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What does the hospital diabetic clinic do for you?
V Hartnell MB BS, CP Trainee, Plymouth Vocational Training Scheme

Correspondence to: Dr V Hartnell, 94 Beaumont Street, Milehouse, Plymouth, Devon PL2 3AQ

Abstract
The work of a district’sdiabetic clinic was audited to assess workload; it focused
on patients’ reasons for attendance, outcome of their appointment and
recording of specified parameters in the notes.
Results highlighted the failings of a clinic organised on traditional lines. Most
appointments (70%) were for routine follow-up, all patients were given another
appointment and, for at least 27%. this was the only action undertaken. The
clinic performed poorly in routine screening and was ineffective, particularly in
relationship to skills and services available in primary care.

Key rrorcis: diabetic clinic, audit, general practitioner

tional and practical support in con- registrar and consultant in general

Introduction
Much research into long-term diabetic
care comparcs the primary care team t o
the hospital diabetic clinic. from which
care is being devolved. Thcre ha$ hcen
little objective evidcrice t o support the
vicw o f the clinic as a standard of exccl-
lence or to show up the failures which
began the search for alternative mcthods
of care.
The debate ovcr thc care of diabetics
is relevant to the care of all chronic dis-
eases and is an area where gencral prae-
tice has a key role’. Diabetcsisone ofthe
few conditions where long-term main-
tenance of good metabolic control may
rcducc mortality and morbidity and
where screening for complications can
prevent their progression by allowing
earlier treatment’ ’: the case for effective
follow-up is unarguable.
Historically, care for diabetics has
been organised around hospital-bascd
diabetic clinics. In r h t carly 1970s. the
situation had become barely tolerable;
the patient inevitably had to take time
off work, travel and wait to sce a new
houseman at almost every attendance at
the diabetic clinic scrimmage. His medi-
cal notes got thickcr and thicker so that
both hc and the young doctor found the
fleeting consultation unrewarding‘. I n
addition to thesc problems, scveral
audits performcd in the primary care sct-
ting showed that a substantial propor-
tion of the diabetic population was not
undcr the supervision o f a hospital clinic
in any caseS’.
I n an attempt to find a solution to
these problcms, numerous shared care
schemes have been csplorcd and those
involving GPs closely have shown cxcel-
lent results’ ”.. Where patients from
diabetic clinics have been discharged
before establishing an cffcctive system
of planned review. together with cduca-
junction with GPs. results have been
poor”
Because of these contradictory
results, the involvement of the GP has
not become standard practice. Many
GPs are taking the initiative themselves,
however, and this trcnd may be encour-
aged by recent contract changes provid-
ing funds for “mini-clinics” in gencral
practice.
The 1984 joint report by the British
Diabetic Association and the Royal Col-
legc of Physicians on provision of ser-
vices for diabetics concentrated on the
provision of hospital staff and services.
Hospital diabetic clinics exist in about
2 0 out of 234 districts. Details for iden-
tifying thc involvement of GPs are
unavailable but, of thesc, 49% would
discharge non-insulin-requiring diabe-
tics to the GP, 20% would d o so only with
regular clinic review and only 7% would
discharge insulin-requiring diabetics to
the care of their GP15.
In the debate about diabetic care, the
hospital diabetic clinic is assumed to be
the “gold standard” against which all
othcr schemes are compared. Outside
the few centres which are actively
involved in research, there is little objec-
tive information to support this view and
many may still resemble those described
by Hasler’. This paper audits the work of
one diabetic clinic t o show its strengths
and weaknesses and to add fuel to the
debate over the respective roles of the
G P and the hospital in the care of diabe-
tics in the future.
Patients and methods
Thc.clinic which was audited is based in
the district gcncral hospital in Plymouth.
scrving an urban and rural population of
around 400,000. Two clinics are held per
week. staffcd by a senior house officer.
medicine with a special interest in
diabetes. There is also a dietitian, two
specialist health visitors in diabetes. a
phlebotomist at most sessions and part-
time clerical assistance. Surse support is
confined to that o f weighing the patients
in the waiting room and acting as “traffic
wardens”. due to the lack of space for
clinical activity and a lack of trained,
interestcd staff. There is no com-
puterised or manual register or any recall
of defaulting patients. The manual
records do not use a particular format
and results are not filed chronologically.
There is no space in the clinic for an on-
site chiropodist but, for two clinics a
month, a consultant ophthalmologist
and his clinical assistant attend, in addi-
tion to the usual staff, and perform
fundoscopy after visual acuity has been
tested and mydriatics instilled.
On average: 50 patients are seen in a
morning. After arrival, the patient is
wcighcd by the nurse and a blood sugar
estimation is performed by the
phlebotomist or the nursing staff. After
a wait, he/shc sees one of the doctors for
an average of 10 minutes. The patient’s
notes and personal record book aim to
help in a discussion of current control. At
the end of the consultation, results arc
recorded in a brief pre-printed letter
which is given to the patient to take to
hisher GP as communication of the visit
and notification of any significant
findings. Further blood tests can be
requested as the patient leaves the clinic.
An audit of 100 successive clinic
attenders’ notes was performed over one
week, which included an “eye clinic”.
The reason and outcome of attendance,
duration of attendance at the clinic and
the most recent recording of certain
parameters of diabetic care prior to the
appointment were noted in those
patients attending for over five years.

