Features of primary care associated with variations in process and outcome of care of people with diabetes.

BACKGROUND: There is now clear evidence that tight control of blood glucose and blood pressure significantly lowers the risk of complications in both type I and type II diabetes. Although there is evidence that primary care can be as effective as secondary care in delivering care for people with diabetes, standards in primary care are variable. Previous studies have shown that practice, patient or organisational factors may influence the level of care of patients with diabetes. However, these studies have been conducted in single geographical areas and involved only small numbers of practices. AIM: To determine the standard of diabetes care in general practice and to determine which features of practices are associated with delivering good quality care. DESIGN OF STUDY: A questionnaire survey and analysis of multi-practice audit data. SETTING: Three health authorities in England, comprising 169 general practices. METHOD: This study was conducted with a total population of 1,182,872 patients and 18,642 people with diabetes. Linkage analysis was carried out on data collected by a questionnaire, routinely collected health authority data, and multi-practice audit data collected by primary care audit groups. Practice annual compliance was measured with process and outcome measures of care, including the proportion of patients who had an examination of their fundi, feet, blood pressure, urine, glycated haemoglobin, and the proportion who had a normal glycated haemoglobin. RESULTS: Median compliance with process and outcome measures of care varied widely between practices: fundi were checked for 64.6% of patients (interquartile range [IQR] = 45.3-77.8%), urine was checked for 71.4% (IQR = 49.7-84.3%), feet were checked for 70.4% (IQR = 51.0-84.4%), blood pressure for 83.6% (IQR = 66.7-91.5%), and glycated haemoglobin was checked for 83.0% of patients (IQR = 69.4-92.0%). The glycated haemoglobin was normal in 42.9% of patients (IQR = 33.0-51.2%). In multiple regression analysis, compliance with measures of process of care were significantly associated with smaller practices, fundholding practices, and practices with a recall system. Practices with more socioeconomically deprived patients were associated with lower compliance with most process measures. Practices with a greater proportion of patients attending hospital clinics had lower compliance with process and outcome measures. Being a training practice, having a diabetes mini-clinic, having more nurses, personal care, and general practitioner or nurse interest in diabetes were not associated with compliance of process or outcome of care. CONCLUSIONS: Despite recent evidence that complications of diabetes may be delayed or prevented, this study has highlighted a number of deficiencies in the provision of diabetes care and variations in care between general practices. Provision of high quality diabetes care in the United Kingdom will present an organisational challenge to primary care groups and trusts, especially those in deprived areas.     

Diabetes care from diagnosis: effects of training in patient-centred care on beliefs, attitudes and behaviour of primary care professionals

In a randomised trial, general practitioners and nurses in 21 practices were trained in patient-centred consulting and use of materials for people with Type 2 diabetes (GPs 0.5 days; nurses 1.5 days; two optional follow-up half-days). Twenty practices formed the comparison group. Professional beliefs, attitudes and behaviour were measured (pre-trial, close-of-course and end-of-trial), supported by patient reports of nurse behaviour (141 trained: 108 comparison patients, 1 year after diagnosis). A total of 49 practice nurses responded (29 trained; 20 comparison). Trained nurses rated relative importance of patient-centred to professional-centred care as greater than comparison nurses. Trained nurses became less keen on the approach during the trial, and perceived time constraints persisted. Patients diagnosed later in the study were less likely to recognise intervention materials. Trained nurses rated delivery of important aspects of care and satisfaction with style of care as lower than comparison nurses, but patients were more positive about delivery of care from trained than comparison nurses. Although nurses rated patient-centred care as important, whether or not they had been trained as part of the trial, the short, generalizable training programme significantly reduced nurse perceptions of their ability to deliver it. Nonetheless, patients reported that important aspects of diabetes care were delivered more if their nurses had been trained in patient-centred consulting. This raises issues concerning measurement scales completed by trained professionals.     

Practice nurses: characteristics, workload and training needs.

