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Diabetes care – moving with the times

Who has followed the progress of the new National Institute for Health and Care Excellence (NICE) guidelines for type 2 Diabetes and the controversial recommendations made by NICE in the first draft guidelines, which came out for review at the beginning of this year 2015?

At that time I was working for Diabetes UK as one of their nurse advisors, I was responsible alongside a dietician colleague for reviewing the full guidelines and then feeding back to NICE. As many of you may be aware, there was a huge outcry by all stakeholders who could not believe what NICE were suggesting, in terms of second line management for type 2 diabetes among other things. Unrealistic suggestions concerning on-going management and targets were also unacceptable in those first draft guidelines.

Thankfully, the team who were working on these guidelines for NICE responded positively to the comments and criticisms they received, and the second draft that was subsequently produced has made a number of significant changes. It is to be hoped these changes will remain in place when the full guidelines are published sometime this month (October 2015). It looks like the second line management of type 2 diabetes will have a greater choice of drugs available; sensible recommendations concerning blood glucose monitoring will also be part of this guidance.

The emphasis on 'individualised care' needs to be taken note of, because there is not a 'one size fits all,' as most of you will know anyway; now the guidance should be giving you the freedom to exercise your own clinical judgement and stay within the guidance. An additional section will hopefully signpost nurses to weight management and the numerous aspects of care involved there. Again, obesity and how to tackle this with individuals cannot be ignored; we do so at our peril, and that of our patients. We will be signposted to NICE guidance on lipid management, as this is a risk factor in diabetes.

Interestingly, the units used for measuring Hba1c now needs to follow the International Federation of Clinical Chemistry(IFCC), something the consultants in my patch are reluctant to do. When I began working as a community diabetes specialist nurse in March this year, I was surprised to see that certain practices always recorded their Hba1c as Diabetes Control and Complications Trial (DCCT) aligned or percentages, now it seems that NICE is being more direct. It is hard to make these changes, as we get so used to the way we have done things in the past, but it is like burying your head in the sand to try and keep going the old way, when the mmol/mol measurement is internationally recognised.

Perhaps now, those who are dragging their heels, once this guidance is published in the very near future, will feel they perhaps should join the majority. What happens in your area, have you made the switch as it was advised May 2011, when dual reporting was used initially? We need to move with the times.

It looks like there will be several sections focussing on targets, how to involve our patients more in decision making about their treatment and management, how they can make changes and what they can do. Let's not be driven by Quality and Outcomes Framework(QOF) targets (if that is what they are still called), and let's be more considerate for those who are frail/elderly and will not benefit from longer term risk reduction. Who wants to take more and more drugs, that give more and more unpleasant side effects, when they are unlikely to produce substantial outcomes. I am at times finding myself at odds with the occasional GP, who wants to push Hbac11 levels down and may not be considering the person and their age or frailty.

Do look out for the latest type diabetes guidelines, they are a good source of guidance for those with less knowledge, and a benchmark for others. I have only mentioned a few of the new aspects that have been introduced this year, there are many more change. The summary guidelines are only 52 pages long (unlike the several hundred pages of the full guidelines) and will be available from the NICE website in due course. Perhaps the algorithm may be useful for you.