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A GP’s Practical Perspective of Diabetes Care in Southall

A GP’s Practical Perspective of Diabetes Care in Southall. Dr A K Sandhu. Motivation / Vision. Glimpse of care in Southall / 1992. Challenges ?. The “INVERSE CARE LAW”. Change the delivery of patient care Challenge the Inverse Care Law Create society with improved health awareness.

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A GP’s Practical Perspective of Diabetes Care in Southall

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  1. A GP’s Practical Perspective of Diabetes Care in Southall Dr A K Sandhu

  2. Motivation / Vision • Glimpse of care in Southall / 1992

  3. Challenges ? • The “INVERSE CARE LAW”

  4. Change the delivery of patient care Challenge the Inverse Care Law Create society with improved health awareness My Vision

  5. How ? • Educating the patients with goal oriented advice • Emphasising on Primary Prevention of Diabetes • Providing the self monitoring tools to patients

  6. Practice Diabetes Care New Diabetes pt Registration / Identification Practice Nurse Seen by Clinicians GP • All needed Education and Advice given. • Baseline tests taken Review after 3 months with blood test reports. Review.

  7. Diet Exercise Weight Other factors Continue monitoring progress Thereafter always give goal orientated education and advice. uncontrolled controlled Lifestyle Advice Monitor 4-6 weekly • Dietetic Advice • Podiatry Care (Annually) • Health / Physical activity promotion

  8. Practice Based Staffing • Dieticians • Health Care /Physical Activity Educators • Clinicians trained in Diabetes Care • Podiatrist • Dedicated Reception Team

  9. Audit • Monitoring monthly audits • Outcomes (62% of patients achieved HbA1c ≤ 7.4% in May 2004)

  10. Belmont Health CentreDiabetes QOF for May 2004

  11. Southall Health Improvement Project (SHIP) • Health promotion for the Community in Southall (evidence available)

  12. What’s new • SHIP link with GP network (last Wednesday of every month) • One of the areas to be covered will be Diabetes Risk Assessment targeting 16-35 year olds

  13. Local provision – what’s needed ? • Gap between Primary and Secondary Care needs to be bridged by improving communication systems (GP education seminars / regular updating and evaluation meetings) • Cohesion in services provided both in Primary and Secondary care - by Clinicians, Diabetes Specialist Dietetics, Physical Health Educators and Pharmaceutical companies working together, under the organised project of Diabetes Risk Assessment Framework.

  14. Diabetes nGMS vs Practise Diabetes care

  15. Diabetes nGMS Targets Vs Achievements

  16. 0 0

  17. Incidence of Myocardial Infarction • 3 patients (0.1% of total practice patient population) had a Myocardial Infarction event from April 2003 till 2004 • Of these three patients 1 patient from the diabetic population experienced a MI event during this period

  18. Why try better care ? • Rewards both for the patient and the team • More cost effective for the NHS / Social Services at various levels

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