AIM. This study set out to identify the present and future training needs of practice nurses in South West Thames Regional Health Authority and to examine these needs within the nurses' current and changing workloads and social, educational and occupational profiles. METHOD. A questionnaire was sent to 899 practice staff identified by family health services authority records whose salaries were in part reimbursed and in whose job title the word nurse appeared. The questionnaire enquired about personal and practice demography, tasks and activities currently undertaken, perceived role development and training requirements, and preferred organization of training. RESULTS. A total of 620 completed questionnaires were returned (69%). Nurses' work involved treatments, immunizations investigations, administration, first contact with patients, support to the general practitioner and health promotion. The areas of role development selected most commonly by nurses were counselling skills (60%) and health promotion (54%); in terms of training the most popular areas were communication skills (62%) and the theory and practice of health promotion (48%). Fewer than one third of the nurses who were engaged in health checks for elderly people or the provision of diabetes care, asthma care or advice about the human immunodeficiency virus (HIV) and the acquired immune deficiency syndrome (AIDS) held an appropriate qualification. CONCLUSION. Practice nurses in the region were engaged in a wide range of activities for which many have had little formal training; the majority wished to develop their role and undertake further training. If practice nurses are to play a key part in the development of primary care services they must be adequately prepared for their clinical and health promotion role.     

Involvement of the primary health care team in coronary heart disease prevention.

BACKGROUND. Recent years have seen a vast increase in the amount of health promotion activity undertaken in general practice. AIM. This study set out to identify the level of general practitioner and nurse involvement in activities aimed at coronary heart disease prevention and to examine variations in involvement. METHOD. A questionnaire survey was undertaken of a sample of general practitioners across England and the nurses who worked in their practices. RESULTS. Of 1696 randomly selected general practitioners 64% completed a questionnaire, of 928 practice nurses 71% responded and of 682 health visitors and 679 district nurses 52% and 40% responded, respectively. Of the general practitioners 94% reported that they were involved in assessing lifestyle risk factors in the routine consultation and regular assessments most commonly involved blood pressure testing and inquiry about smoking status. Eighty six per cent of practices were reported by the practice nurse as having well person clinics; these clinics were usually run by the practice nurse. Clinics for the management of specific lifestyle risk factors were also usually run by practice nurses, although many doctors were involved in hypertension clinics and cholesterol clinics. Health visitors and district nurses had a low level of involvement in this practice based clinic activity. Involvement of general practitioners and practice nurses in coronary heart disease prevention was associated with training in health promotion and positive attitudes towards prevention and health promotion. The level of involvement of practice nurses in health promotion was associated with the support received from primary health care facilitators, family health services authorities and district health authorities. CONCLUSION. Members of the primary health care team appeared to have their own distinct area of preventive activity. However, this division did not appear to be a result of organized teamwork and deployment of skills and expertise according to a clearly defined management protocol. Instead it seemed to be a product of general practitioner contract and management arrangements which tended to encourage an approach to general practice health promotion which revolved around the practice nurse and which hindered the development of a broader team based approach to planning and delivery of health promotion in relation to the needs of the practice population.     

Developing a training programme in patient-centred consulting for evaluation in a randomised controlled trial; diabetes care from diagnosis in British primary care

Aim: To develop a feasible/theoretically based training programme in patient-centred consulting, for evaluation in a randomised controlled trial of diabetes care from diagnosis. Methods: The programme was developed with four primary care teams and their patients in an action research framework, with observation of diabetes review consultations before and after training, and evaluated by questionnaire after each training session, among 23 general practitioners and 32 practice nurses from 21 practices in the trial. Results: The observation study identified opportunities and obstacles to introducing a patient-centred approach into daily practice, especially in relation to time management and skill needs. The modified training programme was rated highly by participating general practitioners and nurses. Conclusions: Developing training programmes with the help of participating primary care teams ensures relevance and feasibility. Patient-centred consulting demands a shift from habitual consulting patterns. Practitioners are implementing the approach in practice, and the impact on patients is now under evaluation in the randomised controlled trial.     

Detection of psychological distress by practice nurses in general practice

BACKGROUND: The general practitioner (GP) has traditionally been the first port of call for people with psychiatric morbidity but increasingly other members of the primary care team see the patients first, particularly practice nurses. The numbers and roles of practice nurses have expanded greatly over the past decade and it is important that practice nurses are able to recognize patients with psychiatric morbidity. This paper reports a study to determine the abilities of 24 practice nurses to detect psychiatric morbidity in patients attending their clinics. METHODS: Twenty-four practices were randomly selected from 41 practices recruited from South London and Kent. One nurse per practice took part in the study. Patients were asked to complete a 12-item General Health Questionnaire (GHQ-12) while waiting for their appointment with the practice nurse. Following their consultation, the practice nurse rated the patients' level of psychological distress on a five-point rating scale. RESULTS: The response rate of patients was 97% (N= 1710). The GHQ case rate was 36%. The mean detection rate by practice nurses when identifying significant distress was 16% (between nurse variation, 0% to 61%). The mean specificity was 96% (variation 77% to 100%). A second analysis, changing the nurse criterion to recognition of distress increased the mean sensitivity rate to 58% (variation 31% to 84%) but the mean specificity rate decreased to 66% (variation 26% to 95%). CONCLUSIONS: These results demonstrate that practice nurses' caseloads include a high proportion of patients with psychiatric morbidity and that agreement with the GHQ classification of psychiatric morbidity is modest. Therefore, training in detection will be crucial for the nurses.     

