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EDITORIALS: Gareth Williams Diabetes black spots and death by postcode BMJ 2001; 322: 1375-1376 [Full text]

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Time is running out for diabetic patient care in NHS

John K Wales   (16 June 2001)

Rearranging the deckchairs

Peter Davies, Seth Jenkinson   (19 June 2001)

In defence of practice nurses (and primary care)

Mairi Cassels   (26 June 2001)

Time is running out for diabetic patient care in NHS 16 June 2001
John K Wales, chairman, Association of British Clinical Diabetologists General Infirmary at Leeds Send response to journal: Re: Time is running out for diabetic patient care in NHS	EDITOR - Gareth Williams in his Editorial1 is quite correct in drawing attention to the potential disasters ahead for diabetic patient care. The disturbing picture of unequal provision, staffing variations and deficiencies of specialist diabetes care has been highlighted by a recent survey of 77% acute NHS Trusts undertaken by the Association of British Clinical Diabetologists (ABCD). Diabetic patient care is a team activity but few teams have all the players, all the time. The number of Consultant Physicians with an interest in diabetes was less than 30% of the figure recommended, only 12% had the recommended number of diabetes specialist nurses and 27% diabetes services were without specialised dietetic services. Chiropody input was variable and only half had diabetic foot clinics. Over a quarter of districts had no patient register or co-ordinated retinopathy screening programme. To add insult to injury, of 24 5 bids for additional resources or service improvements only 44% had been successful confirming the "Cinderella" role for our speciality. An important factor in gaining more support appeared to be the existing resource of the service - "to those that have, shall be given more" accentuating the inequalities in the service. This lack of resources for diabetic patient care will be further accentuated in the next 10 years when the numbers of diabetic patients in the UK will double to reach 3 million. Therefore there is an urgent need for increased investment across the board in primary and specialist care - not "robbing Peter to pay Paul". Also the monies should be ring fenced from marauding fashionable high-tech specialities. The Scots seem to be more committed to make their Diabetes NSF a success and may well indicate a way forward for the NHS as a whole. ABCD has presented the results of the survey to the Expert Group of the NSF but of course the NSF which is eventually published is a political document produced by the Department of Health with all the constraints that implies. However a lack of urgency and pious sentiments without extra resources can only lead to disasters for diabetic patients if not in the short-term, certainly in the long-term with added complications and even more cost to the patient and the healthcare budget. John K Wales chairman, Association of British Clinical Diabetologists The General Infirmary, LEEDS, LS1 3EX A summary of the ABCD survey and the questionnaire used can be seen on the ABCD website - www.diabetologists-abcd.org.uk 1. Williams G. Diabetes black spots and death by postcode. BMJ, 2001: 322: 1375-6 (9 June.)
Rearranging the deckchairs 19 June 2001
Peter Davies, Salaried general practitioners Mixenden Stones Surgery, Halifax. HX2 8RQ, Seth Jenkinson Send response to journal: Re: Rearranging the deckchairs	Professor Williams in his editorial (1) perpetuates the old myth that people with type 2 diabetes mellitus are victims of their illness. Clearly they are not. Type 2 diabetes is the final result of dysfunctional behaviour over many years prior to the diagnosis being made and people themselves, wittingly or unwittingly, are very much creators of this illness. We live in a world where it is rapidly becoming abnormal to be of a sensible weight (BMI between 19 and 25). The cause of this is that people are eating too much high calorie, high fat food and doing too little exercise, either in their work or leisure. As this behaviour pattern continues the inevitable result is an increased prevalence of obesity and type 2 diabetes. But it must be remembered that no one forces people to be idle and no one compels people to eat too much. These are choices made by adults and to have any impact as health professionals we must find ways of altering the choices people make before they get to the diabetic clinics, by when it is largely too late to deal with what is end stage social and environmental pathology. In this regard we note with guarded optimism the report from Tuomilehto et al. (2). The dire consequences of failing to intervene early are well described in the study of Roper et al. (3) One of the most disabling beliefs that overweight people hold is that a cure will soon be found for it. This attitude hinders individuals from accepting responsibility for their own body mass. Articles such as (4) and (5) help to support this attitude and so further discourage and de- motivate people from making changes. We need to re-emphasise the agency of the individual in being responsible for the choices they make about eating and exercise. At the same time we need to attack the structural ill health of the food and drink industry. These are not purely medical concerns but to ignore these issues is to accept an unhappy and futile role trying to salvage healthy bodies from the effects of a ruinous lifestyle. We would simply be shuffling the (very expensive) deckchairs with great skill on a sinking ship. 1. Williams, G. Diabetes, black spots and death by postcode. BMJ 2001 322:1375-6 2. Tuomilehto,J , Lindstrom,J, Eriksson,J.G. et al N Eng J Med 2001; 344:1343-50 3. Roper et al. Excess mortality in a population with diabetes. BMJ 2001 322:1389-93 4. Despres, J-P Drug treatment for obesity. BMJ 2001 322:1379-80 5. Arterburn et al. Extracts from Clinical Evidence. Obesity BMJ 2001 322:1406-9
In defence of practice nurses (and primary care) 26 June 2001
Mairi Cassels, GP Principal Townhead Health Centre, Glasgow Send response to journal: Re: In defence of practice nurses (and primary care)	Professor Griffiths in his editorial (1) suggests that there is a risk of type 2 diabetic patients receiving substandard care from practice nurses in primary care. In fact practice nurses have become increasingly skilled in chronic disease management (including diabetes) and, I would contend, have transformed the quality of care in this field in the past decade. In addition, there are many GP's with a special interest and a wealth of experience in diabetes. Many, like myself, are active members of Primary Care Diabetes UK. Where adequately resourced (and ideally with input from community podiatry and dietetics, access to retinopathy screening, and good links with secondary care) primary care can provide a high quality diabetic service. Addressing other cardiovascular risk factors is part of the bread and butter of good primary care. It is also relatively easy to ensure that patients are not lost to follow up. The escalating prevalence of type 2 diabetes must surely mean that primary care will play an increasing role in its management. Primary and secondary care should recognise each other's strengths and work together to achieve the best possible care for our patients. 1.Williams G. Diabetes black spots and death by postcode. BMJ, 2001:322:1375-6 (9 June)