Download Practice guidance on the care of people with diabetes

PRACTICE GUIDANCE ON THE CARE OF
PEOPLE WITH DIABETES
( incorporating ‘Early Identification’ guidance)
This guidance was prepared on behalf of the Practice Division of the Royal Pharmaceutical
Society of Great Britain (RPSGB).
Additional paper copies may be requested by contacting:
Lorraine Fearon
Practice Division
Royal Pharmaceutical Society of Great Britain
1 Lambeth High Street
London
SE1 7JN
Telephone: 0207 572 2409
Email: [email protected]
All rights reserved. No part of this publication may be reproduced, stored in a
retrieval system, or transmitted in any form or by any means - electronic,
mechanical, photocopying, recording or otherwise - without the prior written
permission of the Royal Pharmaceutical Society of Great Britain.
November 2004
Practice guidance on the care of people with diabetes
Practice Guidance
on the Care of
People with Diabetes
(incorporating ‘Early Identification’ guidance)
November 2004
Third Edition
RPSGB Diabetes Task Force 2004
Prepared in conjunction with Diabetes UK
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Practice guidance on the care of people with diabetes
First edition 1999
Second edition 2001
Published by the Royal Pharmaceutical Society of Great Britain
Further copies are available from:
Practice Division
Royal Pharmaceutical Society of Great Britain
1 Lambeth High Street
London
SE1 7JN
Tel: 020 7572 2409
e-mail: lorraine.fearon@ rpsgb.org
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Practice guidance on the care of people with diabetes
Contents
Foreword
..................................................................................... 6
1.
Executive Summary .................................................................................. 7
2.
Policy Context
..................................................................................... 8
2.1 National Plans for diabetes ................................................................... 8
2.1.1 The National Service Framework (NSF) for diabetes (England) …… 8
2.1.2 The National Screening Committee (NSC) ....................................... .9
2.2 New General Medical Services contract ............................................... 9
2.3 Vision for Pharmacy in the new NHS (‘Vision’) (England).................... 10
2.4 Building on the best ............................................................................. 10
2.5 New Pharmaceutical Services contract ............................................... 10
2.6 Information on diabetes care................................................................ 11
3.
Clinical Guidelines ................................................................................. 12
4.
Epidemiology & health economics ....................................................... 13
5.
Teamworking
................................................................................. 15
5.1 Becoming integrated into the healthcare team ................................... 15
5.2 Useful skills and attitudes ................................................................... 16
5.3 Potential barriers to new services ....................................................... 16
5.4 Communication .................................................................................. 16
6.
How to get started ................................................................................... 17
7.
Clinical Governance ................................................................................. 18
8.
Practice Guidance .................................................................................. 19
8A
The pharmacist's role in the primary prevention of diabetes ..................... 19
A1 Opportunistically promotion of a healthy lifestyle .............................. 19
A2 Targeted prevention programmes ……………………………………...20
8B The pharmacist's role in detecting undiagnosed diabetes ......................... 20
B1 Monitoring OTC sales ....................................................................... 21
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Practice guidance on the care of people with diabetes
B2 Supporting local screening campaigns ............................................... 21
B2.1 Liaising with other diabetes professionals ................................. 21
B2.2 Who should be targeted ............................................................ 22
B2.3 Referral levels ……….………………………………………...……22
(a) Presenting with symptoms of diabetes ………………………. 23
(b) Presenting with risk factors, but no symptoms of diabetes .... 23
B2.4 Recommended training ............................................................. 25
B2.5 Equipment/ premises ................................................................ 25
B2.6 Initiating the test ........................................................................ 26
B2.7 Undertaking the test .................................................................. 26
B2.8 Documentation .......................................................................... 27
B2.9 Communicating results ............................................................. 27
B2.10 Confidentiality .......................................................................... 28
B2.11 Personal Liability ...................................................................... 28
B2.12 Requests to purchase testing equipment ................................ 28
B2.13 Advertising the service.............................................................. 29
8.C The pharmacist's role in the prevention of complications .......................... 29
C1 At the presentation of the first prescription ......................................... 29
C2 At the presentation of a repeat prescription ....................................... 30
C3 Self-Monitoring 32
C4 Related services ................................................................................. 33
8.D
Referral criteria
.................................................................................. 34
8.E
Quality assurance
.................................................................................. 35
8.F
Funding
................................................................................... 35
9.
References
................................................................................... 36
10.
Appendices
................................................................................... 37
Appendix 1 The nGMS contract: Annex A .......................................................... 37
1.1 Diabetes
................................................................................... 37
1.2 Medicines management ...................................................................... 38
Appendix 2 Useful Information ........................................................................... 39
2.1 Useful addresses ............................................................................... 39
2.1.1 Organisations .......................................................................... 39
2.1.2 Websites (more) ..................................................................... 40
2.2 Diabetes UK
................................................................................... 42
2.3 Specific references .............................................................................. 43
2.4 Textbooks
................................................................................... 45
2.5 Diabetes Journals ............................................................................... 45
2.6 Relevant CPPE courses ..................................................................... 46
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Practice guidance on the care of people with diabetes
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Practice guidance on the care of people with diabetes
2.7 Diabetes courses ................................................................................ 46
2.8 Projects in diabetes care, involving pharmacists in the UK ................. 47
2.9 UKCPA Diabetes Special Interest Group ............................................ 48
Appendix 3 Contacts list for diabetes care (example) ....................................... 49
Appendix 4 Summary of WHO Diagnostic criteria for Diabetes ........................ 50
Appendix 5 MEP Code of Ethics – Testing of Body Fluids ................................ 51
Appendix 6 Diabetes Audit ................................................................................. 52
Appendix 7 Dietary care planning and diabetes ................................................. 55
Appendix 8 Suggested management targets for people with diabetes .............. 58
Appendix 9 Patient Screening Questionnaire................................................... 59
Appendix 10 Summary for criteria for referral (case identification) .................... 60
Appendix 11 Blood glucose meters (whole blood & plasma equivalent results) 61
Appendix 12 Glucose test record form (example), for retention in pharmacy ... 62
Appendix 13 Patient consent form for case identification test ........................... 63
Appendix 14 GP referral forms (case identification) .......................................... 64
Appendix 15 Diabetes Care Leaflet (example) .................................................. 65
Appendix 16 Questionnaire for People with diabetes (example) ....................... 67
Appendix 17 Glossary
................................................................................... 69
Appendix 18 Acknowledgements ...................................................................... 70
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Practice guidance on the care of people with diabetes
Foreword
I would like to thank Irene Gummerson for updating the existing practice guidance on ‘The
Care of People with Diabetes’ together with ‘The Early Identification of Diabetes’ and merging
them into this single document. I should also like to thank the rest of the original Task Force
for their input and specifically, Judy Cantrill, who has given enormous support to the project
from its conception.
As Chairman of the Society’s Diabetes Task Force, I was responsible for both sets of original
guidance, which subsequently led to my involvement in the development of the National
Service Framework for Diabetes.
It gives me great pleasure to see how the pharmacy profession has developed, so that
pharmacists now provide diabetes services within primary and secondary care. This is due to
the efforts of many within the profession who have a special interest in diabetes and who have
pioneered developments and supported the establishment of special interest groups outside
the Society.
I hope you will find the guidance useful in whatever sector of the profession you work. I am
sure that community pharmacists, in particular, will find it essential reading in their quest to
develop practice that will offer great benefits to patients and to the NHS in general.
Gill Hawksworth
Immediate Past President of the Royal Pharmaceutical Society of Great Britain
Immediate Past President of the Royal
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Practice guidance on the care of people with diabetes
1. Executive Summary
This Guidance has been prepared for pharmacists in Great Britain to help them and their staff
to recognise areas where they can improve and develop their services to people with
diabetes.
Its aim is to describe best practice, and to facilitate an approach to diabetes care, that is
consistent with that of the other members of the diabetes team.
Its main objectives are:
At patient level to:
• Promote diabetes prevention;
• Increase early identification of diabetes;
• Improve knowledge and skills of people with diabetes in dealing with their treatment, to
reduce the severity and incidence of immediate and late diabetes complications;
• Improve the wellbeing of people with diabetes
At pharmacy level to:
• Raise awareness of pharmacists and pharmacy staff of the importance of focusing
their intervention on diabetes care;
• Promote the diabetes care services, together with other health care providers and
Diabetes UK;
• Encourage documentation of pharmacists’ interventions, outcomes and evaluation of
services
• To guide on the provision of the highest standards of care, when dealing with people
who have diabetes.
The RPSGB document ‘Early Identification of Diabetes’1, has been incorporated with the
second edition2 and updated into this, the third edition of the Practice Guidance.
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Practice guidance on the care of people with diabetes
2. Policy Context
In 1989 in St Vincent in Italy, a meeting of diabetes experts and patient group representatives
from around the world resulted in the St Vincent Declaration (SVD), which defined general
research and organisational goals to improve diabetes care3. A joint working group, consisting
of representatives from the SVD and the EuroPharm Forum, produced SVD Pharmacists
guidelines4. These were adapted to form the PharmaDiaB Programme5, which looked at the
role pharmacists played in the implementation of the SVD.
This Guidance has evolved from the PharmaDiaB programme, and has been developed in
consultation with Diabetes UK.
Meanwhile, pharmacy as a profession had been moving forward. The RPSGB publication,
“Pharmacy in the New Age: Building the future6 had the management of
chronic conditions and the promotion and support of healthy lifestyles, both important aspects
of diabetes care, as two of its strategic aims. The environment in which this strategy is being
taken forward is still one of substantial re-organisation and reform, both by the Department of
Health in England and by pharmacy organisations. In addition, the Department of Health in
England is currently focussed on improving chronic disease management in the NHS.
There are a number of documents of particular relevance to this Guidance:
• The National Plans for diabetes
England (www.dh.gov.uk); Scotland (www.show.scot.nhs.uk);
Wales (www.wales.nhs.uk); N.I. (www.crestni.org.uk/publication/diabetes);
• The new General Medical Services (GMS) contract (www.bma.org.uk);
• A Vision for Pharmacy in the new NHS (‘Vision’) in England (www.dh.gov.uk);
• ‘Building on the best: choice, responsiveness and equity in the NHS’ in England
(www.dh.gov.uk);
• The proposed framework for the new pharmaceutical services (PhS) contract
(www.psnc.org.uk).
2.1 The National Plans for diabetes
Wales, Scotland and Northern Ireland (see websites above) all prioritise diabetes and have
set standards for delivery of care. The main priorities for action are very similar, although dealt
with in a different way and to different timescales. All have similar actions to take, but use
different words to describe them. For more specific information, it is suggested pharmacists
contact the relevant national Diabetes UK offices. However, here are some more details of the
English National Plan, referred to as the National Service Framework (NSF) for diabetes, to
illustrate the scope.
2.1.1 The National Service Framework (NSF) for Diabetes (England)
This builds upon the vision of the St Vincent Declaration3. Its goals are to:
• Decrease the incidence of Type 2 diabetes;
• Improve health outcomes of people with diabetes;
• Reduce unacceptable variations in the quality of services for people with diabetes
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Practice guidance on the care of people with diabetes
Standards for Diabetes Services
The Diabetes NSF contains twelve standards in the following nine areas:
• Prevention of Type 2 diabetes;
• Identification of people with diabetes;
• Empowering children, young people and adults with diabetes;
• Clinical care of adults with diabetes;
• Clinical care of children and young people with diabetes, including the transition; from
specialist paediatric diabetes services to specialist adult diabetes services;
• Management of diabetes emergencies;
• Care of people with diabetes during admission to hospital;
• Diabetes and pregnancy;
• Detection and management of long-term complications of diabetes and the provision of
integrated health and social care.
The Diabetes NSF: Delivery Strategy (England) emphasises the setting up of diabetes
networks.
Early milestones to be achieved by 2006 involve retinopathy screening and diabetes registers.
All other diabetes specific milestones are to be achieved between 2006 and 2013.
2.1.2 The National Screening Committee (NSC) (www.nelh.nhs.uk/screening)
The National Screening Committee (NSC) is producing service specifications, information and
quality assurance standards for retinopathy screening, for England, Wales, Scotland and
Northern Ireland. Furthermore, the NSC is piloting a Type 2 diabetes screening programme in
England which is due to report at the end of 2005.
2.2 The new General Medical Services (nGMS) contract
A new contract has been agreed across the UK for the provision of general medical services.
This aims to systematically reward practices on the basis of quality of care delivered to
patients through the Quality and Outcomes (Q&O) Framework. It covers a limited number of
disease areas, including diabetes, and measures both process (e.g. 'has the cholesterol been
measured?') and outcome (e.g. 'how many people with diabetes have a cholesterol less than
5mmol?'). The higher a practice scores on the measured indicators, the more it is paid. It is an
optional system in that practices can choose not to try to earn the points, but their financial
viability would be doubtful in that case.
The Q&O Framework presents opportunities (and risks) to pharmacists, and may help them to
focus attention on areas where GPs (and PCOs) have a vested interest in improving clinical/
health promotion outcomes. The list of relevant quality indicators in Annex A of the new
contract and an insight into the value of the ‘points’, can be found in Appendix 1.
The NPA (for members Tel: 01727 85 86 87 ext. 3127; otherwise through the LPC) ‘quick reference guide
to the quality indicators in the new GMS contract’ also includes ‘what services community
pharmacists can offer to support GP practices’, examples of published evidence base, and
practical resources to help with service development.
.
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Practice guidance on the care of people with diabetes
2.3 A Vision for Pharmacy in the New NHS (‘Vision’) (England)
This document describes the progress made so far against the targets set in Building the
Future6, and emphasizes extended roles for community and PCT pharmacists, such as:
•
•
Public health
¾ tackling smoking cessation, obesity and minimizing health inequalities.
Supplementary and independent prescribing
¾ diagnostics and monitoring;
¾ medicines management within the NSFs.
The ‘Vision’ states that PCT pharmaceutical advisers and pharmacist members of PCT
professional executive committees (PEC) have a key role in taking this work forward.
Pharmacists living/ working in Wales, Scotland and Northern Ireland should be aware of
pharmacy documents relevant to their nations e.g. ‘Remedies for Success: A Strategy for
Pharmacy in Wales’, and ‘The Right Medicine: A Strategy for Pharmaceutical Care in
Scotland’.
2.4 ‘Building on the best: choice, responsiveness and equity in the NHS’
This outlines plans to increase access in primary care, including developing a range of primary
care providers, as alternatives to appointments with GPs. Chronic disease management could
happen in pharmacies rather than GP practices. (www.dh.gov.uk)
2.5 The new pharmaceutical services (PhS) contract (proposed).
The Pharmaceutical Services Negotiating Committee (PSNC) is working with the Government
towards a new PhS contract for community pharmacists working in England and Wales. Up to
date information on the new contract is available at www.psnc.org.uk.
Proposals so far, of relevance to diabetes:
•
Essential services (to be offered by all contractors)
¾ include dispensing, repeat dispensing, signposting, clinical governance,
promoting of healthy lifestyles, medication waste disposal.
