Changing diabetes by improving control: Solutions

What solutions does NICE recommend?
On 28 May the National Institute for Health and Clinical Excellence (NICE) published new clinical guidelines on the management of type 2 diabetes (NICE, 2008). The updated guidance now advocates that people with diabetes should aim to maintain their HbA_1c below 6.5% when their diabetes is managed by lifestyle interventions or metformin therapy. With this tightening of the target it becomes even more important to help people with diabetes improve their blood glucose control. So what does the guidance suggest as a solution for improving glycaemic control?

Right from the first pages it places huge importance on the individual with diabetes, and the need for structured education for each person or carer, at the time of diagnosis, at annual review and when starting insulin therapy.

We are only scratching the surface with our current provision of structured education as defined by NICE and I fear that it is those who do not attend education sessions who suffer. Group education does not fit all and in addressing this, I feel we need to build on the expertise and enthusiasm of practice nurses, having been one myself for many years. It is largely down to practice nurses that QOF clinical indicators have been met. However, they need time and resources to keep up with developments.

I am sure many nurses will read with interest the requirement to employ this structured education when starting insulin. If that definition were applied then some patients would wait a very long time before receiving the treatment. How many of us starting insulin in people with type 2 diabetes have access to a structured programme which is evidence based, has specific aims and learning objectives, has a structured curriculum in writing and is delivered by trained educators? Pressure has been put on practices to take on insulin initiation with little support in some cases. Hopefully, we can use this document to lobby for improved resources.

NICE has also recommended that self-monitoring of plasma glucose should be available to almost everyone – not just those on insulin therapy. Yet, here again, education is essential as people are more likely to meet a target if they know what it is, and why it is important! Indeed, Adrian Sanders, Chair of the All Party Parliamentary Group on Diabetes (APPGD) commented: ‘Patient barriers to insulin need to be broken down by earlier, ongoing education about the role [HbA1c] has to play in helping them achieve blood glucose targets.’

Basically, if someone with type 2 diabetes understands their blood glucose results, and is taking action based on them, then they should not be restricted from self-monitoring. Hopefully, this will prevent the rationing of test strips when used effectively, while discouraging prescriptions for those who monitor but take no action. NICE also recommends that the monitoring be assessed on an annual basis in a structured way, including assessment of: self-monitoring skills; the quality and frequency of testing; how the results are used; and the impact on quality of life.

Self-monitoring of plasma glucose is an important aspect of patient engagement, and NICE has recognised education as a vital step to improving control.

Call to action: Your response
The recent report ‘The National service framework (NSF) for diabetes. Five years on… are we half way there?’ (Diabetes UK, 2008) has highlighted the fact that although a good standard of clinical care of adults with diabetes has been achieved, there is still room for improvement. For example, the report awarded Standard Four 3 out of 5 stars.

In light of this report, the Journal of Diabetes Nursing would be delighted to receive any initiatives that improved control in people with diabetes. For example, an initiative which helped to break down barriers to improving glycaemic control, or improved education of people with diabetes. 

Submissions could be short letters or articles of up to 2000 words. Contact the editorial team at the journal to discuss ideas on 020 7627 1510. Or send your submissions to: The Editor, Journal of Diabetes Nursing [email protected]. Responses will be considered for publication in the Journal of Diabetes Nursing.