C O N F E R E N C E R E P O R T

ABCD Autumn 2001 Meeting

An Irish perspectiveDr Richard Firth, Consultant Diabet-ologist at the Mater MisericordiaeHospital in Dublin, was invited by theChairman to describe the situation of dia-betes care in Ireland, as an interesting per-spective on the UK position. Dr Firth saidthat organised diabetes care in theRepublic had really only started with hispredecessor at the Mater, the legendaryProfessor Ivo Drury. A St VincentDeclaration Action Group had beenformed, though some time after the UK.

In Ireland, unlike the UK, hospitalswere in competition for patients, as theydid not have specific catchment areas andwere allowed to take them from anywherein the country. Traditionally, diabetes carehad been under-resourced and theseresources had been unevenly spread. Thediabetology specialty was a small one –there were only about 20 diabetologists inthe country – and was represented profes-

sionally by the Irish Endocrine Society. Inthe past there had been no incentive forGPs to handle diabetes but this was chang-ing. There were now more resources butthese were going to primary care, whichthe government thought was a cheaperoption.

Specialists in Ireland were alarmed bythe fact that developments were beingdriven, apparently, by a trinity of adminis-trators, government and the GPs. Theysaw what was happening in the UK andwere concerned to have a say in the newIrish arrangements. Specifically, theywanted to achieve the following:● type 1 diabetes to be managed only in

the secondary sector;● inimum standards to be set for GP dia-

betes practice (these standards to be setby the specialists);

● all specialist diabetes nurses and dieti-tians in the community to be attachedalso to specialist units.

Contributions from the floorA vigorous discussion followed, in thecourse of which a number of interestingand perceptive comments and suggestionswere made from the floor, as is invariablythe case at ABCD meetings.

NSF and St VincentThe work of the St Vincent Declaration inthe UK was being continued alongside theNSF by the Diabetes Service DevelopmentGroup. The Diabetes NSF was intended todefine strategy for a period of five years.Politicians, patients and primary care weredriving the changes in the UK.Shared/integrated care only worked well ifit was structured. Specialist directionwould result in an enhanced service.

Redistribution of resourcesRedistribution of money was all very well,but no-one knew where or what the moneywas presently, so how was redistribution to

182 Pract Diab Int July/August 2002 Vol. 19 No. 6 Copyright © 2002 John Wiley & Sons, Ltd.

Association of British Clinical DiabetologistsHighlights of the Autumn 2001 Meeting

22/23 November 2001, Dublin, Ireland

Members of the Association of British Clinical Diabetologists (ABCD) from all over the United Kingdom met for twodays in the congenial atmosphere of The Jury’s Ballsbridge Hotel in Dublin to discuss two important medico-political/professional topics: the National Service Framework for Diabetes and its implications for secondary diabetescare; and the role and responsibilities of the diabetes specialist nurse in relation to those of the diabetologist. Themeeting was an opportunity also for delegates to debate the clinical significance of postprandial hyperglycaemia andto update and inform themselves through state-of-the-art lectures and discussions on a range of other interesting andrelevant clinical issues.

C O N F E R E N C E R E P O R T

THE NSF: IMPLICATIONS FOR SECONDARY DIABETES CARE

A discussion led by John Wales, Chairman, ABCD

Introducing an important discussion on the subject of the National Service Framework for Diabetes (NSF), the Chairman of ABCD,John Wales, suggested that the reasons for the NSF included the following:

● pressure for high standards of diabetes care;● expanding numbers of those with the disease;● inability of the present system to cope with those numbers;● heightened patient aspirations and● the desire by the government to save money.

Dr Wales pointed out that the final decisions of the NSF might not necessarily be the same as the recommendations of the ExpertGroup; ultimately, decisions would be made by the Secretary of State, and these would be influenced, inevitably, by political and eco-nomic considerations. The NSF might recommend one of three options, namely the following:

● no changes to the present arrangements (Dr Wales thought this was unlikely);● changes but no additional resources or a redistribution of existing resources (he described this as a long-term disaster) or● changes with some extra resources (this could turn out to be a curate’s egg).