Practical Diabetes NovembedDecember Vol8 No 6 239


Choice of parameters studied
Choosing appropriate parameters of
diabetic care is important if the audit is
to adcquately reflect the standards of
carc. Three equally important aspects of
diabetic care were considered. with
potential recorded parameters:
,Metcibo/icaiitl .syinprorn coritrol - blood
glucosc. glycosylatcd haemoplobin.
weight. hypoglycacmic cpisodcs aiid
symptoms of hyperglycacmia
Screenirig for complicririons - blood pres-
sure, fundoscopy proteinuria. cxamina-
tion of feet for pulses and sensation
Edirrarion - encouraging compliance
and independence in managing diabetes.
consulting a dietitian. chiropodist or
health visitor. reduction in smoking
habit and encouraging membership of
thc BDA.
Whilc clear-cut tests with numerical
values apply t o the first section and
simplc performance of a clinical cxam-
ination may be audited for the sccond.
the third section. possibly from the
patient's point of view the most impor-
tant. is far harder to define and varies for
each indi\,idual.
The parameters chosen for this audit
were:
Discussion
The bulk ofclinicM,ork isconcerned R i t h
routine follow-up. 'l'liis can be seen to be
ineffective by the small amount that is
done for the patients. both at the consul-
tation a n d in the p o o r scrccning figures.
Perhaps the description of the clinic is
enough t o explain. to some extent. the
difficulties facctl by staff i n pro\ idiiig
regular and effective monitoring a n d
scrcening. The pressure of time may
explain thc four admissions to thc
diabetic ward whose more complex prob-
lems may have bccn manageable mithin
an outpatient setting The lack o f a for-
mal record and recall system is partly to
blame. Computerisation is being consid-
ered. but the clerical and doctor tinic t o
support the change is daunting and
unavailable at present.
Lines of communication need improv-
ing both bctwecn hospital specialties and
the patient's GP. The lack o f information
on those patients already seen by the
ophthalmologists shows this. as docs the
lack o f any information in the patient's
notes about what services the GP can
provide. Appropriate care cannot be
planned without this basic information.
On a brighter note. the strengths o f
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fundoscop!. t i ere m o r e impressive than
those Tor rccording o f H b i l , , .These arc
thc very areas where < ; I 3 ma). feel the
lack of spccialict help " ' . .l'he role of
diabetic health visitors has not bccn
explored: their enormous contribution is
an educational one a n d . as already
described. far more difficult to audit.
This hospital clinic is not able to pro-
\ idc basic survcillance of all diabctics.
even if this wcre desirable. I Iowever. i t
has invalu:ible specialist consultative
resources. and health visitors and dieti-
tiam trained in education - n o r only for
the patients. but also for the primary
health care team.
l ' h c inevitable conclusion is that tlie
diabetic clinic and the GP need t o work
in a symbiotic relationship and not in iso-
lation. There should be a specialist
centre for diabetes available t o every
diabetic". The rolc o f this clinic should
focus o n specialist services required for
the carc of diabetics and takc a lead in
education - both for the diabetics arid
those who will be educating them i n the
primary care setting". As a result of this
audit, the provision o f services in the dis-
trict is under revicw and the first diabetic
cducation day for CiPs has been held

