Rory Hafford talks to Dr Anna Clarke of the Diabetes Federation of Ireland on plans to tackle the relentless march of type II diabetes
Dr Anna Clarke heads up the Health Promotion and Research portfolio in the Diabetes Federation of Ireland; and she knows that she has her work cut out. Just check the figures, for openers: as many as 180,000 people have diabetes in Ireland. This, in itself, is cause for concern. But when you factor in that as many as 60,000 of those are undiagnosed, then you know the problem is a ticking timebomb.
Build in another 60,000 people who are categorised as ‘pre-diabetic’ and who will go on to develop full-blown type II diabetes, unless they radically change their lifestyle, and you may then begin to get some understanding of the scale of what the Diabetes Federation of Ireland is up against.
“The word ‘epidemic’ is one that is overused. But, when you put it next to the problem of type II diabetes in Ireland, it fits,” Dr Clarke told Irish Medical Times.
“Everyone knows someone who has the disease. And that’s just one of the reasons why we need to do something to address this problem.”
The something she has in mind can be summed up in one word: screening.
“You can tell just by looking at people on the street who is at high risk. These people should be identified and screened. This condition is a silent killer. Lots of people have it for at least seven years prior to diagnosis and, in that time, many complications can take hold,” said Dr Clarke.
Saving money
She argues that screening is feasible and cost-effective. “If you pick up diabetes at the sub-clinical stage, you are saving the health service money, ultimately; and you are improving the quality of life for people at risk.”
And who is best placed to do this job of screening? Why, the GPs, of course. However, it is not something that Dr Clarke expects primary care physicians to take on for nothing.
“GPs need to be paid for diabetes care on receipt of audit data. Effective management of this condition can be carried out by GPs. But, for the most part, this is not happening at the moment. And I can’t see it happening unless and until the GP contract is renegotiated.”
An ad-hoc basis
She says that some GPs are doing diabetes screening, but it is on an ad-hoc basis. The majority of ‘screening’ is carried out through work-health initiatives, in which people are sent for an ‘MOT’ and diabetes can be uncovered in this way.
There are things happening behind the scenes. If you wait around for initiatives to be implemented via the HSE, you will be left waiting. A Government Expert Advisory Group published a ‘way forward’ document on diabetes management some 15 months ago. The document contained some good things. However, nothing has happened since, and one detects a sense of frustration among the good folk who ply their trade in the area. A case of delay built upon delay, resulting in inertia.
“We need more effective self-management strategies at primary care level,” said Dr Clarke. “And it is for that reason that we developed an education programme and delivered it in 2007, ‘08 and ‘09. It was very well received. So much so, that we trained up practice nurses to deliver the programme. Everything on the programme is available free of charge.
Very positive
“All the GPs who have availed of it have been very positive about it and feel it results in the patients being incentivised. One of the major advantages is that it gives patients a forum to share their thoughts and feelings on the condition; something that they have never had an opportunity to do in the past. But, with this programme, they do.”
The HSE document, A Practical Guide to Integrated Type 2 Diabetes Care, sets out a solid framework. It advocates a comprehensive diabetes service with three key components (or the ‘three Rs’, if you will): patient registration, recall and regular review. And annual and comprehensive review is regarded as the crucial element of integrated diabetes care.
But, as we have read elsewhere in this special diabetes supplement, the theory is laudable, but the practice is underpinned by funding which we simply do not possess.
Routine intgegrated care, according to the document, involves the patient, GP, practice nurse, diabetologist, clinical nurse specialist in diabetes, dietician, ophthalmologist and podiatrist. All patients with type II diabetes should have access to specialist services such as endocrinology, vascular, cardiology, nephrology and psychology, as needed. Care provision begins with initial assessment and follows with regular review that includes a comprehensive annual review.
And, here is the rub: “In order to provide this level of care, protected time is required and this has funding implications for all levels of service – primary, secondary and tertiary care…,” according to the HSE document.
Fixed ideas
Dr Clarke also has fixed ideas on medication: it should not be the first port of call: “It should be self-management, followed by support. GPs also need to be aware of the side-effects of diabetes medication. We get calls from patients who have been prescribed a course of tablets, but who have decided not to take them because of concerns over side effects. And, here is the point, they are just too afraid to say it to their GP.”
The HSE document on diabetes care and management highlights a number of problems in relation to medication. For instance, take the treatment of hypertension as a possible complication in diabetes: “In patients with type II diabetes, the use of ACE inhibitors or ARBs can be associated with acute renal failure, since patients often have significant renovascular disease. These medications should be avoided if there is a high suspicion of renel artery stenosis. Renal function should be assessed prior to initiating therapy and in the weeks following by measuring serum creatinine and eGFR…”
It is a point that Dr Clarke takes up: “When it comes to diabetes and medication, there are constant developments. Traditionally, you started with a glucophage and worked upwards. This is no longer the case, however. It’s an area in constant flux, so much so that our next study day will, in part, focus on the old versus the new medication.”
If she had one word of advice for GPs in relation to their patients, it would be this: “Listen.”
About Greg Baxter
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