•
Advanced Services
¾ Medicine Use review;
¾ prescription intervention service.
•
Enhanced services (specification and value agreed nationally, commissioned by local
PCOs)
¾ may include, diabetes screening, CHD screening, full clinical medication
review, smoking cessation services, care home support.
clinical medication review, smoking cessation services, care home support.
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Practice guidance on the care of people with diabetes
The National Plan for diabetes in England (NSF for Diabetes) specifically mentions
pharmacists in terms of case identification and medicines management, and is relevant to
pharmacists in community, specialist care or in GP practices. Government documents like the
‘Vision’, and ‘Building on the Best’; as well as the nGMS contract show the opportunities for
pharmacists in extending their role. The challenge will be using these opportunities within the
new PhS contract, to start and sustain funded new services.
Although at present pharmacists are not generally recognized by other professions as being
part of local diabetes networks, the Department of Health’s long-term conditions care group
workforce team is looking at how the roles of all health care professionals, including
pharmacists, might be enhanced to provide better support for people with diabetes.
To date, pharmacists generally view their role in the diabetes networks, in terms of liaising
with a variety of people (e.g. GP-practice staff, diabetes specialist nurses), to ensure the
patient receives the appropriate medication/ appliance (e.g. tablet/ insulin, pen/cartridge,
needles, lancets, blood glucose strips etc).
Pharmacists wanting to extend their roles, could start by contacting their PCO and finding out
about local priorities. This could lead to local discussion and plans to involve pharmacists in
new services linked to new the PhS contract, and LPS. Whether pharmacists have the
opportunity to specialise more in secondary care, will depend on those pharmacy managers
with an interest in progressing diabetes care and forging links with diabetes professionals.
The equivalent of the PSNC in Scotland is the Scottish Pharmaceutical General Council
(SPGC).
2.6 Detailed information on diabetes care
The confidence and expertise to provide services for people with diabetes can only be
provided by pharmacists with good under-pinning clinical knowledge and competence in the
management of diabetes. If they are unable to demonstrate this to other health professionals,
then they will struggle for “clinical credibility” when discussing medicines management issues
with them.
This Guidance does not contain detailed information on the pathology, complications and
drug treatment of Type 1 and Type 2 diabetes. Resources that pharmacists can use to
identify and fill their CPD and CE needs with reference to diabetes management are given in
the Guidance under Information Sources in Appendix 2.
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Practice guidance on the care of people with diabetes
3. Clinical guidelines
Pharmacists should access the latest national and local clinical guidelines as
appropriate to their area of work. The list below is not an exhaustive one, as work is
being continuously reviewed and updated, and new publications are released.
Additional organizations which may be of interest include CREST in Northern Ireland
(www.crestni.org.uk/publication/diabetes)
.
SIGN (Scottish Intercollegiate Guideline Network) (www.sign.ac.uk):
¾ Management of diabetes;
¾ Report on a recommended minimum data collection in a person with
diabetes.
NICE (National Institute for Clinical Excellence) (www.nice.org.uk)
¾ Clinical Guidelines for Type 2 diabetes;
ƒ
management of blood glucose;
ƒ
management of blood pressure and dyslipidaemia.
¾ Management of Type 2 diabetes
ƒ
renal disease prevention and early management;
ƒ
retinal screening and early management;
ƒ
footcare.
¾ Management of Type 1 diabetes
¾ NICE Health Technology Assessment Reports (clinical & cost
effectiveness) of:
•
ƒ
pioglitazone and rosiglitazone in the treatment of Type 2 diabetes;
ƒ
patient education models for diabetes;
ƒ
continuous subcutaneous insulin infusion for diabetes;
ƒ
long-acting insulin analogues for diabetes.
British Hypertension Society (www.bhsoc.org)
¾ Guidelines for the management of hypertension.
•
Local Primary Care Organizations (PCOs) and hospital Trusts may have produced
local guidelines. These will contain local interpretation and policy on the
implementation of the National Guidance. In general these can be found on the
PCO/ hospital Trust web-sites (www.nhs.uk). Diabetes may also be part of the local
development plan – which can be found on the local PCT website.
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Practice guidance on the care of people with diabetes
4. Epidemiology and health economics
Diabetes Mellitus is a chronic, progressive, lifelong condition, which is characterised by
chronic hyperglycaemia with disturbances of carbohydrate, fat and protein metabolism.
Type 1 diabetes results from destruction of the insulin producing pancreatic beta cells. It
generally affects younger non-obese people.
Type 2 diabetes is caused by a combination of insulin resistance and defective beta cell
function.
Diabetes is becoming more common:
• Around 1.4 million people are currently diagnosed with diabetes in the UK; and
there may be a further million with undiagnosed Type 2;
• Type 1 diabetes is increasing in children, particularly in under fives;
• Type 2 diabetes is increasing (with increasing rates of obesity, and sedentary
lifestyles) across all groups, including children and young people, and ethnic
groups.
The prevalence of Type 2 diabetes is rising globally, and is predicted to reach 3 million in the
UK by the year 20108.
Significant inequalities exist in the risk of developing diabetes, both in access to health
services and the quality of those services, and also in health outcomes. This is of particular
relevance with regard to Type 2 diabetes. Risk may accumulate if an individual belongs to
more than one of these groups:
• Of non-white ethnicity;
• Less affluent:
o Type 2 diabetes is more prevalent
o higher morbidity and mortality
• Prisoners;
• Obese;
• Elderly. One in 20 people over 65 in the UK has diabetes, and this rises to one
in five in the over 85s. The elderly Type 2 are less likely to be cared for by a
specialist diabetes team. This is a particular problem for those who live in
residential and nursing homes where between 7% and 10% of residents have
diabetes9.
Estimates of the precise cost of diabetes vary because of the difficulty in standardizing data to
be included. In one study, diabetes accounts for some 9% of hospital costs10. The NSF
Standards7 (England) document quotes the figure as 5% of NHS costs. The presence of
complications increases the costs to social services four fold, and is also estimated at using
up 4 to 5 % of the prescribing costs.
Complications from diabetes, e.g. coronary artery and peripheral vascular disease, stroke,
diabetic neuropathy, amputations, renal failure and blindness result in increased disability,
reduced life expectancy and significant health costs to society. Although the onset of Type 2
diabetes is less dramatic than that of Type 1, the long-term sequelae are similar and equally
devastating and it is not a mild form of diabetes.
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Practice guidance on the care of people with diabetes
An individual may have Type 2 diabetes for many years before diagnosis, and up to 50% will
have already developed microvascular complications by the time they are diagnosed11. Many
also have an increased risk of coronary heart disease.
Diabetes has a major impact on the physical, psychological and material well-being of
individuals and their families, as well as health and social services costs.
Clinical targets mentioned in the guidelines (Section 3) for glycaemia, blood pressure and
dyslipidaemia may not be achievable in all patients. Individual patient targets need to be
assessed in relation to age, general health and other risk factors. Even if the ideal levels
cannot be reached despite attempts to improve treatment, it is important to recognise that any
improvement in blood glucose, blood pressure and lipid levels will help to reduce the overall
risk of complications.
People with Type 2 diabetes will need to know that the condition is progressive, and additional
therapies may have to be added in the future.
Pharmacists should focus on the patient’s overall regimen and not just the medication for their
diabetes i.e. the generalist vs. the specialist role. It will also help patients to see the
importance of other aspects of their drug therapy e.g. antihypertensives, lipid lowering drugs,
aspirin etc. For optimal control of diabetes and hypertension, patients are likely to be
prescribed increasingly complex regimens, as time goes by.
A significant proportion of Type 2 diabetes can be prevented or delayed by a healthy lifestyle.
Early detection, monitoring and appropriate management can reduce the risk and progression
of the complications.
The provision of education and follow-up of people with diabetes is usually the responsibility of
the ‘diabetes team’. There is potential now, with an increase in medicine management
schemes and the advent of supplementary prescribing, for more formal involvement of
pharmacists who see patients on a regular basis.
Community pharmacists are the most accessible healthcare professionals to many chronically
ill people. Pharmacists from other sectors may also find at times (e.g when conducting a
medicines review in a GP practice with the patient present, or giving out dispensed medication
from the Out-patients pharmacy) that they have the opportunity to remind, reinforce and
extend the education of the patient, evaluate the patient’s knowledge and facilitate patient
concordance.
Good lines of communication, liaison and referral should be established between all health
professionals so that pharmacists become part of the ‘diabetes team’ and a positive mutual
understanding of the contribution that each profession can make is developed.
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Practice guidance on the care of people with diabetes
5. Teamworking
5.1 Becoming integrated into the healthcare team
People with diabetes are cared for by a range of health professionals (the diabetes network)
and it is important that pharmacists find out who the key professionals are within their
localities.
In primary care, key professionals are:
• GPs;
• Nurses (practice, consultant, practitioner, school, district, PCT, diabetes specialist,
health visitor);
• Dietitians;
• Pharmacists (community, GP practice);
• Pharmaceutical advisers to PCOs, LHBs, LHCCs.
Other professionals who may be involved locally include registered optometrists and
podiatrists, care workers and clinical psychologists.
Primary Care Organizations produce Local Health Delivery Plans that span three years of
planned service delivery and development. By sourcing this information pharmacists can
identify and highlight to local health organizations the areas where they could provide services
to support delivery of this plan. The plan may also provide information on specific individuals
responsible for managing diabetes services in the organization. Some GP practices also
provide annual reports/ delivery plans that are available for the general public.
Within secondary care, the key health professionals involved in the care of people with
diabetes will be:
•
•
•
Hospital doctors (including diabetologists, endocrinologists, paediatricians);
Nurses (including Diabetes Specialist Nurses, LINK nurses (nurses on general
wards who have extra training for a particular disease);
Hospital pharmacists - There are an increasing number of specialist pharmacists
managing diabetes in secondary care. They would be a useful source of clinical
expertise as well as local prescribing policy.
Others who may be involved include dietitians, podiatrists, accident and emergency
departments, clinical psychologists and ophthalmologists.
Appendix 3 contains an example of a template that pharmacists could use for keeping a
record of contact details for members of their diabetes team.
The patient (and carer) is considered to be a member of the ‘diabetes team’. Their
understanding of diabetes care and the patient’s role in self-care (as appropriate) is important.
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Practice guidance on the care of people with diabetes
5.2 Useful skills and attitudes
Pharmacists should implement and develop diabetes care in collaboration with other health
professionals, Diabetes UK, patients and their families. Each professional should be able to
learn from and work with others, sharing information about patients, as appropriate, ideally
with the individual’s (or their carer’s) consent (see ‘Confidentiality’ in the MEP12). Team work
requires a clear definition of the goals and responsibilities of each professional, and their legal
liabilities.
Pharmaceutical care is a patient care system based on partnership and it aims to achieve
definite therapy outcome to improve an individual’s quality of life.
Useful skills and attitudes include:
•
•
•
•
•
•
•
Good communication;
Tact, respect, empathy, diplomacy;
Being culturally sensitive;
Recognising when the patient is receptive to information;
Tailoring information to an individuals’ needs and capabilities;
Considering the carer and family as well as the person with diabetes;
Knowing one’s limitations - referring appropriately.
5.3 Potential barriers to new services
• Lack of understanding and respect for other professional roles;
• Lack of a private counselling area;
• Lack of time and funding:
¾ This is a current barrier for community pharmacists to develop services
linked to chronic disease management. [The new PhS and nGMS contracts
may help to resolve this. Another possibility is LPS].
• Patient confidentiality (patient may not wish test results to go to GP practice);
• Lack of appropriate skill-mix in the workplace
• Conflicting messages from different professionals.
5.4. Communication
When communicating with the public, due regard should be given to the RPSGB, Medicines,
Ethics & Practice (MEP)12 guidance e.g. promoting a service, communicating test results to the
patient.
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Practice guidance on the care of people with diabetes
6. How to get started
Pharmacists should:
•
Update their diabetes-care knowledge. Diabetes care involves much more than just
drug treatment. Appendix 2 contains useful information and reference sources to help
with this.
•
Be aware of the World Health Organisation (WHO) diagnostic criteria for diabetes,
summarised in Appendix 4;
•
Be aware of how diabetes care is organised locally e.g. shared care arrangements,
local guidelines/ protocols, managed diabetes networks (MDN) etc. The local PCT
Pharmaceutical Adviser should be able to guide them towards the local diabetes coordinator, if available, who would know;
•
Have the names and contact numbers of appropriate diabetes team professionals (see
Section 5.1, Appendix 3), as well as local committees and Diabetes UK contacts;
•
Ask their LPC/ chief hospital pharmacist/ PCT Pharmaceutical Adviser if there is a
pharmacist on the local diabetes planning and implementation groups. If so, it would
be worth making contact with him/her. If not, and they feel that have enough
experience for this role, they could ask the LPC/ chief hospital pharmacist to nominate
them as their representative;
•
Any local information on services, training and campaigns that pharmacists identify
should be fed back to local representatives pharmacy organizations, so that they can
disseminate information to local pharmacists in the usual way e.g.
¾
¾
¾
¾
¾
LPC/ chief hospital pharmacist;
Local CPPE tutor;
Local pharmacy development group (if established);
NPA co-ordinator;
LHB/PCO adviser.
•
When appropriate, pharmacists could show this ‘Practice Guidance’ to their local GPs,
practice nurses, their Local Optical Committee and other healthcare professionals,
explaining that it has the approval of the RPSGB and Diabetes UK;
•
However, it may be more useful to consider the main areas of interest the pharmacist
has in developing closer ties with a GP practice in managing people with diabetes.
They could then arrange to meet with the GP practice manager (or appropriate GPpractice nurse) to discuss the potential for the pharmacist’s input (e.g. screening,
referral, managing patients the GP practice identify as having medicines related
problems).
•
When planning a new service, a pharmacist should give consideration to adequate
staff provision.
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Practice guidance on the care of people with diabetes
7. Clinical Governance
Clinical governance is a means of delivering high quality services to patients. There are four
main components:
•
•
•
•
Clear lines of responsibility and accountability for the overall quality of clinical care;
A comprehensive programme of quality improvement activities;
Clear policies aimed at managing risks;
Procedures for all professional groups to identify and remedy poor performance.
Sections in this Guidance that focus on quality issues are:
•
The pharmacists role in detecting undiagnosed diabetes [Section 8B]
¾ B2.5 Equipment/ Premises;
¾ E
Quality assurance.
•
Appendix 5
MEP Code of Ethics
¾ Testing of Body Fluids
•
Appendix 6
Diabetes Audit
The RPSGB website provides links to the following relevant documents:
•
•
•
•
•
MEP Code of Ethics;
An Organisation with a Memory, Department of Health;
Clinical Governance in Community Pharmacy – Guidelines on Good Practice for
the NHS, Department of Health;
Beyond the baseline: The role of clinical governance facilitators working with
community pharmacists;
RPSGB Policy papers: Achieving excellence through clinical governance:
¾ England and Wales version
¾ Scotland version
For further information and support on clinical governance, contact:
e-mail: [email protected]
20
Practice guidance on the care of people with diabetes
8. Practice Guidance
Because the RPSGB is the regulatory and professional body for pharmacists in England,
Scotland and Wales, the primary objective of this Guidance is to focus on standards and
professional behaviour.
