DOI: 10.1046/j.1464–5491.2003.01063.

Specialist general practitioners and diabetes clinics in

Specialist
Original article
Oxford, UK
Diabetic
DME
Blackwell
1464-5491
20 Article
GPs and Ltd,
Medicine
Publishing
Science diabetes
2003clinics in primary care A. Nocon et al.
Ltd.

primary care: a qualitative and descriptive evaluation

A. Nocon, P. J. Rhodes, J. P. Wright, J. Eastham*, D. R. R. Williams†, S. R. Harrison‡ and
R. J. Young§

Abstract
Department of Clinical Epidemiology and Public Aims The aim of this study was to evaluate an innovative approach to the provision
Health, Bradford Hospitals NHS Trust, Bradford, of primary care-based diabetes services in Bradford, UK. The service model differs
*Nuffield Institute for Health, University of Leeds,
Leeds, †The Clinical School, University of Wales from others in comprising 19 clinics which offer a specialist service, intermediate
Swansea, Swansea, ‡Department of Applied Social between primary and secondary care, to all patients within the Bradford area.
Science, University of Manchester, Manchester, and
§Department of Diabetes and Endocrinology, Methods The study included: analysis of referral, attendance and register data;
Salford Royal Hospitals NHS Trust, Salford, UK questionnaires to general practitioners (GPs) and specialist clinic providers;
Accepted 6 May 2003 qualitative interviews with clinic and other professional staff and patients; and
an economic analysis.
Results The 19 clinics adopt a range of organizational models. In the first
31/2 years, 2415 patients were referred. There was a significant reduction in out-
patient attendances at hospital, but also a significant increase in overall patient
attendances. Specialist clinic patients differed from hospital patients in being older
and having had diabetes for longer since diagnosis. Ten of the 14 clinics run by
practising GPs attracted more referrals from within their practices than from
outside. GPs and patients across the city believed the clinics were valuable, the
main benefits being geographical accessibility, availability of specialists in a com-
munity setting, short waiting times for first appointments at most clinics, and
continuity of staff. Their reservations included a lack of strategic planning in
the location of clinics, long waiting times at some clinics, and poor communica-
tion at some clinics with referring GPs. The cost of the primary care clinics is
similar to hospital clinics.
Conclusions This model of specialist primary care services offers an opportunity
to develop diabetes services that are convenient to patients, popular with prac-
titioners, and increase capacity. However, the shortcomings as well as the advant-
ages of the model need to be addressed if it is to be implemented elsewhere or
for other patient groups.
Diabet. Med. 21, 32–38 (2004)
Keywords specialist general practitioners, primary care, quality, hospital demand

who need them. This has led, in both affluent and less developed
Introduction countries, to examination of ways in which services could be
The increasing prevalence of diabetes highlights the urgency of reconfigured, frequently with an emphasis on the development
ensuring that appropriate services are accessible to the patients of primary care services. In the UK, the concept of specialist
general practitioners (GPs) and clinics in primary care has
attracted increasing interest and support. Professionals
Correspondence to: Professor John Wright, Department of Clinical
Epidemiology and Public Health, Bradford Hospitals NHS Trust, Bradford BD9 welcome it as a means of providing local services for patients
6RJ, UK. E-mail: [email protected] and developing specialist clinical interests [1,2]. Planners and

