Sixty Years of Diabetes Management in Primary Care

Mike G Kirby

Disclosures

British Journal of Diabetes and Vascular Disease. 2012;12(6):315-320. 

 

• Abstract and Introduction
• Therapeutic Advances
• Insulin Therapy
• Intensive Therapy
• Advances in Monitoring and Insulin Delivery Devices
• Insulin Delivery Systems
• Health Service Strategies
• Preventing Diabetes and Minimising the Complications
• What Have We Learnt Over the Last 60 Years?

• References

Abstract and Introduction

Abstract

The incidence of diabetes has increased exponentially over the last 60 years, meaning that the management of diabetes solely by specialist healthcare professionals is no longer feasible. Since the 1970s, primary and community healthcare professionals have increasingly treated patients with diabetes. Advances in diabetes equipment and new treatments have further enabled patients to be treated more conveniently in the community and this has enhanced their quality of life. There has also been an evolution in health service strategies for diabetes – notably growing acknowledgement of the benefits of intensive glycaemic treatment for patients with type 2, as well as type 1 diabetes, and the now well-recognised importance of effective shared care programmes between primary and secondary healthcare professionals. Thus, the organisation and delivery of care for patients with diabetes has improved dramatically since 1952.

Introduction

Sixty years ago people with diabetes would have been managed mainly by specialists in hospital. The remorseless increase in numbers of patients with type 2 diabetes has made this no longer practical. Since the 1970s increasing numbers of primary and community healthcare professionals in the UK have assumed responsibility for the routine review, monitoring and management of patients with diabetes.

There are of course, other reasons for the increased role of primary healthcare professionals in the care of contemporary diabetes management. New treatments and advances in monitoring and delivery devices have allowed more effective and flexible management strategies.

Healthcare professionals are also increasingly aware of the importance of quality of life and attention has become focused on disease management that is more suited to patients' lifestyles and provision of services closer to home. Additionally, many patients today expect to be actively involved in their treatment. They are better informed and less likely to accept advice unquestioningly from healthcare professionals.

Hence diabetes care has evolved and new concepts have been introduced. These include intensive therapy for patients with type 2 diabetes as well as those with type 1 diabetes. It is also appreciated now that diabetes is a cardiovascular disease and that a holistic approach to treatment (incorporating: education, lifestyle advice (including exercise), attention to blood pressure and dyslipidaemia), is essential to improve patients' outcome and well being. For patients with complications, a multidisciplinary team approach is essential. However the majority of uncomplicated patients are now managed exclusively in primary care by well trained practice nurses supported by a GP with an interest in diabetes. We have also seen the development of GPs with a special interest (GPSIs) who are fully accredited in the management of this condition, and they often provide support to neighbouring practices, as do community physicians.

Attempts in patients with type 2 diabetes mellitus to lower their blood glucose levels near to normal by intensive blood glucose control undoubtedly benefits some patients, but it also has the potential to do harm. An National Prescribing Centre (NPC) Rapid Review summed it up well in their headline, 'Blood glucose lowering and mortality in type 2 diabetes: not too little, not too much.^[1] The management of complex cases has become the realm of the hospital diabetes specialist.