The PSNC’s resource pack, ‘Diabetes Services - A Guide for Community Pharmacists’, is a
practical guide for community pharmacists in extending their role in diabetes care. New
services are categorized under the headings of the different Standards of the NSF for
Diabetes (England). This can be accessed at www.psnc.org.uk.
Both resource packs are designed to complement each other, and it would be useful for
Community Pharmacists to read the following practice guidance in conjunction with the
PSNC’s resource pack. Another useful guide is the Diabetes UK ‘Recommendations for the
provision of services in primary care for people with diabetes’ (www.diabetes.org.uk). The
sections on diet and management targets have been reproduced in Appendices 7 and 8 in
this Guidance.
The potential for pharmacists to help with the implementation of the National Plans for
diabetes standards is discussed in this Guidance, in terms of input at the level of prevention,
detection and treatment:
A.
B.
C.
D.
E.
The pharmacist’s role in the primary prevention of diabetes
The pharmacist’s role in detecting undiagnosed diabetes
The pharmacist’s role in the prevention of complications
Referral criteria
Quality standards.
Not every pharmacist will wish, or be able, to implement all the suggestions contained within
this document. The information within this document has therefore been divided into Essential
Practice and Desirable Practice, to help pharmacists prioritise areas for implementation.
Pharmacists in community, hospital and GP practices may have the opportunity to be involved
in A to E above. Community pharmacists may have a more formal structure for their enhanced
services in the future with their proposed PhS contract (see Section 2.5).
8A. The pharmacist’s role in the primary prevention of diabetes
The pharmacist’s role in promoting healthy lifestyles has been discussed in the RPSGB
publication “Pharmacy in a New Age: Building the Future6 (www.pharmacyinthefuture.org.uk)
and also the “Vision” (England) (www.dh.gov.uk).
21
Practice guidance on the care of people with diabetes
Essential Practice
A.1 Opportunistic promotion of a healthy lifestyle
Factors such as obesity and lack of physical activity have been strongly linked with the
incidence of Type 2 diabetes and the rising world prevalence of Type 2 diabetes is mainly
attributed to lifestyle changes. The modern diet of fast foods and high calorie drinks is not
helpful. The prevention of obesity in children and young adults is particularly important. In
addition, people with diabetes are also at significantly increased risk of developing
cardiovascular disease and this is a major cause of premature death. Pharmacists should try
to maximise their use of information material. Leaflets can be obtained from local health
promotion units, pharmaceutical companies, Diabetes UK (direct or printed off the website)
and other sources, e.g. the British Heart Foundation. Promotion of a healthy lifestyle is of
course important at all stages of the disease process, whether it is primary prevention of
diabetes or secondary prevention of complications. The importance of regular eye
examinations should also be promoted as diabetes is the leading cause of blindness in people
of working age7.
The main risk factors that can be identified and modified by the adoption of a healthy lifestyle
are; high body mass index (BMI), sedentary lifestyle, unhealthy diet, smoking, excess alcohol
intake. BMI is calculated by dividing the weight in kg by the height in metres2. A BMI of 2530kg/m2 is referred to as overweight, and > 30kg/m2 as obese.
Pharmacists in community (and at times in hospital or GP practices), are ideally placed to
recommend the following for diabetes prevention: healthy diet (low fat, low sugar, low salt,
high fibre), reducing BMI to healthy levels, reducing calories, increasing physical activity, e.g.
walking, swimming. Advice on increased physical activity should be realistic and possible, and
should include information about local facilities. It is important to discuss what the person with
diabetes enjoys doing. Levels of activity should be built up slowly and the pace should make
them breathe a little faster, but not to be so out of breath that they cannot talk. Adults should
aim to do half an hour five or more days a week.
Desirable Practice
A2. Targeted Prevention Programmes
Formal diabetes prevention programmes should target those at risk (see B2.2) of
diabetes. It is important that people at risk are aware of diabetes symptoms, lifestyle
factors and serious complications, e.g. coronary artery disease, stroke, etc. resulting in
increased disability and reduced life expectancy.
22
Practice guidance on the care of people with diabetes
8B. The pharmacist’s role in detecting undiagnosed diabetes
In the UK it has been estimated that there are a million people with diabetes (mainly Type 2)
who remain undiagnosed and are thus denied the benefits of treatment13. The guidance in this
section has been developed to help pharmacists who are thinking of setting up an early
identification (screening) service for diabetes, and has been shown14 to be an effective tool.
NB This Guidance relates to
early identification of people
with possible elevated blood
glucose and not to diagnosis.
Diagnosis of diabetes must be
confirmed by an appropriately
qualified health professional
following further testing using
accredited laboratory services,
in line with World Health
Organization (WHO) diagnostic
criteria (Appendix 4).
Community pharmacists see people who are
apparently well, in addition to those with
diagnosed medical conditions. They are likely to
come into contact with people with undiagnosed
diabetes who rarely access their GP and other
mainstream NHS services. Community
pharmacists have been identified within the
Diabetes NSF (England) as being well placed to
detect people presenting with signs of diabetes,
both in their local knowledge of people and when
responding to symptoms
Early detection of diabetes is important, particularly Type 1 diabetes where symptoms
are very obvious, and also in Type 2 where symptoms are less so. In Type 2, it has been
found that microvascular complications are present at diagnosis in up to 50% of patients.
Pharmacists considering setting up an early case
identification service for diabetes are advised to
contact their Primary Care Organization before
setting up any new service to ensure it has their full
support and fits with local policy. It is also advisable
they consult the professional requirements relating
to diagnostic testing and health screening as set out
in the Code of Ethics12.(see Appendix 5)
Thus, the sooner an individual
knows they have diabetes, gets
professional advice and acts on it,
the more chance they have of
delaying the progression of the
long term complications.
Pharmacists should be alert to the
possibility of undiagnosed
diabetes when conducting medication reviews and taking case histories, and refer for a test as
appropriate.
Essential Practice
B.1 Monitoring OTC sales
This offers a very important opportunity. When ‘responding to symptoms’ or to requests for
OTC products for: cystitis, vaginal thrush, persistent cutaneous infections (e.g. boils, styes,
skin chafing under the breast, athlete’s foot and other fungal infections), pharmacists should
have a high index of suspicion for diabetes. This is of particular importance if the condition is
recurrent.
23
Practice guidance on the care of people with diabetes
Desirable Practice
B.2 Supporting local screening campaigns
Community pharmacists who are taking part in screening for diabetes, and have referred
individuals to their GPs, have enabled those with undiagnosed diabetes to obtain an earlier
diagnosis and therefore earlier access to appropriate advice and treatment14.
B.2.1 Liaising with local diabetes professionals
•
When planning an early identification service, pharmacists should always liaise with
appropriate members of the local healthcare team (see Section 5.1), as well as clinical
biochemistry service (pathology department) personnel. The public health department
within the local Primary Care Organization may be a useful first point of contact;
•
It is good practice to consult with other members of the team on the choice of testing
method. Factors such as clinical reliability, acceptability, practicality and funding need
to be considered;
•
Clear referral pathways to the GP practice should be agreed, with a fasttrack appointment system when required. Where appropriate, GPs should be made
aware that patients will be asked for permission to forward test results to them. It is
good practice to let GPs have a copy of this Guidance so that they understand that
quality assurance procedures are being followed and that tests are being undertaken
by trained and competent staff;
•
Pharmacists should discuss the nature of the feedback offered to clients with the local
team, and should ensure that advice/ information provided is consistent with, and
complementary to, that provided by other members of the team.
B.2.2 Who should be targeted
A useful patient screening questionnaire can be found in Appendix 9
•
‘At Risk’ Groups (source: Diabetes UK):
¾ White people aged over 40 and people from black, Asian and minority ethnic
groups aged over 25 years with;
o a first degree family history of diabetes (parent or sibling);
o who are overweight/ obese (see A1), and who have a sedentary
lifestyle;
o who have ischaemic heart disease, cerebrovascular disease, peripheral
vascular disease or hypertension;
¾ Women who have had gestational diabetes (Diabetes UK recommend screening at
one year post-partum and then three yearly);
¾ Women with polycystic ovary syndrome who are obese;
¾ Those known to have impaired glucose tolerance or impaired fasting glycaemia
(see Appendix 4 for definitions).
24
Practice guidance on the care of people with diabetes
•
People presenting with symptoms potentially related to diabetes:
¾ Increased thirst/ dry mouth;
¾ Polyuria/ especially nocturia (may lead to bedwetting in children and incontinence
in older people);
¾ Weight loss despite increased appetite;
¾ Extreme tiredness/ lethargy;
¾ Slow healing wounds;
¾ Cystitis;
¾ Neuropathy – tingling, pain and numbness in feet, legs or hands;
¾ Visual changes such as blurred vision.
•
People presenting with signs potentially related to diabetes:
¾ Recurrent/ persistent cutaneous, mucosal and soft tissue infections e.g. vaginal
thrush/ balanitis (penile thrush);
¾ Loss of sensation in lower limbs;
¾ Fatty deposits in the eyelids (xanthelasmeta).
B.2.3 Referral levels
Agreement should be reached locally on protocols and referral levels, since there is some
variation in opinion from one area to another. The WHO diagnostic criteria for diabetes are
set out in Appendix 4. The following referral levels, based on the WHO criteria, are
suggested as a basis for discussion. An example of their use in practice can be found in
reference 14.
An example of a referral criteria summary sheet is set out in Appendix 10.
(a). Presenting with symptoms found in diabetes
Refer to GP practice
Anyone presenting with clear symptoms of diabetes, should be referred to their GP. Urgent
referral should be made in cases where signs/ symptoms i.e. weight loss, thirst, polyuria,
lethargy etc. have developed more acutely, and Type 1 diabetes is suspected, especially in
children.
(b). Presenting with risk factors, but no symptoms of diabetes
Risk factors for diabetes are set out above.
(b)1. Overnight fasting, finger-prick blood test
This is probably the most useful test at the present time although it has not proved popular
with patients (source: Diabetes UK), having a relatively low compliance rate.
[Some blood glucose monitoring meters display whole blood (WB) readings, and other convert
the later into a ‘plasma-equivalent’ (PE) reading (shown in brackets below).
25
Practice guidance on the care of people with diabetes
See Appendix 11 for more details]
When arranging appointments for tests, consideration should be given to the length of time
that patients will not have eaten. Pharmacists should check with members of the local team
what is recommended locally as the minimum number of hours that will count as an overnight
fast (this will be important in the case of shiftworkers).
Results in mmol/ l:
< 5.6 WB low probability of diabetes
(see sections B2.8 & B2.9)
(< 6.1) PE
5.6 – 6.0
probability of impaired fasting
glycaemia
refer to GP practice
(6.1-6.9)
6.1-11.0
probability of diabetes
refer to GP practice more
urgently
refer to GP practice with fasttrack appointment
(7.0-12.1)
≥ 11.1
high probability
(≥ 12.2)
In advance of an overnight fasting test, the patient should be advised not to eat after bedtime,
and to drink only water (since eating will invalidate the test unless the result is <5.6 mmol/l (PE
< 6.1 mmol/l), in which case the likelihood of diabetes would be very low).
(b)2.
Random, finger-prick blood test
Random tests can be misleading and appropriate feedback to patients is essential. A random
test on someone who has not eaten for 4 hours may be classed as a ‘fasting test’, by some
professionals. Check with other members of the local team what the referral levels should be
in relation to the last meal.
A person with a test result ≥ 11.1 mmol/l (PE ≥ 12.2 mmol/l), should be referred to their GP
practice at the earliest opportunity for further tests.
If levels are between 5.6 and 11.0 mmol/l (PE 6.1 – 12.1 mmol/l) a re-test should be offered using
a fasting sample (b)1. This is probably best done by the GP (but check locally), where the
laboratory results can be taken as the first of two required diagnostic tests.
A random test result of < 5.6 mmol/ l (PE < 6.1 mmol/l) indicates a low probability of diabetes.
26
Practice guidance on the care of people with diabetes
Results in mmol/ l:
< 5.6 WB
low probability of diabetes
(see sections B2.8 & B2.9)
probability of diabetes
Offer a re-test using a fasting
sample (b)1. This is probably
best done at the GP practice
where the laboratory result can
be taken as the first of the two
required diagnostic tests (but
check locally)
refer to GP practice with fasttrack appointment
(< 6.1) PE
5.6 –
11.0
(6.1-12.1)
≥ 11.1
high probability
(≥ 12.2)
(b)3.
Urine-strip test, 2 hours after a meal
Report any glucose detected
Urine testing, using testing strips, is not ideal because of the increased risk of false negatives.
However, this has been one of the most widely used tests in pilots due to the relative simplicity
of use, and cost.
For optimal results using this test, the bladder should be emptied just before a meal, and then
if possible not again until 2 hours after the meal, when the test is done.
(b)4.
Random urine-strip test
Report any glucose detected
A random urine test can risk falsely reassuring many people with a negative result.
People with risk factors and a negative test should be advised to re-test 2 hours after a meal
(b)3, or to mention their concerns about diabetes, when they next see their GP or nurse.
NB.
It is useful to
check that people who are
given a strip to self-test at
home are not colour-blind
and can differentiate
between the colours
shown on the container.
27
Practice guidance on the care of people with diabetes
B.2.4 Recommended Training
Pharmacists, pharmacy technicians and other staff who are to be involved in testing must be
suitably trained in the procedures to be followed and the advice given to patients.
•
Training should cover the following areas:
¾ Developing and working within standard operating procedures;
¾ Testing (this includes completion of any training programmes provided by
equipment suppliers to ensure competence in the use of equipment and in
interpretation of test results);
¾ Quality Assurance arrangements;
¾ Referral criteria/procedures;
¾ Feedback to patients (advice giving);
¾ Giving a simple explanation about the nature of diabetes;
¾ Explaining about the probability of diabetes in relation to the test result;
¾ False negatives - why they can occur;
¾ Safe handling of sharps;
¾ Record keeping;
¾ Giving consistent lifestyle advice (e.g. on diet and physical activity);
¾ Reinforcing the person’s desire to take care of themselves;
¾ Medicine management issues relevant to diabetes;
¾ Clinical governance and liability issues;
¾ Insurance.
Multidisciplinary training, organized with other local diabetes professionals is encouraged.
B.2.5 Equipment/Premises
[see Appendix 5 for MEP (Code of Ethics) guidance on Testing of Body Fluids]
All procedures, including disposal of clinical waste, must be in accordance with Health and
Safety Executive (HSE) requirements.
•
Blood glucose meters
¾ Quality Assurance (see Section E);
Meters should be of a recognised quality standard (CE marked or equivalent);
¾ Meters should be suitable for frequent and/or professional use. There should be
no possibility of contamination from previous tests;
¾ Disposable finger pricking devices (e.g. Unistik 2) should be used;
¾ For each test undertaken it is good practice to keep a record of the meter used,
testing strip type and batch number. An example of a suitable record form is
included as Appendix 12. Some PMR systems can be used for this purpose.
