Diabetes – Care Planning Annual Review – what does it involve?

Living with diabetes is a lifelong learning process, whether you are newly diagnosed or have had diabetes for many years.  Monitoring your health with diabetes is vital to help reduce the risk of some complications associated with it. 

This monitoring includes checking your blood glucose, blood pressure, blood fat levels, the condition of your feet and ensuring your eyes are screened yearly for possible signs of retinopathy (eye changes).

Care Planning has been implemented in most practices across Milton Keynes.This has involved training health care professionals in the re-designing of how the care is delivered for the management of diabetes annual reviews.

How does the Annual Review Work?
Stage One
A twenty to thirty minute appointment is made:

At this appointment the following tests will be carried out.  

Laboratory tests and investigations

  • Blood glucose control: an HbA1c blood test will measure your long-term blood glucose control. The range to aim for should be 6.5 - 7% (Individual targets to be discussed and agreed) 
  • Kidney function: urine and blood tests will detect any protein that your kidneys maybe producing. These tests check that your kidneys are working correctly.
  • Blood fats (cholesterol / lipids): this blood test measures your blood fat levels.

       A total cholesterol of below 4.0mmol/l or less, LDL <2mmol/l HDL >1mmol/l

The results of these tests will be sent out to you either by post or email (if agreed) prior to your Stage Two apppointment - Annual Review (below) in order to help you plan the discussion for this appointment.

*Please note all ranges will vary from person to person — it is meant to be a guide so you know what to aim towards. If you have any questions, ask your diabetes care team.

Physical examination

  • Weight is often calculated as a Body Mass Index (BMI) which calculates adult weight in relation to height. Waist measurement will also be done as it is an important marker of increased risk of heart disease. These measurements may help you underdstand if you need to lose weight to help improve the control of your diabetes.
  • Legs and feet will be examined to check your skin, circulation and nerve supply. If necessary, you can be referred to a state registered podiatrist.
  • Blood pressure will be taken. A blood pressure for diabetes is recommended at or less than 130/80 but this will also be discussed as individual targets by be advised. If it is higher than this level, you can discuss the possible reasons why at your Stage Two - Annual review appointment. Keeping your blood pressure under control has been proven to be beneficial for people with diabetes (UKPDS). 

Stage Two
An appointment for an ‘annual review’ with a PN with an interest in diabetes, diabetes specialist nurse or GP.  This should be made ideally two - three weeks after your stage one appointment so that your results can be sent to you to review.

  • At this appointment you will have the oppotunity to work together with the nurse/GP to review every aspect of your care.  There will be time to discuss:
  • Your general wellbeing; how you are coping with your diabetes at home, work, school or college.
  • Your current treatment and medications, your diabetes control, discuss any hypos or any problems / concerns that you may have.
  • Feel free to raise issues that may be concerning you such as: smoking, alcohol intake, stress, sexual problems, physical activity levels and any eating issues. Good diabetes care is possible  by working with your diabetes team. 
  • You will be encouraged to ask questions and request more information especially if you are unsure or worried about your diabetes or treatment plan.
  • Whilst the new Care Planning system is in process of being set up,some patients may be invited to an appointment at the surgery around the same time as you are seen at the hospital diabetes clinic (Maple Unit). It is important that you attend both clinics initially.
  • At the Stage Two appointment, you will be encouraged to finalise a care plan with agreed goals for the next year with support from your diabetes team. You may need to be reviewed before next years appointment but this will be discussed with you at the time.

More information on Care Planning from the NHS Leaflets:

Did you know a care plan will help you manage your condition better?

Help and advice for living life well with a long term condition