During the past year, three important studies have provided evidence that tighter glycaemic control (to <7% glycated haemoglobin) in older adults with type 2 diabetes does not provide substantial benefit and may increase the risk of adverse outcomes. These findings, which some experts and policy makers found surprising, should lead to the re-evaluation of recommendations about what constitutes high quality care for these patients.

The management of type 2 diabetes in the United Kingdom takes place largely in primary care and is strongly influenced by the requirements of the quality and outcomes framework (QOF)—an annual reward and incentive programme, which although voluntary provides a substantial proportion of general practitioners’ income. From April 2009, general practitioners in the UK will need to reduce glycated haemoglobin in half of their patients with type 2 diabetes to below 7% to earn the same amount that they are currently paid for achieving a target of 7.5%. The average practice that achieves this level of performance will be paid around £3000 (€3375; $4250). Tens of thousands of patients will need to be given additional oral treatment or will be treated with insulin. Treatment with insulin brings with it an increased risk of hypoglycaemia and the additional costs of daily blood glucose monitoring and the insulin itself. It may …