Special Interest In Diabetes Research Articles

A prospective re-audit on insulin prescribing and administration practices in a university teaching hospital

Abstract Introduction Insulin is a high-alert medication which can cause significant patient harm if used inappropriately and has been identified as a significant medication safety concern in Galway University Hospitals. The first hospital-wide insulin review[1] was conducted in 2022 to evaluate insulin prescribing/administration practices and identify/develop quality improvements inclusive of: -The appointment of a senior pharmacist with a special interest in diabetes (June 2022), -An updated insulin record (November 2022; previous edition June 2019), -Development/implementation of a bespoke local eLearning module for the safe use of high-alert medications including insulin (March 2023), and -Continuous education on appropriate use for healthcare staff and patients/carers. Aim The aim was to conduct a similar insulin study to assess performance since the previous review, and develop further quality improvements as needed. Methods This study was conducted over one day in June 2023 on 24 wards by 26 interprofessional data collectors. Inclusion criteria comprised inpatients prescribed and/or administered insulin for the previous 72 hours. Exclusion criteria comprised non-admitted patients, short stay wards, critical care, maternity, and psychiatry. The protocol and tool were approved by the local Clinical Audit Committee, piloted with four inpatients, and communicated to all data collectors prior to commencement. Generated data were anonymous and securely stored. Data analysis was carried out using Excel by three independent researchers to confirm reliability of results. Results In total 557 inpatients were reviewed, of which 21% (116/557) had diabetes and 10% (56/557) were prescribed insulin. Nearly three-quarters (73%; 41/56) were prescribed a meal-time supplement, whilst 68% (38/56) were prescribed regular insulin – of which 63% (24/38) comprised prescribing errors, an improvement from 78% (32/41) in 2022. Administration errors comprised 84% (32/38) of records, similar to the 88% (36/41) error rate observed in 2022. Approximately one-fifth (21%; 8/38) of insulin orders were not signed by a prescriber, compared to 12% (5/41) the previous year. More than nine out of ten prescribers clearly documented the correct insulin name, dose, and administration times, and 71% (27/38) documented a medical council registration number, bleep, or name for contact purposes, compared to 59% (24/41) the previous year. Failure to document administration times was noted in 42% (16/38) of instances compared to 46% (19; n=41) the previous year. Insulin was not double-checked by a second independent individual in 21% (8/38) of cases, compared to 29% (12; n=41) in 2022. Conclusion Results have identified an overall practice improvement. Building on recent interventions implemented and incorporating newer strategies will aid in enhanced insulin use. An updated version of the insulin record has been implemented due to the recent discontinuation of the referenced perioperative fluid and the introduction of non-referenced blood ketone monitors. High leverage strategies such as ePrescribing is a current consideration to standardise practices. Conducting a study over a longer period may identify further trends. Strengths include study robustness, interprofessional collaboration, and transferability to other hospitals. Disseminating results and promoting benefits should encourage Irish hospitals to participate in a standardised national annual review to optimise patient care.

Approach toward diabetic nephropathy and its management in patients with type 2 diabetes: results of a web-based italian survey

AIM The purpose of this survey was to investigate the attitudes and clinical approach of Italian diabetologists toward diabetic nephropathy (DN). METHODS A 28-item web survey was distributed to Italian diabetologists by the Associazione Medici Diabetologi. The first part of the questionnaire was aimed at describing the sample of clinicians involved (age, gender, practice setting, etc.). The second part analyzed more deeply the clinical approach to DN. RESULTS Two hundred and thirty-five clinicians, expert in the field (over 44% have been working as diabetologists for more than 20 years) and well distributed across the country, participated in the survey. The lack of medical care provided from a team remains a main concern, since only in a minority of diabetes centers diabetologists can collaborate with health professionals with expertise and a special interest in diabetes. Screening of DN is performed at first visit by 95% of participants. Urinary albumin creatinine ratio and estimated glomerular filtration rate by CKD-EPI are two approaches used. The relevance of intensive glycemic treatment respect to the onset and progression of DN is mostly considered in patients with microalbuminuria, less frequently in patients with more advanced kidney disease. Almost the totality of participants prescribes renin angiotensin system blocking drugs for the treatment of hypertension, mainly in presence of albuminuria. This class of drugs is less frequently recommended in normotensive patients with microalbuminuria. Regarding the new anti-hyperglycemic drugs, more attention is paid for SGLT2 inhibitors or GLP-1 receptor agonist. CONCLUSIONS The present survey highlights the clinical relevance of DN and the high attention for this diabetic complication by Italian diabetologists. Although the lack of medical care provided from a team remains a main concern, the diabetologists are engaged in promoting educational and screening programs. They are also in keeping with guidelines in choosing antihypertensive treatment or new antihyperglycemic drugs showing to protect kidney function. Finally, participants to the survey declare that they are willing to collaborate with nephrologists, mainly in the more advanced stage of DN. KEY WORDS diabetes mellitus; chronic kidney disease; SGLT2 inhibitors; GLP-1 receptor agonist; diabetic nephropathy.

