1. DR ROGER GADSBY COMORBID CHRONIC CONDITIONS

2. GP PERSPECTIVE nGMS CONTRACT SHOULD WE APPLY DISEASE SPECIFIC GUIDELINES FOR DIABETES TO PEOPLE WITH CO-MORBIDITIES? TWO CASE HISTORIES SOME KEY ISSUES FROM GP PERSPECTIVE

3. MY EXPERIENCE Full Time GP 26 years P/T Senior Lecturer in Primary Care Interest in Diabetes 20 plus years Warwick Diabetes Care RCGP textbook on diabetes in nGMS

4. NEW GP CONTRACT CLINICAL DOMAIN 550 points in 10 disease areas Diabetes, CHD, Hypertension, Stroke, Cancer, Hypothyroidism, COPD, Epilepsy, Mental health, Asthma 99 points for diabetes. (only other disease area with more points is CHD) Covering Infrastructure (register) Process Quality

5. NEW GP CONTRACT HOW TO ACHIEVE MAXIMUM CLINICAL POINTS 1 INFRASTRUTURE Trained staff, dedicated clinic time, good IT and recording, clinic template, register, call & recall system 2 PROCESS Get bloods done, record information etc. etc. 3 QUALITY Educate, empower, review and up titrate medications 4 EXCLUSION CODES For those individuals on maximal doses of therapy, or who choose not to attain a target or targets, or those for whom it is not medically advisable to attain a target or targets

6. NEW GP CONTRACT GPs have adapted well to this new process The clinical areas cover most of the important areas of morbidity. Many patients have several co- morbidities and therefore appear in several clinical indicator areas Most practices are scoring high numbers of points So most GP practices have developed strategies to deal with issues of co-morbidities and whether specific targets are appropriate for individual patients These issues can only be addressed on an individual patient basis. General Practice is where this usually happens and is therefore pivotal

7. GP PERSPECTIVE SHOULD WE APPLY DIABETES TARGETS TO PEOPLE WITH COMORBIDITIES? Evidence Base for good glycaemic control - up to 75? Evidence base for Cholesterol – up to 80? Evidence base for BP – up to 80 years? But people with significant co-morbidities excluded from trial populations. I teach. If person has diabetes as their only significant disease, and they are otherwise healthy and living independently Discuss with individual and treat to target

8. GP PERSPECTIVE Those who have significant co-morbidities, high dependency levels or dementia In consultation with individuals, their family and carers 1 Ensure symptomatic control 2 Avoid hypoglycaemia 3 Avoid intensive monitoring Data from a large community study in Wales in 1990s suggest 2/3 of people over 75 are in this latter category and 1/3 in former

9. GP PERSPECTIVE CASE HISTORY 1 - Frank aged 70 Type 2 DM from 1993, Hypertension from 1999 TIA with confusion in 2000 (brain scan multi infarct dementia), Memory loss from 2000, Parkinsonism from 2002, BPH from 2003 with dribbling, Glaucoma from 2003. HBA1c 6.7%, Chol 3.4 Creatinine 130 Metformin 850mgs bd, Aspirin 75mgs daily, Simvastatin 40 mgs daily, Madopar 250 tds, irbesartan 300mgs daily, finasteride 5mgs daily, detrusitol 4mgs daily, paracetamol prn, G. Timolol Attends OPD for eyes, & parkinsons, GP for diabetes and all the rest Walks with 1 stick, looked after by wife who realises he may not get better but wants everything done to try. Main effect on QOL - memory loss and dribbling

10. GP PERSPECTIVE CASE HISTORY 1 - Frank aged 70 DM, BP, Chol & Glaucoma are well controlled Parkinsons reasonably controlled Memory loss getting worse Nocturia & dribbling at present are the most upsetting symptoms Walks with shuffling gait and 1 stick. Goes out only with wife, who gets upset and anxious by his forgetfulness. She is happy for him to have all his medications She wants him to be better, but is coming to terms with the fact that he wont

11. GP PERSPECTIVE CASE HISTORY 2 - Anne aged 71 Bipolar disorder from 1994 Type 2 diabetes from 1998 – diet controlled HBA1c 6.5% TIA in 2001 brain scan - cerebral a occlusion and ischaemia Overdose 2003 Depakote 250 bd, Sulpiride 200 bd, Tegretol retard 200 bd, atorvastatin 40 daily, aspirin 75 daily, Zopiclone 7.5 nocte Attends Psychiatric OPD & GP for rest of care Lives alone, poor compliance, uses nomads for drug dispensing, Wt reduction in 2 years from 116Kg to 100kg. Excellent paid carer

12. GP PERSPECTIVE CASE HISTORY 2 - Anne aged 71 Wouldnt manage alone without support of carer When she takes her medications she is stable. Nomads have helped concordance Advice about healthy eating has enabled significant wt loss and excellent diabetes control

13. KEY ISSUES FROM GP PERSPECTIVE 1 nGMS Contract – QOF, exclusion codes 2 Individual assessment – General Practice in pivotal position 3 Problems of multiple out patient attendances looking after different parts of the body. 4 Patient, Family and Carer agendas may not be same as healthcare professionals 5 Importance of concordance, education and understanding of risk

14. WARWICK DIABETES CARE THE UNIVERSITY OF WARWICK COVENTRY CV4 7AL Tel: (024) 7657 2958 Fax: (024) 7657 3959 E-mail: diabetes@warwick.ac.uk Website: www.diabetescare.warwick.ac.uk