1. Dr Jon Tuppen GPSI Diabetes

2. Consider this case ♂ DOB 14.5.57 14 May 2007 15:28 Smoker (137R.) "6-7 a day“ had a routine taxi driver medical examination - letter from Dr. Coull, had high B.P readings - 175/120, and 2+ of sugar in urine, no symptoms, not on any medication @ present, going through very stressful period. o/e - B.P - 175/112, H.R - regular, Chest - HS - normal, no murmur advice to get bloods done including fasting glucose, Hba1c, repeat B.P readings on 2 different occasions with nurse 1 wk apart, ECG, start on lisinopril tablets 5mg & r/w in 3-4 wks time. Smoking cessation advice (Ua1Nz) what would you have done from here? What is the diagnosis?

3. Bloods Serum glucose level (44f..): 6.60 mmol/L Serum creatinine level : 120.00 umol/L Serum cholesterol level : 6.00 mmol/L Serum sodium level : 139.00 mmol/L Serum albumin level (XE2eA): 46.00 g/L Serum globulin level (XE2eB): 25.00 g/L ALT/SGPT serum level (44G3.): 88.00 iu/L

4. Surgery05 Jul 2007 14:16 Alcohol units (Ub171): 6.0 Units/Week Ex-smoker (Ub1na) Requested note for work regarding "fit" to work. He has just been informed if he doesn't get a letter today he would loose his job as a taxi driver. Bp- 168/118, 169/113, 167/109. Appt made to see GP.

5. Serum HDL cholesterol level (44P5.): 0.92 mmol/L Serum LDL cholesterol level (44P6.) "Specimen unsuitable for LDL Cholesterol due to high triglyceride concentration." Serum cholesterol level (XE2eD): 6.90 mmol/L Serum triglyceride levels (XE2q9): 7.21 mmol/L Serum cholesterol/HDL ratio (XaEUq): 7.50

6. Would you like anything else? HbA1c level (DCCT aligned) (XaERp): 6.1 % Is this any use?? CVD risk assessment done (10yr value) (Y04e8): 32.43 %

7. So what happened?? Surgery07 Nov 2007 11:58 O/E - Diastolic BP reading (246A.): 104 mmHg Body mass index - observation (22K..): 34.77 Kg/m² O/E - weight (22A..): 119.000 Kg (18 st 10 lb) O/E - Systolic BP reading (2469.): 146 mmHg NotesBP review - high risk pt, obese BMI 34, HTN, Impaired fasting glycaemia, Hyperchol, still smoking!, taxi driver. Discussed CV risks and strategies. 32%. Smoking - has contacted cessation service, but not followed up. BP 154/113 - repeat slightly better. BMI - taking exercise, agreed for prescription for health, due to see dietician shortly. BP still high - inc lisinopril to 20mg od. Repeat bloods, to call for results. Review in 1/12 - consider antiobesity med. CR 120 - eGFR 60,54. amlodipine tablets 10mg atorvastatin tablets 10mg lisinopril tablets 20mg

8. Next contact was…….. Surgery29 Sep 2008 09:07 “thinks is diabetic. Polyuria and polydypsia for 6/52 with assoc wt loss, feeling tired. FHx of DM -father, grandparents. d/w pt significance and pts understanding. Keen for testing. Sent for fasting bloods U&E, LFT, Chol, Glu, TFT, FBC. r/v with results”.

9. Risk ? What risk? Serum glucose level (44f..): 20.50 mmol/L Urea and electrolytes (X77Wi) Serum sodium level (XE2q0): 139.00 mmol/L Serum triglyceride levels (XE2q9) Serum triglyceride levels (XE2q9): 105.15 mmol/L Biochemical test (X77W9) "Sodium and potassium done by direct ISE. TRIGLYCERIDE AND GLUCOSE PHONED TO SURGERY 06/10/08. SUGGEST URGENT REPEAT TO ASSESS LIPID AND GLUCOSE LEVELS."

10. Is it important what style we use to deal with patients?

11. Engaged empowered patient Organised proactive system Partnership = Better outcomes We know what works….. The evidence base for all long term conditions In England : The Diabetes NSF Internationally: The Chronic Care Model - Wagner

12. had at least one check up in the last 12 months and discussed ideas about the best way to manage their diabetes agreed a plan to manage their condition over the next 12 months discussed their goals in caring for their diabetes And in diabetes… The % of adults who report they…… From ‘Managing Diabetes’ Healthcare Commission: 2007

16. NHS Next Stage Review “High Quality Care For All” commitments: By 2010 all 15.4 million people with a long term condition will be offered a personalised care plan. A new Patients’ Prospectus will provide people with long-term conditions information about the choices that should be available locally to enable them to self care in partnership with the health and social care professionals Personalised Care Planning and the Patients’ Prospectus

17. ...the individual, their needs and choices at the centre of the process. Goal setting to support people to achieve outcomes such as walking unaided or return to work … includes helpful and relevant information, through an Information Prescription, for example about conditions, treatments, care services, benefits, and support groups. … includes support for self care. The Patients’ Prospectus will drive demand for self care services such as access to peer support networks, generic or disease specific courses, tools and devices and healthy living advice. Promotes choice. …coordinated services for those that need it, contingency planning. Action planning and review. Results in a single overarching care plan Individualised services, meeting holistic needs. Wider choice supports commissioning decisions A process of discussion, negotiation and shared decision making that takes place between the person and their professional who have an equal partnership Care Planning – the National Messages …… Personalised Care Planning

18. Task: Design from scratch a diabetic system for your practice and consider how it integrates with other parts of local diabetes care Consider things like Admin Who does what When will be it be held Where will be it be held Audit Who else do you need to involve? Education of workforce Who has main responsibility? etc Consider from the patients side What will you want ? What information do you need? What will you main concerns be? Time commitment on diabetes care Impact on work/ family / insurance etc