Development of diabetes register in low-mid income country: survey of healthcare professionals’ behavioural change wheel

Background: There has been and ongoing research and development on diabetes care in Ndokwa community of Nigeria, and one of the items to be addressed is development of diabetes register in some of the health facilities. This study assesses the behavioural change wheel of the healthcare professionals to address the willingness of the primary healthcare providers willing to scale up and sustain the diabetes register; and how glycaemic control and metabolic syndrome factors in diabetes patients were assessed.Methods: The study adopted clinical observational approach and survey questionnaires. A descriptive cross sectional method evaluated how glycaemic control among diabetes patients (n=42) was assessed. Clinical observations were at Catholic Hospital Abbi, while the survey of healthcare professionals (n=71) included health facilities in other communities. Data from questionnaire and test results was analysed using Microsoft Excel Data Analysis Toolpak 2010.Results: It is observed that 62% wished they had a diabetes register. Over 50% of the patients showed presence of >2 metabolic syndrome indices. Further, ≈52% disagreed that diet, exercise, medication, quitting smoking and less stress contributed to effective control and management of diabetes.Conclusions: Most of the respondents thought that their practice did not have a special interest in diabetes. There is prevalence of metabolic syndrome, but the majority of healthcare professionals did not view lifestyle as effective to control diabetes. These observations highlight the need for diabetic education on healthcare professionals and patients.

Solving the clinical inertia conundrum

Solving the clinical inertia conundrum

Do insulin injections make you fat?

A locum now, I work in other people’s surgeries. It can be most instructive. At one surgery I found that a very dedicated partner with a special interest in diabetes was bringing a middle-aged man with type 2 diabetes back for monthly visits. Each time his sugars were high and each time she increased his insulin. Anybody who has run a diabetes clinic will be familiar with this scenario. Increasing the insulin fails to bring down the blood sugar; it simply makes an already tubby middle-aged man fatter and fatter. But why, it crossed my mind, does insulin make people fat? We are all on insulin, whether endogenous or, as in this patient’s case, injected. So the question is: ‘How does insulin injected peripherally and subcutaneously differ from insulin released in …

264 How well established are links with allied medical and surgical specialties in CF care?

Objectives CF is a multi-system chronic disease and frequently management relies on the involvement of specialities beyond the respiratory physician. The UK CF Standards of care [1] set out recommendations around provision of specialist input from allied health professionals. The links vary amongst CF centers and we wished to assess the variability with a view to informing best practice. Methods We surveyed all 24 (83% response rate) adult CF centres and asked about links with allied health care specialities most commonly involved in CF care including diabetes, rheumatology, ENT, obstetrics, hepatology and palliative care. Results See the table. All centres have access to specialist CF diabetes services (some from diabetologists and some from members of the CF team with a special interest in diabetes). Importantly, all centres had access to the mandated specialist services, although these may be at different sites. TableAvailability of specialist servicesSpecialityAd hoc availability (%)Specialist with CF interest (%)Joint clinic (%)Diabetes00100Hepatology253540Rheumatology45505ENT45550Palliative care35650Obstetrics5905 Conclusion The links in CF diabetes appear to be best established. There is a wide variability of practice with regard to other allied specialist CF services in the UK. Whether outcomes are affected by variation in practice remains to be established.

