Author's reply

BMJ 1995; 311 doi: https://doi.org/10.1136/bmj.311.6998.190a (Published 15 July 1995) Cite this as: BMJ 1995;311:190
  1. Chris Butler,
  2. Nigel Stott
  1. Lecturer Professor Department of General Practice, University of Wales College of Medicine, Llanedeyrn Health Centre, Cardiff CF3 7PN

    EDITOR,--We are heartened by the responses to our paper, which questioned the wisdom of setting targets for glycaemic control in the absence of normative data and an understanding of the psychology of motivation. P D Home asserts that the targets were based on normative data. Unfortunately, the data he quotes from the Newcastle hospital sector do not seem to be available for scrutiny, and general practice data were obtained from 186 patients in four practices specially selected for their interest in diabetes and audit.1 We found several consensus statements about targets but no normative data in the documents Home cites. In contrast, our conclusions were based on a district-wide approach, involving 37 practices and 3022 patients. We also considered data on a further 2880 patients from four other centres.

    Home's experiences regarding the attainability of targets for large numbers also run counter to ours and to those of the diabetes control and complications trial, in which less than 5% of patients receiving intensive treatment achieved control that would be categorised as “good” by the targets.2 Home seems to suggest yet another target, based on the trial's finding that microvascular complications rise steeply with a haemoglobin A1c concentration above 7.5%. But if the original targets are well grounded why are haemoglobin A1c values between, say, 7% and 7.5% (which are now so clearly associated with improved outcomes) classified as “poor” by the targets Home defends?

    Questioning targets does not imply a lack of support for optimal metabolic control; it simply means that we doubt the value of one approach based on metabolic idealism. With regard to our local targets, our paper makes it clear that these are based on the previous performances of the practices and comparison with peers.

    It may be helpful in the future to be explicit about the purpose and status of any target. If general systems theory is used as a framework,3 this could be: (a) longer term, population targets based on normative data from representative samples that may be used as in the Health of the Nation; (b) consensus targets based on experts' views that set metabolic ideals for the single minded; and (c) targets, based on negotiation with individual people, that recognise the relevance of metabolic ideals, informed choice, the psychology of setting targets, and people's contexts. Those of us who work in primary care will find the third category most helpful, ethically sound, and the least maternalistic.


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