32 © 2003 Diabetes UK. Diabetic Medicine, 21, 32–38

 Original article 33

politicians see the potential to reduce pressure on over-stretched operation, relationships with other GPs and with the hospital,
secondary care and to meet increasing demand [3,4]. the benefits of the clinics, and problems that still needed to be
Well-organized primary care can be as effective as second- addressed. A separate questionnaire was sent to all (142) GPs out-
ary care in relation to follow-up and metabolic control, but side the specialist clinic practices about their referral practice,
standards are variable [5,6]. It is essential that primary care relationship with the clinics, and assessment of the clinics’
advantages and shortcomings. This was followed by face-to-face
should meet the standards in the National Service Framework
and telephone interviews with a sample of eight GPs (including
for Diabetes, which include comprehensive, high-quality, par-
six non-respondents to the questionnaire) and two practice
ticipative and supportive care in managing diabetes (standard nurses (nominated by GPs as responsible for diabetes clinics in
3) and regular surveillance for the long-term complications of their practices), in order to examine the issues in more depth.
diabetes (standard 10) [7,8]. Semistructured interviews were undertaken with 55 patients (in
There are a number of models of specialist diabetes services their own homes, places of work, or the researchers’ offices) to
within primary care in the UK [4,9,10]. The development of explore their experiences of diabetes and of health services:
shared disease management, rather than the traditional demar- names were selected at random from the diabetes register
cation between primary and secondary care, provides models following purposive sampling to include different age groups,
for primary care involving specialist practitioners, team- ethnic origin and care locations, and 26 interviews were carried
working, and a graded system of responsibility based on existing out in South Asian languages. Economic analysis used data
from the diabetes register, the clinics’ activity database, expend-
expertise, though clear role definition and avoidance of both
iture data for service components and professional groups, and
duplication and gaps in care are essential [9,11–13]. This study
information from laboratory and pharmacy systems. Project
reports on the evaluation of a service model which involves the management included a multidisciplinary steering group with
provision of secondary care services in a primary care setting service user representation, a mixed service users’ advisory group,
by specialist primary care teams. and an Asian women’s advisory group for participants who did
In Bradford, specialist diabetes clinics led by GPs with a not speak English [14,15].
special interest in diabetes were established in 1998 to alleviate Semistructured tape-recorded interviews with patients were
increasing waiting times for secondary care following the based on closed questions and a detailed topic guide: these were
retirement of a hospital diabetologist and a delay in recruiting necessary in order to undertake comparable interviews in South
a successor. Health Action Zone status provided the resources Asian languages using bilingual interviewers. Interviews in Eng-
to finance 19 clinics, with support from diabetes specialist lish were partially transcribed. Those with South Asian patients
were fully transcribed and translated by the interviewers.
nurses, part-time podiatrists and dieticians, and community-
Coding and analysis were undertaken jointly by two members
based retinal screening cameras. The clinics serve three Pri-
of the research team using Text Detective software. Analysis
mary Care Trusts (PCTs) with a population of 380 000, 32% followed a framework approach [16], based on themes both
of whom are registered with practices that have specialist clin- pre-identified and emergent from the interviews. Themes were
ics. Training initially consisted of a 2-day workshop for GPs; discussed with service users at advisory group meetings.
more frequent workshops were subsequently introduced, with Quantitative data were analysed using SPSS (SPSS Inc., Chicago,
some sessions for GPs to discuss individual cases with consult- IL, USA), which generated descriptive statistics. Townsend
ants and others open to other healthcare professionals. deprivation scores were calculated from postcode data [17].
The clinics are for patients with: (i) insulin-treated diabetes— Changes in hospital attendances during three 1-year periods
newly diagnosed; (ii) insulin-treated diabetes with poor (1 year before introduction of specialist clinics, introductory
control (for stabilization); (iii) insulin-treated diabetes—for year and second year) were analysed using one-way ANOVA.
review and follow-up; (iv) non-insulin-treated diabetes—
for transfer to insulin and referral back to practice; (v) non-
Results
insulin-treated diabetes—receiving maximum oral therapy;
HbA1c > 9% (for control). Clinic operation

Two of the specialist clinics were run by a community diabet-

Methods
ologist (on a sessional basis on behalf of two GPs), one by a
The evaluation was carried out between 1999 and 2001 and diabetes specialist nurse, three by a former GP (two later taken
used a range of sources. Data were extracted on referrals to and over by GPs working outside their own practices), and 13 by
attendance at the specialist clinics (from a dedicated clinic data- GPs in their own practices. The clinics ran from one to four
base) and the hospital out-patient clinics (from the Trust’s PAS times a month and lasted around 3 h, with a target attendance
database). Characteristics of patients were obtained from the
of eight patients per clinic. Clinical support was provided by the
Bradford diabetes register, containing data on 12 000 patients
community diabetologist. Diabetes specialist nurses attended
receiving care in primary and secondary care locations. Inter-
views were conducted with 24 specialist clinic and other profes- 13 of the 19 clinics regularly and two further clinics occasion-
sional staff to gain familiarity with clinics’ operation and staff’s ally; in the remainder, practice nurses worked alongside GPs.
views. A detailed questionnaire was sent to the 19 specialist The role of diabetes specialist nurses varied from working
clinic providers to obtain information about staffing, clinic alongside the GP to running the clinic with the practice nurse.