. Cilycosylatcd haemoglobin this clinic lie in its educational and spec- (with approval for the new Postgraduatc
Blood pressure ialist resources. Almost all paticnts had Education Allowance scheme).
Fundoscopy seen the dietitian in the past five years - We are facing the age of GPs as con-
Session of cducation with a dietitian more than had had their blood pressure sumers of health services o n behalf o f
measured. Similarly. the figures for their patients. Should not the GP
These represent different aspects of
diabetic care and were available from the
rccorded data in tlic notes. T h e date of Table 1 Table 2
tlie most recent rccording under each Reason for attendance Outcome o f attendance
category was noted and expresscd in the
time bands shown in the results.
Altered treatment 74
New problem: self-referred I
Dietitian 13
Results New problem: GP-referred 3 Health visitor 6
The vast majority of our paticnts Chiropodist 0
New patient from GP 4
attended for routine follow-up. 'The Investigation 9
sample included an "eye clinic" and this Review of new management 4 €ducation 9
presumably increased the numbers Fundoscopy 18
Fundoscopy 18
attending for fundoscopy (Ghle I ) . Admission 4
Thc outcome of these appointments Routine follow-up 70 Routine follow-up 100
-
-
u'as intcnded to indicate clinic activity Total 173*
Total sample number 100
(Eible2). No distribution o f activities per Total sample number 100
patient was obtained. but it can be seen Patients attending for >5 years 68
that all were given a routine appoint- *More than one outcome possible per
ment (so none wcre discharged) and pa tient
even if only one ..activity" is allowed per
patient. then 27% has no outcome other
Table 3
than follow-up and the actual figure is
probably much higher. This may be due Recording of parameters
to no action being rcquircd. however, ~

thc results in the third chart o n screening Timescale < 1 year > 1-<5 yrs >5 yrs Not rec Total**
activities show that these activities are at HhA I ( 20 9 62 9 100
an extremely low level, with only 29% o f BP 17 27 51 5 100
patients having a n HbA,, recorded in the Fundoscopy 27 16 20 18 81*
previous five years. and only 44% with a
blood pressure recording. Dietitian 28 38 31 3 100
fibkc 3 does give some room for hope.
Only 3% of patients had never been able * Expressed as % of total sample (68)of patients attending clinic for more than 5 years
to see the dietitian and 18% had not had " A further 19% of patients was recordedas being under the care of the ophthalmologist
fundoscopy performed. already, no further details available on date or result of fundoscopy

240 Practical Diabetes November/December Vol8 No 6


Original Articles
What does thevhospital diabetic
clinic do for you?
attempt to negotiate with the hospital to
provide the support that is needed?
Perhaps the coming changes in the NHS
will make this easier, perhaps notI9.
These results demonstrate that GPs
should not only audit their own work,
but should be interested in the quality of
those who work with them in providing
care for their patients.
Acknowledgements
I would like to acknowledge the help and
support of the Plymouth Diabetic Team,
Dr K Hunter, Consultant Physician, Mrs
P Roseman and Mr C Soper, Diabetic
Health Visitors, Miss W Kramarenko,
Dietitian.
Also thanks to the GPs of the
Plymouth district and surrounding area
who showed me what can be achieved in
general practice, and thanks to the
patients themselves.
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Practical Diabetes November/December Vol8 No 6
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Dates for your Diary
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241