Inequalities in provision of systematic care for patients with diabetes

GPs are now playing a greater role in the care of people with diabetes; however, the level of performance in primary care is variable. Practices with a recall system and diabetes mini-clinic have been shown to achieve better outcome of care of patients with diabetes. Systematic care also requires effective community-based diabetes services and access to primary care diabetes teams including dieticians, chiropodists, and optometrists and ophthalmologists.

The aims of this study were to determine how services for people with diabetes are organized in primary care and whether there are inequalities in systematic care of people with diabetes.

A piloted postal questionnaire was sent to all 327 general practices in three health authorities in England serving a population of >2 million people. The three health authorities provided practice-based routine data relating to all general practices.

A total of 264 (80.7%) practices replied; 236 (89.4%) employed a diabetes recall system and 196 (74.2%) reviewed their patients in a diabetes mini-clinic. Multiple regression showed that having a recall system was associated independently with a GP [odds ratio (OR) 6.2; 95% confidence interval (CI) 2.6-14.9] or a practice nurse (OR 3.5; 1.4-8.7) with an interest in diabetes. Having a diabetes mini-clinic was associated independently with a GP with an interest in diabetes (OR 4.1; 2.1-7.8), a practice nurse having attended a diabetes course (OR 2.8, 1.3-6.2), practices with more partners (OR 1.2 per additional partner; 1.0-1.4) and fundholding practices (OR 2.6; 1.2-5.5). One hundred and sixteen (43.9%) practices had a chiropodist present in the practice, and 90 (34.1%) had a practice-based dietician. A chiropodist and a dietician were significantly more likely to be attached in training practices and in less deprived areas. A practice-based dietician was significantly associated with larger practices.

Providing high quality primary care is essential to meeting the government's agenda of reducing inequalities. This study shows high levels of structured diabetes care which are not related to deprivation. However, practices in more deprived areas still lag behind practices in more affluent areas in terms of access to members of the diabetes team. To improve care of people with diabetes in primary care, deficiencies and inequalities highlighted in our survey must be addressed. The results of this survey will be valuable to primary care groups and organizations responsible for commissioning diabetes services.