© 2003 Diabetes UK. Diabetic Medicine, 21, 32–38

 34 Specialist GPs and diabetes clinics in primary care • A. Nocon et al.

Figure 1 Trends in patient attendances at hospital and specialist primary care clinics.

Podiatrists and dieticians were available at approximately populations) had developed waiting lists for first appointments,
every other session at 13 clinics, at other clinics less frequently reflecting the hospital situation that the clinics were set up
or not at all. Team-working was variable, with some profes- to address—in the 2 years from October 1999, 16% of all
sionals excluded from case discussions and service planning at new hospital patients waited > 12 weeks for an out-patient
some clinics. Some clinics offered on-site eye testing, some appointment. Overall, non-attendance rates in 2000 at the
offered domiciliary visits, some employed interpreters. specialist clinics stood at 25%, with a range of 12–37% at
different clinics: higher non-attendance rates were recorded at
inner-city clinics with high minority ethnic populations. The
Referrals and attendances
total number of attendances at the clinics was 3809. Non-
From April 1998 to September 2001, 2415 referrals were attendance at the hospital out-patient department was 19%
made to the clinics, of which 42% were internal referrals from during the same period, with 2405 actual attendances, even
GPs within the clinic practices. Of the remaining 58%, half though hospital follow-up procedures were more limited than
were to the 13 specialist GPs based in their own practices and those at the clinics.
half to the other six clinics run by non-GPs or, more recently,
to GPs based outside their own practices, all of which were in
Register data
inner-city locations with high demand. Only four of the clinics
led by GPs in their own practices received more external than Table 1 provides information on the characteristics of the
internal referrals. patients attending the specialist clinics and hospital service.
As at August 2001, 2067 patients were attending the clinics Specialist clinics provide access to a higher proportion of
(17% of all patients on the diabetes register), 1746 attended patients from non-white ethnic minorities. This difference is
the hospital (14%), and 8359 received care from their GP statistically significant [χ 2 = 12.7, P < 0.0001)]. There was no
or mini-clinic (69%). Figure 1 shows the trends of hospital significant difference in the Townsend deprivation scores of
and primary care clinic attendances. Mean monthly hospital specialist clinic and hospital patients.
attendance fell from 478.5 in the year preceding specialist We were unable to use the register data to evaluate either
clinics (1997/1998), to 396.8 in the introductory year and 361.6 process or biomedical outcomes for patients attending the
in the second year (1999/2000), a 25% reduction (F = 13.0, specialist clinics, as problems with incomplete data entry and
P < 0.0001). There was no significant fall in numbers of new inconsistencies in practice information led to major concerns
referrals to or new attendances at the hospital. The mean monthly over their accuracy, while over-writing of information made it
number of attendances in hospital and specialist clinics impossible to track patients who moved between different care
combined was 648.1 by 1999/2000, an increase of 35% (169.6; locations. Clinic providers did, however, extract data for
95% confidence interval 109.5, 229.6) from 1997/1998. 2000 from individual practice databases, which were then
Recorded attendance at the clinics has varied between two aggregated by PCT. According to these, HbA1c was measured
and 20 patients, with some clinics consistently running at low for 99 –100% (depending on PCT) of patients attending the
or high levels of activity. Three clinics (initially run by the specialist clinics, blood pressure for 99–100%, cholesterol
former GP, in inner-city areas with high minority ethnic 86 –99%, foot examination 78 –79%, and retinal screening

