Diabetes services show the way for chronic care

A phrase that is being increasingly used in the medical media is that “GPs are ideally placed to…” While this is indeed true in many instances and can be very gratifying, it needs to be viewed in context. That context is the saturation of general practices throughout the country with work commitments. This is also occurring at a time when the secondary care services are going through a very difficult period, resulting in an ever-increasing GP workload, much of which is not resourced.

To assume that general practice can just ‘fill in the gaps’ without extra resources is dangerous and wrong. It is not tolerated in other sectors. Nobody expects the pilot of an airplane to carry out cabin duties to the passengers, or school teachers to do detailed psychological assessments on their pupils, even though they are also ‘ideally placed’ to do so.

The origin of modern-day general practice

The Health Act 1970¹ introduced the ‘choice of doctor’ scheme for public patients to avail of ‘general practitioner services’. Until then, public patients who could not afford treatment had to attend the ‘dispensary’ and see the dispensary doctor. Medication was then ‘dispensed’ free of charge to the patient. Private patients fended for themselves. 

Typically, ‘GP services’ at the time were the type of sickness services that are provided by modern out-of-hours co-ops. GPs at the time were mainly male, single-handed, not vocationally trained and working from a building attached to their home.² GPs were often regarded as failed consultants. Computerisation was unheard of and for many, even manual records were basic. Hospital consultants diagnosed and managed chronic disease, with the GP merely filling the prescriptions and looking after intercurrent illness. As such, the service was demand-led and easy to provide with basic equipment and resources from a converted garage with no administrative backup. In 1989, the GP contract was altered slightly, but the basic conditions and remuneration remained the same.

Modern general practice in Ireland

Currently, the picture has totally changed. Now the majority of GPs are computerised and shortly all will be have been vocationally trained. Many have specialised equipment including ECG machines, home and ambulatory BP monitors, spirometers, etc. General practice is now regarded by the Medical Council as a specialty in its own right. GP specialist training encourages holistic, long-term treatment for a family unit over a lifetime. GP specialist training places are highly sought after. Chronic disease management is but a single strand of the varied patchwork of care that the GP aims to provide. 

With their intimate knowledge of the patient and their environment over a long period, and by the fact of working in the patients’ community building up trust over generations, GPs get to know their patients in a unique way that no other specialty can aspire to. This becomes even more important as the axis of specialist care has moved  away from the community towards more sophisticated, multidisciplinary centralised care. Along with computerisation, the expansion of the GP workforce over the last 20 years to now include practice nurses, secretaries and practice managers means that they are ideally placed to care for chronic disease in the community. However, they are not currently resourced to do so.

Evolution of specialist medical care

While this fundamental change has been happening in general practice, hospital and secondary care has also changed fundamentally. Increased knowledge and more sophisticated treatments have meant increasing subspecialisation, with multidisciplinary team care focusing on a single disease, shorter inpatient times and hugely increased costs. Best practice demands that these multidisciplinary teams should only be sited in ‘population centres’ which may be far removed from the patients’ place of residence. 

This ‘reconfiguration’ has resulted in the removal of services from many of the local or ‘county’ hospitals. Thus hospital has become a very expensive, centralised, highly resourced commodity. It does not make sense to have these resources being used to look after people with uncomplicated illness where social factors may be as important as (or even the cause of) the medical issues concerned. This is especially so when these medical issues ‘venture not as single spies but in battalions’. 

Thus your typical middle-aged patient with type 2 diabetes is often obese and suffering from several comorbidities; including hypertension, obesity and osteoarthritis of large joints. Psychological comorbidities such as depression and low self-esteem are often part of the picture and are essential to deal with if there is to be concordance with lifestyle advice and medication. Lifestyle issues such as lack of exercise, poor diet, tobacco smoking and excessive alcohol intake are not unusual,³ and addressing them in a holistic patient-centered way is a fundamental part of the management of chronic disease. 