28
Practice guidance on the care of people with diabetes
• Blood testing strips
These should always be date checked.
• Urine testing strips
These should always be date checked.
• Disposal of sharps and testing strips
Sharps should be disposed of in a properly designed sharps container available in the
pharmacy. Procedures should be put in place for seeking to avoid and dealing with needle
stick injuries. Used testing strips should be disposed of as clinical waste.
• Premises
The requirements of the Code of Ethics12 service specification 3 (pharmacy premises and
facilities) should be considered. The specimen collection and test should not be
undertaken within the dispensary or any area of the pharmacy where food and drink is
consumed. An appropriate area for communicating results and giving advice, which
provides a degree of privacy, should be available.
B.2.6 Initiating the test
•
The procedure to be followed, should always be explained to the individual;
•
A form confirming the request for the test should be signed and dated by the individual
and retained for one year. A copy could be given to the patient. This form should also
give details of the procedure. An example of such a form is set out in Appendix 13;
•
People undertaking urine tests should be advised how to use the testing strips.
Ideally, this advice should be supplemented with written instructions. (The use of
individually wrapped packs produced by some manufacturers can be considered.)
Pharmacists may also consider using pre-printed forms in both English and other local
languages where this is appropriate.
B.2.7 Undertaking the test
•
Testing and communication of results should only be carried out by staff that is trained
and competent;
•
Sources of training could include local diabetes nurses, meter company
representatives and professional services pharmacists;
•
A Standard Operating Procedure (SOP) should be designed, and signed up to by staff
involved in the service;
•
Pharmacists should ensure that they have appropriate input into the test process,
communication of results and provision of advice, and should ensure that local
agreements are followed where relevant.
29
Practice guidance on the care of people with diabetes
B.2.8 Documentation
•
Pharmacists may consider forwarding a copy of the test result to the patient’s GP, if
the patient has given their consent (see Appendix 13). Where appropriate, the result
should specify the timing of the patient’s last meal in relation to the test. An example
of a referral form is set out in Appendix 14;
•
It is good practice to consult with members of the local diabetes team to discuss
whether they would wish to be notified for their records of negative tests where the
patient has no symptoms of diabetes;
•
The results should be retained in the pharmacy, where possible, stored on a pharmacy
PMR system (see ‘prompts’ below);
•
Pharmacists may wish to consider setting up computer prompts with a view to inviting
patients to retest after a specified length of time (subject to agreement with the local
team). Prompts may also be used to remind pharmacists to ask patients periodically if
they are experiencing any symptoms associated with diabetes.
N.B. Pharmacists should ensure that the requirements of the Data Protection
Act 1998 for data collection and use are complied with. Information obtained
in the course of professional activities is confidential and should be disclosed
only with the consent of the patient other than in the specific circumstances
described in the Code of Ethics12 (Part 2: section C).
The provisions of the Access to Health Records Act which came into force on
November 1, 1991 should be observed. An example of a useful record form,
for retention in the pharmacy, is found in Appendix 12.
B.2.9 Communicating the result
•
Written confirmation of the results should be given with a clear explanation. The use of preprinted forms in both English and other local languages may also be considered;
•
Pharmacists should ensure that the manner in which the result is communicated does not cause
undue alarm to the patient, particularly if an elevated glucose level is detected. A suitable
phrase might be ‘this test has shown a possible rise in blood glucose which needs further
checking by your GP or nurse’;
•
When communicating the result pharmacists should never indicate to a patient that he/she has
diabetes. A diagnosis of diabetes can only be made by a GP or other suitably qualified health
professional following further testing;
•
If a patient withholds consent for an elevated glucose test result to be forwarded to their GP or
nurse, they should be advised to seek medical advice and to take the results with them;
30
Practice guidance on the care of people with diabetes
•
If a test result indicates a very low probability of diabetes and the patient has no symptoms of
diabetes, general advice on diabetes awareness and the need to be vigilant should be
considered. Patients in ‘at risk’ groups may be given advice on healthy lifestyles, including diet,
the importance of physical activity etc.;
•
Patients undertaking a urine test at home should be advised to report back to the pharmacy if
the result of the test is positive and to make an appointment for further tests at their GP practice;
•
To ensure consistency of local messages, pharmacists are advised to discuss with other
members of the local team what type of literature would be appropriate to hand out to patients
when supplementary information on diabetes is requested. This might include locally approved
literature or leaflets available from Diabetes UK . For a catalogue call 0800 585 088 or visit
www.diabetesuk/catalogue/order.htm
B.2.10 Confidentiality
Pharmacists are reminded of their duty of confidentiality as set out in the Code of Ethics12.
B.2.11 Personal liability
Pharmacists should ensure that the service is covered by professional indemnity
insurance arrangements in respect of themselves, their staff and the patients who are
being tested (CDA/ NPA). Pharmacists setting up a clinic should check if they need to
register as a clinic with CHAI/ CSCI.
B.2.12 Requests by members of the public to purchase testing equipment
•
It is essential to establish whether any local policies/ guidelines on blood glucose
monitoring exist, as they are increasingly being put into place;
•
Pharmacists should be personally involved in responding to requests from members
of the public to purchase testing equipment and wherever possible, determine the
purpose of the intended purchase. If the equipment is being purchased for early
identification purposes, appropriate advice should be given;
•
If a patient with diagnosed diabetes who is currently testing urine asks about the
purchase of a blood glucose meter, they should be advised to check whether their GP
would be prepared to prescribe the necessary testing strips and lancets, so that they
can make an informed choice about whether or not to purchase;
•
Pharmacists should be satisfied that any meter sold is accurate and that local
resources are available for training, advice and maintenance. Pharmacists should
check whether the patient understands when and how often to test, what results to
expect and how to act on those results.
31
Practice guidance on the care of people with diabetes
B.2.13 Advertising the service
As this is a professional service any publicity must comply with the requirements of the
Code of Ethics12.
The National Screening Committee is researching the value of screening, and also the most
effective ways of identifying those at risk. According to the NSF for Diabetes (England), results
should be published in 2005.
C. The pharmacist’s role in the prevention of complications
This area offers the greatest potential for input by pharmacists i.e. providing support and
education to people with diabetes. Education alone does not necessarily lead to improvement.
It is important to provide information in a way that motivates the individual to change
behaviour. Knowledge of the cycle of change and the stages at which a change in behaviour
is most likely will be useful. If the patient is not receptive on a particular occasion, it may be
worthwhile trying again at a more appropriate time.
In the guidance below, the term ‘carers’ includes Care Home Staff who may also need support
and advice in managing residents who have diabetes.
C.1 At presentation of the first prescription
Essential Practice
(a). The pharmacist should confirm the patient has diabetes (in case of prescription
error) and establish themselves as a source of information on diabetes care e.g.
medication, diet. The pharmacist must know where to find the information or be able to direct
the patient to the most appropriate source.
(b). The management of all medicines is a specific role for pharmacists and so it is particularly
important that this role is fulfilled. On receipt of the prescription, the dosage regime
should be checked and the prescription assessed for any drug interactions,
sensitivities, allergies and contraindications.
The patient’s (or carer’s) understanding should be checked, on the use of any device, or on
the dosage and timing of the medication. Information should be extended and reinforced as
appropriate [e.g. mode of action, how to prevent or cope with possible side effects such as
hypoglycaemia].
The patient should be informed of their exemption
status and of what is not available on
NHS prescription (e.g. testing meters)
NB A position statement on
the safe disposal of needles
and lancets (sharps) has
been produced by Diabetes
UK and can be found on
www.diabetes.org.uk, within
the healthcare professional
section).
For people on insulin:
•
•
•
Storage requirements
Basic stock control
Disposal of used needles and syringes
32
Practice guidance on the care of people with diabetes
Provision of equipment for safe disposal such as Sharps containers is variable. Pharmacists
should find out what the policy is in their area and advise the patient accordingly.
[Availability of patient ID cards and other items (information can be obtained from Diabetes
UK).]
(c). OTC purchases by or for people with diabetes should be checked for interactions and
contra-indications
(d). Promotion of membership of Diabetes UK. Full details of how to obtain membership of
Diabetes UK are included in Appendix 2.2. Diabetes UK Careline is available to both patients
and professionals for information and support on all aspects of living with diabetes.
Desirable Practice
(d). A newly diagnosed patient often has many questions, and using a diabetes practice leaflet
may prompt them to ask for information (an example of a practice leaflet is given in Appendix
15).
(e). If possible, the diagnosis should be recorded on the pharmacy PMR system.
(f). People with diabetes are an ideal target for medicine reviews, and pharmacists should
explore the opportunities the new PhS contract might bring.
C.2 At presentation of a repeat prescription
Essential Practice
(a). Check for:
• Anomalies in the prescription: For patients on insulin, the formulation and
administration device they use should be checked. Additions, missing items, dosage
changes, different formulations, should be queried with the patient (or carer) to check it
is what they have been told to expect. It is best to check with the patient (or carer) first
before querying with the doctor. It may be useful also to check that the patient is
receiving regular supplies of their monitoring equipment (appropriate to how often they
have been advised to test by the doctor or nurse) as well as their drug treatment;
•
Drug interactions with both prescribed and non-prescription medicines;
•
Side effects to medication, particularly signs of hypoglycaemia with many oral
hypoglycaemic agents, gastrointestinal reactions to metformin and oedema with the
thiazolidinediones (glitazones);
•
Concordance with medication and healthcare advice.
Desirable practice
(b). A short questionnaire could be handed out (see Appendix 16), for the patient or
carer to complete whilst waiting for their prescription. The responses can then be used as a
basis for discussion (see also C2c and C2d) when the medication is handed out. It will also
help the pharmacist identify patient education needs which may have arisen since the first
prescription was presented. The questionnaire could also form the basis of the community
pharmacist’s own register of people with diabetes to use alongside the PMR. It would be good
‘PR’, to inform the local GPs and practice nurses of the use of the questionnaire so that they
are aware of the pharmacist’s involvement.
33
Practice guidance on the care of people with diabetes
(c). Patients or carers vary in their understanding and each should be treated as an individual.
Pharmacists could remind, clarify information and educate patients /carers in a
graduated manner. As time is scarce and it has been shown that people only remember 2-3
points, only a small amount of information should be given at a time. Use should be made of
written information to back up what is said to the patient/ carer. A brief note could be put on
the pharmacist’s PMR or other record of the information provided and the date, so that next
time they may be reminded of what they had already spoken to the patient or carer about.
Suggested topics for education / clarification include:
General health promotion:
• Alcohol consumption
• Diet: healthy eating
- no need for special diabetic foods
- weight reduction
• Physical activity
• Smoking cessation.
N.B. Physical activity is encouraged for
everybody with diabetes to help reduce the
risk of long-term complications and to
maintain an acceptable weight. Exercise
can also improve sensitivity to insulin and
therefore help control blood glucose levels.
Patients wishing to embark on strenuous
exercise should be advised to eat
beforehand. Older patients should be
advised to check with their GP before
embarking on any new regular or
strenuous activities. Types of activities to
be recommended may include a brisk
walk, swimming etc.
Diabetes care:
• Footcare
• Use of testing strips/ meters
• Prevention of long term
complications
• Regular eye examinations
• Sick Day rules
• Signs of hypoglycaemia
• Signs of Hyperglycaemia
Diabetes UK has produced information leaflets on a number of these topics. A free catalogue
of these can be obtained by contacting Diabetes UK Distribution Service (Freephone 0800
585088). It is useful to find out which leaflets the local practice uses and try to obtain a supply
of the same. Pharmacists should always check that the information they provide to patients or
carers also conforms to local guidelines / information.
(d). Check on progress:
It is useful to review patient-held record if available. This might form a useful basis for
assessing a patient’s understanding of their condition and any change in treatment.
The diabetes practice leaflet (example in Appendix 15) can be given to a patient at any time,
if the pharmacist realises that the patient has not had one before, or if the pharmacist wishes
to open up a dialogue about diabetes care with them. It may prompt a query ‘that they didn’t
want to bother the doctor or nurse about’.
If a carer is collecting the prescription for someone else, they could be asked to pass on the
questions to the patient, with the suggestion that they phone the pharmacist if they have any
problems.
34
Practice guidance on the care of people with diabetes
(e). Special situations
e.1 Dealing with teenagers and young adults
Control of diabetes is sometimes difficult in teenagers and young adults for a number of
reasons including heightened self-awareness, the desire to lose weight, excessive
consumption of alcohol and other ‘rebellious behaviour’. It is not uncommon for teenagers
with diabetes, particularly girls, to miss out or reduce insulin doses as a method of dieting
without telling anyone. Others may refuse to monitor blood glucose, resulting in poor
glycaemic control. If the pharmacist thinks any of their patients may fall into this category,
they should ensure the patient’s knowledge of how to deal with hypoglycaemia or ketoacidosis
is up to date. They may wish to remind themselves of the requirements for emergency
supplies as set out in Medicines, Ethics and Practice12. If the pharmacist can gain the trust of
the young person, they should endeavour to reinforce education on appropriate diabetes care.
e.2 Diabetes and minor illness
All patients with diabetes should be advised to check with a pharmacist before buying
medicines over the counter. If a patient is normally well controlled and OTC medicines are
being used in relatively small amounts for limited periods, the glucose content is unlikely to
cause a problem. Note should be taken of the license of OTC medicines, whether they are to
be used with caution in people with diabetes.
C.3 Self-Monitoring
As mentioned in B2.12, it is essential to establish whether any local policies/ guidelines on
Blood Glucose Monitoring exist, as they are increasingly being put into place.
A review of patient self-monitoring can be found in a MeReC Bulletin15. However Diabetes UK
has found that the use of this bulletin has led to a lot of confusion, and to people being denied
test strips, and would prefer professionals to use The National Diabetes Support Team
Glucose Monitoring Factsheet available at www.cgsupport.nhs.uk/diabetes/Resources.asp
Essential Practice
(a). A source of monitoring equipment
Community pharmacists are ideally placed to sell blood glucose testing meters and give
appropriate advice on their use. However, it is important they work with other members of the
diabetes team. It is useful to find out what equipment is recommended locally. Some GP
practices prefer not to prescribe monitoring strips and lancets for use with blood meters,
especially if patients are already well controlled using urine tests - blood testing being
perceived as being more costly than urine testing.
Before giving advice on the use of monitoring equipment a pharmacist should ensure they are
competent to do the following:
•
Assess the most suitable meter for each patient
or
Provide the patient with enough information to enable them to make their
own informed choice
35
Practice guidance on the care of people with diabetes
•
Demonstrate the correct use of equipment.
In order to do this the pharmacist must have a knowledge of all the available meters and be
trained appropriately in how to use the equipment. A full list of currently available monitoring
equipment is available from Diabetes UK and useful summary tables can be found in MIMS.
