Brent has one of the highest prevalence of Diabetes in UK of about 4.6% (17,000 people with diabetes) with a large ethnic mix (mainly South Asians and Afrocarribeans) and with a high diabetes complication rate (eg. prevalence of retinopathy is 41%). Hence, management in diabetes is a major priority for Brent teaching primary care trust. Actual prevalence at local GP surgeries ranges from 0.6 to 9%
Before 2001, the majority of Diabetes care in Brent was taking place in secondary care in Brent. However due to a very high prevalence of Diabetes and limited capacity in secondary care, provision of diabetes care was being stretched. For example, waiting time for a person with diabetes to be seen from a GP referral to see a consultant for a new appointment was over 20 weeks; waiting time for follow up appointments was more than 12 months and an average waiting time for a person with diabetes to be seen in clinic was 45 minutes. It was decided that the way forward in Brent’s Diabetes care was to have an integrated care in order to deliver a more user friendly local services to people with Diabetes and to allow secondary care to concentrate in developing specialist care.
From 2002 till 2004 a series of meetings between various stakeholders took place in Brent. The purpose was to develop a new model of care for people with Diabetes using national guidelines, local stakeholder analysis and local service user focus group work to inform and guide the process. Four main areas of person centred elements were addressed – 1. How can a person with diabetes have an immediate access if they had a problem with their Diabetes without attending A&E. 2. Can all people with diabetes have access to a specialist Diabetes team. 3. Can people with diabetes be seen nearer their home rather than to make a trip to their local hospital (encouraging closer to home care) and 4. Can people with diabetes be provided flexibility and convenient times for their appointments
How this service improves
People with diabetes can see a named diabetes specialist nurse (DSN) on the same day when they are referred by a GP and no appointment is needed for these clinics.
Why this service is a good example of shared practice
This model remove service gaps in care whilst ensuring all people with Diabetes receive the care they need, when they need it from appropriately skilled staff in the community setting working in an integrated manner.
To ensure that people with diabetes will experience a seamless diabetes care via an integrated approach involving both primary care and the specialist care and also to up skill the knowledge in primary care.
People will have continuous screening and assessment in primary care and GP can also refer people with diabetes to the intermediate specialist care for services not available in practice, e.g. weight management, education, podiatry.
A named DSN presence in each locality working with GP and nurses to up skill diabetes care in the primary care setting.
Intermediate Specialist care
The intermediate specialist care acts as an interface between primary and secondary care. For each locality in Brent, there is a DSN to provide diabetes care to the local community. Each DSNs in the 5 localities in Brent also conduct email, telephone consultations for both healthcare professionals as well as people with diabetes, and visit people with diabetes who are housebound on request of district nurses. Moreover, there is variety of education courses throughout Brent catering for various ethnic communities and languages e.g. DAFNE, DESMOND and ‘managing diabetes during Ramadan’ which details of the programme could also be found on our shared practice database. Anyone in the primary care trust can refer people with diabetes to these courses including staff and family members of people working in the trust. The overall clinical governance of the Brent Diabetes service is provided by a consultant community diabetologist. See www.brentdiabetes.com
The following types of people with diabetes are referred to the DSN in the intermediatry care team, for example:
- Poorly controlled people with diabetes who require maximisation of their insulin therapy
- Those people with diabetes discharged from hospital and require short term follow up
- People with diabetes who require referral to the group education sessions
- Diabetes woman requiring pre-conceptual care
A diabetes Nurse Practitioner led rapid access clinic:
A diabetes Nurse Practitioner led rapid access clinic has also been set up by the PCT as part of the intermediate specialist care with the aim to improve diabetes care for people with diabetes in Brent, and is not an emergency service.
In each locality of the PCT, a diabetes nurse practitioner runs a clinic and work closely with the consultant physician. GPs can also telephone or email their local consultant with any specific queries, or seek advice from the consultant ophthalmologist at North West London Hospitals NHS Trust and clinical lead for Brent Diabetic Retinopathy Screening.
People with diabetes do not need an appointment and are referred for blood glucose stabilisation, frequent hypos and/ or hyperglycaemia, titration of anti-hyperglycaemics including insulin, difficulty with insulin delivery devices and blood glucose meters. GPs can refer people with diabetes using the Diabetes community services referral form and people with diabetes will be seen on arrival of the clinic. If people with diabetes appear independently, GP will also be informed.
The Diabetes Nurse lead rapid access clinics was set up because people with diabetes were waiting a long time for specialist appointments and very often they simply need reassurance of whether they are doing the right thing, for example, minor concerns about pens, medicine and blood glucose meters that could not be answered at GP surgery. When GPs get to know of the service they are also happy to refer people with diabetes to these clinics and has proven very successful. People with diabetes are willing to travel if they can be seen by a diabetes specialist on a particular day without needing to make an appointment.
Only specific group of people with diabetes are seen at the secondary care:
Type 1, gestational diabetes, foot ulcers, renal, children and any inpatient assessment and management and people who have diabetes complications.
All DSNs in Brent are responsible for the outpatient and inpatient care in the secondary care and this has the advantage to be able to cover each other when on holiday without deskilling anyone in the team.
Training to healthcare professionals
‘Behaviour change skills in diabetes management’ was delivered to GPs, consultants, dietitians, DSNs and the multi-disciplinary team involved in diabetes care, which is to provide a stimulating course on the use of behavioural approach and to increase knowledge of the skills and strategies requires. This training ensures the healthcare professional to have increased confidence in their ability to manage diabetes and allow the whole team to provide a consistent advice and approach for people with diabetes.
The training is a 3 day course and the programme covers, e.g. first contact skills, dealing with emotions/ reflecting feelings, difficult clients, cognitive behaviour therapy strategies, implications for practice and how to overcome the obstacles etc.
The work is accountable to the provider section of Brent Teaching Primary Care Trust.
People with diabetes have positive feedback regarding to the services that they appreciate the local access and the audit results of the education sessions show that being on the course has had a beneficial effect on HbA1c. Waiting times to see a specialist in Brent has been reduced from 20 weeks to less than 4 weeks. There has also been a 50% reduction in Accident and Emergency attendances.
No extra funding was required and staffs were relocated to fit the new model of care.
Funding was ,however, required for extra training diabetes nurses. This included prescribing and advanced nursing skills. Also costs are further incurred for accreditation and running costs for DESMOND and DAFNE programmes.
It is important to have the service support by a DSN who is a care champion and able to support practices in adopting the care.
Closer relationships were developed between GPs, nurses, DSNs and all other multi-disciplinary teams across the primary, intermediate and secondary care through professional development and trainings e.g. the behaviour change training. This not only provides a teaching element to primary care staffs but also enhance the clinician relationships across the integrated care. The climate of good working relationships enables a more effective communication between clinicians and they know each other roles and system better which is a highly advantage for people with diabetes.
Model of care in Brent could be downloaded from the right hand column on this page.