© 2003 Diabetes UK. Diabetic Medicine, 21, 32–38

 Original article 35

Table 1 Characteristics of patients Reasons for not referring included: patients’ preference for
hospital (17 respondents), unknown quality of care (11), lack
Specialist clinics Hospital clinic
of transport (8), inconvenient locations for patients (6), and
Patients (n) lack of confidence in the skills of specialist clinic staff (4). One
Type 1 203 440 PCT restricted referrals to clinics within the trust, even though
Type 2 1757 1250 patients might live nearer to clinics outside the PCT boundary.
Age (years) Most (84%) GPs who responded (including 97% of those
Type 1 median 35 31 who had made referrals) stated, in response to a closed ques-
IQR (Q1–Q3)* 28 –45 17–43 tion, that the clinics were providing a valuable service, 4%
Type 2 median 64 63 disagreed, and the remainder gave no opinion. In response to an
IQR (Q1–Q3) 53–72 52–71
open-ended question, they cited a range of benefits and criti-
Age at onset (years) cisms (Box 1). These were corroborated in the interviews. Five
Type 1 median 18 14
GPs selected a specialist clinic in the belief that the clinic would
IQR (Q1–Q3) 11–25 9–23
Type 2 median 53 49 not ‘poach’ patients: the fear that patients would register with
IQR (Q1–Q3) 44–62 40–59 the clinic practice was cited in other interviews as a concern for
GPs. The potential for GP deskilling was raised by both spe-
Duration (years)
Type 1 median 18 13 cialist GPs and diabetic specialist nurses, who expressed con-
IQR (Q1–Q3) 9 –29 6–25 cern about the inappropriate referral of patients who did not
Type 2 median 8 10 need specialist care. Lack of back-up from, or integration with,
IQR (Q1–Q3) 4–13 5–17 secondary care was mentioned by some GPs and in discussions
Ethnicity (Types 1 and 2) with other professionals. There was also some concern about
Percentage of patients: White 56.0% 61.9% lack of clarity about the respective roles of referring GPs and
Non-white 44.0% 38.1%
specialist clinics, which meant that duplication and omissions
*IQR, Interquartile range expressed in terms of the values Q1 (first could occur. For example, responsibility for managing associ-
quartile, or 25th percentile) and Q3 (third quartile, or 75th percentile). ated factors (such as hypertension or cholesterol) was not set
out in advance. It is important to note that most GPs’ views
were based on their contacts with their nearest specialist
68 –73%. Within the first 3 years of operation, over 700 clinics, rather than the full range of clinics.
patients attending the clinics were started on insulin therapy
within the community.
Patients’ views

Twenty-four of the interviews with service users were with

GPs’ views
patients attending the specialist clinics. The majority spoke
Of 85 GPs outside the clinics who completed the questionnaire positively about the clinics, often comparing them favourably
(60% response rate), 84% had made referrals to the clinics. with their experiences of hospital care; their evaluation

Box 1 General practitioners’ views of specialist clinies

Advantages
I Geographical convenience for patients
II Access to specialists in a community setting
III Short waiting times for first appointments
IV Continuity of and familiarity with staff
V Sufficient time for patients in appointments
VI The availability of diabetes specialist nurses
VII A range of services on the same site
VIII Improved diabetic control, compared with standard GP care
IX Better communication with GPs, compared with hospital
Criticisms
I Lack of planning in location of clinics
II Long waiting times for first appointments (for three clinics)
III Poor communication with referring GPs
IV Lack of information provided about the clinics
V Concerns about the quality of care from specialist GPs (both general concerns and in relation to individual patients)
VI Confusion over clinics’ and referring GPs’ responsibilities for patient care
VII Concern about the potential for ‘poaching’ of patients
VIII Concern over the potential for atrophy of relevant clinical skills in non-specialist GPs