Free to publish – Free to read

Full Text: August 2001 saw the birth of the British Journal of Diabetes & Vascular Disease (Figure 1): an open-access peer review journal.1 Free to publish and free to read. The founding editorial board and publisher (MediNews Diabetes) aimed to deliver a free journal to the diabetes team and vascular professionals with a special interest in diabetes. Despite the shifting sands of time and a change of publisher (SAGE) the journal has remained true to its founding philosophy - publication is on merit, not on ability to pay and free online access remains available worldwide (www.bjdvd.com) plus an extensive – mainly UK - print circulation. Evolution- The journal attracted much attention and was soon receiving good quality experimental and clinical science manuscripts. However it was felt that these articles, especially experimental and pre-clinical studies, were not within the focus of the British Journal of Diabetes & Vascular Disease, thus Diabetes & Vascular Disease Research was conceived –and is now also a SAGE journal and has an impact factor of 2.59. Over the years the organisation of topics has changed, for example the Healthcare management, The diabetes care team and Trans-cultural medicine sections have been absorbed into the Achieving Best Practice and Current Topics sections which better reflect the broader-based content of submitted material. Landmark Studies was a regular highly popular section – but how many truly Landmark Studies are undertaken? Not enough to warrant special attention 6 times a year for 12 years. Interestingly one of the studies reviewed is consistently amongst the top ten of our most read online articles.2 The British Journal of Diabetes & Vascular Disease has also challenged convention with the production of two Jubilee issues.3,4 The celebrations for the golden and diamond jubilees of Her Majesty Queen Elizabeth II afforded opportunities to reflect on changes in the understanding and treatment of diabetes during her reign. Most of the articles in these issues were written by authors who had first hand experience of the changing face of diabetes and vascular disease care. The increased costs of print and post – both financially and environmentally mean that digital communications are likely to become more popular (assuming that these approaches have a smaller ecological footprint). The British Journal of Diabetes & Vascular Disease is pleased to be able to celebrate its 12th birthday as an original open-access journal, with an ongoing commitment to support authors to publish free of charge whilst providing free reader access. As for what the future holds: tomorrow is another day.

Clinical Perspectives on Motivational Interviewing in Diabetes Care

During the past two decades, prolific development has occurred in the areas of medication and self-management technology options for people with diabetes. No other time period since the introduction of insulin therapy in the 1920s has seen such significant improvements in diabetes care. However, despite these improvements, there are still sizable gaps in quality outcomes for people with diabetes. These gaps in care are manifested in research reflecting that overwhelming numbers of people with diabetes do not meet guidelines for glycemic control, blood pressure, and lipid levels.1,2 These care gaps are also accompanied by challenges clinicians experience in facilitating behavior change across the entire spectrum of diabetes care: physical activity, diet, weight loss, regular use of medications, and the use of well-established algorithms linking self-monitoring of blood glucose to medication and lifestyle self-management. We, as clinicians, experience pain and frustration when our patients with diabetes develop complications that could have been delayed or prevented by enhanced self-management. But few of us received training to prepare us for the seemingly daunting tasks of working with the ambivalence, resistance, depression, and burnout that many experience living with diabetes. Few illnesses affect as many aspects of life as diabetes.3 For decades, I practiced in primary care with a special interest in diabetes. After pursuing additional training, I transitioned my practice several years ago to working exclusively in diabetes care with a special interest in the behavioral aspects of self-management. My practice now is populated by referrals from other clinicians to see people who are struggling with or completely neglecting their diabetes self-management. In this article and a second one that will be published in the next issue of Diabetes Spectrum , I will share perspectives on motivational interviewing (MI). This collaborative approach to diabetes care offers clinicians who are …

The fifth UK paediatric diabetes services survey: meeting guidelines and recommendations?

AimTo assess the provision of UK paediatric and adolescent diabetes services and examine changes in service delivery since 2002.MethodQuestionnaires were sent to the lead paediatric consultant from all paediatric and...

Elective admissions: the journey for the person with diabetes

Elective admissions: the journey for the person with diabetes

Diabetes care in Ireland: A survey of general practitioners

Aim To investigate the organisation of diabetes care in general practice in Ireland and identify areas for future development. Methods Survey of a representative sample of 600 general practitioners (GPs). The questionnaire contained closed and open-ended questions addressing 4 topics; characteristics of the practice, diabetes care delivery, use of services and opportunities for developing diabetes care. Results The response rate was 44% ( n = 262). There were an additional 86 responses to a follow-up shortened version of the survey resulting in a 58% response rate for 9 key questions. The majority of respondents were from an urban (43%, n = 112) or a mixed area (39%, n = 101) and 19% of practices were single-handed ( n = 66). The reported prevalence in participating practices was 0.7% for Type 1 diabetes and 2.8% for Type 2 diabetes. Forty-five percent of GPs maintained a diabetes register ( n = 157) while 53% reported using guidelines ( n = 140). A formal call recall system was reported by 30% ( n = 78) with a further 20% ( n = 54) reporting a regular if informal approach to calling patients for review. With regard to the use of diabetes related services 63% reported direct access to a dietician ( n = 165), 57% direct access to chiropody services ( n = 149) and 89% had direct access to retinopathy screening ( n = 234). There was a significant association between maintaining a diabetes register and other aspects of care delivery such as engaging in formal recall ( p < 0.001), using guidelines ( p < 0.001) and a declared special interest in diabetes ( p = 0.001). Of a number of choices 75% of GPs thought that training was the principal opportunity for improving diabetes care. In response to the open-ended questions GPs cited lack of resources, time constraints and workload as barriers to effective care delivery. Conclusions Delivery of diabetes care in Ireland remains largely unstructured. Key challenges to improving diabetes care appear to extend to the system and organisational level of care delivery.

