NATIONAL INSTITUTE FOR HEALTH & CARE EXCELLENCE – UNITED KINGDOM
Heart and Diabetes Center NRW, Bad Oeynhausen, Germany
Diabetes clinics
They have just appointed a new young consultant at my hospital and I am told that they are going to start a special diabetes clinic – will this offer any advantage to me?
Most hospitals these days have at least one senior doctor who specializes in diabetes. By running a special diabetes clinic they can bring together all the specially trained doctors, nurses, dietitians and chiropodists, and this should mean a better service for you and other people attending the clinic. You will have the benefit of seeing people who have special training in diabetes, and most people find this a big advantage.
My doctor is starting a diabetes clinic in the local group practice and tells me that I no longer need to attend the hospital clinic. It’s much more convenient for me to go to see my doctor but will this be all right?
You are fortunate that your general practitioner has a special interest in diabetes and has gone to the trouble of setting up a special clinic in the practice for this. Many doctors and practice nurses have had special training in diabetes and these general practice-based diabetes clinics are becoming more common. We are sure that your hospital specialist will know about this, and may even attend the doctor clinic from time to time. If you have any anxieties, why not discuss it with your doctor? Many doctors like to look after people with diabetes in general practice without the need to visit hospital. This is usually all right as long as you have uncomplicated diabetes and are well controlled, but you should be aware of the sort of care that you should expect.
Although they do a blood test every time I go to our local diabetes clinic, they now only test my urine once a year when they look at my eyes and check my blood pressure – why is this?
With the introduction of HbA1c measurement and blood glucose monitoring, the value of urine testing is really for the detection of protein (albumin) in the urine as an indicator of possible kidney damage. This does not need to be done more often than once a year in people who are quite well and free from albumin in their urine. As a general rule everyone with diabetes should have their urine, eyes, feet, and blood pressure checked annually.
Why do I have to wait such a long time every time I go to the diabetes clinic?
If you think about it, you probably have quite a lot of tests done when you go to the clinic. It takes time to get the answers back and the results all together before you see the doctor. This is particularly likely to be so if you have had a blood glucose measurement, as the HbA1c levels measured in the clinic take time to process. Although it may be irritating to have to wait for these results, they are very important as they can be used in a two-way discussion between you and the doctor to review your control and progress with diabetes. Many clinics use this waiting time for showing educational films or videos about diabetes and for meeting the dietitian and/or chiropodist, as well as the diabetes specialist nurse. If the clinic appears to be badly organized then you have good grounds for complaint.
What determines whether my next appointment is in 1 month or 6 months?
Generally speaking, if your control is consistently good you will not need to be seen very often; on the other hand, if your control is poor it is likely that you will be seen more often. This is not, as you may perhaps think, a subtle form of punishment, but it will give you and your medical advisers more opportunity to sort out what is wrong. At my clinic we have a mixture of people from young children to very old pensioners – why do they not have special clinics for young people?
Young people with diabetes have special needs, which are not usually met by an ordinary diabetes clinic. Growing up and learning to be independent places extra strains on diabetes control and young people prefer a more informal approach from members of the diabetes team. Some hospitals find it difficult to make these changes and there may be extra costs. However, clinics for young people have been set up in many parts of the country and you could ask your doctor if you could be referred to one of them.
We have a specialist nurse in diabetes working in the diabetes clinic that I attend. What does she do?
Most clinics in this country now employ specialist nurses who spend their whole time working with people with diabetes. They may work in the community and/or the hospital and have a variety of titles in UK for example – Diabetic Health Visitor, Diabetic Community Nurse, Diabetic or Diabetes Liaison Nurse, Diabetes Specialist Nurse, Diabetes Sister, Diabetic or Diabetes Care Sister, etc. These senior nurses spend most of their time educating people, giving advice (much of it on the telephone), making decisions about management, and teaching other members of the medical and nursing staff about diabetes. They are experts in their field and are central members of the diabetes care team.
As a newly diagnosed person with diabetes what sort of care should I expect?
Diabetes
It seems surprising that the government has not given some clear guidelines about diabetes care. Yes it is surprising when you consider that over a million people in the UK have diabetes and that it uses up a great deal of NHS money. In fact the Department of Health started to set up such a scheme, called the National Service Framework (NSF) for Diabetes. Similar schemes have already appeared for other branches of medicine such as cardiology and mental health. Consultations with the NSF for diabetes started in 1999 and the expert committee made its report in April 2001. It was expected that the government would roll out the project by the end of 2001. In October of that year the Minister of Health announced that the plans for diabetes would be released in 2002 but that the programme would take place over 10 years and that funding would start in April 2003. We presume that the NSF for Diabetes has turned out to be much more costly than expected and the government is therefore delaying its launch until they can be sure to fund it.
The first section of the NSF was published in 2001. This consists of the agreed standards and we must wait until April 2003 before the funding for this important project will start to appear.
We can only hope that the NSF will be adequately funded to cause a real improvement in diabetes care right across the country.
Monitoring and control
Note also that the National Institute for Clinical Excellence (NICE) has produced detailed guidelines for diabetes care. They deal with blood glucose and blood pressure and lipids.