Nursing consultations and control of diabetes in general practice: a retrospective observational study

Background

Diabetes affects around 3.6 million people in the UK. Previous research found that general practices employing more nurses delivered better diabetes care, but did not include data on individual patient characteristics or consultations received.

Aim

To examine whether the proportion of consultations with patients with diabetes provided by nurses in GP practices is associated with control of diabetes measured by levels of glycated haemoglobin (HbA1c).

Design and setting

A retrospective observational study using consultation records from 319 649 patients with diabetes from 471 UK general practices from 2002 to 2011.

Method

Hierarchical multilevel models to examine associations between proportion of consultations undertaken by nurses and attaining HbA1c targets over time, controlling for case-mix and practice level factors.

Results

The proportion of consultations with nurses has increased by 20% since 2002 but patients with diabetes made fewer consultations per year in 2011 compared with 2002 (11.6 versus 16.0). Glycaemic control has improved and was more uniformly achieved in 2011 than 2002. Practices in which nurses provide a higher proportion of consultations perform no differently to those where nurse input is lower (lowest versus highest nurse contact tertile odds ratio [OR] [confidence interval {95% CI}]: HbA1c ≤53 mmol/mol (7%) 2002, 1.04 [95% CI = 0.87 to 1.25] and 2011, 0.95 [95% CI = 0.87 to 1.03]; HbA1c ≤86 mmol/mol (10%) 2002, 0.97 [95% CI = 0.73 to 1.29] and 2011, 0.95 [95% CI = 0.86 to 1.04]).

Conclusion

Practices that primarily use GPs to deliver diabetes care could release significant resources with no adverse effect by switching their services towards nurse-led care.     

Practice nurses'' workload and consultation patterns.

BACKGROUND. There are calls for the role of the practice nurse to be developed and extended. Before areas for further training and education can be identified, baseline data are needed on practice nurses' current activity and workload. AIM. A study was undertaken to analyse the activity of practice nurses in two large inner city general practices and to assess the skills mix of the nursing staff required to meet the needs of the practices. METHOD. The study practices had a combined list of 26,000 patients, 80% of patients attracting a deprivation allowance. Each practice employed three practice nurses. A nurse activity index with 45 codes was constructed to describe patient-nurse consultations. Activity codes were categorized into traditional treatment tasks, extended role tasks or diagnosis and management tasks. For eight months, practice nurses in practices Y and Z recorded activity index codes for each patient consultation. Practice Y also recorded the source of referral and the age and sex of the patient. RESULTS. There were 13,898 practice nurse consultations during the study period, equivalent to an annual nurse consultation rate of 0.8 per patient. Compared with the practice population as a whole, the patients attending the practice nurses in practice Y were older (mean age 43 years versus 37 years, P < 0.001). Those attending the practice nurses in practice Y were also more likely to be female (61% of consultations were with female patients compared with 50% of the practice population as a whole, P < 0.001). In practice Y, patients referred themselves to the practice nurse in 42% of consultations, 32% were follow-up consultations and in 25% of cases the patient had been referred by a doctor. The most common reasons for nurse consultation were blood tests (15% of procedures in practice Y and 18% in practice Z) and dressings (13% in both practices). Most procedures in practices Y and Z were in the traditional treatment category (61%), 26% were in the extended role category and 9% in the diagnosis and management category (3% coded 'other', 1% uncoded). Between practices, the greatest difference in recorded procedures was for asthma check ups (7% of procedures in practice Y compared with 2% in practice Z). CONCLUSION. This study describes the workload of practice nurses in two inner city practices over eight months. Other practices could use the activity index to make comparisons over time and between practices. Up to 60% of nurses' work in the study practices could be done by a nurse without extended training and up to 30% could be done by a health care assistant, but with some loss of quality. It is suggested that half the nursing hours available to a practice should be offered by a nurse with extended training in order to undertake and develop extended role tasks and diagnosis and management tasks.     

Determining priorities for change in primary care: the value of practice-based needs assessment.

