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BMJ. May 16, 1998; 316(7143): 1505–1506.

Shifting of care for diabetes from secondary to primary care, 1990-5: review of general practices

Elizabeth C Goyder, MRC/Trent training fellow in health services research,a Paul G McNally, consultant physician,b Michael Drucquer, general practitioner,c Nicola Spiers, medical statistician,a and Johannes L Botha, senior lecturer in epidemiologya

An annual and comprehensive review is regarded as a crucial element of structured diabetes care,1,2 and general practice is increasingly providing this service.3 Developments in diabetes care in general practice have been encouraged by changes in national policy, which since 1993 have included specific payments for doctors offering structured diabetes care, and local initiatives including diabetes education programmes and multipractice audits.

We examined attendance by diabetic patients at outpatient clinics and general practices between 1990 and 1995 to determine whether there had been a change in the proportion of patients with diabetes reviewed in primary and secondary care. The practices were running diabetes programmes that qualified for payments for management of chronic diseases in 1995.

Subjects, methods, and results

Of 10 general practices selected at random in the city of Leicester, seven agreed to participate, and five of them had organised diabetes care programmes. The two other practices did not organise routine review for their patients with diabetes and were excluded from this analysis. Five hundred and fourteen adult patients (1.53% of the total population) who had diabetes diagnosed before 1995 and were still registered at the end of 1995 were identified from prescribing records and practice registers. Dates of diagnosis, visits to diabetes outpatient clinics, and diabetes reviews in general practice were extracted from general practice records between February and June 1996. A diabetes review in general practice was defined as a contact with a doctor or nurse, including examination for at least three potential complications or risk factors—for example, retinal examination, foot examination, urine analysis, weight, and blood pressure. Visits related only to diabetes control were therefore excluded.

The table shows trends in patterns of care. Overall, the proportion of patients reviewed annually in general practice doubled from 17% (48/282) in 1990 to 35% (180/514) in 1995, and the proportion seen in diabetes outpatient clinics fell from 35% (99/282) to 30% (155/514). The patients seen in both primary and secondary care in the same year fell from 6% to 2%, and the proportion reviewed in neither setting decreased from 54% to 37% (table). Of the 282 patients diagnosed before 1990 and still registered at the end of 1995, 42 were reviewed in general practice in 1990 and 84 in 1995 (P<0.001 by McNemar’s test). The proportion of newly diagnosed patients (n=232) reviewed in general practice in the year after diagnosis also increased over the same period (P=0.001 by χ2 test for trend), and the number of new cases diagnosed annually increased from 36 in 1990 to 60 in 1994 (P=0.02).


This study shows an increase in both case finding and the proportion of patients with diabetes being reviewed within general practice. This finding applied to both newly diagnosed cases and to those diagnosed before 1990. However, the proportion of patients being seen in outpatient diabetes clinics did not fall proportionally. Greater activity in primary care may increase the pressure on hospital services through increased detection of problems requiring referral,4 but we found no evidence that the number of patients seen in general practice and outpatient clinics in the same year had increased.

As with other recent changes in general practice activity,5 the previously unmet needs of patients are more likely to be met than care being shifted from  outpatient clinics to general practice. More than a third of patients were not reviewed at all in 1995, so the scope for increasing activity in general practice is large but unlikely to be easily funded by taking resources from secondary care.

Numbers (percentages) of patients with diagnosed diabetes reviewed in general practices and diabetes outpatient clinics between 1990 and 1995


We thank all the general practices and patients with diabetes who contributed to the study.


Funding: ECG was supported by a training fellowship in health services research funded by the Medical Research Council and Trent regional office.

Conflict of interest: None.


1. Krans HMJ, Porta M, Keen H. Diabetes care and research in Europe: the St Vincent declaration action programme. Copenhagen: World Health Organisation; 1992.
2. Marks L. London: British Diabetic Association; 1996. Counting the cost: the real impact of non-insulin dependent diabetes.
3. Leese B, Bosanquet N. Change in general practice and its effects on service provision in areas with different socioeconomic characteristics. BMJ. 1995;311:546–550. [PMC free article] [PubMed]
4. Alexander W, Ward J. Primary and specialist care in diabetes. Lancet. 1997;349:578. [PubMed]
5. Lowy A, Brazier J, Fall M, Thomas K, Jones N, Williams BT. Minor surgery by general practitioner under the 1990 contract: effects on hospital workload. BMJ. 1993;307:413–417. [PMC free article] [PubMed]

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