S:t Vincentdeklarationen 10 år
The St.Vincent Declaration
The Acropolis Affirmation
Av Carl-David Agardh
I oktober 1989 sammankallade Världshälsoorganisationens (WHO) och Internationella Diabetesfederationens (IDF )Europakontor representanter för regeringar, patientorganisationer och professioner till ett möte i den italienska bergsbyn St Vincent för att diskutera hur diabetesvården i Europa kunde utvecklas och förbättras.Resutatet blev St Vincentdeklarationen,som på många sätt varit vägledande och drivande i utvecklingsarbetet inom diabetesvården i Europa.I St Vincentdeklarationen anges övergripande mål och kortsiktiga 5-årsmål för diabetesvården.
Istanbul ’99
På dagen 10 år efter det ursprungliga mötet firades St Vincentarbetet med ett möte i Istanbul. Vid genomgången av vad som åstadkommits under de 10 år som gått kunde man bl.a.konstatera att alla länders regeringar utsett kontaktpersoner för det fortsatta arbetet, s.k.Liason Persons, att nationella diabetesprogram utvecklats i två av tre länder i Europa och att the European Organization for the Study of Diabetes (EASD) förstärkt organisationen genom sin aktiva medverkan sedan 1995. Tyvärr kunde man också konstatera att det varit svårt att utläsa om de ursprungliga målen i St Vincentdeklarationen uppnåtts i brist på kontinuerlig registrering av resultat.
Mötet avslutades med att de närvarande godkände det dokument som skall utgöra basen för det framtida arbetet, the Istanbul Commitment 1999.Istanbul Commitment 1999
People with diabetes still needlessly go blind, develop endstage kidney failure and suffer high rates of heart attack, stroke and gangrene. Their social lives continue to be marred by ignorance and discrimination.
Powerful evidence now shows that much of this physical and social damage can be prevented.The St Vincent Declaration of 1989 called for prompt and effective action to apply this knowledge and so greatly impove life and health for people with diabetes. To achieve these objectives it is imperative that:
• Individual nations review and renew their efforts to meet the St Vincent objectives.
The St Vincent Declaration has been endorsed by government health departments ,health professional bodies, associations of people with diabetes and many others. Their words must be converted to deeds. They must convene, individually and in partnerships, nationally and locally, to review progress and renew momentum, formulating clear plans of action with feasible, locally appropriate targets and firm dates for their attainment.• People with diabetes are recognised as key members of the ´therapeutic partnership ´.
Effective self-management of the diabetes and active partnership in the treatment team are essential for promoting the health, independence and selfreliance of people with diabetes. This can be achieved only if priority is given to provision of information, education and preparation. The right of access to and explanation of personal health information is an important part of this.• Modern tools and technology used.
The skilled use of modern techniques of treatment and the methods of information technology are of proven value in raising the quality of diabetes care. Health care teams should be trained and equipped, validated support systems and guidelines should be prepared centrally and modified locally, systematic quality improvement should become part of routine care.• Action is accelerated in areas of great need.
Pregnancy in the diabetic woman, physical and emotional health of the child with diabetes, early detection and effective correction of risk factors for diabetic eye and kidney disease, proactive protection from cardiovascular disease are cardinal health objectives, each still requiring intensified effort.
Much has already been accomplished but even more remains to be done. At this meeting in Istanbul, we comit ourselves to the full achievement of the goals and objectives of the St Vincent Declaration. We call upon our governments, patient associations, professional organisations, voluntary social agencies and industrial companies to act together with renewed determination, setting locally acivevable goals and targets but working towards common high standards of care. Urgent and decisive action is needed now.St Vincentarbetet och Sverige
På vilket sätt har diabetesvården utvecklats i Sverige för att kunna leva upp till St Vincentdeklarationens ursprungliga mål och fortsatta målsättningar?Nationella riktlinjer
Nationella Riktlinjer för vård och behandling vid diabetes utgavs första gången 1996 och i en reviderad version 1999. De ger en stabil plattform för regionala och lokala vårdprogram och på ett handfast sätt föra ut aktuell kunskap inom diabetesområdet i praktisk verklighet.
