The project to move the management of patients with type 2 diabetes (T2DM) from secondary care specialists to primary care began in the 1970’s but gained major momentum over the last ten years. It is a central pillar of health policy in the UK but on what evidence is this based?
Most NHS initiatives are based on cost reduction but is this a cheaper option? As a secondary care specialist, my costs for outpatient review are modest; an office, computer, sphygmomanometer, monofilament and support staff. I presume that these are no different to primary care but that the attributed costs are higher due to a costing formula? Furthermore, if my practice is physically moved into primary care, then the numbers of patients reviewed will decrease since the SpR training grades are not be in attendance. Finally, my availability to supervise on-call and in-patient general medicine patients is reduced, needing more resource expenditure in those areas.
Has the increase in primary care management of T2DM led to improvements in outcomes? It seems not, in terms of the surrogate marker of HbA1c, which remains stubbornly unchanged. Furthermore, ‘treatment inertia’ indicating slow escalation of pharmacotherapy including oral medication and insulin is reported to be worse in the UK than in most developed economies. This is not a criticism of general practitioner colleagues. There are currently eight different classes of anti-diabetic medications available in the UK with over thirty commonly used insulin preparations, three of which have been licenced for use in the last twelve months. As a specialist who focusses on diabetes, I struggle to keep up-to-date; why would anyone expect a generalist practitioner and supporting practice nurse to have this specialist knowledge?
The major push for a primary care takeover of T2DM is the massive numbers of people with the condition. Surely this has to be the focus? We need measures to reverse the epidemic and clever means (involving information technology) to allow specialist management of people with this complex disease.
Professor Steve Bain