© 2003 Diabetes UK. Diabetic Medicine, 21, 32–38

 36 Specialist GPs and diabetes clinics in primary care • A. Nocon et al.

Box 2 Patients’ views of specialist clinics

Advantages
I More frequent and more convenient appointments
II Shorter waiting times
III Clinics nearer to people’s homes
IV Easier parking
V A more friendly and personal service
Criticisms
VI Inconvenience of having to make a separate appointment with an optician for an eye examination
VII No facility for contact with a consultant diabetologist on a regular basis
VIII Lack of cover outside clinics, other than through the diabetes specialist nurses
IX Telephone calls to the diabetes specialist nurses being met by an answering machine and messages not passed on
X Lack of transport meant that some people had difficulties attending the clinics
XI Criticisms of the quality of care

overlaps considerably with GPs’ own comments (Box 2). Some Table 2 Distribution of total costs by category*
patients nonetheless expressed criticisms of the clinics, with
Specialist clinics, % Hospital clinic, %
three people highlighting, variously, a long waiting time and
short consultation at the clinic, the quality of care provided, Medical and nurse staffing 42 42
and lack of cover by specialist clinic staff other than diabetes Diabetes specialist nurses 23 17
specialist nurses outside clinic times. Dietician services 9 6
Few patients who did not attend a specialist clinic had heard Podiatry services 7 19
Eye screening 4 6
about them. Where patients had been offered a choice of care
Other costs† 15 10
location, they were most willing to attend a specialist clinic if
it was run by their own GP or within the same practice. If *Based on totals which exclude high-level overhead charges.
attendance at a specialist clinic meant going to another prac- †‘Other costs’ primarily comprise pharmacy and pathology costs.
tice, some patients preferred to remain with their own GP. Of
those who had attended hospital, some had been willing to
move, especially if their condition was stable and they had lim- laboratory expenses. Administrative and clerical support
ited time to attend hospital appointments. costs are included within sessional fees to clinics. The cost per
patient attendance at the hospital diabetes and endocrinology
out-patient clinics during the same period, and for a compara-
Economic evaluation
ble range of inputs, was £123 with allocated Trust high-level
Costings were based on a range of actual and apportioned overheads included and £86 without. Cost per patient attend-
expenditures for both the specialist and hospital out-patient ance at consultant-led hospital clinics was £194 and £136
clinics. Information on resource use by types of input and set- (with and without Trust overheads, respectively). Although
ting was derived from the diabetes register, a separate database there is overlap in case-mix between the two settings, the hos-
set up to record the work of the specialist clinics, actual expen- pital department is likely to include a higher proportion of
ditures on service components and staffing, and information patients with complications or with diabetes that is more
from laboratory and pharmacy systems. As the primary focus difficult to control.
of this part of the evaluation was on estimating the resource Table 2 shows the distribution of costs by category. By far
consequences of any new configuration of services on local the single most important component in the overall cost of
healthcare budgets, the work reported here adopts a purely managing patients in either the hospital or specialist clinics
National Health Service perspective and focuses on the costs of was staffing. Medical and nurse staffing accounted for a simi-
ambulatory management. Given that patients at the specialist lar proportion of the total costs of providing the service in both
clinics would otherwise have been referred to hospital, rather settings: 59% and 65%, respectively. The relative difference in
than being seen by non-specialist GPs, we did not calculate the podiatry costs in part reflected a recognized supply constraint
costs of being seen by the latter. Additional secondary care on the provision of a community-based service. For ‘other
costs related to the management of patients in each of the costs’, a major contributory factor to the relative difference
settings were not included at this stage. was the cost of HbA1c testing, which was significantly more
The average cost per patient attendance at the specialist clin- expensive in the community setting than through the central-
ics in 2000 was £165, with a range of £111–239 at individual ized pathology service. The variation in average total costs
clinics. This includes medical, general nursing, diabetes spe- across the individual specialist clinics was largely due to differ-
cialist nursing, dietetic and podiatric inputs, consultant sup- ences in the organization and scale of service delivery in these
port, drugs and pharmacy costs, diagnostic testing and other clinics, particularly overall attendance levels and non-attendance