The Chairman concluded by emphasising what he considered to be the two key requirements for better diabetes care in the UK: moreresources and more integration of care.

be costed? Perhaps it was better not to havediabetes costed out precisely. A finitebudget meant that you could not exceed it.The vagueness that resulted from diabetesbeing subsumed within the general medi-cine budget might have advantages.Redistribution of resources from the hospi-tal service to primary care would probablybe by stealth, e.g. by not replacing consult-ants when they retired. However, more pri-mary care diabetes would mean moredemand for secondary care!

A computer model of diabetes care sug-gested there was little difference in costsbetween primary and secondary care.

Motivation and training inprimary careA different mind set was required in gen-eral practice. Currently there was a rangein GP diabetes referrals in Wolverhamptonof 20–80%. Why? In North Tees there hadbeen no differences in diabetes outcomesbetween three MAAGs, although twoinvolved 50% hospital care and the otheronly 25%. Was this because of a uniformlyabysmal level of care or because it was verydifficult to set targets for outcomes? InBasildon, all GPs were divided into one ofthree groups so far as diabetes was con-cerned, ranging from those who deliveredminimum care to those who had com-pleted a one-year distance-learning courseat Warwick. The latter would take overmore and more patients and were beinggiven a financial incentive of £40 perpatient. The question was asked as towhether a one-year Warwick course wasenough. If so, why bother to train as a spe-cialist for seven years?! It had to be remem-

bered that many GPs had no special inter-est in diabetes – after all, the specialists hadchosen diabetes. Should there be trainingprogrammes for GP diabetes specialists?

In many places it was not the GPs whowere delivering diabetes care – it was thepractice nurses! In the Republic, there wasa growing involvement in diabetes bynurses. The Mater offered a two-yearHigher Diploma through a one-week full-time course. Courses for practice nurseswere being developed. The RCP shouldaddress these matters urgently.

Joint Specialist SocietyClinical Effectiveness ForumThe Chairman asked Ken Shaw to reporton the deliberations of the Joint SpecialistSociety Clinical Effectiveness Forum (JSS-CEF), a body driven by the DoH, in thecontext of the NSF. Professor Shaw saidthe forum was looking to establish physi-cian-specific professional standards, whichwould be independent of the effects ofresources and local structures, i.e. couldapply wherever one was and whatever one’slocal resources, and could be used to assessthe clinical performance of individuals andform the basis for an ‘annual appraisal andrevalidation process’. The JSSCEF defineda standard as ‘a measure serving as a basisor example or principle to which otherscan conform or should conform or bywhich the accuracy or quality of others isjudged’. It specified that a standard should● be clearly defined● be measurable● be recordable so that comparative data

can be collected● be shown to have some direct rele-

vance to the quality of clinical care● have a clear purpose● be applicable to the majority of physi-

cians working within the specialty● have threshold standards set at a level

below which practice would be consid-ered unacceptable.Each standard should consist of a rec-

ommendation, an indicator and a target.There should be two performance indica-tors for each specialty. Based on the GMCpaper, Good Medical Practice 2001, theRoyal College of Physicians had submittedrecommendations of good practice foracute physicians. These were underpinnedby the GMC revalidation programme. TheRCP-advised template for good medicalpractice comprised the following parame-ters:● good clinical care● maintaining good medical practice● teaching and training, appraising and

assessing● relationships with patients● working with colleagues● probity● health.

Professor Shaw concluded by saying thatthe third stage of pilot revalidation was tocommence in February 2002.

JSSCEF-recommendedstandards and the real worldThe audience felt that local appraisals wererequired – national recommendations weremeaningless. However, managers wereunimpressed by local proposals; onlysomething backed by the NSF would gal-vanise them. Whatever happened with theNSF, standards were going to happen.

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ABCD Autumn 2001 Meeting

Dr Essex described the evolution of thediabetes specialist nurse (DSN) role inCroydon over the period 1980–2001.Initially, the posts evolved in a piece-meal fashion, with close liaison betweenthe hospital and the community. TheDSNs, although employed by differentorganisations, worked as a team andshared the workload. The teamexpanded in number and there werenow three DSNs employed by theCommunity Trust and two by the Acute

(Hospital) Trust. They were managedseparately but clinical accountability tothe consultant diabetologist was clearlydefined in all their job descriptions.

