The Saint Vincent Declaration has had a dramatic and continuing effect in Europe. The declaration—formulated at a meeting attended by senior health care politicians and representatives of diabetes associations from almost every European country—focuses on the need to raise the quality of care and life for diabetic persons. It sets several target dates for reduction of diabetic complications and, most appealingly, is written on a single page. The European office of WHO has presented the declaration for action to every European national health department. Through the International Diabetes Federation, national diabetes associations (where they exist) have been activated at both health professional and patient levels.

In the United Kingdom, the Saint Vincent Declaration has received notable support and has led to the formation of a Joint Task Force for Diabetes, cosponsored by the Government Department of Health and the British Diabetic Association and coordinated with government advisors to devise a method of implementing the recommendations within the United Kingdom health care context. The project is now complete. The report of the Saint Vincent Joint Task Force for Diabetes [7] summarizes key facts and prioritizes needs for each target area defined by the declaration. It aims to focus attention on the diabetes problem for both purchasers and providers of care. These proposals have been widely implemented locally, often facilitated by local diabetes services advisory groups. Central guidance prepared by the Health Department's Clinical Outcomes Group will have an important influence in shaping future patterns of patient care.

Without doubt, attention can be focused on diabetes care, and the potential preventability of many diabetic complications can be highlighted by the organized advocacy of a clearly articulated set of goals by both patients and health professionals. This combined undertaking must be interpreted and modified for the social, economic, and professional structures and cultures of each country, but the special role of WHO, with its access to national health departments, is an asset not to be lightly dismissed.

The United Kingdom has made its own significant contributions to the accumulation of knowledge and evolution of thought about NIDDM. Two major factors have contributed to giving a particularly British "spin" to the management of NIDDM. The first is the influence of the British Diabetic Association, founded in 1934 by Dr. R.D. Lawrence and writer H.G. Wells; the association now has a membership of over 150 000, an enshrined lay majority governance, and strong medical, scientific, and health professional sections. The second is our nationwide, comprehensive (if currently somewhat troubled) National Health Service. With these two bodies working in concert, the potential for universal, high-quality, well-monitored health care provision is substantial if not yet fully realized. In caring for patients, professional and interpersonal skills at the individual clinical interface are of the essence, but it is clear that organization at local, regional, and national levels, creation of the means for standardized clinical self-audit, and use of information technology all can greatly facilitate reaching the objectives of continuous improvement in the quality of diabetes care with its direct effect on the life and health of persons with NIDDM.

The following is a somewhat selective appraisal of current experience with NIDDM care in the United Kingdom.

Attitudes

The Diabetologist's Point of View

Diabetologists now aim to disseminate their ideas about diabetes care among all of the core members of the health care team, including physicians, specialist nursing staff, dietitians, podiatrists, and patients and concerned others. Correction of hyperglycemia is still seen as the central challenge of diabetes care, but particularly in NIDDM, attention to the associated abnormalities of blood pressure, plasma lipid levels, and adiposity and deviations from a healthy lifestyle are recognized as equally important components of a therapeutic menu individualized for each patient. Motivation, purpose, achievable goals, and shared problem ownership bind the management plan with the local health care system and cultural values.

The doctrine of glycemic near-normalization for care of NIDDM—although remaining central to the diabetologist's credo—is still regarded as strongly held belief rather than knowledge-based fact. However strongly the findings of the Diabetes Control and Complications Trial [8] and the growing epidemiologic data support this thesis, direct, scientifically acceptable evidence of benefit of glycemic near-normalization in NIDDM is still awaited. It is hoped that the United Kingdom Prospective Diabetes Study will provide an answer (see "United Kingdom Prospective Diabetes Study 17: A 9-Year Update of a Randomized, Controlled Trial on the Effect of Improved Metabolic Control on Complications in NIDDM"). Postponement or prevention of future complications is the putative reward for the sometimes arduous disciplines to which the conscientious patient is expected to adhere. Persons with NIDDM are often older, set in their ways, and only too ready to accept the comforting and widely pervasive view that they have "mild" diabetes.