Genom Dagmaröverenskommelserna skall sådana vårdprogram utformas av respektive hvudmän. Den politiska förankringen i programarbetet är väsentlig för att fastställa det verkliga behovet av resurser för vårdens bedrivande. I de Nationella Riktlinjerna påpekas också att individuella vårdöverenskommelser skall upprättas. Detta ger ett utmärkt tillfälle att tillsammans med pateintorganisationens företrädare inleda en dialog kring vårdens utformning i samverkan.NDR
1996 påbörjades också ett nationellt arbete med att mäta resultatet av diabetesvården i Sverige genom det Nationella Diabetesregistret.Efter 1998 års registreringar kan man konstatera att 26.000 patienter registrerats vid medicinkliniker, 14.000 inom primärvården och 1.000 inom barnsjukvården i landet. Om vi räknar med att 3-4% av befolkningen i Sverige har diabetes, dvs. 270.000-360.000 personer, innebär det att resultat endast finns tillgängliga i den här formen från c:a 15 %.För att kunna uppfylla St Vincentdeklarationens mål är det en förutsättning att en kontinuerligt mäta verksamheten och verksamhetens resultat. Det är därför beklagligt att detta inte sker, trots att instrumentet finns där.
Genombrott-Diabetes
Sedan ett år pågår också ett arbete med att föra ut aktuell kunskap i faktiskt förbättringsarbete genom projektet Genombrott-Diabetes, som bedrivs i Landstingsförbundets regi. Under ett år har ett 20-tal team från hela Sverige arbetat med att på sina egna arbetsplatser genomföra ett systematiskt förbättringsarbete med denna modell som grund.Arbetet avslutas med en konferens i Stockholm den 4 februari 2000. Sammantaget kan man säga att diabetesvårdens
utveckling i Sverige haft de yttre förutsättningar som krävs för att uppfylla St Vincentdeklarationens mål. Det är därför extra beklagligt att anslutningen till Nationella Diabetesregistret inte varit större. Här finns en outnyttjad potential för fortsatt förbättringsarbete. Carl-David Agardh
Professor,Liason Person för Sverige Endokrinologiska kliniken,
Universitetssjukhuset MAS,Malmö
E-post:carl- david.agardh@endo.mas.lu.se
UPP
The St.Vincent Declaration
Diabetes care and research in Europe:
Diabetes mellitus in Europe: A problem at all ages in all countries.A model for prevention and self care.St Vincent (Italy), 10-12 October 1989.
A meeting organized by WHO and IDF in Europe.Representatives of government health departments and patients organizations from all European countries met diabetes experts under the aegis of the WHO Regional Offices for Europe and the International Diabetes Federation in St Vincent, Italy, on October 10-12, 1989.
They unanimously agreed on the following recommendations, and urged that they should be presented in all countries throughout Europe for implementation.
Diabetes mellitus is a major and growing European health problem, a problem at all ages and in all countries. It causes prolonged ill health and early death. It threatens at least ten million European citizens.It is within the power of national governments and health departments to create conditions in which a major reduction in this heavy burden of disease and death can be achieved.
Countries should give formal recognition to the diabetes problem and deploy resources for its solution. Plans for the prevention, identification and treatment of diabetes, and in particular its complications (blindness, renal failure, gangrene and stroke) should be formulated at local, national and European regional levels. Investment now will earn great dividends in the reduction of human misery and in massive savings of human and material resources.The general goals and fiveyear targets listed below can be achieved by the organized activities of the medical services in active partnership with diabetic citizens, their families, friends, and workmates and their organizations; in the management of their own diabetes and education for it; in the planning, provision and quality audit of health care; in national, regional and international organizations for disseminating information about health maintenance; and in promoting and applying research.
General goals for people - children and adults - with diabetes
Sustained improvement in health experience and a life approaching normal expectation in quality and quantity. Prevention and cure of diabetes and its complications through an intensification of the research effort.Five-year targets
Elaborate, initiate and evaluate comprehensive programmes for detection and control of diabetes and its complications, with selfcare and community support as major components. Raise awareness in the population and among health care professionals of the current opportunities and the future needs for prevention of the complications of diabetes and of diabetes itself. Organize training and teaching in diabetes management and care for people of all ages with diabetes, for their families, friends and working associates and for the health care team.Ensure that care for children with diabetes is provided by individuals and teams specialized both in the management of diabetes and of children, and that families with a diabetic child get the necessary social,economic and emotional support.
