Diabetes Shared Care Programs

Diabetes shared care programmes aim to:

• establish criteria for who should have the major responsibility for an individual's diabetes care;
• introduce clinical management guidelines for diabetes which set minimum standards of care;
• introduce a system of documentation for the doctor's records and to facilitate communication between the interdisciplinary team.

This generic model requires local adaption to ensure its suitability and to develop the necessary sense of ownership. The consultative process between specialist diabetes services and representatives of GPs has been facilitated by the establishment of divisions of general practice. But not all GPs belong to divisions and private specialists may feel disenfranchised by this process.

Since the potential benefits for patients are clear, the specialists' ideology questions the decision of some GPs not to embrace at least the management guidelines. It is acknowledged that these schemes already place an additional burden on already over-burdened bush doctors and the major stated reason for non-participation is lack of time. Another is the lack of specific remuneration for GPs who take the extra time to implement the guidelines and perform the recommended annual review for diabetes complications. A further problem is that unlike in a specialist setting, the patient may not consult the GP specifically about their diabetes. However, none of these are acceptable medico-legal reasons for failure to perform a necessary duty. Whilst guidelines might offer protection for those who adhere to them, they might increase the medico-legal risk for those who do not adopt them.

Another issue is the competence of individual doctors in performing the tasks documented in the guidelines. For example, examining for diabetic retinopathy is recommended every one to two years for all people with diabetes. This requires formal testing of visual acuity and examination of the fundi through dilated pupils. The procedure is time consuming and requires specific skills. For doctors who perform this procedure themselves, either by choice or due to lack or specific specialist services nearby, their competency must be assured both for their own protection and for the good of the patient. There has already been successful litigation for failure to detect and treat diabetic retinopathy that resulted in visual loss.

From the perspective of a specialist service, the potential benefits of these programmes include:

• improving the overall standard of diabetes care and patient outcomes;
• the opportunity to enhance GPs' knowledge of diabetes care;
• improving access to specialists for patients with problems that require specialist care;
• reducing overall diabetes-related health care costs;

while concerns include:

• lack of mechanisms to ensure the competence of doctors performing the guideline tasks;
• the quality of care received by patients;
• attending doctors who do not implement the guidelines;
• lack of resources to appropriately implement the programme.

Currently, most of these projects are funded by Commonwealth Department of Health grants to divisions. While this has facilitated their introduction, the criteria for fund expenditure has not always enabled the necessary resources to be obtained. Furthermore, the understandable requirement for formal evaluation has placed an extra burden on participating GPs and discouraged more widespread adoption of these programmes. Since numerous studies have documented their benefits, it is now time to reduce the emphasis on evaluation and concentrate on funding their implementation.

While there remain some issues that require resolution, there seems little doubt that the shared care concept will play an increasing role in the caring for people with chronic conditions in the future.

Dr Stephen Colagiuri