© 2003 Diabetes UK. Diabetic Medicine, 21, 32–38

 Original article 37

Box 3 Conclusions from the evaluation

I The need for strategic planning, to ensure equity of access

II Effective capacity planning, to avoid both under-utilization and the saturation of clinic lists through appointments
for routine monitoring, while ensuring that patients needing more intensive longer-term support can receive it
III The need for agreed quality standards and protocols
IV Audit mechanisms to monitor the appropriateness of patients attending clinics
V Clarity about shared responsibility with referring GPs
VI Adequate funding to ensure consistent provision of relevant staff
VII Multidisciplinary team-working, in both sharing information and making decisions
VIII Multidisciplinary representation, including primary and secondary care, at policy and planning forums
IX An integrated system of patient care, with direct referral pathways and single overall clinical co-ordination of hospital
and community-based specialist clinics
X The need for reliable register data for monitoring performance and outcomes [8]

rates. Although a more appropriate basis for the comparison specialist clinic providers’ group has recognized the need to
of cost would have been in relation to patient-based outcomes ensure uniformly high standards of care at all clinics and addi-
rather than the number of patients seen, problems with data tional training has been introduced, linked to re-accreditation.
quality prevented this. The location of the clinics was based on GPs’ interest in dia-
betes rather than a strategic response to need. The proportion
of minority ethnic patients from inner city wards is higher at
Discussion the clinics than among hospital attendees; however, not all
Most GPs outside the clinics believe the clinics are providing areas of the city with high-density minority ethnic populations
a valuable and popular service, a view that is shared by the have convenient access to clinics.
patients who attend them. The clinics offer a local service and The economic evaluation highlights difficulties in relation to
enable a shift of responsibility from secondary to primary care. overheads, the range of costs for individual specialist clinics,
Although there was a reduction in hospital out-patient activity and, crucially, outcomes for patients. The overall finding,
of 25%, the total number of hospital and specialist clinic nonetheless, is that there is no noticeable difference in the cost
attendances increased by 35% by the second year of the of the specialist and hospital out-patient clinics, even though
service. This may reflect a greater awareness of diabetes the sessional payments to GPs are considerably higher than the
on the part of both patients and practitioners and the higher £160–200 national norm for GPs with special interests [20].
profile of diabetes locally. It may also reflect specialist clinics The average cost of the specialist clinics could be reduced by
being used inappropriately to review patients normally seen addressing the lower attendance rates at some clinics.
in routine general practice. In addition, the finding that 42% In conclusion, the clinics represent an important and inno-
of referrals were internal practice referrals raises a question vative extension of traditional primary care for patients with
about equity of access for patients across the city. diabetes. They go further than many current examples of spe-
Healthcare quality can be evaluated along six dimensions: cialization within primary care, in that secondary care tasks
accessibility, equity, acceptability, efficiency, appropriateness are taken on not by one or a few interested individuals, but
and effectiveness [18]. Our evaluation gathered qualitative across a large number of practices serving three PCTs. The
and descriptive data on the first four. Although the specialist Bradford approach does have a unique history and funding
clinics appear to be popular with both service users and pro- source, which resulted in a unique response. The key com-
fessionals, we need to be wary of an over-reliance on satisfac- ponents of the model can, nonetheless, be applied to other
tion levels [19]. It is not enough for people to like and be settings, provided that its shortcomings are recognized and
satisfied with a service: effectiveness and appropriateness also addressed.
need to be demonstrated. We were unable to compare clinical We do not suggest that the Bradford approach is the only
outcomes between clinics, standard primary care and hospital means of improving the quality of primary care diabetes ser-
because of systematic flaws in the diabetes register. Even if this vices. An alternative is to raise standards throughout primary
had been possible, attribution would have been difficult. In care [13,21], rather than relying on islands of specialist exper-
addition, the heterogeneity of the clinics would make com- tise. Such an approach also involves costs, often considerable,
parison of combined outcomes of limited value. We were also if GPs are to take on responsibilities they would previously
unable to assess the appropriateness of referrals to the clinics, have passed to secondary care, as well as the additional train-
although professionals who were interviewed expressed some ing required. There is also a danger that a focus on one specia-
concern. lism, underpinned by financial incentives, could lead to a
The specialist clinics presented a range of different models decreased emphasis on other areas of healthcare. Such a dan-
rather than a single uniform approach. GPs’ variable experiences ger is at least reduced in Bradford, where PCTs commission a
of the clinics may have been a reflection of this variability. The wide range of specialist primary care services [22,23].

