian, 2013). The high rate means that clinicians working in primary care need to be alert to newly presenting type 1 diabetes and to have an informed understanding of its management. In this edition of the Journal, our continuing professional development module features diabetes care in children and young people. In light of the significant hazards presented, in particular, by late diagnosis, we believe that thoughtful reading of the module and completion of the linked questions will meaningfully enhance patient care.

Consultations: Ensuring effectiveness despite time pressures
Time is a precious commodity in primary care, where appointments are set and timed. In this edition of the Journal we feature an article that has direct implications for time management in the diabetes consultation. Structured setting of goals may be more time consuming in the short term, but shared decision-making can save time, and increase understanding, in the long term. In the latest instalment of our “In the consultation room” series (starting on page 44), we present practical insight into setting shared goals and how this can improve patient care and understanding.

In some consultations, overcoming a language barrier may be crucial to successful outcomes. And while the Journal has regularly featured aspects of diabetes care in hard-to-reach groups, it is over 5 years since we last focused on the role of interpreters in consultations (Greenhalgh, 2008). In an article on this aspect of diabetes care (starting on page 31), the authors acknowledge the important role that interpreted consultations have in allowing people access to diabetes care and improving the quality of that care. The concept of a triadic (i.e. three-person) consultation is introduced and the challenges that come with this are appraised. Simple tips are provided on how we can make these consultations more effective, while acknowledging that they may inevitably be more time consuming.

The quality of 21st century diabetes care and the changing times we are living in
The Journal has always examined issues affecting the provision of high-quality diabetes care in practice. Another of our articles (starting on page 16) reinforces this, highlighting the wide variation that exists in the delivery of diabetes care between clinical commissioning groups (CCGs) and the even wider variation between individual practices in England. In the article, it is argued that this variation is unacceptable and suggested that efforts to reduce variability should be focused on improving those practices that have the lowest performance. The authors examine why some practices might be performing relatively poorly and present strategies to recognise and correct this. Finally, it is re-affirmed that CCGs have now taken on the responsibility to deliver high-quality diabetes care in primary care.

This disparity between CCGs is essentially the “inverse care law” written large. This concept – in essence, the most socially deprived areas getting the lowest-quality primary care – was first described by Julian Tudor Hart, reflecting on healthcare provision in the Welsh valleys in the 1960s (Hart, 1971). The Welsh Government has recently been objectively examining diabetes care and has published a Diabetes Delivery Plan to provide a framework and time-scale for action by all those involved in influencing and delivering diabetes care in Wales (Welsh Government, 2013). In this edition, the two PCDS Committee members representing Wales – in a year in which the Principality celebrates the centenary of Dylan Thomas’s birth – appraise this development plan and ponder realistic time-scales.

Another system aimed at improving the quality of patient care is QOF. We are now nearing the end of the current “QOF year”, and, among other aspects of working with this system, practitioners will be making decisions about exception reporting, in order to avoid imposing inconvenience and inappropriate demands on certain individuals. In a comment (on page 14), Kev Hopayian explores the ethical dilemmas that exception reporting presents. He argues that decisions about the optimum care of people with diabetes should be neither the paternalistic “doctor knows best” nor the computer-driven “protocol states best”. He argues for patients and practitioners to make joint decisions, but acknowledges that this will require primary care team members to learn new skills in communicating risk and enabling patient involvement.

Anniversaries: A time to look both backwards and forwards
All anniversaries are a time to reflect, celebrate and learn. The fact that Shakespeare was born 450 years ago this year puts many of the more contemporary anniversaries into context. He wrote:

“Come what come may,
Time and the hour runs through the roughest day.”

We are sure of time’s arrow flying forwards but we should also reflect that, in this century, primary care has emerged from a challenging start to make very good use of time and available resources, in order to ensure high-quality diabetes care. It is time for politicians and commissioners to recognise this contribution and resource primary care appropriately and equitably.