There is now general recognition in the United Kingdom of the central importance of regular (annual) review of each patient's status, with a systematic search for risk factors and early manifestations of disease linked to a program of corrective action and a follow-up system to monitor the patient's response to treatment. This paradigm almost inevitably requires the creation of comprehensive and active patient registers and computerized information systems to ensure that, at the very least, all diabetic patients are offered the advantage of status screening and modern care. Active registers also serve as the basis for collecting the data necessary to show that the major goals of the Saint Vincent Declaration (see Appendix)—reduced incidence of new retinopathic blindness, renal failure, lower-extremity amputation, and cardiovascular morbidity and mortality—are being achieved. Such registers are central to systems of continuous quality improvement. In the United Kingdom, registers are currently maintained by some diabetes care clinics, but they are not population-based, fail to include patients treated in primary care, and may contain duplications. However, virtually every United Kingdom general practice has a patient register, which, when combined, would include the entire population. A major initiative is now under way to introduce a simple and readily usable diabetes data set [9] with vocabulary and definitions robust enough to enable local, regional, and national aggregation and ascertainment. Of course, patient confidentiality and other sensitive questions of data ownership and handling must be respected; some progress has been made in this area by including the patients themselves in the planning and provision of services. Diabetic persons should be viewed not so much as consumers but as accredited coproducers in the challenging project of providing comprehensive, preventative diabetes care.

The Generalist's Point of View

In the United Kingdom in recent years, there has been a major change in the attitude of primary care generalists and general practice teams toward diabetes care. The practice of referring diabetic patients to a hospital-based diabetes clinic for diagnosis and care has been largely reversed. In part, because of overwhelmed hospital clinics referring patients with NIDDM back to general practitioners and to a long-held view that NIDDM should be the concern of primary care providers, the reversal has been accelerated by the offer to general practitioners of a small financial premium for undertaking such care. The response to this shift of clinical responsibility has been variable. Some general practice teams have set up special neighborhood diabetic clinics that follow written protocols for care in which the practice nurse plays an important role and in which specialists such as optometrists and podiatrists are also used. Although some generalists still perceive NIDDM as a "mild" disease, they will probably be influenced by information from the British Diabetic Association and the Saint Vincent initiative and by development of professional collaborative links with local diabetes specialist teams. Early diagnosis of individual cases of NIDDM is essentially a primary care concern, but considerable uncertainty remains about policies for systematic diabetes screening. As discussed above, only at the general practice level can complete population-based registers for diabetes be compiled.

Use of a general practice team offers patients the advantages of convenience and familiarity and integrates diabetes care with more comprehensive care. Although primary care is considered to be less expensive than hospital-based clinic or diabetes center care, such savings are probably short term and illusory and can only be fully realized by redeploying resources from (or downsizing) the specialist teams. The results could be seriously damaging to patients' interests (see "Structures of Care Provision" below): Variation among primary care practitioners in level of diabetes-related knowledge and skills make the ready availability of diabetes specialists of major importance.

The Patient's Point of View

Public awareness campaigns, the high public profile of the British Diabetic Association, and media interest in diabetes are increasing awareness about the disease among British citizens. The British Diabetic Association distributes leaflets describing "what diabetes care to expect" for newly diagnosed adults, diabetic children and their families, and diabetic persons who are hospitalized. For patients with NIDDM, particularly if there are no symptoms, the denial response is readily invoked: "Diabetes sounds terrible, but I feel OK"; "The tablets will cure it"; "I'm getting on in years and have to expect this kind of thing"; "I don't want to eat differently from my family"; and "I don't want injections—I've only got the mild type of diabetes" are common and probably universal reactions. They need to be considered in any patient education system and repeatedly addressed before the full therapeutic partnership can be achieved. Modern diabetes care has become increasingly complex. From the patient's viewpoint, care should be flexible and individualized. Discussion and education are essential items of diabetes care management.