BACKGROUND: Primary care is being expected to expand the range of services it provides, and to take on many of the tasks traditionally provided in secondary care. At the same time, general practitioners (GPs) will become increasingly responsible for assessing their patients' health care needs and commissioning care from other providers. This article describes an approach taken in one general practice to meet these difficult challenges. AIM: To examine whether information on health and health care needs, when used as the basis for a priority setting exercise, can provide a useful first step in planning primary care provision within a practice. METHOD: A three-stage process of information-gathering from a number of sources, including continuous data recording of patient contacts and a postal survey of all adults registered with the practice, identification of key findings and discussion of associated issues, and priority setting of proposals for practice development using the nominal group technique. RESULTS: Continuous data recording of patient contacts with GPs and the practice nurse provided data on 4489 GP contacts with 2027 patients, 1000 district nurse contacts with 101 patients, and 361 health visitor contacts with 172 clients. More than 70% of patient records had been computerized, with 600 diagnostic READ codes identified and 11,500 separate entries made. The socioeconomic and health survey questionnaire achieved an 84% response rate. Following the priority-setting exercise, 28 proposed practice developments were identified. These were reduced to a final list of eight. CONCLUSION: A comprehensive method of practice-based needs assessment, when used as the basis for some form of priority setting, has great potential in helping to plan primary care services within a practice. The success of such initiatives will require a substantial investment of resources in primary care and fundamental changes to the way in which primary care is funded.     

The role of the general practitioner in the community care of people with HIV infection and AIDS: a comparative study of high- and low-prevalence areas in England.

BACKGROUND: Policy for the care of people suffering from HIV and AIDS has changed over the past decade. Schemes for shared primary and secondary care have been met with varying success, and patients may be reluctant to become involved. No systematic evaluation comparing the views of primary care providers and users in areas of varying HIV prevalence has been published. AIM: To examine the role of general practice in areas of England with low and high human immunodeficiency virus (HIV) prevalence and to compare barriers to general practice care in each area. METHOD: We used focus groups, semistructured questionnaires and interviews in north London (high HIV prevalence) and Nottingham (low HIV prevalence). RESULTS: Four focus groups took place in London. A total of 411 general practitioners (GPs) in London and 405 in Nottingham replied to postal questionnaires. Overall, 121 primary care staff in 40 London practices and 26 staff in five Nottingham practices were interviewed. In all, 54 people infected with HIV were interviewed in London and 20 in Nottingham. Providers and users regarded the 24-hour availability and the familiar environment of general practice as its key assets. Lack of expertise and time were its disadvantages. Providers were concerned about inadequate communication with specialist services. Although providers were concerned about confidentiality, whether they had liberal and sympathetic attitudes was more important in deciding whether people with HIV used the service. In the low-prevalence area, general practice involvement was the result of individual initiatives, and practices were not integrated into specialist care. In the high-prevalence area, HIV care was more usual in general practice, but there was also little integration with HIV services. CONCLUSIONS: In high-prevalence districts, a strategy to make HIV care routine for all GPs may be appropriate. In low-prevalence areas, a network of selected, strategically located, relatively high-involvement practices may be more effective in meeting the primary care needs of people with HIV infection and acquired immunodeficiency syndrome (AIDS).     

Patient focus groups about nurse-led shared care for the chronically ill

Traditional care offered to chronically ill people does not succeed in bridging the gap between primary and secondary care in a way that suits chronic patients' needs. So-called nurse-led shared care may offer a solution, in which a specialised nurse practitioner plays a co-ordinating role at patient level. In this article two nurse-led shared care models for patients with diabetes mellitus type 2 and chronic obstructive pulmonary disease (COPD) are looked upon through the patient's eye. Joint focus groups are conducted in which patients judge the models according to their experiences and indicate the importance they attribute to quality issues. Most of them experience the shared care models as positive and prefer them compared to traditional care. The main quality aspect concerns the provision of information, although its performance needs improvement. The outcome indicates that the qualitative method of patient focus groups should become standard procedure in evaluating the shared care, supported by quantitative means.     

Teenage health and the practice nurse: choice and opportunity for both?

Teenage health issues and the means to address them have caused increasing concern over recent years. This study investigated the involvement and training of practice nurses, the topics raised during consultations with teenagers, and the comfort of the practice nurses in dealing with these topics. Data were collected using a postal questionnaire survey (response rate 80.6%). Expansion of the role of the practice nurse in teenage health may be appropriate but needs to be supported by training.     

