The Pharmaceutical Journal
Vol 270 No 7232 p75-76
18 January 2003

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Pharmacists need to be proactive in the care of patients with diabetes

The National Service Framework for Diabetes delivery strategy has at last been published, six months later than expected. Zoë Gross investigates where pharmacy fits in and how pharmacists can help deliver the strategy

Related websites
DoH: NSF diabetes (more)

Rather than waiting to be asked, pharmacists will need to be proactive if they are to take advantage of the opportunities available to them caring for patients with diabetes. According to the Department of Health, in the second part of the National Service Framework for Diabetes, published last week, "pharmacists are a regular point of contact for people with diabetes and can play a central role in improved medicines management". The strategy focuses on primary care and, unfortunately, the only other reference made specifically to pharmacy in the strategy is that diabetes services are well positioned to take advantage of extending prescribing to pharmacists.

Dr Gillian Hawksworth, chairman of the Royal Pharmaceutical Society's diabetes task force and Vice-President of the Society, told The Journal that although the strategy only mentions pharmacists with regard to these two points, the strategy "creates an opportunity for pharmacists to establish themselves within the health care team, which is mentioned throughout the document, and to develop services for patients following the Royal Pharmaceutical Society's practice guidance on the care of people with diabetes and more recent guidance on early identification of these patients".

In a letter sent to Dr Hawksworth recently, David Lammy, Parliamentary Under-Secretary of State for Health, said that he was pleased that the Society had been involved in the early stages of developing the NSF for Diabetes. He added: "I fully recognise and appreciate the important role that pharmacists play in the care and treatment of people with diabetes, both in the community setting and in secondary care."

In a statement issued this week by the Society, Nigel Graham, head of practice, said: "The Society welcomes the opportunity for pharmacists to work with primary care organisations to help them meet the targets and challenges laid out in the stategy."

Raising awareness of diabetes

Dr David Colin-Thomé, national clinical director for primary care at the Department of Health, says that pharmacists need to raise awareness among patients at high risk of diabetes that they should look for symptoms or at least be screened for diabetes. At any one time about 50 per cent of people with diabetes are undiagnosed and it takes an average of seven years before a diagnosis is made, by which point patients may already have early vascular disease. People at high risk need to be reminded that it is worth having at least one test for diabetes, he says.

Dr Colin-Thomé adds that the most effective screening is a blood test and pharmacists will need to have the appropriate facilities to undertake screening. At the moment it is not known how frequently people should be screened for diabetes and the Department is commissioning research on this. The Department's long-term conditions care group workforce team is looking at how the roles of all health care professionals — including community pharmacists — might be enhanced to provide better support for people with diabetes.

The strategy says that PCTs should ensure that systematic treatment regimens for people with diabetes are in place by 2006. At the heart of these will be regular reviews which will be based on a diabetes record and a care plan developed and agreed jointly between the patient with diabetes and a member of the diabetes team. Dr Colin-Thomé comments that in the future many pharmacists may well be able to carry out chronic disease management reviews, even if it is by monitoring hypertension. They have "as key a role as doctors and nurses", he says. But the realisation of their role will depend on the development of local pharmaceutical services and maybe a new pharmacy contract to explore that option.

However, Irene Gummerson, a community pharmacist with a special interest in diabetes, says that there is no easy way of getting involved in the delivery of care for patients with diabetes. "It is difficult to say what can pharmacists do specifically in diabetes." It might be more of a case of what pharmacists can do in medicines management and targeting people with diabetes and hypertension, she says.

The strategy notes that the Department of Health is developing guidance for medicines management in long-term conditions, supporting the NSF for diabetes, renal services and long-term conditions, and this is expected to be available this year.

Mrs Gummerson says that the document does not say that pharmacists should set up clinics and only mentions pharmacists and supplementary prescribing in a "general sort of way". However, she points out that in "Illustrative targets for local priorities", a document issued by the Department alongside the delivery strategy last week, pharmacists are named as staff for whom education should be provided on the symptoms and signs of diabetes to help identify people with diabetes [standard 2].

Pharmacists need to be proactive in taking part in this NSF, she adds. "I think that if we sit in our pharmacies and do nothing we will be not approached." Mrs Gummerson advises that pharmacists who want to get involved in extended diabetes services should liaise with the local pharmaceutical committee and possibly the pharmaceutical adviser at the PCT to see if there is a way of linking in to PCT plans.

"As far as I can see, it is the PCTs which have all the money for services." She suggests that pharmacists could get involved in helping PCTs and GPs achieve standards by improving the quality of prescribing and by getting involved in medicines management in establised schemes.

Education programmes

The strategy also says that structured group education programmes are a good way for PCTs to give patients advice and information about the importance of diet, physical activity and cessation of smoking to help avoid the risk of developing complications of diabetes.

So how can pharmacists get involved? Green Light Pharmacy, which has branches in Euston and Eastcote, London, runs two pharmacist-led diabetes support groups to help educate people about their condition. One is for Bengali men with diabetes and is held at the company's branch at Euston, and another is for mixed English-speaking patients with diabetes which is run in conjunction with a local charity and meets at the charity's premises in London.

John Foreman, consultant pharmacist at Green Light Pharmacy, explains that both groups meet monthly and different topics are covered at each meeting, such as medication, diet and foot care. Dietitians from secondary care or a diabetes nurse are also brought in to speak at these meeting. Those patients who meet in the pharmacy have their blood pressure measured as well as baseline levels such as cholesterol and HBA1c. The usual attendance is 10 to 15 people at each meeting, and funding has come from the health action zone.

Mr Foreman adds that the Bengali Bridge Project is expected to start again in April and that it will provide educational evenings covering areas such as diabetes, chronic heart disease and asthma (PJ, 21 July 2001, p77).

Pharmacist-led diabetes clinics

In secondary care, pharmacists are already involved with and leading diabetes clinics. A number of such clinics are already running in hospitals in north east England — including University Hospital of North Durham, Darlington Memorial Hospital and Sunderland Royal Hospital (PJ, 8 June 2002, p799) — and can provide continuity of care between primary and secondary care.

Paul McLean is in charge of the pharmacist-led clinic at University Hospital of North Durham. Mr McLean explains that the weekly clinic is overseen by a consultant diabetologist who refers patients to the clinic. Lipids, blood pressure and diabetic control are routinely checked and patients' GPs are given recommendations for treatment and any changes to current medicines.

In terms of the NSF delivery strategy, he says that pharmacists can get involved in areas such as redesigning services for patients with diabetes. However, pharmacists are going to have to put their own ideas forward rather than being invited to do so.

In summary, there is plenty of scope for pharmacists to get involved in helping deliver the standards of care set out in the NSF for Diabetes. However, they need to be proactive if they are to take part and make a difference to patient care.

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