Clare Gerada, one of the vice-chairs of RCGP council, has come up with a powerful one-liner she uses on civil servants and planners: ‘It's general practice that makes the NHS work, and it's GPs who make general practice work.’ But, writes Daniel Furmedge, here in the UK we are not doing enough to enthuse undergraduate students about coming into the discipline (page 581). The prevailing attitudes that he reports are as depressing as ever — and don't sound as if they have been improved by the increased experience students get in general practice. For now we do seem to be able to fill the training posts, but the bigger worry is the entrenched views of the hospital doctors that seem to percolate through much of the NHS.
So here are a clutch of papers dealing, in one way or another, with diabetes. According to Norman Waugh (page 533) the prevalence of diabetes is now 4.7% in one part of the UK, and has doubled between 1994 and 2003. The general consensus is that it will rise further as the population ages and gets heavier. Already most of the care for patients with diabetes happens in general practice, so the only people who can deal with this growing problem are primary care teams and our patients.
Two qualitative studies paint contrasting pictures of the kind of care we provide. On page 569 a Canadian team explores how GPs deal with the decision to change patients with type 2 diabetes from oral agents to insulin, and presents us with a microcosm of good general practice. The doctors reveal themselves trying to help their patients achieve the best control they can, while taking account of each one's resources and social circumstances. In contrast, the study on page 555 uncovers rather scattered views that patients have picked up about good foot care. From the patients' views I concluded that we simply don't devote enough time to this aspect of diabetes. There are so many tasks to complete that — perhaps — this one gets squeezed out. Like everything else in education it needs time, and repetition. For a quick revision course on what we should be talking about, turn to the Top Tips' on page 590. As well as working to current best practice, we shall also have to keep abreast of future developments. The editorial on page 531 provides some pointers to the kind of treatments we might have to learn about in future. Just like our patients and their foot care, one reading of this piece was not enough for me to retain any of the details when so much of the physiology was completely new.
The Holy Grail in this field is to prevent the problem in the first place. There is a growing consensus that cardiovascular risk starts to rise before diabetes can be diagnosed according to the accepted criteria (page 541); and that we should be trying to identify patients with impaired glucose tolerance in order to delay or avert the onset of frank diabetes. On page 541 a feasibility study directed specifically at the prevention of diabetes reports early findings, with interventions of an exercise programme and different types of diet. The study on page 535 used motivational interviewing directed at a modest target of 5% weight loss, and reports encouraging results, and the Counterweight study has similar results on page 548.
These three papers are a challenge to those of us (like me) whose efforts to help patients lose weight in the past have been mostly unsuccessful, and who have argued that the nation's collective BMI is a cultural problem that cannot be solved by dumping it on GPs — Domhnall MacAuley expressed this view in a past issue of the journal.1 But the doubts remain. Weight loss of 5% achieved by 24% in the Exeter study (page 535), or an average of 3 kg among the 45% of those recruited after 1 year in the Counterweight study (page 548) could, if sustained, translate into substantial population health gains. But the outcomes may not be enough to keep patients and staff motivated, outside the context of a research study. The editorial on page 533 encourages GPs not to be too pessimistic, but also that UK governments need to be bolder and introduce what are bound to be unpopular measures to help us all collectively to reduce our risks of developing diabetes. Like the author, I'm not holding my breath.
- © British Journal of General Practice, 2008.
