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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 2 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 3 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 4 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 5 Practice guidance on the care of people with diabetes 6 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 7 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 8 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. 9 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 10 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. . 11 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. 12 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. 13 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; management of blood glucose; management of blood pressure and dyslipidaemia. ¾ Management of Type 2 diabetes renal disease prevention and early management; retinal screening and early management; footcare. ¾ Management of Type 1 diabetes ¾ NICE Health Technology Assessment Reports (clinical & cost effectiveness) of: • pioglitazone and rosiglitazone in the treatment of Type 2 diabetes; patient education models for diabetes; continuous subcutaneous insulin infusion for diabetes; 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. 14 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. 15 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. 16 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. 17 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. 18 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. 19 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 41 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] 42 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 47 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 48 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] 49 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……………………………………………………………….. 67 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. 68 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. 69 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) ............................................................. 70 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. 71 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 72 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 73