The current state of general practicediabetes care in the West of Ireland

AbstractThis study aimed to assess the care provided to patients with diabetes in general practices in the West of Ireland. A postal questionnaire was sent to all 103 general practices in County Galway. The questionnaire assessed diabetes prevalence and maintenance of a diabetes register, use of guidelines for the care of diabetes, appointments systems and the provision of specialised diabetes clinics in general practice, referrals to the hospital specialist team, and opportunities for developing diabetes care.The response rate was 76%. Mean estimated prevalence of diabetes was 2.7% (range 0.1–9.5%). A diabetes register was maintained by 33% of practices. Diabetes care guidelines were used by 56%. Thirty‐five percent of practices had GP(s) and 33% had practice nurse(s) with a special interest in diabetes. Only 12% had a formal call/recall system with 41% having doctor or nurse initiated diabetes appointments. One in 10 practices reported running specific diabetes clinics.There is considerable scope for development of primary care diabetes services in the West of Ireland. Priority areas include the development and maintenance of diabetes registers, workforce enhancement through staff training in diabetes care and the adoption of best practice guidelines. All of this will require additional resources and incentives for GPs. Copyright © 2009 John Wiley &amp; Sons.

Decision‐making: initiating insulin therapy for adults with diabetes

This paper is a report of a study to describe nurses' perceptions of decision-making and the evidence base for the initiation of insulin therapy. Several theoretical perspectives and professional's attributes underpin decision-making to commence insulin therapy. The management of type 2 diabetes is moving from secondary to primary care and this affects how clinical decisions are made, by whom and the evidence base for these decisions. A postal survey was conducted with a stratified sample of 3478 Diabetes Specialist Nurses and Practice Nurses with a special interest in diabetes across the four countries of the United Kingdom. A total of 1310 valid responses were returned, giving a response rate of 37.7%. The questionnaire was designed for the study and pilot-tested before use. Responses were given using Likert-type scales. Data were collected during 2005 and 2006, and one reminder was sent. People with diabetes are seen as having little influence in decision-making. Consultant physicians appear to be influential in most decisions, and the nursing groups held varying perceptions of who made clinical decisions. Nurses' identified different responsibilities for those working solely in secondary care from those working in both community and secondary care. Practice nurses were not as involved as anticipated. Nurses working with people with diabetes need to encourage them to become more active partners in care. Clinical guidelines can assist in decision-making where nurses are least experienced in initiating insulin therapy.