Structures of Care Provision

General practice primary care and hospital-based specialist teams are, to some extent, now seen as alternatives in diabetes health care in the United Kingdom and are becoming complementary services. From the patient's point of view, the best quality of care is obtained when these two groups collaborate flexibly. The elements necessary for collaborative care are largely in place in the United Kingdom. Special diabetes centers now exist in most localities, each serving a population of approximately 250000 to 300000. Although often based in and supported by a hospital that is usually a semi-independent trust in the new "internal market" configuration of the British National Health Service, diabetes centers interface with community services on the one hand and with specialist departments and units of the hospital on the other. These centers are the natural focus for special diabetes skills, education, and services of many kinds for an entire locality. When operating optimally, the centers work in flexible collaboration with general practice teams, with each group providing services geared to the individual needs of the patient as well as to the primary care team's level of skill and organization. Diabetes centers are ideally situated to provide systematic courses of patient and postgraduate education and to be an academic focus for the locality's health care professionals. These centers can provide rapid assistance when new or difficult clinical problems arise and can readily refer patients to special hospital units as required. Centers can also be used for off-hours patient activities, branch meetings of the British Diabetic Association, and so on. What needs to be clearly established is the joint ownership of these centers, with the specialist team taking primary responsibility but with real input in policymaking and operational practice coming from primary care and patient users. The current methods of National Health Service funding do not easily embrace such an anomalous structure, which lies at the interface between the hospital and the community, the professional and the public; the future success and development of diabetes centers depend more on cost sharing than on cost shifting. However, it is hoped that the advantages to the patient (and the ultimate fiscal benefit of reduction of expensive complications) will be so patent that as much flexibility will be displayed by financial management as by clinical caregivers.

Shortfalls and Solutions

Many of the shortfalls in the care of NIDDM in the United Kingdom are caused by traditional attitudes that regard the disease as mild; the failure of universal recognition of the great potential for reducing the risks for complications, the personal suffering that accompanies these complications, and the large burden on the payer (in the United Kingdom, the taxpayer) that well-organized, comprehensive preventative care can create; and the historical separation of primary care and specialist services for diabetes in the United Kingdom. All of these problems are potentially remediable but require discussion among the interested parties, setting of goals, adjustment of practice, and creation of patient management systems to which all are committed. The strongest justification for this major effort is the welfare of persons with diabetes.

Each person with NIDDM should have an individualized management plan based on the individual's clinical needs and preferences and the clinical resources locally available to best meet them. To the greatest possible extent, each person with diabetes is expected to be his or her own "care manager," with a clearly written program of what he or she expects to happen, where, when, and by whom. Such plans need periodic revision and updating, which must also be included in the schedule. Each patient must explicitly agree on the provision of items of care. Whether they come from the primary provider or the specialist team is of little consequence as long as they are provided competently and acted on appropriately.

The existence of a diabetes center in each United Kingdom health care locality is highly desirable for the many reasons discussed above and also to act as the local unit of data collection and analysis, where, at a professional level, inadequacies of care can be monitored, remedial action can be taken, and improvement can be ascertained. It is crucial that diabetic persons be allowed to play an effective role in organizing and providing their own care; increasingly, patients are sufficiently informed to do this. The British Diabetic Association is currently promoting the creation of local diabetes services advisory groups [10], which comprise representatives of diabetes specialty professions, primary providers, patients, and caregivers and those now responsible for commissioning health care services (the purchasers). The purpose of these advisory groups, some of which have been functioning for almost 3 years, is to formulate a strategy for optimizing care for diabetes with the resources available in a particular locality. The availability of suitably anonymous process and outcomes data for comparison can be a most effective spur to quality improvement. Aggregated regionally and nationally, these data will provide evidence of success—and sometimes indicators of failure—in the achievement of the ambitious, overarching European objectives of the Saint Vincent Declaration.