Given the epidemiology of diabetes, it is understandable that there is a shift in routine management from secondary to primary care. Whether there is enough support for primary care is debatable but usually there is enough guidance to manage non insulin treated patients – and even those on non complex insulin regimes. So far so good! However, there is a risk that patients with T1DM may get caught up in the rush to transfer care out of hospital. In fact, this week’s episode of Pulse describes a commissioning intention of a CCG to actively promote it.
However, it is often not understood that T1 and T2 diabetes behave like two separate conditions when it comes to glucose lowering. Furthermore, there is a major difference in the education that these patients require, specifically the intricacies of carbohydrate counting, correction doses and the detailed awareness of the profiles of a variety of rapid and longer acting insulin, not to mention pump therapy. Type 1 patients often possess. There is also the higher risk of hypoglycaemia including unawareness with all the associated issues including the impact on driving.
Whilst it is possible that practices have the skills to manage T1 patients, it is unlikely that this can be done without significant support from specialist care. This can come in a variety of ways including education sessions, virtual or e-consultation to name a couple. It is unclear from the proposals as to how this will be done. Furthermore, there is no acknowledgement that T1 patients are often highly motivated and educated about their condition, commonly having more knowledge about ‘their’ diabetes than the health care professional treating them. Significant input would be necessary to convince these patients that the transfer of care does not come at the expense of clinical care.
Overall, the location of care is not important, ensuring that the right patient is seen by the right clinician is vital to ensure that this group of patients are not disadvantaged.
Dr. Mark Freeman