GPs had come to appreciate the enor-mous benefits of the DSN role and wereincreasingly referring patients both tothe hospital and community DSNs. Asmore diabetes care was being devolvedto primary care, the role of the commu-nity DSN had shifted away from thehospital and there was closer involve-

ment with primary care teams, espe-cially with practice nurses. The natureof the relationship with ConsultantDiabetologists had become less clear.Objectives and working patterns werediscussed with community managersbut not always with consultants or GPsand there were sometimes areas of dis-agreement about working practice andaccountability. Clinical problems werehowever routinely discussed with theconsultants.

THE ROLE AND RESPONSIBILITIES OF DSNs IN THECOMMUNITY

A discussion led by Nina Essex

The Croydon experience

Professional issues raisedIt was suggested that there were a numberof important professional issues concern-ing the roles and responsibilities of theDSN, for example the following:● audit/monitoring of clinical practice

of DSNs;● clinical accountability of specialist

nurses – could they be accountable tonon-consultants?

● the legal position regardingautonomous advice on medicationand

● the implications of managing DSNsgeographically, i.e. separately, ratherthan as members of a single clinicalpractice.Scrutiny of the literature revealed the

following external influences on the DSNrole:● Royal College of Nursing (RCN)

Guidelines, which contained defini-tions;

● the NHS Plan, which devolved morework to already struggling nurses(probably for reasons of economics);

● the development of intermediate careservices, initially without secondaryinvolvement, and

● the legal framework.Additionally, the Crown Reports 1999

had reviewed the supply and administra-tion of prescription-only medicines(POMs). They defined new prescribertypes – an independent type (doctors anddentists) and a dependent type (nurses andothers). The latter group would prescribeaccording to group directives and bothgroups would have access to the completepatient medication records.

Finally, the Patient Group Directiveswere an important influence on nurse pre-scribing. They were described in HealthServices Circular 2000/26 and had beendrawn up by a multidisciplinary group(doctor/pharmacist/DSN). Every drug wasto be detailed.

Possible solutionsDr Essex suggested some possible waysforward.● DSNs working in a particular geo-

graphical area should be managed as asingle team. Close working relation-ships were vital.

● DSNs should share a single base, ide-ally at the hospital diabetes centre,although different team membersmight work in separate locations.

● Objectives should be agreed jointlybetween non-clinical managers andclinicians.

● Primary and secondary care shouldwork closely together.

DiscussionDuring a plenary discussion that was evenmore vigorous than that on the NSF, thefollowing points were made.● About one-third of delegates had expe-

rienced problems similar to those inCroydon.

● Relations that had been harmoniouscould be disrupted by communityDSNs being split between (and sepa-rately managed by) different PCTs.The problem was exacerbated whenconsiderable distances were involved.

● The problems did not really arisewhen the community DSNs were

employed by the hospital diabetes cen-tre.

● If hospital specialists were not allowedto have an input into the contracts ofnurse consultants, where did medicalaccountability lie?

● The RCN requirements for continuedprofessional development were moregeneral and philosophical than centredon specific nursing skills.

● Similar problems were being encoun-tered with chiropodists in some PCTareas. By no means all PCTs were seek-ing to expand their range of activities,however. Some felt they had morethan enough to do without taking onextra responsibilities.

● The Birmingham Ladywood experi-ence had been that an initially veryforceful approach by the GPs, exclud-ing consultants and the hospital dia-betes service from virtually everything,had gradually given way to a moreemollient attitude and a recognition ofthe importance of hospital involve-ment and indeed the lead role of sec-ondary care.

● Key words in all of this were seamlesscare and communications.

● ABCD could perhaps help. In its sub-mission to the NSF, the Associationhad stressed the importance of team-work but also emphasised the crucialrole of the consultant diabetologist.

Note: During the discussions it was sug-gested that ABCD meet with the UKAssociation of Diabetes Specialist Nursesto discuss the various points raised andattempt to find some agreed solutions tothese problems.

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ABCD Autumn 2001 Meeting

ABCD DEBATE

Motion: ‘This House believes that the control of postprandial hyperglycaemia is an important part of diabetes management’.

For: Dr Charles Fox (Northampton)

Dr Fox suggested that the resistanceto the concept of postprandial hyper-glycaemia (PPBG) as a significant riskfactor for diabetes complications andpremature mortality was a sign of theway diabetologists in the UK – acountry that had been responsible forthe invention of both the insulin pen(John Ireland) and the blood glucosemonitor (Peter Sonksen) – were ceas-

ing to be in the forefront of diabetescare. As an illustration, he pointedout that there were 133 000 insulinpump users in the USA – and only800 in the UK.

