1. A GP’s Practical Perspective of Diabetes Care in Southall Dr A K Sandhu

2. Motivation / Vision Glimpse of care in Southall / 1992

3. Challenges ? The “INVERSE CARE LAW”

4. Change the delivery of patient care Challenge the Inverse Care Law Create society with improved health awareness My Vision

5. How ? Educating the patients with goal oriented advice Emphasising on Primary Prevention of Diabetes Providing the self monitoring tools to patients

6. Practice Diabetes Care New Diabetes pt Registration / Identification Seen by Clinicians Review after 3 months with blood test reports. Review.  All needed Education and Advice given.  Baseline tests taken GP Practice Nurse

7. Thereafter always give goal orientated education and advice. Continue monitoring progress Lifestyle Advice Monitor 4-6 weekly Exerci se Di et Weig ht Other factors  Dietetic Advice  Podiatry Care (Annually)  Health / Physical activity promotion controlled uncontrolled

8. Practice Based Staffing Dieticians Health Care /Physical Activity Educators Clinicians trained in Diabetes Care Podiatrist Dedicated Reception Team

9. Audit Monitoring monthly audits Outcomes (62% of patients achieved HbA1c ≤ 7.4% in May 2004)

10. Belmont Health Centre Diabetes QOF for May 2004 % Total Practice Population 3249 Patients with Diabetes Type 1(13) + 2(173) 1865.72% Diabetes with Hypertension 14276.34% HbA1C <7.411762.90% HbA1C >7.4 6937.10% HbA1C >10.0 147.72% HbA1C <10.0 17292.47% Blood Pressure Controlled (<140/80) 14477.42% Blood Pressure Uncontrolled (>140/80) 4222.58% Cholesterol <5 14577.96% Cholesterol >5 4122.04% Microalbuminuria Nagative 11863.44% Microalbuminuria Positive 6836.55% No Diabetic Retinopathy 15281.72% Diabetic Retinopathy 3418.28% Serum Creatinine Normal 16588.70% Serum Creatinine Raised 2111.29%

11. Southall Health Improvement Project (SHIP) Health promotion for the Community in Southall (evidence available)

12. What’s new SHIP link with GP network (last Wednesday of every month) One of the areas to be covered will be Diabetes Risk Assessment targeting 16-35 year olds

13. Local provision – what’s needed ? Gap between Primary and Secondary Care needs to be bridged by improving communication systems (GP education seminars / regular updating and evaluation meetings) Cohesion in services provided both in Primary and Secondary care - by Clinicians, Diabetes Specialist Dietetics, Physical Health Educators and Pharmaceutical companies working together, under the organised project of Diabetes Risk Assessment Framework.

14. Diabetes Mellitus Clinical Indicators ActualTarget No of points available Register of patients with DM100% 6 BMI recorded in last 15months95.20%90%3 Smoking status recorded in last 15 months99.04%90%3 Smoking cessation advice given100%90%5 HBA1c recorded in last 15 months96.12%90%3 HBA1c<= 7.4 in last 15 months49.24%50%16 HBA1c<= 10 in last 15 months84.20%85%11 Retinal screening in last 15 months59.20%90%5 Peripheral pulses in last 15 months67.32%90%3 Neuropathy testing in last 15 months66.83%90%3 BP recorded in last 15 months97.13%90%3 BP<= 145/85 in last 15 months71%55%17 Microalbuminuria testing in last 15 months87.86%90%3 Creatinine testing in last 15 months94.69%90%3 Patients with proteinuria or microalbuminuria treated with ACEI or A250%70%3 Cholesterol recorded in last 15 months95.17%90%3 Cholesterol <= 5mmol/l in last 15 months67.69%60%6 Influenza vaccination given in last 7 months88.83%85%3 Diabetes nGMS vs Practise Diabetes care

15. Diabetes nGMS Targets Vs Achievements

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18. Incidence of Myocardial Infarction 3 patients (0.1% of total practice patient population) had a Myocardial Infarction event from April 2003 till 2004 Of these three patients 1 patient from the diabetic population experienced a MI event during this period

19. Why try better care ? Rewards both for the patient and the team More cost effective for the NHS / Social Services at various levels