Use of the consultation satisfaction questionnaire to examine patients'' satisfaction with general practitioners and community nurses: reliability, replicability and discriminant validity.

BACKGROUND: Primary health care services are the most frequently used in the health care system. Consumer feedback on these services is important. Research in this area relates mainly to doctor-patient relationships which fails to reflect the multidisciplinary nature of primary health care. AIM: A pilot study aimed to examine the feasibility of using a patient satisfaction questionnaire designed for use with general practitioner consultations as an instrument for measuring patient satisfaction with community nurses. METHOD: The questionnaire measuring patient satisfaction with general practitioner consultations was adapted for measuring satisfaction with contacts with a nurse practitioner, district nurses, practice nurses and health visitors. A total of 1575 patients in three practices consulting general practitioners or community nurses were invited to complete a questionnaire. Data were subjected to principal components analysis and the dimensions identified were tested for internal reliability and replicability. To establish discriminant validity, patients' mean satisfaction scores for consultations with general practitioners, the nurse practitioner, health visitors and nurses (district and practice nurses) were compared. RESULTS: Questionnaires were returned relating to 400 general practitioner, 54 nurse practitioner, 191 district/practice nurse and 83 health visitor consultations (overall response rate 46%). Principal components analysis demonstrated a factor structure similar to that found in an earlier study of the consultation satisfaction questionnaire. Three dimensions of patient satisfaction were identified: professional care, depth of relationship and perceived time spent with the health professional. The dimensions were found to have acceptable levels of reliability. Factor structures obtained from data relating to general practitioner and community nurse consultations were found to correlate significantly. Comparison between health professionals showed that patients rated satisfaction with professional care significantly more highly for nurses than for general practitioners and health visitors. Patients' rating of satisfaction with the depth of relationships with health visitors was significantly lower than their ratings of this relationship with the other groups of health professionals. There were so significant differences between health professional groups regarding patients' ratings of satisfaction with the perceived amount of time spent with health professionals. CONCLUSION: The pilot study showed that it is possible to use the consultation satisfaction questionnaire for both general practitioners and community nurses. Comparison between health professional groups should be undertaken with caution as data were available for only a small number of consultations with some of the groups of health professionals studied.     

Nurse staffing and quality of care in UK general practice: cross-sectional study using routinely collected data

Background

In many UK general practices, nurses have been used to deliver results against the indicators of the Quality and Outcomes Framework (QOF), a ‘pay for performance’ scheme.

Aim

To determine the association between the level of nurse staffing in general practice and the quality of clinical care as measured by the QOF.

Design of the study

Cross-sectional analysis of routine data.

Setting

English general practice in 2005/2006.

Method

QOF data from 7456 general practices were linked with a database of practice characteristics, nurse staffing data, and census-derived data on population characteristics and measures of population density. Multi-level modelling explored the relationship between QOF performance and the number of patients per full-time equivalent nurse. The outcome measures were achievement of quality of care for eight clinical domains as rated by the QOF, and reported achievement of 10 clinical outcome indicators derived from it.

Results

A high level of nurse staffing (fewer patients per full-time equivalent practice-employed nurse) was significantly associated with better performance in 4/8 clinical domains of the QOF (chronic obstructive pulmonary disease, coronary heart disease, diabetes, and hypertension, P = 0.004 to P<0.001) and in 4/10 clinical outcome indicators (diabetes: glycosylated haemoglobin [HbA_1C] ≤7.4%, HbA_1C ≤10% and total cholesterol ≤193 mg/dl; and stroke: total cholesterol ≤5 mmol/L, P = 0.0057 to P<0.001).

Conclusion

Practices that employ more nurses perform better in a number of clinical domains measured by the QOF. This improved performance includes better intermediate clinical outcomes, suggesting real patient benefit may be associated with using nurses to deliver care to meet QOF targets.     

