Targets: Which ones to aim at?

The world of diabetes care is ever changing, as we know, and the New Year brings with it new targets for biomedical outcomes of that care.

For example, the Joint British Societies’ guidelines on the prevention of cardiovascular disease in clinical practice (British Cardiac Society et al, 2005) include new guidelines for blood pressure, glucose and cholesterol targets for people with diabetes. The guidelines aim to provide a consistent multi-disciplinary approach to the management of these issues and contributing organisations include Diabetes UK and the British Hypertension Society.

The new target for blood pressure is 130/80mmHg (instead of 135/85mmHg for people with type 1 diabetes and 140/80mmHg for those with type 2 diabetes). The target for cholesterol has been lowered from 5.0mmol/l to 4.0mmol/l and the target for HbA_1c has been lowered to 6.5%, from 7.0%.

The new quality and outcomes framework (QOF) indicators for use from April 2006 have also been released recently (NHS Employers, 2005). There are still 93 points available for diabetes, from a total of 1000. However, these new indicators, unfortunately, do not reflect the new guidelines. For example 18 points can be achieved if 60% of people with diabetes have a blood pressure of 145/80mmHg or less. The ‘target’ for cholesterol remains at 5.0mmol/l (70%) and the HbA_1c ‘target’ remains 7.5% (50%).

Despite the clinical improvements achieved by meeting the Joint British Societies’ targets GPs will not receive any extra money for doing so. Given the heavy diabetes workload and agenda that they, and in particular practice nurses (who are the health professionals most likely to implement these guidelines), currently have, is achievement of the new guidelines realistic?

One solution, of course, may be more referrals to secondary and specialist care services of people with diabetes who are unable to meet the new targets, or indeed the QOF indicators, in an effort to relieve the pressure on primary care. However, these services are also under stress due to increased workloads.

It could be argued that the new guidelines merely ‘change the numbers’ and that, as people with diabetes are already receiving care to help them achieve targets, they just need to be informed of the new numbers. However, imagine how someone who has worked hard and has just achieved an HbA_1c within the currently acceptable range, and is, rightly so, pleased with themselves, could feel when presented with a new goal!

To achieve these new targets people with diabetes are likely to need more psychological and lifestyle change support, careful and sensitive explanations of the changes in targets, education and pharmacological interventions as well as negotiated individual goals, all of which takes time.

It also, obviously, takes time to achieve consensus for guidelines and it is laudable that the Joint British Societies have managed to achieve this in relation to theirs. There will always be a time lag between the publication of guidelines and their integration into policy. However, it is unfortunate that neither these nor earlier guidelines for biomedical outcomes in diabetes are not reflected in the QOF.

Nurses working in diabetes care, particularly practice nurses, need to be aware of the new guidelines to ensure they give accurate information to people with diabetes, and endeavour to help them achieve the targets in order to maintain good physical health. However, it will be interesting to see if the new QOF indicators, which are not actually changed for diabetes, will be the targets that most primary healthcare professionals aim for.