When you have just been diagnosed you should have:
• A full medical examination;
• A talk with a registered nurse who has a special interest in diabetes; she will explain what diabetes is and talk to you about your individual treatment;
• A talk with a State Registered dietitian, who will want to know what you are used to eating and will give you basic advice on what to eat in future; a follow-up meeting should be arranged for more detailed advice;
• A discussion on the implications of diabetes on your job, driving, insurance, prescription charges, etc.; whether you need to inform the DVLA and your insurance company, if you are a driver;
• Information about the Diabetes UK’s services and details of your local Diabetes
• Ongoing education about your diabetes and the beneficial effects of exercise, and assessments of your control.
You should be able to take a close friend or relative with you to educational sessions if you wish.
PLUS
If you are treated by insulin, you should receive:
• Sequent sessions for basic instruction in injection technique, looking after insulin and syringes or insulin pens, blood glucose and urine ketone testing and what the results mean;
• Supplies of relevant equipment;
• Discussion about hypoglycaemia (hypos), when and why it may happen and what to do about it.
If you are treated by tablets, you should receive:
• Discussion about the possibility of hypoglycaemia (hypos) and how to deal with it;
• Instruction on blood or urine testing and what the results mean, and supplies of relevant equipment.
If you are treated by diet alone, you should receive:
• Instruction on blood or urine testing and what the results mean, and supplies of relevant equipment.
Once your diabetes is reasonably controlled, you should:
• Have access to the diabetes team at regular intervals – annually if necessary; these meetings should give time for discussion as well as assessing diabetes control;
• Be able to contact any member of the healthcare team for specialist advice when you need it;
• Have more education sessions as you are ready for them;
• Have a formal medical review once a year by a doctor experienced in diabetes.
At this review:
• Your weight should be recorded;
• Your urine should be tested for protein;
• Your blood should be tested to measure long-term control;
• You should discuss control, including your home monitoring results and details of any severe hypos;
• Your blood pressure should be checked;
• Your vision should be checked and the back of your eyes examined with an ophthalmoscope; a photo may be taken of the back of your eyes, and if necessary you should be referred to an ophthalmologist;
• Your legs and feet should be examined to check your circulation and nerve supply, and if necessary you should be referred to a State Registered chiropodist;
• If you are on insulin, your injection sites should be examined;
• You should have the opportunity to discuss how you are coping at home and at work.
Your role:
•You are an important member of the care team so it is essential that you understand your own diabetes to enable you to be in control of your condition.
•You should ensure that you receive the described care from your local diabetes clinic, practice, or hospital.
If these services are not available to you, you should:
• Contact your doctor to discuss the diabetes care available in your area;
• Contact your local Community Health Council;
• Contact the Diabetes UK or your local branch.
NATIONAL SERVICE (
Standard 1: Prevention of Type 2 diabetes
1. The NHS will develop, implement, and monitor strategies to reduce the risk of developing Type 2 diabetes in the population as a whole and to reduce the inequalities in the risk of developing Type 2 diabetes.
Standard 2: Identification of people with diabetes
2. The NHS will develop, implement, and monitor strategies to identify people who do not know they have diabetes.
Standard 3: Empowering people with diabetes
3. All children, young people and adults with diabetes will receive a service which encourages partnership in decision-making, supports them in managing their diabetes and helps them to adopt and maintain a healthy lifestyle. This will be reflected in an agreed and shared care plan in an appropriate format and language. Where appropriate, parents and carers should be fully engaged in this process.
Standard 4: Clinical care of adults with diabetes
4. All adults with diabetes will receive high-quality care throughout their lifetime, including support to optimize the control of their blood glucose, blood pressure and other risk factors for developing the complications of diabetes.
Standards 5 & 6: Clinical care of children and young people with diabetes
5. All children and young people with diabetes will receive consistently high-quality care and they, with their families and others involved in their day-to-day care, will be supported to optimize the control of their blood glucose and their physical, psychological, intellectual, educational, and social development.
6. All young people with diabetes will experience a smooth transition of care from paediatric diabetes services to adult diabetes services, whether hospital or community-based, either directly or via a young people’s clinic. The transition will be organized in partnership with each individual and at an age appropriate to and agreed with them.
Standard 7: Management of diabetic emergencies
7. The NHS will develop, implement and monitor agreed protocols for rapid and effective treatment of diabetic emergencies by appropriately trained healthcare professionals. Protocols will include the management of acute complications and procedures to minimize the risk of recurrence.
Standard 8: Care of people with diabetes during admission to hospital
8. All children, young people and adults with diabetes admitted to hospital, for whatever reason, will receive effective care of their diabetes. Wherever possible, they will continue to be involved in decisions concerning the management of their diabetes.
Standard 9: Diabetes and pregnancy
9. The NHS will develop, implement, and monitor policies that seek to empower and support women with pre-existing diabetes and those who develop diabetes during pregnancy to optimize the outcomes of their pregnancy.
Standards 10, 11 & 12: Detection and management of long-term complications
10. All young people and adults with diabetes will receive regular surveillance for the long-term complications of diabetes.
11. The NHS will develop, implement and monitor agreed protocols and systems of care to ensure that all people who develop long-term complications of diabetes receive timely, appropriate, and effective investigation and treatment to reduce their risk of disability and premature death.
12. All people with diabetes requiring multi-agency support will receive integrated health and social care.
