The care of diabetes mellitus in general practice: Prompting structured care in Islington

Over the past 20 years there have been numerous attempts to improve the care of diabetic patients in general practice. Approximately half of all patients with diabetes do not attend hospital clinics regularly, and require structured care in the community. In addition, there has also been a developing tendency, in the case of those patients who attend hospital clinics, for consultants to transfer their care back to general practitioners. Several reports appeared in the 1970s in which GPs studied the care of their diabetic patients and made suggestions for improvement. Community care initiatives were also reported on the part of hospital consultants which placed new demands upon general practitioners in caring for these patients. These initiatives together with changes in the traditional pattern of diabetic care in the UK are discussed. This thesis describes attempts to foster structured care of diabetic patients in an inner city locality of London beginning in 1983. It evaluates the medical effectiveness and acceptability to patients, general practitioners and optometrists, of a centrally organised prompting system to support the primary care of Type II diabetic patients. In a prospective randomised study involving two hospital outpatient clinics, 38 general practices and 14 optometrists, 181 non insulin treated patients were randomly allocated to prompted care in the community, or to continued attendance at their hospital clinic (control group). Community care consisted of coordinated six monthly prompts sent to patients for laboratory tests followed by clinical review in general practice in normal surgery time, with annual dilated fundoscopy by high street optometrists. Hospital care consisted of the usual care offered at the diabetic clinics of the district general hospital. Prompted structured care was found to be safe and effective over a 21/2 year period. It was acceptable to patients, interfaced well with the practice of local GPs, and proved popular with optometrists. This approach to organising primary care of Type II diabetes in a district is further discussed