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PJ Online | News feature: Diabetes clinics: hospital pharmacists lead the way for community colleagues

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The Pharmaceutical Journal
Vol 268 No 7201 p799-800
8 June 2002

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News feature

Diabetes clinics: hospital pharmacists lead the way for community colleagues

The International Diabetes Federation last week appealed for better management of type 2 diabetes. As other professionals reach capacity, pharmacy-led clinics for type 2 diabetes patients are taking off around the United Kingdom. Naomi Kempner looks at some of the newest projects and services and plans for the future

Diabetes week
Diabetes Week is from 9–12 June 2002. Further information can be found on the Diabetes UK website (www.diabetes.org.uk).


Naomi Kempner is a freelance pharmacy writer

The International Diabetes Federation last week called for "urgent action to stem the growing epidemic of type 2 diabetes by identifying those at high risk and preventing complications by more aggressive management of blood glucose control".

More diabetes clinics are needed because doctors want their patients to be seen more often

The federation's president, Professor Sir George Alberti, also warned of the potentially crippling health care costs for type 2 diabetes, which already affects huge numbers of patients in the UK. Not only is an ageing population driving up the incidence of this condition, but it is increasingly apparent in younger people, especially the obese. This has important implications for the planning and provision of care for these patients who not only have to deal with day-to-day control of their diabetes but who are at high risk of its complications — cardiovascular disease, retinopathy, nephropathy and neuropathy.

Role for pharmacists

Pharmacists have always had a role in diabetes care, not only in supplying treatments and equipment, but also, more recently, in screening, monitoring diabetic control and education provision.

Now, pharmacy is taking a lead in providing diabetic clinics. In a development in Durham, hospital pharmacists are paving the way for their contemporaries in the community by setting up and refining a clinic model that will roll out into primary care.

David Campbell, head of pharmacy, North Durham Healthcare NHS Trust, says that increasing the capacity for clinics in a secondary care setting is not believed to be the solution for type 2 diabetes care. The long-term view in his area is that these clinics should take place in settings convenient for patients, such as community hospitals, GP practices, and suitably equipped pharmacies.

Increasing services are needed, he says, not only because of the rising incidence of the disease but also because doctors want their patients to be seen more often (every two to three months). This would stem the risk of complications by increasing control of blood glucose, blood pressure and lipid levels.

With physicians seeing newly diagnosed patients and those with complications, and with nurses already running clinics, the extra workload in type 2 diabetes care has been taken up by a hospital pharmacist with a strong interest in, and knowledge of, diabetes. It is hoped that community pharmacists will eventually take on this role and lead it into primary care.

Mr Campbell says that his idea, of involving pharmacists in such clinics, has been well received by his primary care trust, which agrees that the service should be developed in secondary care. A clinic has now been set up and has been running since March. Initial financial support has been received from a pharmaceutical company, with subsequent funding scheduled to come from the primary care trust.

What HbA1c reveals

The United Kingdom Prospective Diabetes Study showed that if HbA1c, a marker of blood glucose, is reduced by 1 per cent, the risk of heart attack is reduced by 14 per cent and the risk of eye and kidney damage by up to nearly 45 per cent, yet the vast majority of patients with type 2 diabetes do not achieve adequate control of their blood glucose levels, particularly their post-meal glucose, according to the International Diabetes Federation.

Paul McLean, the senior clinical pharmacist who currently runs the service as part of the diabetic team at University Hospital, North Durham, explains that newly diagnosed patients are referred to his weekly clinic in the diabetic centre by a consultant diabetologist. Mr McLean routinely tests lipids, blood pressure and HbA1c (a measure of long-term diabetic control, see Panel right) and carries out other investigations if needed. Writing prescriptions for new medicines and adjustment of existing medication is carried out by the patient's general practitioner on receipt of a letter from the clinic. Mr McLean says that initial worries about communication between the hospital and GPs have been unfounded, with all his suggestions fulfilled so far. It is hoped that a community pharmacist will be appointed for a second clinic planned for Shotley Bridge Hospital, County Durham.

A natural progression

Another new pharmacy-led hospital diabetes clinic is run at Sunderland Royal Hospital. It is specifically for type 2 diabetes patients with complications, such as hyperlipidaemia or hypertension. As in Durham, all the patients have been seen previously and referred by a consultant. The additional capacity will allow patients to a see a health professional more frequently — once a month rather than twice a year.