Desirable Practice
(b). Check patients’ monitoring
As community pharmacists see many people with diabetes (and carers) more regularly than
other health care professionals, they are in an ideal position to remind them of the need to
test, and also to check on how well the advice that has been given, is being followed.
Pharmacists working in secondary care and in GP practices may also have the opportunity to
give advice.
The pharmacist could find out from the patient or carer:
• how they have been advised to monitor their diabetes (i.e. blood or urine testing and
frequency of tests)
• the desired range of glucose levels
• what the results have been like recently (they may have them with them on a patientheld record card).
Pharmacists should be alert to symptoms such as tiredness that could be the result of lack of
monitoring and poor blood glucose control.
(c). Meter testing
The need for quality control should be explained to patients or carers and they should be
advised to check their meters according to manufacturers’ instructions if they think there is a
problem. It may be useful to find out what services are available locally for testing meters.
Some pharmacists may consider offering a meter testing service themselves, possibly
involving local meter representatives (who are often nurses).
(d). Patients should be encouraged to keep appointments for check-ups
This would include those at GP clinics and others such as the optometrist and/or
ophthalmologist for regular eye checks, or registered podiatrists for scheduled foot checks.
Pharmacists can reinforce the importance of these in helping people with diabetes to monitor
their condition and reduce the overall risk of complications.
C.4 Related services
Desirable Practice
(a). A smoking cessation service could be offered, and/ or the pharmacist could link
into smoking cessation services set up locally. Smoking is an additional risk factor for
cardiovascular and peripheral vascular disease, both of which are more common in people
with diabetes.
Advice on starting up a smoking cessation service can be accessed from:
•
NPA (direct for members, otherwise through the LPC) smoking cessation resource list
•
PSNC – in the Diabetes Resource pack
•
Local PCO smoking cessation personnel (if available)
36
Practice guidance on the care of people with diabetes
(b). Get involved in local medicines management projects
Pharmacists have an increasing opportunity to be involved with medicines management and
concordance. According to the NSF for older people, ‘medicines management aims to
prevent, detect and address medicines-related problems and to achieve optimum use of
medicines’.
In practice, medicines management takes place at two levels:
At population level medicines management is about improving outcomes and reducing
health inequalities by using medicines more effectively across the health system. This
includes measures such as improving repeat prescribing systems, reducing waste of
medicines, introducing evidence-based formularies and guidelines; generic prescribing;
synchronisation of quantities; deletion of medicines no longer needed and optimisation of
doses.
At individual patient level medicines management is about achieving concordance in
prescribing and medicine taking. Concordance is a process based on partnership, whereby
health professionals and patients work together to agree on what should be prescribed and
patients are supported in taking medicines.
There are many ways in which pharmacists can contribute to the concordance process.
Firstly, in terms of giving patients greater knowledge, pharmacists can play a vital role in
offering patients information about their condition, treatment and signposting them to other
sources of information. Pharmacists can also give patients the confidence and knowledge
needed to open dialogue with their prescriber and ask for a review if appropriate.
Secondly, as pharmacists take on an increasing role as supplementary prescribers, and
through repeat dispensing, they will be in a better position to make shared decisions with
patients about the medicine that is most appropriate to their particular needs and priorities.
Practical Tools for reviews can be found at www.medicines-partnership.org e.g.
•
•
‘Room for review, a guide to medication review’;
Concordance project evaluation toolkit.
The NPA (for members) and the PSNC both have medicines management resources packs.
D. Referral criteria
Pharmacists should refer people with diabetes to an appropriate professional.
(Appendix 3 is a handy list to fill in local contact numbers e.g. diabetes specialist nurse,
optometrist, dietitian etc).
Areas requiring referral include:
• Foot problems
• Poor glycaemic control
• Blurred vision
• Women with diabetes who are planning a pregnancy or who have had a recent positive
pregnancy test (if not already seen by a doctor)
• Drug addicts
• Patients with concerns the pharmacist feels they cannot deal with.
Pharmacists need to check locally what the current referral process is, as each area will have
different protocols.
37
Practice guidance on the care of people with diabetes
E. Quality Assurance
It is essential for pharmacists to periodically review the service they provide to people with
diabetes. The benefit of review is that it provides pharmacists themselves, other health
professionals and other bodies, e.g. the SHA/HB/PCO (if additional funding is being applied
for) with important feedback and evidence of the benefit of the pharmacist’s increased input
into the care of people with diabetes.
(Appendix 6 contains examples of some audits which could be used to monitor the quality
the service).
Blood glucose meters
These should be subject to regular documented quality assurance (QA), using appropriate
control solutions (which should be date checked) to maintain confidence in both the
equipment and the operator. Manufacturers of testing equipment may have a role in QA.
It is essential that links are established with the local clinical biochemistry services (pathology
department) who should be able to provide advice on QA procedures and samples of whole
blood and glucose solutions for QA purposes;
F. Funding
Funding issues should be resolved locally before setting up the service. The introduction of
the new community pharmacy (PhS) and nGMS contracts may provide increased
opportunities for funding the service. LPS may also be considered.
Advice on putting a bid in to meet local PCO targets, etc can be accessed from the following
organizations:
•
•
PSNC e.g. PSNC ‘Sources of Funding Guide’ (www.psnc.org.uk under ‘Resources –
publications’);
NPA (direct for members; otherwise through the LPC) e.g. quick guide references to
NHS targets in England and Scotland, quick reference guide to the GMS contract,
preparing a business proposal etc. Otherwise each organization may give
individualised advice to community pharmacists on request.
9. References
1. The Royal Pharmaceutical Society of GB (2001). Practice Guidance on Early Identification
of Diabetes by Community Pharmacists (1st edition).
2. The Royal Pharmaceutical Society of GB (2001). Guidelines for Community Pharmacists
on the Care of Patients with Diabetes (2nd edition).
3. Diabetes Care and Research in Europe: The St Vincent Declaration (1990). Diabetic
Medicine 7: 360.
4. St Vincent Joint Task Force for Diabetes, Department of Health, British Diabetic
Association (1995).
5. The PharmaDiaB programme, Euro PharmForum (1996).The Role of the Pharmacist in
Diabetes Care .
38
Practice guidance on the care of people with diabetes
6. The Royal Pharmaceutical Society of GB (1997). Building the Future: A strategy for the
21st century pharmaceutical service.
7. The Department of Health (2001). The National Service Framework for Diabetes:
Standards.
8. McCarthy D et al. (1994). International Diabetes Institute, Melbourne, Australia. Global
Estimates for Projections.
9. British Diabetic Association report (1999). Guidelines for practice for residents with
diabetes in care homes.
10. Currie CJ, et al. NHS acute sector expenditure for diabetes: the present, future, and
excess in-patient cost of care. Diabetic Medicine 1997; 14: 686-692.
11. Harris MI at al. (1992). Onset of NIDDM occurs at least 4 – 7 years before clinical
diagnosis. Diabetes Care 7: pp 815 -819.
12. Royal Pharmaceutical Society of GB (2004) Medicines, Ethics & Practice (MEP). A Guide
for Pharmacists.
13. British Diabetic Association Report (1996). Diabetes in the United Kingdom.
14. Lawal AG, et al. Opportunistic screening for Type 2 diabetes within inner city community
pharmacies. Int J Pharm Pract 2003; 11: R10.
15. The National Prescribing Centre. When and how should patients with diabetes test blood
glucose? MeReC Bulletin 2002; 13 (1):1-4.
39
Practice guidance on the care of people with diabetes
10. Appendices
Appendix 1
The new GMS contract - Annex A:
Quality Indicators – Summary of points (Diabetes and Medicines Management
sections)
1.1 Diabetes Mellitus (Diabetes)
Indicator
Ongoing Management
The percentage of patients with diabetes:
DM 2. - whose notes record BMI in the previous 15
months
DM 3. - in whom there is a record of smoking status in
the previous 15 months except those who have never
smoked where smoking status should be recorded once
DM 4. - who smoke and whose notes contain a record
that smoking cessation advice has been offered in the
last 15 months
DM 5. - who have a record of HbA1c or equivalent in the
previous 15 months
DM 6. - in whom the last HbA1c is 7.4 or less (or
equivalent test / reference range depending on local
laboratory) in last 15 months
DM 7. - in whom the last HbA1c is 10 or less (or
equivalent test / reference range depending on local
laboratory) in last 15 months
DM 11.- who have a record of the blood pressure in the
past 15 months
DM 12.- in whom the last blood pressure is 145/85 or
less
DM 16.- who have a record of total cholesterol in the
previous 15 months
DM 17.- whose last measured total cholesterol within
previous 15 months is 5 or less
DM 18.- who have had influenza immunisation in the
preceding 1 September to 31 March
Points
Maximum
threshold
3
90%
3
90%
5
90%
3
90%
16
50%
11
85%
3
90%
17
55%
3
90%
6
60%
3
85%
40
Practice guidance on the care of people with diabetes
The new GMS contract - Annex A (continued):
Quality Indicators – Summary of points (Diabetes and Medicines managements
sections)
1.2 Medicines Management
Points
Med 1
2
Details of prescribed medicines are available to the prescriber at
each surgery consultation
There is a system for checking expiry dates of emergency drugs
at least on an annual basis
Med 3
2
Med 4
3
The number of hours from requesting a prescription to availability
for collection by the patient is 72 hours or less (excluding
weekends and bank/local holidays)
Med 5
7
Med 6
4
Med 7
4
Med 8
6
Med 9
8
Med
10
4
A medication review is recorded in the notes in the preceding 15
months for all patients being prescribed four or more repeat
medicines (excluding OTC and topical medications): Standard 80
per cent
The practice meets with the PCO prescribing adviser at least
annually and agrees up to three actions related to prescribing
Where the practice has responsibility for administering regular
injectable neuroleptic medication, there is a system to identify
and follow up patients who do not attend.
The number of hours from requesting a prescription to availability
for collection by the patient is 48 hours or less (excluding
weekends and bank/local holidays)
A medication review is recorded in the notes in the preceding 15
months for all patients being prescribed repeat medicines
(excluding OTC and topical medications): Standard 80 per cent
The practice meets with the PCO prescribing adviser at least
annually, has agreed up to three actions related to prescribing
and subsequently provided evidence of change
A simplified view of the ‘points’
In 2004-5 a point is worth a nominal £75 and this rises to £125 in 2005/6.
These values are for an 'average size practice' of approx 5800 patients with average prevalence of the
disease being discussed, and the value of a point for an individual practice varies according to both
parameters, but not in a straightforward way.
GP Practices will no longer be paid contributions towards staff costs, nor fees for 'items of service' etc
and so much of the 'points money' is considered by GPs to be actually ‘old money’ dressed up in a new
way. However, GP practices may still need help in achieving their points and consider using pharmacists
as a cost-effective option
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Practice guidance on the care of people with diabetes
Appendix 2
Useful information
Below are a number of journal references, textbooks, courses etc. to help
pharmacists update their knowledge of diabetes. An additional, and very accessible,
way of learning is from the people one meets who have diabetes. It can also be a
good learning opportunity if pharmacists can arrange to ‘sit in’ with a member of the
diabetes team during a diabetic clinic session. This liaison would also help strengthen
interprofessional relations.
2.1 Useful Addresses
Where to obtain current information:
2.1.1 Organisations
British Heart Foundation
Tel: 020 7935 0185
Website: www.bhf.org.uk
British Hypertension Society
Tel: 020 8725 3412
Website: www.bhsoc.org
BMJ Medical Journal
Tel: 020 7387 4499
Website: www.bmj.com
Cochrane Centre UK
Tel: 01865 516300
Website: www.cochrane.co.uk
Collaborative National Medicines Management Services Programme
(for examples of diabetes projects)
Tel: 0151 794 8137 (Richard Seal)
Website: www.npc.co.uk/mms
e-mail: [email protected]
Diabetes UK
(see Appendix 2.2)
Information Centre and Library
Royal Pharmaceutical Society of Great Britain
Tel: 020 7735 9141
Website: www.rpsgb.org.uk
e-mail: [email protected]
Medicines Management Project (CHD)
Tel: 01388 606141 (John Dixon)
e-mail: [email protected]
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Practice guidance on the care of people with diabetes
National Prescribing Centre
(for MeReC Bulletins, GP Prescribing Support Documents, Competency
Framework and other documents)
Tel: 0151 794 8134
Website: www.npc.ppa.nhs.uk
For NPA members:
NHS Development Department
National Pharmaceutical Association (NPA)
(for resource packs and advice on the provision of services)
Tel: 01727 85 86 87 ext. 3127
e-mail: [email protected]
NHS Direct
Tel: 0845 46 47
Website: www.nhsdirect.nhs.uk
NHS – link to PCOs and hospital information
Website: www.nhs.uk
Pharmaceutical Services Negotiating Committee (PSNC)
(Diabetes Resource Pack, for services by community pharmacists)
Tel: 01296 432823 (Barbara Parsons)
Website: www.psnc.org.uk
e-mail: [email protected]
UKCPA
Tel: 0116 277 6999
e-mail: [email protected]
e-mail: [email protected]
2.1.2 Useful websites (more)
Diabetes sites:
www.aadenet.org
(American Association of Diabetes Educators)
www.bma.org.uk
(British Medical Association – for nGMS contract etc)
www.diabetes.audit-commission.gov.uk
(Audit Commission)
www. diabetes.org.uk
(Diabetes UK)
www.diabetes.org
(American Diabetes Organisation)
43
Practice guidance on the care of people with diabetes
www.diabetes-healthnet.ac.uk
(Diabetes Audit and Research – DARTS)
www.diabeteswellnessnet.org.uk
(Diabetes Research and Wellness Foundation)
www.idf.org
(International Diabetes Federation)
www.iddtinternational.org
(Insulin Dependent Diabetes Trust)
www.webshowcase.net/input
Insulin Pump Therapy Group
Government documents:
www.pharmacyinthefuture.org.uk
(Pharmacy in the Future, NHS Plan)
www.natpact.nhs.uk
(has a useful pharmacy site)
www.dh.gov.uk
(Dept. of Health website, for NSFs etc)
www.dh.gov.uk/PolicyandGuidance/OrganisationPolicy/PrimaryCare/Commissioning/Commissio
ningArticles/fs/en/CONTENT_ID=4081669&chk=eH/XMv
(for GMS contract, Quality and Outcomes Framework – or through the BMA website, if having
difficulties)
The NHS Improvement Plan. Putting people at the Heart of Public Services
National Standards, Local Action: Health and Social Care Standards and Planning Framework
2005/06-2007/08
Management of Medicines: A resource to support the implementation of the wider aspects of
medicines management for the NSFs for diabetes, renal services and long term conditions
www.wales.nhs.uk
(NHS Wales, NSF)
www.show.scot.nhs.uk/diabetes
(Diabetes Framework, Scotland)
www.crestni.org.uk/publication/diabetes
(NSF for Diabetes in Northern Ireland)
www.nice.org.uk
(NICE guidelines)
www.sign.ac.uk
(SIGN guidelines)
Medicines Information:
www.druginfozone.nhs.uk
www.ukmi.nhs.uk
www. emc.medicines.org.uk
www.ncbi.nlm.nih.gov/PubMed
44
Practice guidance on the care of people with diabetes
Medicines Management
www.managingmedicines.com
National electronic library for health
www.nelh.nhs.uk
Postgraduate Education
www.cppe.man.ac.uk
(Centre for Pharmacy Postgraduate Education (CPPE))
2.2 Diabetes UK
Diabetes UK is the leading national charity representing the interests of all people
with diabetes.