Congenital rubella, diabetes and HLA

Keywords Congenitalrubella.HLA.Type1diabetes.VirusAbbreviationCRS Congenital rubella syndromeTo the Editor: In a recent Editorial, Edwin Gale reviewedthe congenital rubella syndrome (CRS) and the postulatedrole of viruses in type 1 diabetes, pulling together most ofthe literature that links congenital rubella and diabetes [1].He concluded that the case appears sound for type 2diabetes, but is at most only suggestive for type 1 diabetes.However, he did not reveal the whole story, in particular,the evidence for HLA associations with diabetes in CRS.Gale quotes Menser et al. [2] on the incidence ofdiabetes following CRS, but fails to mention that theseinvestigators also reported that the HLA A1-B8 haplotypewas present in 44% (eight out of 18) of their CRSparticipants with diabetes. HLA A1-B8 was first docu-mented as being increased in frequency in insulin-depen-dent diabetes just 2 months earlier in the same journalin 1974 [3]. In the CRS participants, this haplotype waspresent in 75% (three out of four) who were insulin-dependent, with ages at onset of 1.5, 12, 12 and 24 years,and in 36% (five out of 14) who were on oral agents or dietalone, with ages of onset of 28–34 years. The frequency ofHLA A1-B8 in the background white population is 10%.Gale states that these studies were carried out ‘by authorswith no special interest in diabetes’, but in fact co-authorJ.A. Burgess was, and still is, a diabetologist.HLA A1-B8 (-DR3-DQ2) is the classic autoimmunehaplotype—associated not only with susceptibility to type 1diabetes in the non-CRS population but also with otherautoimmune diseases such as myasthenia gravis, systemiclupus erythematosus, chronic active hepatitis and coeliacdisease—and has been associated with the epidemiology ofrubella [4, 5]. The CRS–diabetes–HLA association wasconfirmed in the New York cohort of 274 patients [6]. Inthis case, Gale acknowledges the high rate of insulin-requiring diabetes following the rubella epidemic of 1964–1966 in New York, but judges that ‘given the interest of theinvestigators, the sample may have included a dispropor-tionate number of children with diabetes’, and, ‘ascertain-ment bias may have contributed to this very high rate, whichis otherwise unexplained’. In the context of a critical eval-uation of the literature, these statements appear distinctlysubjective. The New York data strengthened the associationof CRS with type 1 diabetes, because not only was thefrequency of HLA DR3 higher in the CRS patients, but alsothe frequency of HLA DR2, known to be protective againsttype 1 diabetes in non-CRS populations [7], was decreased.Further evidence for an autoimmune mechanism in CRS-associated diabetes comes from other studies not includedin the review. These demonstrated that T cell clones fromboth CRS and non-CRS type 1 diabetic individuals, raisedin response to epitopes in the islet autoantigen glutamicacid decarboxylase, reacted to peptides from rubella virus[8]. There are several cogent reasons why CRS could haveset the stage for type 2 diabetes. Babies with CRS were‘small for dates’ and had a reduced beta cell mass, and may

Do characteristics of practices and general practitioners influence the yield of diabetes screening in primary care? The ADDITION Netherlands study

Objective. To investigate whether the yield of population-based diabetes screening is influenced by characteristics of the general practitioner (GP) and the practice. Design. Cross-sectional study. Setting. Seventy-nine general practices in the south-western region of the Netherlands. Subjects. From 2002 to 2004, 56 978 people were screened for diabetes. GPs completed a questionnaire containing items on the GP (age, gender, employment, special interest in diabetes, providing insulin therapy) and the practice (setting, location, number of patients from ethnic minority groups, specific diabetes clinic, involvement of practice assistant, practice nurse or diabetes nurse in diabetes care). Main outcome measures. The ratio screen-detected diabetic patients/known diabetic patients per practice (SDM/KDM) and the number of detected diabetic patients per practice adjusted for practice size and age distribution (SDM per standardized practice). Results. The yield of screening per practice varied widely. Higher age of the GP (regression coefficient 0.20; 95% confidence interval, CI 0.07–0.34), urban location (−4.60; 95% CI −6.41 to −2.78) and involvement of the practice assistant (2.27; 95% CI 0.49–4.06) were independently associated with SDM/KDM. Using the other outcome variable, results were similar. Additionally, cooperation with a diabetes nurse was associated with a lower yield. Conclusion. A lower yield of screening, reflecting a lower prevalence of undiagnosed diabetes, was found in practices of younger GPs and in urban practices. A lower yield was not associated with an appropriate practice organization regarding diabetes care nor with a specialty of the GP in diabetes. The wide variation in the yield of screening stresses the importance of a screening programme in each general practice.

Share good practice

It's been an interesting few weeks for diabetes. As rosiglitazone hits the headlines for all the wrong reasons, there is exciting news about the possible role of thiamine in preventing complications. There has also been much discussion about a Healthcare Commission report (2007) on the state of diabetes services in primary care trusts (PCTs). The report suggests that the majority of PCTs are failing to provide a ‘good’ or ‘excellent’ level of service to patients with diabetes. As a nurse practitioner and academic clinical lead with a special interest in diabetes, I found this discouraging. However, my suspicion is that these figures do not reflect the experiences of many practitioners and patients, and that, rather than be disheartened, we should see this as an opportunity to demonstrate and share innovative ways in which we are developing care.

