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The impact of the UKPDS on diabetes nurses

Maggie Watkinson

Although all diabetes nurses will be aware of the results of the United Kingdom Prospective Diabetes Study (UKPDS), many may have failed to recognise the huge implications for diabetes nursing.

Although most of us suspected that good diabetes control for people with type 2 diabetes was desirable, it is now known to be so. This knowledge will lead to an increased emphasis on efforts to help people acquire that control. The evidence is clear that good blood glucose control reduces the risks of developing micro-vascular complications (UKPDS Group, 1998a) and tight blood pressure control reduces the risks of developing both microvascular and macrovascular complications (UKPDS Group, 1998b). Although many GPs will manage hypertension in people with type 2 diabetes independently, there may be more individuals on maximum oral diabetes therapy being referred to secondary care for conversion to insulin, to achieve blood glucose control. This, of course, means that diabetes nurses based in secondary care will be seeing increased numbers of patients and at an earlier stage.

Pressured workload
The existing pressured workload of many diabetes nurses will create obvious concerns about how this situation might be managed. While some may argue that there is now is the ideal time to press for more diabetes specialist nurses (DSNs) in the secondary sector, others will claim that the UKPDS results will have no more impact on the numbers of DSNs as did the results DCCT results (DCCT Research Group, 1993)!

An alternative solution is to continue developing primary care diabetes services and encourage more GPs and practice nurses to care for their patients using insulin. This is probably the more politically acceptable option given the initiatives regarding the integration of primary and secondary care. However, if this occurs, there are implications for the education, training and continuing support of primary care health professionals. There are still many areas with no ‘formal’ diabetes facilitators and even where they do exist there is often insufficient provision to cope with the current demand. Primary care services are also pressured, both clinically and organisationally, e.g. with the advent of changes resulting from the formation of Primary Care Groups.

It is therefore evident that in order to provide effective care and improve outcomes for people with type 2 diabetes, resources are urgently required – whether they are channelled into primary or secondary care. 

Costs of health professionals’ time
There are also other financial implications of the UKPDS which arise from the increased use of multiple therapies. For example, 29% of individuals in the ‘tight control of blood pressure’ group required at least three anti-hypertensive agents (UKPDS Group, 1998b). The cost effectiveness part of the study demonstrated that the increased costs of medication were offset by the reduction in complications (UKPDS Group, 1998c), though the costs of health professionals’ time were not. 

It is also recommended that local screening initiatives are established for high risk groups as it has been demonstrated that up to 50% of newly diagnosed people with type 2 diabetes present with existing complications (UKPDS Group, 1998a). 

These financial issues, of course, have political implications. The benefits of investing in preventative care have been demonstrated; however, it remains to be seen if current and successive governments can implement policies which will survive both political and organisational change, to enable the long-term goals to be met. 

Diabetes nurses, whatever their roles and wherever they are based, need to think carefully about how the results of the UKPDS will affect not only the care they provide to individual patients, but also the services in their area. In conjunction with the multidisciplinary team, they will need to determine the resources – personnel, time and money – which will be required locally to provide effective care to people with type 2 diabetes.

Effective communication with health authorities and Primary Care Groups will be essential to ensure that the results of this important study are acted upon; diabetes nurses should not miss this opportunity to influence the purchasers of diabetes care.

Although all diabetes nurses will be aware of the results of the United Kingdom Prospective Diabetes Study (UKPDS), many may have failed to recognise the huge implications for diabetes nursing.

Although most of us suspected that good diabetes control for people with type 2 diabetes was desirable, it is now known to be so. This knowledge will lead to an increased emphasis on efforts to help people acquire that control. The evidence is clear that good blood glucose control reduces the risks of developing micro-vascular complications (UKPDS Group, 1998a) and tight blood pressure control reduces the risks of developing both microvascular and macrovascular complications (UKPDS Group, 1998b). Although many GPs will manage hypertension in people with type 2 diabetes independently, there may be more individuals on maximum oral diabetes therapy being referred to secondary care for conversion to insulin, to achieve blood glucose control. This, of course, means that diabetes nurses based in secondary care will be seeing increased numbers of patients and at an earlier stage.

Pressured workload
The existing pressured workload of many diabetes nurses will create obvious concerns about how this situation might be managed. While some may argue that there is now is the ideal time to press for more diabetes specialist nurses (DSNs) in the secondary sector, others will claim that the UKPDS results will have no more impact on the numbers of DSNs as did the results DCCT results (DCCT Research Group, 1993)!

An alternative solution is to continue developing primary care diabetes services and encourage more GPs and practice nurses to care for their patients using insulin. This is probably the more politically acceptable option given the initiatives regarding the integration of primary and secondary care. However, if this occurs, there are implications for the education, training and continuing support of primary care health professionals. There are still many areas with no ‘formal’ diabetes facilitators and even where they do exist there is often insufficient provision to cope with the current demand. Primary care services are also pressured, both clinically and organisationally, e.g. with the advent of changes resulting from the formation of Primary Care Groups.

It is therefore evident that in order to provide effective care and improve outcomes for people with type 2 diabetes, resources are urgently required – whether they are channelled into primary or secondary care. 

Costs of health professionals’ time
There are also other financial implications of the UKPDS which arise from the increased use of multiple therapies. For example, 29% of individuals in the ‘tight control of blood pressure’ group required at least three anti-hypertensive agents (UKPDS Group, 1998b). The cost effectiveness part of the study demonstrated that the increased costs of medication were offset by the reduction in complications (UKPDS Group, 1998c), though the costs of health professionals’ time were not. 

It is also recommended that local screening initiatives are established for high risk groups as it has been demonstrated that up to 50% of newly diagnosed people with type 2 diabetes present with existing complications (UKPDS Group, 1998a). 

These financial issues, of course, have political implications. The benefits of investing in preventative care have been demonstrated; however, it remains to be seen if current and successive governments can implement policies which will survive both political and organisational change, to enable the long-term goals to be met. 

Diabetes nurses, whatever their roles and wherever they are based, need to think carefully about how the results of the UKPDS will affect not only the care they provide to individual patients, but also the services in their area. In conjunction with the multidisciplinary team, they will need to determine the resources – personnel, time and money – which will be required locally to provide effective care to people with type 2 diabetes.

Effective communication with health authorities and Primary Care Groups will be essential to ensure that the results of this important study are acted upon; diabetes nurses should not miss this opportunity to influence the purchasers of diabetes care.

REFERENCES:

Diabetes Control and Complications Trial Research Group (1993) The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. New England Journal of Medicine 329 (14): 977-986
UK Prospective Diabetes Study Group. (1998a) Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). The Lancet 352 (9131): 837-853
UK Prospective Diabetes Study Group. (1998b) Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38. British Medical Journal 317: 703-713
UK Prospective Diabetes Study Group. (1998c) Cost effectiveness analysis of improved blood pressure control in hypertensive patients with type 2 diabetes: UKPDS 40. British Medical Journal 317: 720-726.

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