© 2003 Diabetes UK. Diabetic Medicine, 21, 32–38

 38 Specialist GPs and diabetes clinics in primary care • A. Nocon et al.

This evaluation has, nevertheless, highlighted a number of 8 Department of Health. National Service Framework for Diabetes:
lessons that can be learned from the Bradford experience and Delivery Strategy. London: Department of Health, 2002.
9 Greenhalgh PM. Shared Care for Diabetes: a Systematic Review.
several key points that need to be addressed when developing
Occasional paper 67. London: Royal College of General Practitioners,
specialist primary care services elsewhere. Issues arising directly 1994.
from the data are highlighted in Box 3. Two additional issues 10 Whitford DL, Roberts SH. Sustainability of organised care in a
that require consideration emerged from this study. First, the District. Diabet Med 2002; 2 (Suppl.): A100.
clarification about the role of specialist clinics: whether these 11 Vrijhoef HJM, Spreeuwenberg C, Eijkelberg IMJG, Wolffenbuttel BHR,
van Merode GG. Adoption of disease management model for dia-
should carry out a tightly defined set of tasks, provide a screen-
betes in region of Maastricht. Br Med J 2001; 323: 983–985.
ing service for secondary care, and /or act as local centres of 12 Eijkelberg IMJG, Spreeuwenberg C, Mur-Veeman IM, Wolffenbuttel
excellence, offering advice and support to other primary care BHR. From shared care to disease management: key influencing
practices. Second, the recognition of the opportunity costs of factors. Int J Integrated Care 2001; 1: 2. http://www.roquade.nl /
GPs running specialist clinics, and of the implications for other IntegratedCare
13 Audit Commission. http://www.diabetes.audit-commission.gov.uk/
GPs and practice staff.
casestudies/ Accessed 2002.
14 Rhodes P, Nocon A, Booth M, Chowdrey M, Fabian A, Lambert N
et al. A service users’ research advisory group from the perspectives
Acknowledgements
of both service users and researchers. Health Soc Care Community
This evaluation was funded by Diabetes UK under grant 2002; 10: 402–409.
15 Rhodes P, Nocon A, Darr A. A research advisory group for South
number BDA:RD99/0001833.
Asian women with diabetes who do not speak English. Consumers in
NHS Research News 2002; Summer: 4.
16 Ritchie J, Spencer L. Qualitative data analysis for applied policy
References research. In Bryman A, Burgess RG, eds. Analysing Qualitative Data.
1 Pringle M. Implementing a Scheme for General Practitioners with London: Routledge, 1994; 173–194.
Special Clinical Interests. London: Royal College of General Practi- 17 Townsend P, Phillimore P, Beattie A. Health and Deprivation. London:
tioners, 2001. Croom-Helm, 1988.
2 Department of Health. The NHS Plan. Cm 4818. London: Depart- 18 Maxwell R. Quality assessment in health. Br Med J 1984; 288:
ment of Health, 2000. 1470–1472.
3 Department of Health. Shifting the Balance of Power Within the 19 Williams B. Patient satisfaction: a valid concept? Soc Sci Med 1994;
NHS: Securing Delivery. London: Department of Health, 2001. 38: 509–16.
4 Audit Commission. Testing Times: a Review of Diabetes Services in 20 Sanderson D. Evaluation of the GPs with Special Interests (GPwSIs)
England and Wales. London: Audit Commission, 2000. Pilot Projects within the Action On ENT Programme. York: York
5 Griffin S. Diabetes care in general practice: meta-analysis of ran- Health Economics Consortium, 2002.
domised control trials. Br Med J 1998; 317: 390–396. 21 Whitford DL, Southern AJ, Braid E, Roberts SH. Comprehensive
6 Khunti K, Ganguli S, Lowy A. Inequalities in provision of systematic diabetes care in North Tyneside. Diabet Med 1995; 12: 691–
care for patients with diabetes. Fam Pract 2001; 18: 27–32. 695.
7 Department of Health. National Service Framework for Diabetes: 22 Hill L, Rutter I. Cut to the quick. HSJ 2001; 111: 24–25.
Standards. London: Department of Health, 2001. 23 McLellan A. Smooth operators. HSJ 2002; 112: 16.

© 2003 Diabetes UK. Diabetic Medicine, 21, 32–38