Impact of UK Colorectal Cancer Screening Pilot on primary care

BACKGROUND: The UK Colorectal Cancer Screening Pilot has recently been completed to evaluate the feasibility of screening using the faecal occult blood test. Screening will be phased in over the next several years, and it is important to consider the impact on the NHS workforce. AIM: To determine the impact of the UK Colorectal Cancer Screening Pilot on primary care workload. DESIGN OF STUDY: A retrospective survey and prospective audit of general practice staff. SETTING: General practice. METHOD: Workload impact was assessed using a postal questionnaire and a prospective audit of activity in participating practices. Questionnaires were sent to practices that had been involved in the Pilot between 6 weeks and 1 year previously. They were sent to a random sample of 59 practices in Scotland and 60 practices in England between February 2001 and March 2002. Audit forms were sent prospectively to 60 practices involved in the Pilot between May 2001 and September 2002. RESULTS: Sixty-seven per cent of GPs, 82% of practice managers, 69% of practice nurses, and 70% of receptionists responded to the questionnaire. Of 60 practices contacted to take part in the workload audit, 38 returned completed 'workload impact audit' forms. Most practice staff indicated they spent 2% or less of their time during the screening period on Pilot-related activities. Forty per cent of GPs thought that a national colorectal cancer screening programme would substantially impact on the workload in primary care. However, there were variations by country: practice staff in Scotland were more likely to think that it would substantially impact on workload than practice staff in England (44.7% versus 26.6%). CONCLUSIONS: The surveys and audit demonstrate that the Pilot has had a discernible, albeit modest, impact on workload in primary care. Workload of particular significance to primary care personnel includes increases in paperwork, administration, and information provision to patients. The majority of primary care staff support the introduction of a colorectal cancer screening programme. However, there is a strong perception, particularly among GPs, that a national programme of faecal occult blood test screening will impact significantly on workload in primary care, and that primary care-based activities generated through screening should be adequately resourced and remunerated.     

Practice nursing in Glasgow after the new general practitioner contract.

Six months after the implementation of the new general practitioner contract in April 1990, practice nurses employed in greater Glasgow were surveyed using a self completed postal questionnaire. Of the 165 practice nurses employed in greater Glasgow 153 (93%) were identified and surveyed. Of these, 131 responded to the questionnaire (86%). The practice nurses were well qualified and experienced. Sixty per cent were under 40 years of age, 68% had been recruited within the previous year and 70% were employed for five sessions or more per week. Many carried out extended nursing duties, including health promotion activities. Many described inadequacies of their employment contract, practice facilities and the functioning of the primary health care team. If service quality is to be assured in practice nursing and practice nurses are to function as key primary health care team workers, then it is important that their role, professional skills, and working facilities are defined, supported and monitored. This should be addressed by general practitioners, practice nurses, and their professional bodies, in collaboration with the health board.     

'They think they can talk to nurses': practice nurses' views of their roles in caring for mental health problems.

BACKGROUND: Primary care teams have been encouraged to develop the care they provide to patients with mental health problems, and a greater role for practice nurses has been advocated. However, little is known about practice nurses' current level of involvement or their perceived strengths and limitations in caring for patients' mental health problems. AIM: To describe practice nurses' current experiences of caring for patients with mental health problems and to explore their perceptions about enlarging this role. METHOD: Pilot interviews were carried out with a purposeful sample of practice nurses to design a postal questionnaire, which was then sent to 635 practice nurses identified from family health services authority lists in six health authorities in the north-east of England. RESULTS: Completed questionnaires were returned by 445 (70%) practice nurses. Most nurses (83%) reported that they commonly saw patients with a range of mental health problems arising indirectly or directly in consultations. Many practice nurses (52%) lacked any formal mental health training and identified a broad range of training needs. A majority (80%) of responders had concerns about their abilities to address mental health problems effectively, given their existing workloads. However, most (61%) were keen to expand their role in mental health care if appropriate support and training were forthcoming. CONCLUSION: There is considerable potential for practice nurses to realize a greater and more effective role in the care of mental health problems in primary care. Developing practice nurses' contribution will require further training and support.     

Organized personal care--an effective choice for managing diabetes in general practice.

A system of diabetic review was introduced in two Southampton training practices in March 1985. Each partner, with the help of the practice nurse, retained responsibility for review of their own diabetic patients. During the study period (1984-86) 213 diabetics remained with the practices. In 1984 there were 94 non-insulin dependent patients who were not receiving hospital outpatient care. Over the study period there was an increase in the surveillance of blood glucose, blood pressure, weight, urine (for protein), fundi, visual acuity and feet for this group so that in 1986 between 79% and 89% of patients were having these parameters checked at least annually. More complications were found and more referrals for specialist evaluation were made. There was a trend towards transfer of care from the hospital to the general practitioner, and the proportion of non-insulin dependent diabetic patients receiving their care entirely from general practice increased from 22% to 60% over the period. There was a small increase in the workload of the general practitioners and a considerable contribution to care was made by the practice nurses. It is concluded that structured personal diabetic care based on a nurse coordinated service is a satisfactory alternative to the 'specialist' general practitioner mini-clinic model.