Reinforce existing centres of excellence in diabetes care, education and research. Create new centres where the need and potential exist. Promote independence, equity and self-sufficiency for all people with diabeteschildren, adolescents, people of working age and the elderly.
Remove hindrances to the fullest possible integration of the diabetic citizen into society. Implement effective measures for the prevention of costly complications..-Reduce new blindness due to diabetes by one third or more.
-Reduce the numbers of people entering end-stage diabetic renal failure by at least one third.
-Reduce the rate of limb amputations for diabetic gangrene by a half.
-Cut morbidity and mortality from coronary heart disease in the diabetic by vigorous programmes of risk factor reduction.
-Achieve pregnancy outcome in diabetic women that approximates to that of non-diabetic women.Establish monitoring and control systems using state of the art information technology for quality assurance of diabetes health care provision and for laboratory and technical procedures in diabetes diagnosis treatment and self-management. Promote European and international collaboration in programmes of diabetes research and development through national, regional and WHO agencies and in active partnership with diabetes patients organizations.
Take urgent action in the spirit of the WHO programme ’Health for All ’ to establish joint machinery between WHO and the European branch of the IDF to initiate, accelerate and facilitate the implementation of these recommendations. At the conclusion of the St Vincent meeting, all those attending formally pledged themselves to strong and decisve action in seeking implementation of the recommendations on their return home.
The Acropolis Affirmation
Diabetes Care - St Vincent in Progress: Athens,March 1995 We representatives of people living with diabetes, and as representatives of health care professions, governments and industry, at the Athens meeting of the Implementation of the St Vincent Declaration.
While recognising:
* that the purpose of the St Vincent Declaration initiative is to achieve a fuller and healthier life for all people with diabetes in Europe and beyond;
* that the principles and targets of the St Vincent Declaration remain valid and attainable;
* that governments have formally endorsed the Declaration at regional world health assemblies,and agreed to work for its implementation;
* that many individuals with diabetes,many health care professionals, WHO-EURO, IDF (Europe), governments, funders, and industrial partners, have already contributed their time and effort with enthusiasm and dedication;
* that many tools and systems for developing and implementing quality diabetes care have been devised and tested under auspices of the St Vincent initiative.
Now call upon all concerned to resolve:
* that WHO/EURO and IDF (Europe) actively promote collaborative and practical strategies with diabetes associations, health care providers, government, the European Union, other health care programmes, health care funders, and industrial partners, to bring into full use the tools and methods now developed;
* that the use of a planned strategy, together with structured information for monitoring and evaluation, is essential for progressive improvement in the quality of diabetes care;
* that special attention be given to developing further:
1 .practical means of countering the social discrimination and financial penalties suffered by people with diabetes;
2.the empowerment of people with diabetes and the provision of adequate resources to achieve this through education for them, and for all who care for them;
3.the means of meeting the needs of special groups of people, including children and adolescents, pregnant women, the elderly, and cultural minority groups, by securing readier access to care of high quality;
4.the understanding of the savings in health and financial costs achievable through timely care to prevent complications of diabetes;
5.the improvement of the basic and continuing education of professionals, and enhancement of their work in teams, in order better to meet the needs and feelings of individual people with diabetes and their carers;
6.the prevention and early detection of diabetes,its related problems,and Iong-term complications;
7.the provision of services through the flexible integration of primary health care, specialist teams, and patient groups, on a locality basis;
8.the emergency aid for people with diabetes caught up in natural or manmade disasters;
* that twinning programmes, international partnerships, and mutual aid be stimulated and reinforced across Europe, along with initiatives to develop the role of non-medically qualified professionals and to maximize the activities of diabetes magazine editors;
* that basic and health services research and development be vigorously promoted to secure the foundations of future quality diabetes care, in cooperation with national professional and research organisations, the European Association for the Study of Diabetes, and the research programme of the European Union
The Acropolis Affirmation was adopted with acclamation by all participants in the final Session of the Athens meeting,and with individual commitment to work for its full implementation.
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