Yvonne Swift, the senior clinical pharmacist running this service, says that she is very much a part of the multidisciplinary diabetes team at her hospital. Her patients tend to have uncontrolled hypertension or hyperlipidaemia, with a high risk of cardiovascular complications. Her remit includes adjusting medication. "A type 2 diabetes clinic is a natural progression [from the current level of care provided] and a good opportunity for pharmacists," she says.

Looking to expand

A similar, longer established pharmacy-led diabetes clinic, at Darlington Memorial Hospital, is now looking to extend its once-a-week service in a sister hospital.

Dr Labib Tadros, clinical lead pharmacist, has been running the Darlington clinic for over a year, and a one-year pilot study prior to that. His time is purchased from pharmacy by the hospital's diabetes service. He approached the consultant diabetologist at his hospital about the potential for pharmacists, aware of the problems of managing diabetes patients. (Dr Tadros pointed out that a third of patients admitted to coronary care and intensive care had diabetes.) The clinic now has just under 200 patients seen every three months, or sooner if complications arise. It has started accepting cases from primary care, as well as the hospital's consultant diabetologist. Any complications are managed according to a protocol (although the pharmacist does not prescribe) and patients are discharged back to primary care.

The clinic is now providing training in type 2 diabetes management for other pharmacists. Dr Tadros says that his centre now has Centre for Pharmacy Postgraduate Education accreditation for its three-day course. Although run mainly for hospital pharmacists, community pharmacists have attended with a view to setting up clinics in GP surgeries.

However, Noel Dixon, a community pharmacist with a special interest in diabetes, thinks it is still early days for community pharmacy-run diabetes clinics. "Although clinics for type 2 diabetes patients might be run by community pharmacists at some stage in the future, they need to be thought through extremely carefully," he warns. They cannot be run along the same lines, for example as anticoagulant clinics. The complex nature of diabetes requires input from optometry and chiropody among many other disciplines. His view is that diabetes clinics funded by PCTs would probably continue to involve specialised GPs, rather than pharmacists.

One company with an embryonic community pharmacy diabetes clinic is the Pharmacy Care Group, in Nuneaton. Primary care pharmacist Mohammed Ibrahim explains that the group already runs diabetes screening services, medication reviews and provides blood glucose and blood pressure monitoring that can be downloaded over the telephone. Other tests they carried out include HbA1c, micro-albuminuria and lipid profiles.

At the moment, patients are mainly self-referred and pay for services, with pharmacists liaising with their GPs where necessary. However, Mr Ibrahim says that the company is aiming to expand its services to include referrals from primary and secondary care.

Many other pharmacies around the UK are running services for diabetes patients that could evolve into clinics. Mr Tim O' Donoghue, Green Light Pharmacy, London, described his largely education-based service which has now been translated into Bengali with support from his PCT, and which he intends to expand.

A trial of pharmacy testing of HbA1c was reported last year with the conclusion that pharmacists were well placed to provide such a service. Regular testing combined with education, helped poorly controlled patients to gain better management of their diabetes.

Training

The advent of local pharmaceutical services may tempt many community pharmacists to think about running diabetes clinics. But this is a larger step further forward than existing screening, patient education and other extended roles.

However, the increasing number of patients with type 2 diabetes and the current limits on existing services may open this field to pharmacists with a special interest in this condition. We now see models of pharmacy-led care and the potential reward for pharmacists in providing extra capacity and preventing complications in patients with type 2 diabetes.

As mentioned previously, further training in diabetes care is offered by the Darlington Memorial Hospital. Pharmacists interested in this, or requiring further details of the clinic's protocol can contact Dr Labib Tadros by e-mail (lbmtadros@hotmail.com).

Other centres also provide training in diabetes care, aimed at primary health care professionals.

Warwick Diabetes Care offers a certificate or masters degree in diabetes care and can be contacted on 0247 6572958 (www.diabetescare.warwick.ac.uk). The certificate is a nine-month course with flexible learning, including either on- or off-site courses and a CD-ROM package. The masters degree is also flexible and runs on a modular basis with core and optional topics.

Another course on diabetes management is offered by the DTC primary care training centre near Bradford (tel 01274 617617), www.primarycaretraining.co.uk.

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