The skinny bell curve

One size does not fit all.

We know that it is the combination of achieving the 3 treatment targets that has the best benefit for people with diabetes. Achieving the combination will keep people with diabetes healthier for longer and reduce complications.

This is why the 3 treatment targets are one of the two diabetes indicators in the CCG Improvement and Outcomes Framework that was published on the 31st of March.

“Diabetes patients that have achieved all the NICE-recommended treatment targets: Three (HbA1C, cholesterol and blood pressure) for adults and one (HbA1C) for children.”

As a manager, I am getting perilously close to talking about things that are for trained clinicians.  However, it is important that managers have a rudimentary understanding in order to have a reasonable level of conversation with clinicians.

What is imperative to tackling this CCGIAF indicator is the absolute necessity for clinicians and managers to unpack, understand what this indicator is trying to achieve.

What this discussion will reveal is that that everyone is different.  What treatment targets might be right for one might not be right for another. NICE Guidance and CCGIAF indicators cannot possibly accommodate the richness of the individual.

NICE Guidance is very clear that the first consideration is: “1.1 Individualised Care”.  The first sentence in the guidance states:

“Adopt an individualised approach to diabetes care that is tailored to the needs and circumstances of adults with type 2 diabetes, taking into account their personal preferences, comorbidities, risks from polypharmacy, and their ability to benefit from long‑term interventions because of reduced life expectancy.”

In particular, if this indicator is not discussed robustly there is the potential of misunderstanding what needs to be achieved.   Driving people’s treatment targets down en-masse without considering the individualised needs will have detrimental affects.

In particular, treatment targets may need to be varied for older people with diabetes.

The International Diabetes Federation Guidance for older people with type 2 diabetes is very clear (Page 31):

The different HbA1C treatment targets recognise the different, individualised needs of older people with diabetes in particular to prevent hypoglycaemia.

Okay, okay.  I’ll shut up now.  I am out of my depth.  My point is that discussion with you clinical teams is imperative.  It will show that what is required is the narrowing of the bell curve.  A subtle but important distinction to ensure the indicator improves care and outcomes rather than worsen them.