There have been a number of studies exploring the provision of primary care for patients with diabetes. These have largely focussed on the structure of care suggesting that whilst the organisational infrastructure for delivering care to patients with diabetes is in place [3], there is still variation in performance and room for improvement in the quality of care [4], [5]. Some of the variation in care has been shown to be associated with factors such as practice size and socioeconomic deprivation [6] but features such as dedicated clinic provision, staff numbers and training were not associated with compliance of process or outcome of care [4].

Policy support for diabetes care has been provided by the National Service Framework (NSF) [7], National Institute for Health and Clinical Excellence (NICE) guidelines [8] and the implementation of the Quality and Outcomes Framework (QOF; http://www.ic.nhs.uk/statistics-and-data-collections/audits-and-performance/the-quality-and-outcomes-framework accessed 2012 July 9th) which provides incentives for practice performance. Analysis of the QOF data suggests that whilst the care of patients with diabetes has improved, it is difficult to understand how much of this has been due to QOF [9]. Glycaemic control may have improved as a consequence of QOF but not in patients with type 2 diabetes and high HbA1c levels, and more stringent QOF thresholds might be needed in order to produce further improvement [10], [11].

All of these studies rely on either routinely available data or physician report. Several of the key behaviours required in diabetes care are not well recorded in routine clinical sources (such as primary care records) and their most reliable data source may be patients themselves. There are no comprehensive published data on the processes of care delivery for patients with diabetes cared for in primary care.

As one part of a larger study [12], [13] we have previously reported the organisational structure and intermediate outcomes of diabetes care across 99 UK primary care practices (74 in England, 13 in Scotland, four in Wales, and eight in Northern Ireland). The study was designed to better understand the quality of care patients with diabetes received through the performance of six key behaviours. These behaviours covered prescribing to control blood pressure and HbA1c (in patients with poor control), three advising behaviours (for weight management, self-management and general education) and one examining behaviour (foot examination). Practice attributes and a range of individually reported clinician measures were assessed at baseline; measures of clinical outcome were collected over the ensuing 12 months and a number of proxy measures of behaviour (including patient report) were collected at 12 months.

Our analysis of this data found that whilst QOF scores were generally high (with mean practice level percentage achievement rates of over 90% for 12 of the 15 clinical indicators), the mean percentage achievement rates for tight blood pressure control and tight HbA1c control were lower (80% and 68% respectively). Forty-nine practices had one or more clinicians trained to diploma level in diabetes care. Seventy-one practices had a dedicated diabetes clinic. Access to specialist support was variable. Most practices could access a diabetes nurse specialist (53 via secondary care, 28 via primary care) but GPs with a specialist interest in diabetes were rare (not available to 79 practices). Only 23 had access to a diabetes centre in secondary care and 44 practices reported having access to a specialist diabetologist. Forty-two practices did not have access to a dietician and 37 did not have access to a podiatrist.

We present the range of dimensions of care received and the (lack of) correspondence between what clinicians report delivering and patients report receiving. This mismatch between patient and healthcare professionals’ perceptions is likely to be a real phenomenon and highlights important areas where diabetes care can be improved. Most people with diabetes reported receiving their diabetes care mainly in primary care, they reported high rates of having regular physical checks of their eyes and feet but reported lower rates of receiving advice on weight management, self-management and education. A large minority lacked confidence in their ability to manage some aspects of their diabetes; healthcare professionals reported consistently high rates of discussing these areas. The quality of provider communication and involving patients in decision-making has previously been shown to predict patients’ reported diabetes self-management capability, suggesting possible opportunities for improving care and self-management [15].

The difference in rates of reporting between patients and health care professionals could be due to recall bias (with patients forgetting advising behaviours that might be less memorable than an eye check). This is supported by the fact that, for some of the areas of care those patients who had had diabetes for longer reported greater recall. However, given that many of the areas described are of continuing importance this highlights the need to consider what patients need to know and how best to deliver this as well as a role for on-going checks of what patients understand.

From the perspective of the healthcare professionals their higher rates of self-reported performance could represent a desirability response bias (recognising desirable behaviours and subconsciously over-reporting). It may be that clinicians may be tailoring their advice for experienced patients yet reporting their behaviour in relation to their overall population of patients. They may deliver advice to those patients they perceive need it and not to those they know have received the advice before. Even so, patient confidence rates for enacting key behaviours were not influenced by duration of diabetes and were positive for just over half of respondents. The Audit report [14] certainly reports variability but cannot reflect the complexity of patient management and may, from the perspective of improving care in primary care practices, not be reflecting the complexity of patient management. Of the three care processes most often missed (retinal screening, foot examination, urinary ACR) one is not under the control of the practices (retinal screening), one is sometimes performed by non-practice staff (foot examination) and one is reliant on patients remembering to bring a urine sample (urinary ACR). In terms of level of control of risk factors the audit data could take no account of current management or management actions within the practices. Therefore, improving care will be a complex and multi-faceted undertaking.

The limitations of this study include: practices were recruited from a research network and so might be atypical in terms of the care they offer and may offer better care than that delivered in practices that are not in research networks. This would suggest that even higher proportions of patients may be receiving care of a lower standard than that reported here. The response rate to the patient survey was below 50%; patients who responded to the patient survey were anonymous and we have no means of analysing whether or not they were typical of the rest of the patients in the practices from which they come. Their responses have to be regarded with caution in the light of this possible response bias.