Chronic disease care

It is easy to see from this how the traditional chronic disease care model based in large secondary care facilities has now become completely obsolete. Modern secondary care facilities are ideal for diagnosis and initial treatment of complex single diseases such as cancers and vascular events such as myocardial infarction and stroke. However, the long-term care of these conditions after the initial complex management, as well as their primary prevention in the first place, is ideally carried out in general practice. 

Also the diagnosis and management of many chronic diseases such as hypertension, type 2 diabetes, chronic obstructive airways disease and asthma should ideally be based in general practice, with secondary care only being accessed for specific advice or services such as pulmonary function tests. The increasing availability of community-based resources such as dietitians and clinical nurse specialist co-ordinators who are often part of primary care teams make this more and more possible. 

The so called ‘shared care’ model where patients attend secondary and primary care services (along the lines of antenatal shared care) has not been shown to work and is unsuitable for the management of chronic disease.⁴

Currently, the main barrier to chronic disease management happening in general practice is the lack of resources.

This gradual change in the medical landscape over the past 30 years has happened, in the majority of cases, without any extra funding of practices to care for patients with chronic disease. Where practices have been funded, the care provided for patients with chronic disease has been shown to be as good as that of secondary care.⁵ Even practices that are not specifically resourced have shown that they can provide care to a good standard.^6,7

The National Paediatric Immunisation Programme which is based in general practice is an excellent example of how GPs, when adequately resourced, can achieve high uptake rates on a population-based healthcare initiative. The most recent figures from the Health Protection Surveillance Centre⁸ show that overall immunisation uptake is over 90% and in certain areas as high as 94%. Not bad for a system that was in turmoil when GPs took responsibility for it in 1995.

Conclusion

General practice is the natural home for management of uncomplicated chronic disease. Over the years, GPs have shown that they are adept at taking on new challenges and are more than capable of taking on this one. It cannot however be done without resources following the patient.⁹ In the case of diabetes care, these resources include community-based personnel such as dietitians, ophthalmology, podiatry and the educational support of a community-based clinical nurse specialist. Money also needs to be provided for more staff and space in the GP practice premises to cope with the extra workload as well as the administrative and information technology infrastructure to ensure the whole process flows smoothly.

Finally, a clear referral pathway from primary to secondary care needs to be established in the case of complications or poor control requiring more sophisticated treatment or knowledge. Such a co-operative approach has been running between GPs in the mid-west region and the local diabetes service for many years with mutual benefit, enhanced care for the patient and increased job satisfaction for all. Such a win-win situation is good for all. 

References 

1. http://www.irishstatutebook.ie/1970/en/act/pub/0001/index.html
2. Oliver B. Meagher N et al. The present state of general practice in the Republic of Ireland (1982). Modern Medicine of Ireland (Supplement). Modern Medicine Publications 1984.
3. SLAN 2007 report. http://www.dohc.ie/publications/pdf/slan07_report.pdf?direct=1
4. Smith S et al. Effectiveness of shared care across the interface between primary and specialty care in chronic disease management (Review). Cochrane Database Systematic Reviews 2007;3. DOI: 10.1002/14651858.CD004910
5. www.hse.ie/eng/services/newscentre/Audit_Report_of_the_HSE_Midland_Diabetes_Structured_Care_Programme.pdf).
6. O’Connor R. Houghton F. Saunders J. Dobbs F. Diabetes Mellitus in Irish General Practice: level of care as indicated by HbA1c values. European Journal of General Practice 2006;12;2:58-66.
7. O’Connor R. Moloney N. Achieving Best Practice in Diabetes Treatment. Forum 2010 (December);39-40 
8. http://www.hpsc.ie/hpsc/A-Z/VaccinePreventable/Vaccination/ImmunisationUptakeStatistics/QuarterlyReports/2011/File,12983,en.pdf
9. IMO Calls on Government to Address Inequalities in Health- Budget. http://www.imo.ie/news-media/news/imo-news/imo-budget-submission-201/