Everyone knows someone with diabetes type II. It’s a chronic disease that affects up to 5 per cent of the population so there’s a high probability that your mother, father, brother, sister, your friend or you have the condition.
The rising in people with diabetes type II has been known for a long time. So has the risk of patients with diabetes type II developing serious, sometimes life-threatening complications if not adequately screened or monitored. These include diabetes retinopathy (retina damage which can cause blindness), peripheral neuropathy (nerve damage which can cause foot ulcers and, in severe cases, require amputation), renal and cardiovascular problems.
“We have to stop thinking about diabetes as a blood glucose problem. It’s a vascular disease because it impacts the kidneys and eyes through the micro blood vessels and on the heart through the macro blood vessels,” says Dr Velma Harkins, a midlands GP.
An integrated model of care where the majority of patients with diabetes type II are seen three times a year by their GPs and practice nurses with back-up support from community-based diabetes nurses has long been accepted as the best model of care. Those with more complicated or more advanced disease could be seen twice yearly at GP practices with an annual visit to a hospital.
Health professionals attending the seventh annual conference on Diabetes in Primary Care tomorrow in Ballincollig, Co Cork, will no doubt be asking themselves why – with widespread acceptance of this model of care – it’s not the experience of many patients in Ireland.
In fact, apart from some excellent examples of GP-led care in the midlands, the north east, Dublin and Cork itself, many patients with diabetes type II continue to face long waiting lists to see endocrinologists in hospitals.
Why is this the case? Dr Diarmuid Quinlan, Cork GP and member of the National Diabetes Working Group, says it’s a question of resourcing the care of diabetes patients in the community.
“We know it makes financial sense for patients to be seen by their GPs. We know that it will give them a better level of care close to their homes but it takes more time to deal with patients with diabetes for both GPs and practice nurses, and the HSE hasn’t agreed to fund it.”
Harkins is the author of the as yet unpublished new HSE guidelines for integrated care for diabetes type II. “Everyone agrees on the model of care but there is no agreement on how to fund diabetes care at GP practices. The Irish College of General Practitioners (ICGP) withdrew from the National Diabetes Clinical Care Programme last year [as they are waiting] until resources are put in place,” says Harkins, who is the former primary care clinical lead for diabetes at the ICGP.
Harkins, who is based in Banagher, Co Offaly, set up and leads a structured care programme for patients with diabetes type II in the midlands which, she says works very well.
“Take for example, a new patient who came into the surgery with a chest infection that he had had for three weeks.
High mortality
“We did blood tests and discovered he had diabetes type II which immediately required the practice nurse to take his history, talk to him about dietary/exercise changes as well as taking bloods to check his cholesterol levels and a urine sample to check his kidney function. He also needed to be referred to the dietician and referred for diabetes retinopathy screening.
“Following all this, the GP needed to see him again to check the medication dose. And, a multidisciplinary team meeting with the GP, practice nurse and the diabetes clinical nurse specialist was also required. Hospitals simply can’t cope with this level of care for the number of patients being diagnosed with diabetes type II,” says Harkins. The Midlands Diabetes Structured Care programme is funded through Heartwatch and a similar scheme in the north-east gets Diabetes Watch funding.
Last year, 17 specialist diabetes clinical nurses were appointed to support GPs across Ireland in delivering care. But because of the impasse between the ICGP and the HSE, it could be argued that they can’t do their jobs properly. That said, some diabetes clinical nurse specialists do excellent work managing patients in the community while acting as a liaison with hospitals for more complicated cases.
“Part of our role is to educate newly diagnosed patients,” says Joanne Lowe, HSE community diabetes nurse specialist working with patients in south-east Dublin and Wicklow. There is a community-based six-week programme which takes patients through the management of diabetes, their diet and exercise and informs them about the possible complications. GPs in our area can refer patients to this free programme.”
According to Lowe, people like healthcare close to home. “The burden of any chronic disease is to try to manage it on a day-to-day basis. We provide education to GPs’ practice nurses on what to look out for in patients. If we don’t start to prevent diabetes, the costs will be huge.”
If risk factors are identified early enough, full-blown diabetes type II can be avoided. Some diabetes nurse specialists deal specifically with prevention of diabetes type II. “More than 58 per cent of diabetes type II is preventable and we can identify those at risk with a simple questionnaire,” says Bernadette O’Riordan who will speak at tomorrow’s conference about diabetes prevention.
“We can identify people at risk of developing diabetes type II in the next 10 years by finding out their family history, their weight, how active they are, what their diet is like,” says O’Riordan who runs screening programmes at public events, such as agricultural shows, in west Cork. “Then we offer a Walk Away from Diabetes programme to those at risk,” she says.
Research has found that almost 50 per cent of those who attend these programmes continue to follow the dietary and exercise recommendations up to nine months later. So, why can’t these programmes be rolled out over the country in conjunction with GP-led care for diabetes type II patients? “We don’t have a national programme for the prevention of diabetes type II. A lot of the focus is still on sorting out the care of patients with diabetes,” says O’Riordan.
Some doctors suggest it’s because “diabetes is not a sexy disease” so it doesn’t get the priority it deserves. “An interim solution has to be found before the new GP contract is sorted out. Diabetes has a far bigger mortality rate than cancer and we know the best treatment for it. We just need the resources to deliver it,” says Harkins.
Understanding the extra demands on GPs and practice nurses in managing patients with chronic diseases – as opposed to dealing with acute conditions – is central to all of this.