Using data from the DCCT, theUKPDS and the DECODE study,but also smaller-scale studies by Boliand Dornhurst, Dr Fox argued thatthere was clear evidence that PPBG

was associated with the onset andprogression of complications andwith premature mortality in bothtype 1 and type 2 diabetes.DECODE in particular had demon-strated that PPBG, and thereforeimpaired glucose tolerance (IGT),was a greater risk factor than impairedfasting glucose (IFG).

Discussion pointsIGT versus IFGIf we could get preprandial BG down, thengetting postprandial BG down as well wasOK, but for those for whom we could notget preprandial BG down, it was meaning-less. The real debate was about BG excur-sions, not necessarily PPBG. You had toinclude PPBG in order to keep HbA1cdown – as one component. Both sideswere right. The issue was about prioritis-ing. We were talking about the early stagesof type 2 diabetes, the first two or threeyears only. As time went on and the dia-betes progressed, the BG got higher andhigher throughout the 24 hours of the day,so the distinctions between IFG and IGTbecame rather academic. If you had dia-betes yourself, would you monitor PPBG?

Which modality?Which modality would be most likely toachieve the desired result: more attentionto diet, insulin secretagogues, rapid-actinginsulins? So far as the sequence of modali-ties was concerned, we were being led bythe pharmaceutical marketeers. ‘Let us dothe simple things well’ – patients needed tomodify their lives. But the debate was notabout how we did it but should we do it,i.e. control PPBG? We were not debatingabout enthusiasm or doing simple thingsfirst but about whether PPBG mattered.

The Bedford and Whitehall Studies clearlyshowed that it did.

Insulin pumpsMany diabetologists were anti-pump.Pumps were not for everyone but diabetol-ogists should try to get funding for thosewho chose a pump. There were many rea-sons for using pumps other than PPBG.Pumps were simply not a feasible option,because of costs, not because diabetologistswere against them.

PregnancyThere was no dispute that PPBG matteredin pregnancy.

Education and compliancePatients needed to be educated more toreduce their nihilism and enable them tochoose. If patients were already on tabletstwo or three times a day, would addinganother make much difference? DARTSwas an educational problem.

The futureIf there were a system that could measureBG continuously, then both pre- and post-prandial control would be possible. Futuretechnology would allow this to be done.There were large trials in place to showconclusively how PPBG affected beta cellfunction.

SummaryA small number might benefit from target-ing PPBG so by all means try – but it wasnot all that important (Dev Singh). Devfought dirty – he had read DECODE!(Charles Fox).

On a show of hands it was agreed thatthe result was a dead heat.

OTHER LECTURESThe following state-of-the-art lectureswere delivered at the meeting, each fol-lowed by a period of questions and discus-sion:Diabetes in young people (Professor DavidDunger, Addenbrookes Hospital,Cambridge); New treatments for diabeticretinopathy (Dr Paul Dodson)Cushing’s Syndrome (Professor BrewAtkinson, Belfast) New developments ininsulin therapy (Professor David Owens,Cardiff ).

The Chairman, John Wales, concluded themeeting by thanking all the speakers forexcellent presentations and the followingsponsors for their generous support:

Lilly Diabetes Care; Novartis Pharmaceuticals UK Ltd;Servier Laboratories; Takeda UK Ltd.

Conference report by James Wroe

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Doctor Singh pointed out that,although the Whitehall Study hadshown a significant increase in mortal-ity in those with a raised 1 hour bloodglucose, this disappeared whenadjusted for other risk factors. Likewisein DCCT, the increased relative risk fordevelopment of a three-step change inretinopathy disappeared when cor-

rected for – only the mean amplitudeof blood glucose excursions was signif-icant.

Dr Singh accepted that the 2 houroral glucose tolerance test was telling ussomething but the question was howmuch. The two abnormalities of IFGand IGT went roughly hand in hand.Perhaps PPBG was important but in

relationship to everything else it wasnot very important. What was failingour patients was our poor technology:the frequency of dosing and the num-ber of medications that were responsi-ble for poor compliance. PPBG was anissue at the margin of benefit in type 2diabetes. In type 1 diabetes, he main-tained, the evidence was just not there.

Against: Dr Dev Singh (Wolverhampton)