Diabetes UK
10 Parkway
London
NW1 7AA
Telephone: 020 7424 1000
Fax: 020 7424 1001
Website: www.diabetes.org.uk
The Careline is open Monday to Friday 9am to 5pm
It is available to both patients and healthcare professionals, and also offers a
language line translation service.
Tel: 0845 120 2960
Minicom line: 020 7424 1031.
e-mail to [email protected].
Diabetes UK produces a large number of professional and lay leaflets and
catalogues. These can be obtained by contacting Diabetes UK Distribution Services
on 0800 585088.
To join Diabetes UK:
All memberships can be arranged through Diabetes UK Customer Services
Department, Tel: 020 424 1010 or e-mail: [email protected]. Current
membership prices can be obtained from the Diabetes UK website or by contacting
the Customer Service Department.
[Diabetes UK was formerly known as the British Diabetic Association]
45
Practice guidance on the care of people with diabetes
2.3 Specific references
The following is not an exhaustive list but provides references to a number of recent
articles on diabetes in accessible journals.
Summary of topics:
Aetiology and Pathology
Audits
Compliance
Diabetes and its Management
Diagnostic criteria
Education/ Motivation
Ethnic issues
GMS contract
Insulin
Lifestyle
Management of Complications
Medicines management
National Plans
Pharmacist’s role
Screening
Self-testing
Aetiology and Pathology
Aetiology and pathology of Type 2 diabetes mellitus. Hospital Pharmacist 2001;8:5-9
Audits
Examples of audits can be found on the RPSGB website (www.rpsgb.org) eg health
promotion leaflets.
Compliance
Keep taking the tablets (Compliance and oral diabetic therapy). Chemist and Druggist
2000; (Pharmacy Update, October 7): viii
Diabetes and its Management
1) Tackling diabetes: the sweet smell of success? Pharmacy Magazine 2003;IX
(No 1):6
2) Factors affecting self-care activities, postprandial plasma glucose and HbA1c in
patients with Type 2 diabetes. Int J Pharmacy Practice 2002; 10 (suppl): R96
3) Diabetes mellitus Part 1. Independent Community Pharmacist 2002;Aug:33-35
Type 1
4) Treating Type 1 diabetes. Prescriber 2000; 11 (2): 86-87
Type 2
5) Treatment of Type 2 diabetes mellitus. Hospital Pharmacist 2001; 8:10-16
6) Pharmaceutical care needs in the primary care management of Type 2 diabetes
mellitus. Pharmaceutical Journal 2000; 265 (suppl): R6
7) Type 2 diabetes. Chemist and Druggist 2000; 254 (Pharmacy Update, Sept 16): iiv
8) Type 2 diabetes. Chemist and Druggist 2000; 254 (Pharmacy Update, Sept 2): i-iv
9) The modern management of Type 2 diabetes mellitus. Prescribers Journal 2000;
40 (1): 38-48
10) Oral therapies for use in Type 2 diabetes. Pharmacy In Practice 2002;12(1):28-34
11) The thiazolidinediones: a new class of antidiabetic agent. Hospital Medicine
2000; 61 (3): 185-188
12) Oral antidiabetic agents: prescribing and costs. Prescriber 2000; 11 (3): 21, 26
46
Practice guidance on the care of people with diabetes
Diagnostic criteria
1) Diagnostic criteria for diabetes lowered. The Pharmaceutical Journal 2000; 264:
573
2) New diagnostic criteria for diabetes. Chemist and Druggist 2000; 253:10
Ethnic issues
Fasting during Ramadan: A Muslim pharmacist's perspective. Pharmaceutical Journal
2001;267:691-692
Education/ Motivation
1) "Health literacy" impacts on diabetes. Pharmaceutical Journal 2002;269:125
2) The association of psychosocial and diabetes factors to diabetes knowledge.
Int J Pharmacy Practice 2001;9 (suppl):R9
3) The importance of education and patient involvement in the treatment of diabetes.
Int J Pharmacy Practice 2000; 265 (suppl): R20
GMS contract
NPA (direct for members; otherwise through the LPC).
A quick reference guide to the quality indicators in the new GMS contract.
Insulin
1) Insulin analogues revisited. Hospital Pharmacist 2003;10(4):165-173
2) A reference guide to insulin pens. The Pharmaceutical Journal 2000; 264: 890
Lifestyle
1) Rise in Type 1 diabetes among children could be caused by increase in obesity.
Pharmaceutical Journal 2002;269:353
2) Diabetic girls miss insulin doses to lose weight. The Pharmaceutical Journal 2000;
265:153
Management of complications
1) Diabetes Part II: complications. Independent Community Pharmacist 2002;
Sept:26-28
2) Diabetic neuropathy: a management overview. Prescriber 2001;12(21):115-118
Medicines Management
1) Resources available from the NPA, PSNC, NPC, RPSGB.
National Plans
1) Setting the (NSF) standards for diabetes. Pharmacy Magazine 2003;IX (No 1):3435
2) Welsh diabetes standards. Pharmaceutical Journal 2002;268:865
3) Scotland gets diabetes update. Chemist and Druggist 2001;256 (Pharmacy
Update):26
4) Overview of the NSF for Diabetes (direct for NPA members; otherwise through the
LPC):
- NSF for diabetes: standards. Professional Practice Matters 2002; 8(3) 8-12
- NSF for diabetes: delivery strategy. Professional Practice Matters 2003; 9(1) 2-6
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Practice guidance on the care of people with diabetes
Pharmacist’s role
1) How pharmacists can be recognised for helping patients stay on course.
Pharmaceutical Journal 2002;269:187-188
2) PSNC Diabetes Resource Pack, for services by community pharmacists, 1st edition
2002 - (see www.psnc.org.uk , Resources – Publications) [2nd edition due Summer
2004]
Screening
1) Diabetes screening and a role for the High Street pharmacist. Mod Diabetes
Management 2002; 3: 6-7
2) Point-of-care testing in community pharmacy. Pharmaceutical Journal 2001;
267:267
Self-testing
1) Patient self-testing of blood glucose levels lacks evidence, says NPC.
Pharmaceutical Journal 2002;269:208
2) When and how should patients with diabetes test blood glucose. MeReC Bulletin
2002;13(1)1-4
2.4 Text books
The list below provides a few examples of useful textbooks on diabetes. Again, the
list is by no means exhaustive. In addition, the chapter on diabetes in any medical or
therapeutics textbook would be useful.
For a comprehensive list, please access the RPSGB library [catalogue online
http://.olib.rpsgb.org; e-mail: [email protected]]
1) Diabetes in Focus. Patel, A. Pharmaceutical Press: 2nd edition, 2003
(ISBN 0 85369 505 9)
2) Providing Diabetes Care in General Practice. MacKinnon. Class
Publishing: 4th edition, 2002 (ISBN 1 85959 048 9)
3) Vital Diabetes. Fox and MacKinnon. Class Publishing: 2nd edition, 2002
(ISBN 1 872362 93 1)
4) International Textbook of Diabetes Mellitus. DeFronzo RA et al. John
Wiley & Sons Ltd.: 3rd edition, 2004 (ISBN 0 471 48655 8)
5) Staged Diabetes Management. Mazze R et al. John Wiley & Sons Ltd.: 2nd
edition, 2004 (ISBN 0 470 86576 8)
2.5 Diabetes journals
There are a number of journals specifically on diabetes to which pharmacists may
wish to subscribe or borrow from their local GP practice or hospital Trust library:
1) Balance (Available to members of Diabetes UK)
2) Diabetes and Primary Care
3) Diabetes Update (Available to professional members of Diabetes UK)
4) Journal of Diabetes Nursing
5) Practical Diabetes
6) Diabetes & Vascular Disease
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Practice guidance on the care of people with diabetes
2.6 Relevant CPPE courses (and equivalents in Wales and Scotland)
(see website www.cppe.man.ac.uk for more)
Open learning
Study (hrs)
Diabetes Part A & B ....................................................................................16
Improving the Public’s Health through Health Promotion ................................8
Smoking Cessation ......................................................................................8
Nutrition
......................................................................................8
Concordance
.................................................................................10.5
Prescribing in Endocrine Disorders .................................................................3
Prescribing in Coronary Heart Disease .........................................................10
Cardiovascular series: stable angina ...............................................................6
Support care homes with medicines management ........................................12
Workshops
Diabetes, a patient-centred approach
Nutrition - Health Gains
Health Promotion – Smoking Cessation
Medicine Management – diabetes
Medicines Management – hypertension
Medicines Management – heart failure
Medicines Management - stroke
Medicines Management – angina and myocardial infarction
Medicine Management – restoring endocrine balance
Pharmaceutical Care – cardiovascular disease
Medicines Management – medication review
Concordance
2.7 Multidisciplinary courses in diabetes care open to pharmacists
Pharmacists can access the Diabetes UK website for more multidisciplinary courses.
Here are 2 examples (There will be a cost to these courses):
Venue: Warwick
Course title: MA/MSc Applied Health Studies (Diabetes care)
Accredited by: University of Warwick
Contact: Carmel Parrott, Postgraduate Secretary, Centre for Primary Health Care
Studies, University of Warwick, Coventry, W Midlands, CV4 7AL,
Tel: 024 7652 4625; e-mail: [email protected]
Venue: Bradford
Course title: Diabetes management in primary care
Accredited by: Huddersfield University
Qualification: Diploma in diabetes management.
Contact: Primary care training centre, Crow Trees, 27 Town Lane, Idle, Bradford, W
Yorks, BD10 8NT
Tel: 01274 617617; e-mail: [email protected]
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Practice guidance on the care of people with diabetes
2.8 Projects on Diabetes Care Involving Pharmacists in the UK
Disease/ medicines management
1) Pharmacists improving clinical outcomes for diabetes using a disease state
management approach. Journal of Social and Administrative Pharmacy
2002;19(6):210
2) Identifying potential medication related interventions in Type 2 diabetes.
Journal of Social and Administrative Pharmacy 2002;19(5):170-179
3) Help solve diabetic problems. Pharmacy In Practice 2000;10(3):90-95
4) Community pharmacists meeting the needs of patients with diabetes, in
collaboration with other healthcare professionals. Int J Pharmacy Practice
2003;11(suppl):R18
5) Integrating the community pharmacist into the diabetes team: evaluation of a
new care model for patients with Type 2 diabetes mellitus. Int J Pharmacy
Practice 2001;9(suppl):R60
6) Pharmaceutical care needs in the primary care management of Type 2
diabetes mellitus. Int J Pharmacy Practice 2000;265(suppl):R6
7) Diabetes Guide for Community Pharmacists . PSNC 1st edition. [2nd edition
due out summer 2004].
8) PSNC online database projects. www.psnc.org.uk
Pharmacist-led clinics
1) The pharmacist-led diabetic clinic. Int J Pharmacy Practice
2003;11(suppl):R14
2) Patient demand for a diabetes clinic in Danbury. Pharmacy World and
Science 2003;25(1):A58
3) The benefits of a pharmacist-led Type 2 diabetes clinic. Hospital Pharmacist
2002;9(7):204-206
4) Diabetes clinics: hospital pharmacists lead the way for community colleagues.
Pharmaceutical Journal 2002;268:799-800
5) Pharmaceutical care high-risk diabetic patients in an outpatient clinic. Int J
Pharmacy Practice 2002;10(2):85-89
6) Treatment of Type 2 diabetes. Hospital Pharmacist 2001;8:10-16
Pharmacist services for diabetes
1) Type 2 diabetes patients' satisfaction with community pharmacists' services.
Pharmaceutical Journal 2003;270:446-449
2) Service development in community pharmacy. NPA Professional Practice
Matters 2001;7(4)1-8
3) Pharmacy launches translation service (including people with diabetes)
Pharmaceutical Journal 2001;267:77
50
Practice guidance on the care of people with diabetes
Compliance/ concordance
1) Increasing adherence to medications in Type 2 diabetes. Journal of Social
and Administrative Pharmacy 2002;19(6):211
2) Helping patients stay on course. Pharmaceutical Journal 2002;269:187-188
3) Patient education and patient involvement in the treatment of diabetes. Int J
Pharmacy Practice 2000;265 (supple):R20
Monitoring/ screening
1) Monitoring and screening for diabetes. Primary Care Pharmacy 2001;2:17-19
2) Assessing cardiac risk in diabetics. Primary Care Pharmacist 2000;1(2):18-20
3) Can a community pharmacy influence the control of disease in people with
diabetes through the use of a local quality control scheme? Int J Pharmacy
Practice 2000;265 (suppl):R21
4) Diabetes care - a community pharmacy based HbA(1c) testing service..
Pharmaceutical Journal 2001;267:264-266
Raising awareness
1) Diabetes awareness event doubles in size. Chemist and Druggist 2000; 253:6
2.9 UKCPA Diabetes Special Interest Group
United Kingdom Clinical Pharmacists Association (UKCPA) is in the process of
developing Interest Groups in various specialities. It is early days for the Diabetes
Group, but worth investigating. (see Appendix 2.1.1)
51
Practice guidance on the care of people with diabetes
Appendix 3
Contacts list for diabetes care
This template can be used to record contact details of those involved in the care of
people with diabetes.
Profession/ Department
Contact name
Telephone/ e-mail
Diabetes specialist nurse:
Hospital diabetes clinic:
Local diabetes planning &
implementation group (diabetes
networks):
Local clinical and/or network
champion/ manager:
GP contact:
(To discuss problems & joint projects)
Practice nurse:
(To contact with patient problems)
District nurse:
(For queries regarding housebound
patients)
Diabetes co-ordinator/
facilitator/ liaison nurse:
(Health Board, hospital or local
PCO/LHB/LHCC)
(To contact if having problems
initiating dialogue with surgery, about
joint working)
Registered dietitian:
State registered podiatrist:
Optometrist or
Local Optical Committee:
Dentist or
Local Dental Committee:
Pharmaceutical advisers:
Practice pharmacist:
Medicines Information Dept.:
Local Diabetes UK branch:
Regional Diabetes UK office:
52
Practice guidance on the care of people with diabetes
Appendix 4
Summary of WHO Diagnostic Criteria for Diabetes
(source: Diabetes UK; Full text at www.diabetes.org.uk)
In 1999, the World Health Organisation published revised ‘Definition, Diagnosis and
Classification of Diabetes Mellitus and its Complications’, and in June 2000 Diabetes
UK recommended that all healthcare professionals adopt this criteria. They include
the recommendation that the cut off point for diagnosing diabetes using a fasting
plasma glucose should be 7.0 mmol/l. This reflects research evidence regarding the
development of the complications of diabetes.