The metabolic syndrome in China

The metabolic syndrome is a cluster of abnormalities including obesity, dyslipidaemia, abnormal blood glucose and raised blood pressure [1]. Reaven drew attention to this syndrome, which he called syndrome X [2]. Its importance is increasingly recognized in recent years because it predicts cardiovascular disease and the development of diabetes [3–6]. The metabolic syndrome is heterogeneous, so no definition is entirely satisfactory. The World Health Organization (WHO) proposed a definition in 1998 [7]. In 2001, the third report of the National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel) (NCEP-ATPIII) defined it in terms of waist circumference, blood pressure and blood biochemistry [8, 9]. In 2005, the International Diabetes Federation (IDF) made abdominal obesity a prerequisite in the definition [10]. The WHO definition is difficult to embrace because glucose tolerance tests and measurement of insulin sensitivity are seldom performed in clinical practice. In the USA, the revised NCEP and the IDF definitions are quite consistent, with 92.9% agreement [11]. In other ethnic populations, such as Asians, the new ethnic-specific waist circumference criteria may slightly increase the prevalence of the metabolic syndrome [12].

Diabetes services in the UK: fourth national survey; are we meeting NSF standards and NICE guidelines?

Background: Previous surveys of children’s diabetes service provision in the UK have shown gradual improvements but continuing deficiencies. Aim: To determine whether further improvements in services have occurred. Methods: A...

Factors affecting the quality of diabetes care in primary health care centres in Tunis

We have conducted a retrospective medical record review of a random sample of 580 patients with diabetes from 12 primary health care centres (PHCCs) in Greater Tunis. The aim was to assess the quality of diabetes care in PHCCs and to explore factors associated with quality of care. Data were collected concerning patient characteristics, health centre characteristics and process of care criteria. In our sample, recording of care varied significantly between the health centres for all of the process of care criteria studied. Factors significantly associated with improved recording of care were younger patient age (found in 5 of the 10 process of care criteria), use of the new medical records (8 of the 10 criteria), urban health centres (8 of the 10 criteria) and those centres with a doctor with a special interest in diabetes (7 of the 10 criteria). Gender and socio-economic status were not found to be associated with recording of care. The quality of diabetes care in Greater Tunis varies widely between PHCCs and a number of associated factors have been highlighted. A fuller understanding of quality of care within the context of the patients’ environment is essential in order to develop appropriate health interventions.

The ABCD lecture. The diabetes NSF—what is the role of the consultant physician‐diabetologist?

Sue Roberts thought there had never been a better time to help improve the lot of people with diabetes. She acknowledged that it did not always feel like that to those who were working in the specialist diabetes services so she wanted to make clear that she thought it would be impossible to deliver the Diabetes NSF if diabetes specialists were not properly valued. On the negative side, there were problems with recruitment, the stress and strain of having to balance the service demands of general medicine and diabetes, the long wait for the NSF, and concerns about the shifting of focus to primary care and the impending European Working Time Directive. But diabetes could surely capitalise on new DoH thinking about the importance of chronic disease management (CDM) and self-management. Systematic care, originally developed by specialist diabetologists, was seen to be capable of handling very large populations and had taken on a life of its own, away from hospital-based diabetologists. The reasons were of course the epidemic of diabetes and the huge variations in services and outcomes, particularly in ethnic and lower socio-economic groups. NSF targets for systematic care had to be delivered by 2013. Systematic care meant traditional and familiar surveillance and intermediate outcome programmes. The patient-centred approach was reflected in the requirement that every patient should have a named contact, structured education and a care plan. How was the vast task to be addressed? Dr Roberts felt the first thing to do was to set up a Local Implementation Team. This would comprise all those involved in diabetes care in a natural community, including patients, primary care and of course the diabetes specialist. Dr Roberts thought that there would be a wide variety of diabetes networks set up round the country but they would only be successful if they got the power relationships within the NHS right. Specialist care must reconfigure to acknowledge the fact that within 10 years 85% of CDM would be carried out in primary care. New models were being developed already in different parts of the country. These included hospital-led intermediate care outreach programmes and PCT-led initiatives of community diabetologists and GPs with a special interest in diabetes. In terms of the patient's life journey through diabetes, it was obvious that the specialists worked very largely at the expensive end. It would be better to put efforts and resources into the other end. Specialists within a new integrated system would continue to assess the most complex multi-dimensional problems and to manage specialist disease areas such those arising in children and pregnancy. Specialists would co-ordinate and quality assure all the programmes and would run education and training, help to get evidence into practice, co-ordinate joint evaluation and take part in research and development. Above all, they could contribute leadership. Thanking Sue Roberts for her very informative talk and answers to questions, Dr Greenwood said it would have been obvious to her that there was enormous apprehension and anxiety amongst ABCD members about the NSF and the possible dumbing down of the specialist service. Would it be of use if the Association were to provide examples of what was happening? Dr Roberts said she would be very interested in receiving such information. She had no direct powers but could work on the DoH environment so as to improve the chances of better local solutions.