Primary Care Diabetes www.bradfordvts.co.uk Dr Bruce Davies 02/01/2019 Taken from www.bradfordvts.co.uk Bradford VTS Web Pages for General Practice ONLINE RESOURCES Clinical Tutorials for GP Registrars GENERAL MEDICINE 02/01/2019

Introduction - Diabetes 2% of UK population. 66% have been diagnosed. Each GP will find 2-3 new cases per year. 20-30 cases per GP on their lists. 5-10% of NHS budget. Childhood DM doubling every 10 years. 02/01/2019

Topics of Discussion Detection Education & counselling Components of continuing care Aims Management Who to refer CDM and future NSF Audit 02/01/2019

Detection – How / When Symptoms New patient checks 75+ checks Medicals Systematic Opportunistically ANC Other risk factors 02/01/2019

Diagnostic Criteria Random glucose > 11mmol Fasting glucose > 7mmol 2 hours after 75g glucose orally > 11mmol 02/01/2019

Education Lifelong disease Knowledge is power 3 times more likely to die prematurely Reactions vary to what is really bad news Lifestyle changes are needed Specialist health education material Specialist educators 02/01/2019

Education BDA A on going process Not one off Need more information as and when they can use it 02/01/2019

Education Partnership with health professionals – Full multidisciplinary teams 02/01/2019

At Diagnosis Full examination Explanations See a dietician +/- follow-up See a chiropodist +/- follow-up Monitoring education Implications for driving, insurance, DVLA, script charges etc BDA Education about lifestyle 02/01/2019

Once Reasonably Controlled At least annual review Eye surveillance Education when necessary Formal medical review Weight Urine Bloods (HbA1, cholesterol) Review of control Blood pressure Legs and feet Discuss any problems 02/01/2019

Time and Resources Annual check takes about 30 minutes Most practices use a practice nurse 02/01/2019

Aims Patient takes pragmatic responsibility for own health Minimise symptoms Glycaemic control Weight Blood pressure Cholesterol 02/01/2019

Who to Refer? Acutely unwell at diagnosis Insulin treatment required Child Pregnant or pre-conceptual Complications Patient request 02/01/2019

Real Life Mrs A is a 68 year old widow who attends often because of her angina and COPD. She is getting more tired and feels it is due to old age. Must be the angina or breathing getting worse ? 02/01/2019

Maybe Not! 02/01/2019

Mea Culpa I’ve forgotten to test these peoples urine on more than one occaision 02/01/2019

Questions No evidence that self blood monitoring does any good Some evidence of harm! Control of BP in diabetics may be better for long term outcome than blood sugar! How can compliance be improved? 02/01/2019

Questions Many type 2 diabetics would be better off not knowing their diagnosis? The government should have better diet and exercise policies? Hospital care is better than practice care? Primary care is better? 02/01/2019

Homework What drugs when? Treatment of cholesterol? Treatment of BP Treatment of complications 02/01/2019

CDM and Future NSF Small annual fee per GP for “systematic care” + Audit NSF next year will make it better defined and ? Bigger fee 02/01/2019

Audit Heaps of possibilities. Diagnosis. Follow-up. Monitoring. How well controlled. Etc.Etc. 02/01/2019

References Gallichan M. Self-monitoring by people with diabetes: evidence based practice. BMJ 1997;314:964-7 UKPDS 33. Lancet 1998;352:837-53 Diagnosis and classification. Diabetes care 1997;20:1183-97 02/01/2019