Methods and criteria for diagnosing diabetes mellitus
1. Diabetes symptoms (i.e. polyuria, polydipsia and unexplained weight loss) plus
• a random venous plasma glucose concentration ≥ 11.1 mmol/l;
• or a fasting plasma glucose concentration ≥ 7.0 mmol/l. (Whole blood ≥
6.1mmol/l);
• or 2 hour plasma glucose concentration ≥ 11.1 mmol/l 2 hours after 75g
anhydrous glucose in an oral glucose tolerance test (OGTT).
2. With no symptoms diagnosis should not be based on a single glucose
determination but requires confirmatory plasma venous determination. At least one
additional glucose test result on another day with a value in the diabetic range is
essential, either fasting, from a random sample or from the two hour post glucose
load. If the fasting or random values are not diagnostic the 2-hour value should be
used
Classification and terminology
• The terms Type 1 and Type 2 replaced IDDM and NIDDM, and Type 1 and
Type 2 process to describe the cause of insulin-dependent and non-insulin
dependent diabetes respectively.
•
Impaired Glucose Tolerance (IGT)* is a stage of impaired glucose regulation
(Fasting plasma glucose < 7.0 mmol/ and OGTT 2-hour value ≥ 7.8mmol/l but
< 11.1 mmol/l).
•
Impaired Fasting Glycaemia (IFG)* classifies individuals who have fasting
glucose values above the normal range but below those diagnostic of
diabetes. (Fasting plasma glucose ≥ 6.1 mmol/l but < 7.0 mmol/l).
The criteria simplify the diagnosis of diabetes and the ability to diagnose
cardiovascular high risk cases in many people. Earlier diagnosis increases the total
number of people with diabetes, but if they are managed according to Diabetes UK
guidelines, many of these new cases will be diet and exercise controlled. In the long
term, complications should be lessened to the benefit of the individual and to the
health service.
*IGT and IFG are not clinical entities in their own right, but rather risk categories for
cardiovascular disease (IGT) and/or future diabetes.(IFG)
53
Practice guidance on the care of people with diabetes
Appendix 5
Code of Ethics
Section 14
Testing of Body fluids
Pharmacists working in primary care are well placed to provide diagnostic testing and
health screening services to the public, who would expect any such service to be safe
and accurate.
Pharmacists providing diagnostic testing or health screening services must:
(a) Ensure that before providing a service all staff has completed any training
required to ensure competency with the equipment and procedures to be
used and in the interpretation of results. They must be aware of the limits of
the tests provided. The pharmacy must have a designated area, not in the
dispensary, with suitable facilities to perform the tests and provide
counselling;
(b) Institute and operate an appropriate quality assurance programme in order to
ensure the reliability of the results produced;
(c) Ensure that equipment is maintained in good order to ensure that
performance is unimpaired;
(d) Keep up to date with developments in the field and ensure that they are aware
of current advice or local guidance on when to refer patients to their general
medical practitioner;
(e) Before undertaking a test provide an explanation to the patient of the
procedure to be adopted and obtain the patient’s consent;
(f) Communicate the results to the patient in a manner in which they can be
understood. Patients should be fully informed about the significance of the
results and must be provided with any necessary counselling and available
information;
(g) Ensure that adequate documentation is maintained to enable the service to be
audited.
54
Practice guidance on the care of people with diabetes
Appendix 6
Diabetes audit
Introduction
We all try to give the best possible service to our patients and customers, but unless
we monitor the quality of our services, we cannot be certain that we are succeeding.
Our patients/customers will soon tell us if something is going badly wrong with a
service. However, it is not always easy to get feedback about parts of a service that
could be improved. Indeed, minor failures in quality may go unnoticed until a patient
brings it to our attention. In general, complaints are a poor method of detecting
problems. How often have we suffered poor service in a shop or restaurant and not
complained.
Research conducted in the USA suggests that only 4% of dissatisfied customers
complain - the other 96% tell between 10 to 15 other people1. For example, 10
complaints a year could represent 250 dissatisfied customers who have told more
than 2500 other people of their experiences.
We need to obtain a more objective measure of the quality of the service that we
provide so that we can prevent things going wrong rather than waiting for complaints.
Clinical audit is the method used throughout the NHS to monitor and continuously
improve the quality of services. Audit gives an objective view of the quality of a
service and aims to identify areas for improvement.
Monitoring the quality of our work is becoming increasingly important in the NHS. All
professions are expected to have arrangements for clinical governance in place.
Clinical governance aims to ensure that there are processes in place to safeguard
high standards of care and that we continuously improve the quality of services.
Clinical audit is a component of clinical governance and there is an expectation that
all new services funded by the NHS will include systems to audit its quality.
Methods of monitoring quality
There are several methods that we can use to monitor quality.
•
Talking to other healthcare professionals
It is helpful to seek opinions about your service from other healthcare professionals
involved in the care of people with diabetes. They will be able to tell you how they see
your service and whether their patients have told them anything about your service.
They may also be able to tell you about the impact that you have had on the patients
under your care.
55
Practice guidance on the care of people with diabetes
You will need to think carefully about what information you want from the doctors,
nurses, etc. before you approach them. Try to be specific in the questions you ask
them. For example, instead of asking whether they like the service, ask what aspects
of the service are most helpful and what aspects are the least helpful. You may want
to ask the questions face to face or may prefer to use a questionnaire.
There are pros and cons with each system. It is difficult for people to be critical face
to face, so you may not get such an honest appraisal using direct questioning. On the
other hand, questionnaires need careful phrasing if they are going to be useful.
•
Talking to patients and carers
Patients and carers can give you vital comments about your service. Again, you will
need to be sensitive about how you do this and many of the points raised under
talking to other healthcare professionals apply equally to talking to patients or carers.
For example, if you ask whether they are satisfied with the service, you may get a
different answer than if you ask how the service could be improved.
Many studies of patient satisfaction give a false picture. Patients and carers will tend
to be happy with a service just because you are showing an interest in them. Asking
about how you could improve the service could show up areas of the service that you
could do better and will be much more useful to you.
•
Objective measures of quality
The RPSGB has written several audits of aspects of a diabetes service.
•
Counseling
These guidelines suggest that you might wish to counsel a patient about their
diabetes care. The guidelines also remind us that patients only remember 2 – 3
points from a counselling session. It is important to look at whether we are covering
all the points that a patient may need to know. It is equally important to assess
whether they understand the counselling we give.
The Society has written two audits of counselling of people with diabetes. The first
assesses the amount of counselling given and the pharmacist’s assessment of the
patient’s understanding. This gives the pharmacist a record of the counselling and
points that he/she may wish to reinforce on the next visit.
The second counselling audit asks the patient whether they feel that they have
received the right amount of information, not enough or too much information about a
list of topics. If this is repeated at annual intervals, it will show how the patient’s
perception of their understanding changes with counselling. Comparing the patient’s
perception with your own assessment of their understanding will help you assess the
quality of your counselling.
56
Practice guidance on the care of people with diabetes
•
Health promotion leaflets
There are two audits looking at health promotion leaflets. There are many different
leaflets produced by agencies like the Health Development Agency, Diabetes UK,
drug companies, etc. It is difficult for pharmacists to assess the quality of these
leaflets.
The RPSGB have devised a tool to assess the quality of a leaflet about diabetes. It
has been written by an expert in health promotion and will help you work out whether
a leaflet is suitable for your patients.
The RPSGB have also written a simple audit of the availability of leaflets. This
measures whether the leaflets you want to keep are always available for your
patients/customers.
•
Interventions
Recording interventions on prescriptions is a good way of demonstrating the value of
your contribution in safeguarding the patient. Monitoring our interventions will also
show if the same mistake is being made on several prescriptions. We can then bring
it to the attention of prescribers in a more co-ordinated manner. The interventions
audit gives you the tools to record your interventions. You can then analyse them to
see if there are any trends that need attention or any gaps.
•
Referrals
There are two possible reasons for referring a patient/ customer to another
healthcare professional about diabetes, and these are that you suspect they are
having problems with their diagnosed diabetes, or that you suspect they have
undiagnosed diabetes.
In either case, it is helpful to follow up your referral to see if you were right and to get
feedback about the appropriateness of the referral.
The audit of referrals is designed to deal with the detection of undiagnosed diabetes,
although the same principles apply to problems that you detect with your patients
who have been diagnosed with diabetes.
Copies of these audits can be obtained by writing to –
Practice and Quality Improvement Directorate
Royal Pharmaceutical Society of Great Britain,
1 Lambeth High Street,
London SE1 7JN
e-mail: [email protected]
or from the RPSGB website
www.rpsgb.org.uk
57
Practice guidance on the care of people with diabetes
Appendix 7
Dietary care planning and diabetes
[source: Diabetes UK]
Diabetes UK recommends that all people with newly diagnosed diabetes should be
assessed by a Registered Dietitian, who will provide a tailored and individualised
dietary care plan based on the latest evidence of effectiveness.
Dietary and lifestyle support for people with diabetes
Issues that should be addressed include the need for people with diabetes to:
•
•
•
•
•
•
•
•
•
•
Eat regular meals planned around wholegrain, starchy foods, such as bread,
chapattis, potatoes, yam, plantain, rice, pasta, dahl, and wholegrain cereals;
Eat at least five portions of fruit and vegetables each day;
Reduce calorie intake if overweight or obese and increase physical activity;
Achieve and maintain a healthy weight;
Reduce dietary intake of fat, particularly saturated fat;
Reduce sucrose intake;
Aim to include more foods with a low Glycaemic Index;
Reduce dietary salt intake;
Drink alcohol in moderation (<14 units [glass of wine or half pint of beer] per week
for women and <21 units per week for men) - excess alcohol can cause weight
gain, high blood pressure and, in those taking sulphonylurea drugs or insulin, can
make hypoglycaemia more severe; if alcohol is consumed, this should be with or
after food;
People with diabetes should be advised that special diabetic foods are not
necessary - they can be expensive and are often high in fat and calories.
People taking hypoglycaemic drugs and insulin will need further advice on dietary
management to balance their food intake and physical activity levels with their
medication.
Dietary changes need to be agreed at a pace suited to the individual - monthly follow
up appointments are recommended in the initial stages after diagnosis or at times of
transition, such as when medication is changed.
People with diabetes who present with possible eating disorders (e.g. bingeing,
uncontrolled eating, etc) should be referred to a Clinical Psychologist and Dietitian for
a joint programme of care.
Reducing cardiovascular risk
The following dietary changes particularly aim to reduce the risk of heart disease:
•
•
Choose mono-unsaturated fat - found in olive oil, rapeseed oil and groundnut oil;
Aim to eat 2 portions of oil-rich fish each week to boost intakes of omega 3 oils;
58
Practice guidance on the care of people with diabetes
•
•
•
•
•
•
•
Reduce dietary saturated fat - found mainly in animal products, such as meat fat,
cheese, butter, ghee and cream;
Also limit hydrogenated vegetable oils and trans fatty acids - found in some
margarines, biscuits, pastries and processed foods;
Moderate intake of polyunsaturated fat, such as sunflower oil/spreads;
Include some low fat dairy foods, such as semi-skimmed or skimmed milk and low
fat or virtually fat free yoghurts to provide calcium;
Eat more fruit and vegetables - aim for at least 5 helpings per day; fresh, frozen or
tinned in natural juice or dried are fine;
Eat more pulses, such as beans and lentils;
Increase use of fresh foods rather than processed foods.
Recommended dietary changes for people with hypertension and/or renal problems
In addition, the following dietary changes are needed to address hypertension and/or early
renal problems:
•
•
•
•
Tackle obesity;
Reduce salt intake by not adding it at table, and avoiding obviously salty foods
such as crisps, salted nuts, cured meats & fish;
Reduce portion sizes of protein foods such as meat, fish, poultry and cheese;
Keep alcohol within healthy limits
Tackling obesity
Measurements of waist circumference provide a useful guide to the need for an
individual to lose weight:
•
A waist circumference ≥ 102 cm in Caucasian men and ≥ 88 cm in Caucasian
women and ≥ 90cm in Asian men and ≥ 80 cm in Asian women is associated with
a substantially increased health risk.
A 10Kg weight loss can result in:
•
•
•
•
A 30% fall in diabetes related deaths;
A 10mmHg reduction in systolic blood pressure and a 20mmHg reduction in
diastolic blood pressure;
A 50% reduction in fasting glucose in people with newly diagnosed diabetes;
A 10% reduction in total cholesterol, a 13% reduction in LDL cholesterol, a 30%
reduction in triglycerides and an 8% increase in HDL Cholesterol.
Even if patients are unable to lose weight, it is still worthwhile for them to set a goal to
maintain their weight, without weight gain, which can improve diabetes control and reduce
their risk of developing heart disease.
When helping a person with diabetes to lose weight
•
•
•
Establish their readiness to make dietary and lifestyle change and explore
behavioural and/or social barriers to change;
Agree a realistic weight loss goal - aim for 5-10Kg reduction or a reduction of 10
per cent of body weight;
Agree dietary changes at a pace suitable to the person with diabetes - this may
only be two or three changes, but ensure that there is no risk of hypoglycaemia
59
Practice guidance on the care of people with diabetes
•
•
Encourage them to start an exercise plan and to aim to undertake moderate
physical activity of 30 minutes, every day;
Provide regular and ongoing support, to maintain motivation.
Remember that Insulin type and dose and medication type and dose may need
to be adjusted if carbohydrate intake is reduced and/or exercise is increased.
Additional education topics and written information
•
•
•
•
•
•
Discuss meal serving sizes using a plate model to show proportions of
carbohydrate and protein foods - always include vegetables or salad vegetables;
Emphasise the importance of replacing fatty puddings or snacks with fruit;
Look at snacks and frequency of eating - some people with diabetes may eat
additional snacks inappropriately due to their fear of hypoglycaemia;
Suggest alternatives to salt, such as spices, lemon juice, herbs, black pepper or
vinegars;
Explain the benefits of physical activity for the control of weight, blood glucose
and blood pressure;
Ensure that all information is provided in a culturally appropriate manner.
Dietary information and leaflets
Diabetes UK publishes leaflets that provide advice on dietary intake and a Weight
Management Pack.
60
Practice guidance on the care of people with diabetes
Appendix 8
Suggested management targets for people with diabetes
[source: Diabetes UK]
The table below sets out the latest recommended desirable targets for metabolic control
and the control of other cardiovascular risk factors in people with diabetes. The overall
aim should be for metabolic control to be as near to the non-diabetic state as possible,
but targets should be tailored to the individual patient, according to what it is
possible and safe to achieve - over ambitious targets can be
counterproductive. For example, in those with relatively short life expectancy, it may
be inappropriate to impose strict management targets where this may impair quality of
life. The impact of other cardiovascular risk factors should also be taken into
consideration when agreeing targets. It should also be noted that the achievement of
good blood glucose control in patients on insulin therapy may be associated with
asymptomatic hypoglycaemia and an increased risk of severe hypoglycaemic events.
Desirable targets for
People with
Type 1 Diabetes
HbA1c (DCCT standardized) 1
Desirable targets for
People with
Type 2 Diabetes
Less than 7.5%
(without symptoms of hypoglycaemia)
Fasting/Pre-prandial
5.1–6.5 mmol/l
<5.5 mmol/l
Post prandial
7.6–9.0 mmol/l
<7.5 mmol/l
Before going to bed
6.0– .5 mmol/l
Blood pressure 2
Normal albumin excretion rate
<135/85
Abnormal albumin excretion rate
<140/85
<130/80
Lipids
Total serum cholesterol
Body Mass Index
<4.8 mmol/l
<4.5 mmol/l
LDL cholesterol
<3.0 mmol/l
HDL cholesterol
>1.2 mmol/l
Triglycerides
<1.7 mmol/l
<25.0 kg/m2
(lower in ethnic minorities groups)
1
Reference ranges for HbA1c vary depending on the assay method used. Medical practices should check the
reference range in the laboratory they use. The values given above assume that normal HbA1c is < 6.1 per cent
2
Stricter targets are necessary in younger people and in people with early nephropathy who have a good life
expectancy. Diabetes UK are in the process of obtaining a consensus on BP levels from a panel of experts. It is
advisable to discus this with local doctors
61
Practice guidance on the care of people with diabetes
Appendix 9
Patient screening questionnaire
Are you at risk of diabetes?
Diabetes affects about 3% of the population in the UK and Ireland. The most common form is
known as Type 2. Identifying diabetes early means that it can be treated and the risk of
developing the serious complications can be greatly reduced.
Do you have any of the following common symptoms of Type 2 diabetes?
Increased thirst
Going to the loo all the time – especially at night
Extreme tiredness
Weight loss
Blurred vision
Genital itching or regular episodes of thrush
Do you have any of the following risk factors for diabetes?
If you are white
Are you over the age of 40 and have a parent, brother or sister with diabetes?
If you come from a Black, Asian or minority ethnic group
Are you over the age of 25 and have a parent, brother or sister with diabetes?
If you have ticked yes to either of the above;
Are you overweight?
Are you quite inactive (no regular exercise)?
Do you have a history of heart disease or high blood pressure?
If you are a woman
Did you have gestational diabetes during a pregnancy?
Were any of your children large at birth (over 8.8lb/4kg)?
Do you have polycystic ovary syndrome?
If you have any of the symptoms of diabetes but none of the risk factors apply, you should
consult your own GP to discuss likely causes. Do not ignore the symptoms, as they may
indicate problems other than diabetes.
Even if you have no symptoms, if any of the risk factors apply, you may be at increased risk
of diabetes and may wish to take a simple screening test. The test is virtually painless and
available here. The test will not diagnose diabetes, but may indicate if you are at risk. You
should also consider discussing your risk of diabetes with your GP.
Questionnaire devised by Diabetes UK
62
Practice guidance on the care of people with diabetes
Appendix 10
Summary of criteria for referral
(case identification of diabetes)
(A). Symptoms present
Symptoms of diabetes, present
Acute development of symptoms,
suspect Type 1 diabetes
Refer to GP practice with fast track
appointment
Refer to GP practice urgently
(B). Symptoms absent
Risk factors, but no symptoms of diabetes
(1) Overnight fasting, finger-prick test (mmol/l)
5.6 to 6.0
(WB)
(6.1 – 6.9)*
(PE)
6.1 – 11.00
Refer to GP practice
Refer to GP practice more urgently
(7.0 – 12.1)
>11.1
Refer to GP practice with fast track
appointment
(2) Random, finger-prick test (mmol/l)
(>12.2 )
5.6 to 11.0
Re-test on fasting sample
discuss with GP practice
≥ 11.1
Refer to GP practice with fast track
(≥12.2)
appointment
(3) Urine-strip test, 2 hours after a meal
(6.1-12.1)
glucose present
Refer to GP practice
(4) Random urine-strip test
glucose present
Refer to GP practice
* Some meters display whole blood readings (WB), and others convert the latter into
a ‘plasma-equivalent’ (PE) reading (shown in brackets).
63
Practice guidance on the care of people with diabetes
Appendix 11
Blood Glucose Meters
(for finger-prick tests)
This is not an exhaustive list. For other meters please check the information that
comes in the pack with the meter or contact the manufacturer.
There are 2 types:
A
Sampling whole blood
- converting this into a 'plasma- equivalent’ reading
Product
Manufacturer
Medisense - Optium
Medisense - SoftSense
Lifescan - One Touch Ultra
Lifescan - Pocket Scan
InDuo
FreeStyle
Abbott
Abbott
Johnson & Johnson
Johnson & Johnson
NovoNordisk/Lifescan
TheraSense
B
Sampling whole blood
- showing results as 'whole-blood' (no conversion) reading
MediSense - Companion 2
MediSense - Precision QID
Prestige Smart System
GlucoMen
Accutrend
Accu-Chek Advantage
Accu-Chek Active
Abbott
Abbott
DiagnoSys Medical
Menarini
Roche Diagnostics
Roche Diagnostics
Roche Diagnostics
The meters which provide plasma-equivalent glucose values show readings 10 - 15
% higher than meters showing whole blood glucose values.
The Wolfson laboratories which test these meters for the Department of Health, state
that, “The recommendations for all extra-laboratory blood glucose analyses quote a
total allowable error of no more than 10% and an imprecision CV of no more than
5%”.
All the meters listed have met these standards, but it (the lab test) demonstrates that
there is variation between meters and between different batches of test strips for the
same monitor.
64
Practice guidance on the care of people with diabetes
Appendix 12
Example of glucose test record form
(to be retained in the pharmacy for 5 years, unless details are
transferred onto the patient’s PMR)
Glucose Test record form
Patient name…………………………………………………………..……………
Patient address ……………………………………………………………………
……………………………………………...…………………………..…………..
………………………………………………………………………………………
Name of GP …………...……………………..…………………………………
Address……………...………………………………………….…………………
……………………………………………………………….……………………
Consent given for test result to be forwarded to GP
YES/NO
Date and time test undertaken ……………………………………………………
Date and approximate time of patients last meal prior to test ………………….
Type of test undertaken (e.g. fasting, random, blood, urine)
……………………………………………………………………………………………
………………………………………………………………….…………….………….
Serial number (blood glucose meter) …………………………………………………
Testing strip type …………………………………………………………………………
Batch number (testing strips) ……………………………………………………………
Expiry date ………………………………………………………………………………..
Result………………………………………………………………………………………
Test undertaken by
(print)……………………………………(sign)…………………………….………………
Pharmacy stamp
Appendix 13
65
Practice guidance on the care of people with diabetes
Example form to confirm request for a blood glucose test
(to be retained for 1 year)
I wish to have a blood glucose (sugar) test.
Procedure for blood test:
* wash hands in warm water and dry
* the finger will be pricked with a lancet
* a drop of blood will be produced
* the drop will be ‘touched’ onto a strip
* the result will be available in ........ seconds
Approximate time (and date) of last meal:
Time…………….am/pm
Date……………..
Time blood test undertaken………………………………….am/pm
Please tick as appropriate:
I am happy for a copy of the test result to be forwarded to my GP.
Name of
GP…………………………………………………………………………………
Address………………………………………………………………………………
…………………………………………….……………………………………………
Please do not pass on a copy of the test result to my GP.
I have read and understood the procedure. I understand that a high
blood glucose reading will need further investigation and that I do not
necessarily have diabetes.
............................................…....signature………………………………date
...................................................name (printed)
...................................................address
.....................................................
......................................................
66
Practice guidance on the care of people with diabetes
Appendix 14
Example of pharmacy referral form following glucose test
Pharmacy referral
Patient name………………………………………………………………………………………….…
Patient address…………………………………………………………………………………..…….
………………………………………………………………………………………………………….…
This patient has attended the pharmacy and requested a glucose test which has been carried
out in accordance with guidelines agreed locally/nationally/ by the Royal Pharmaceutical
Society of Great Britain.
Type of test carried out:
Overnight fasting, finger-prick test
Result……………………….mmol/l
Random, finger-prick test
Result……………………….mmol/l
Urine strip test, 2 hours after a meal
Result: glucose present
no glucose detected
Random urine strip test
Result: glucose present
no glucose detected
Time and date test undertaken…………………………….…………………………………………...
Date and approximate time patient last ate prior to test……………………………………………..
Other comments………………………………………………………………………………………….
………………………….……………………………………………………….………………..………..
Pharmacist………………………………………………………………..……
Pharmacist signature………………………………………………………….
Pharmacy address……………………………………………………………..
…………………………………………………………………………………...
Pharmacy stamp
Telephone……………………………………………………………………….
Date………………………………………………………………..
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Practice guidance on the care of people with diabetes
Appendix 15
Diabetes Care Leaflet
It is important that you have all the knowledge you need to achieve the best of health,
a good quality of life and avoid the possible complications of diabetes. You will be
receiving advice from your doctor, nurse and others about your diabetes care, but I
want you to know that as your pharmacist, I am always available to answer your
questions.
There may be times when you have forgotten to ask your doctor or nurse something,
or you just want a chat about your diet or medication – please feel free to ask.
I’d like to recommend the following actions:
• Always keep your diabetes clinic appointments (or if unable to keep them, reschedule as soon as possible).
• Stop smoking – it will make a difference to your quality of life. I can help.
• Check and look after your feet every day, even if you see a chiropodist regularly.
• Make sure you have an eye test at least once a year.
• Take up some form of regular physical activity within your capabilities, e.g.
walking, dancing.
About your medicines
• Take your diabetic medication as directed, every day.
• If you are on aspirin, or medication for blood pressure or to lower cholesterol take it regularly as directed.
• Tell me if you are having any side effects, e.g. feeling dizzy or shaky.
• Check before buying a medicine over the counter, to ensure it is suitable.
• Do you know what to do about your medication if you are vomiting, or unwell?
• If you are on diabetic medication - ask for a prescription exemption application
form, if you need one.
• If you are on insulin, have you thought about carrying some form of
identification?
Blood / urine testing
• Test at the recommended times and take your results to your clinic appointment.
• Tell me if you are having problems with your tests between appointments. I will
check and advise you or refer you for an earlier appointment with your
doctor/nurse, if necessary.
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Practice guidance on the care of people with diabetes
New blood meters
• If you are testing urine at present and are thinking about buying a blood glucose
testing meter, check with your doctor/nurse first. If they think your diabetes is
well controlled using urine tests, they may not wish to prescribe lancets (finger
pricking needles) and monitoring strips (they are quite expensive) for use with
blood testing meters.
• If you are already testing blood and have a meter you feel needs changing,
please ask for advice. I can tell you about the benefits of the different meters
available.
• I will demonstrate a new meter for you.
Diabetes UK
This a very useful organization to join for lots of information on looking after yourself –
leaflets, magazines, advice over the phone, etc. Just ring 0845 120 2960 for support
or for information on how to join.
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Practice guidance on the care of people with diabetes
Appendix 16
Questionnaire for People with Diabetes (example)
In our pharmacy we aim to provide a high quality service for people with diabetes
and to work with doctors and nurses etc to make sure that you receive a good
standard of care. In order to help us with this, we would be grateful if you could take
the time to answer a few questions about yourself and your diabetes. Your answers
will be treated in strict confidence.
About Yourself
How old are you?
less than 30yr
31 – 50yr
51 – 70yr
more than 70yr
What are your living circumstances?
Live alone
Live with husband/
wife/ partner
Live with other family
Other (please specify) ............................................................................................
How long have you had diabetes?
I have only just found out
Less than one year
6 – 10 years
More than 10 years
1 – 5 years
Your Diabetes Care
Is your diabetes care to be provided by:
your GP / local surgery
the hospital diabetes team
both
don’t know
When is your next appointment
............................................................................
Which of the following people have you seen about your diabetes?
Yes
No
Don’t know
My GP
A hospital specialist
A diabetes nurse (hospital)
A diabetes nurse (GP practice)
A dietitian
A chiropodist
An optometrist
Other (please specify)
.............................................................
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Practice guidance on the care of people with diabetes
Continued overleaf, please turn over
Education is a very important part of diabetes care. Below is a list of some of the
topics that you need to know about (one or two may not be relevant to you, if so,
just leave blank). Which of the following have been discussed with you so far?
Yes
No
Don’t know
What is diabetes?
Tablets
Insulin & injection technique
Free prescriptions
Hypoglycaemia
(low blood sugar)
Hyperglycaemia
(high blood sugar)
Stopping smoking
Foot care
Diabetes UK
What to do when you are
unwell
Diet
Exercise
Diabetic Complications
Urine testing
Blood testing
Are there any other comments you wish to make about your diabetes or any
concerns that you wish to raise? Please write in the box below:
Thank you for taking the time to fill in this questionnaire. We will only use the
information to help manage your diabetes.
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Practice guidance on the care of people with diabetes
Appendix 17
Glossary
BMA
CDA
CE
CPD
GMS contract
HB
LHB
LHCC
LPC
LPS
NPC
NPA
OTC
PCO
PhS contract
Plasma-equivalent
PSNC
PMR
SHA
British Medical Association
Chemists Defence Association
Continuing Education
Continuing Professional Development
General Medical Services – new GP contract
Health Board (Scotland)
Local Health Board (Wales)
Local Health Care Cooperatives (Scotland)
Local Pharmaceutical Committee
Local Pharmaceutical Services
National Prescribing Centre
National Pharmaceutical Association
Over-The-Counter
Primary Care Organisation
Pharmaceutical Services contract for community pharmacists
(proposed)
see Appendix 11
Pharmaceutical Services Negotiating Committee
Patient Medication Records
Strategic Health Authority
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Practice guidance on the care of people with diabetes
Appendix 18
Acknowledgements
Gillian Hawksworth
Judy Cantrill
Denise Farmer
Mark Galloway
Irene Gummerson
Collette McCreedy
Simon O’Neill
Tracey Thornley
Alexandra Topol
Immediate Past President of the RPSGB,
Community Pharmacist, CPPE Local Tutor
Professor of Medicine,
School of Pharmacy and Pharmaceutical Sciences,
University of Manchester
Assoc. Director of Clinical Pharmacy (Eastern)
London, Eastern and South East Clinical Pharmacy
Support Unit
Northwick Park Hospital
Head of Medicines Management,
Coventry Teaching PCT
Member of Diabetes UK Advisory Council,
Community Pharmacist (E. Moss Ltd)
PEC member (Wakefield West PCT)
Director of Pharmacy Practice
National Pharmaceutical Association
Head of Information and Education
Diabetes UK
Dispensing Development
Boots the Chemist
Principal Pharmacist (New Drugs)
Northwick Park Hospital
Secretariat:
Lorraine Fearon
Practice Division, RPSGB
Contributions:
Liz Griffiths
David Pruce
Head of Secretary & Registrar’s, RPSGB
Director of Practice & Quality Improvement, RPSGB
 Royal Pharmaceutical Society of Great Britain, 2004
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