Background
For many years acute diabetes care had been struggling to cope with the ever increasing number of referrals from GPs and the increasing number of follow ups.
The PCT has 62 general practices and a diverse population in terms of ethnic and socioeconomic factors. The development of practice based diabetes knowledge and skills had been identified by the PCT as a priority area in 2005, and funding was received by the team for strategic planning. The diabetes project was hence developed to ensure that people with diabetes are seen in the community close to where they live for easier access and to reduce waiting times for diabetes care.
No information was available relating to service provision, delivery of care, knowledge and skills relating to diabetes in general practice at the time. One of the first tasks undertaken was a baseline diabetes audit involving a visit to all the practices in the locality. An audit tool developed by A Farooqi was used to examine all areas of diabetes management. The results of the audit were reviewed with the individual practices and gaps in knowledge and skills were identified to help improve the priority areas in which the practice team desired to develop.
Why this service is a good example of shared practice
The service has developed and more people with diabetes are now being cared for by their general practice teams. The primary care team has access to effective tools to help them increase their knowledge, skills and confidence in caring for people with diabetes. The Diabetes Nursing Team also have a shared vision and clear philosophy about what needs to be put forward in order to improve services for people with diabetes.
Staff members working across primary and secondary care were involved in the development of plans as well as service users. The service engages service users and the local communities in planning around all areas of diabetes care and the presence of at least one user representative is required at any planning group, whether this is for an educative event for professionals or an addition to diabetes policies or guidelines. This helps to present the views of the wider users group.
The service redesign now ensures people with diabetes are being seen by the most appropriate professional after triage, and in all clinics there are thirty minute appointment slots for both new and follow up appointments.
People with diabetes have access to a hand held record and are aware of their treatment plan. The record was developed with a small user group in collaboration with clinicians.
As part of a repatriation project in 2005, stable Type 1 and Type 2 people with diabetes are being transferred back to primary care in a phased manner to GP practices that are confident of providing diabetes care in line with the diabetes care pathway. The Diabetes Nursing Team also offer help and support to practices when necessary.
The active management of diabetes in the community led to a reduction in referrals to secondary care services and acute services have become focused on the more complex management problems. Education sessions for district nurses, practices nurses are held on a bi-monthly basis.
Service Provided
Basic diabetes services are provided by General Practice Teams where possible (in line with Quality Outcomes Framework QoF). Competencies for general practices are in place and were developed to reflect the Diabetes Care Pathway as well as the Model of Care.
The Model of care:
Level 1: GP and practice team participate in basic diabetes management
Most practices are working at Level 1 and they provide diagnosis and basic diabetes treatment to the local community, examples are to run smoking cessation clinics within practice, monitor the efficacy of exercise regimens on HbA1c, blood pressure and cholesterol, to promote self management etc.
People with diabetes receive one to one education with practice nurse and a copy of Living with Diabetes booklet and hand held record are given; group education can also be referred for individual needs. Annual review is undertaken at Level 1 and the retinal screening results are discussed.
Level 2: GP and practice team participate in a higher level of diabetes
General practices opt to provide either Level 1 or Level 2 service, relating to the appropriate level of competency. Their services can be further developed once self assessment is done and ratified by executive committee. There are currently 6 General Practices working at level 2, providing enhanced diabetes treatment, management and education to people with diabetes, and this includes the following: Education to people with diabetes, prevention and importance of screening for retinopathy, nephropathy, neuropathy. A programme of diabetes related audit and review of outcomes is expected from Practices working at this level.
The number of people with type 2 diabetes on insulin who receive their routine care at these practices is increasing.
Level 3: Nurse consultant leading the Diabetes Nursing Team
A Diabetes Nursing Team was established in the community and consists of a Nurse consultant, 3 Diabetes Specialist Nurses, an administrator and a dietitian. The team is led by the nurse consultant and people with diabetes can be referred to the team by General Practitioner or practice nurse.
The Diabetes Nursing Team undertakes management of diabetes problems where expertise above the competencies of General Practices is required. Clinical plans are devised by the team and people with diabetes are monitored as required until discharge back to the GP is clinically appropriate.
In the community the Diabetes Nursing Team provide mentorship, education, advice and management for both people with diabetes and healthcare professionals. In order to help practices provide high quality diabetes care, the Diabetes Nursing team attends sessions at general practices when necessary to see people with diabetes with more complex needs who might previously have had to travel to the acute setting for an appointment. They also visit the housebound at home where necessary and support people with their diabetes management through the telephone or emails. A programme of education and support is also available for Residential and Nursing Homes.
All referrals for diabetes are triaged by the Nurse Consultant or the Diabetes Specialist Nurses on a daily basis. The triage process was developed to capture all diabetes referrals from Primary Care Trust GPs and direct them to the most appropriate service as well as to determine the urgency of care required.
Level 3: Clinics for people with diabetes
A number of intermediate diabetes clinics are being held in the community by the team to help manage people requiring more specialised input that can not be provided at General Practices. The aim of the service is to provide specialist care in the community closer to people with diabetes and for those who might have been previously referred to secondary care. A referral to these clinics can be made by any Healthcare Professional, after discussion with the GP and people with diabetes might receive appointments for more than one clinic to fit their needs.
- There are clinics for those newly diagnosed with diabetes and are held three times a week. People who have been newly diagnosed with diabetes will undergo a full examination by the Diabetes Nurse Consultant and will see a dietitian for a full dietary assessment. A full report would then be sent to the General Practitioner and recommendations for future treatment and follow up will be discussed.
- Ongoing management clinics are held twice a week and are held for people who are having problems managing their diabetes or who are developing complications and need to have close monitoring of their condition. Insulin initiation is also provided at these clinics and allows staff to closely monitor and follow up as necessary. People seen at these clinics can also be referred directly to a Health Trainer for further lifestyle education and advice especially with regards to weight loss, increasing exercise and smoking cessation.
- Preconception clinics are diabetes clinics for women of childbearing age to ensure that the right advice and information is given before trying for a baby. The aim of the clinic is to minimise risk associated with diabetes in pregnancy by addressing risk factors that are associated with pregnancy in diabetes before conception. Women who are referred to this clinic are seen twice weekly as insufficient number warranted an exclusive clinic (Depending on where the woman is being seen at the time, these clinics can also be held in acute settings).
- Neurovascular assessment clinics are held weekly and take place to monitor people with vascular or arterial problems or people with symptoms of painful neuropathy.
Level 3: Education for people with diabetes
- Diabetes Education and Self Management for Ongoing and newly Diagnosed (DESMOND) education courses which is held monthly.
- Routine education sessions to which both people with diabetes and their carers can attend. These sessions are held monthly and also are held in the evening for people who cannot attend in the mornings. These sessions are aimed for those newly diagnosed or for those who have had diabetes for a number of years and would like to update their knowledge. The programme of the session includes: What is diabetes? Healthy eating, What care to expect, Treatment targets, eye screening and foot care.
- The “Living with Diabetes” booklet was produced by people with diabetes from the local Diabetes Support Group in collaboration with the Diabetes Nursing Team and is aimed to help anyone with diabetes who wishes to be better informed. The booklet can be downloaded on the right on this webpage. The PCT diabetes team has also produced a hand held record for people with diabetes and this can also be downloaded on the right.
- Diabetes awareness sessions are held for people that are regarded as being at increased risk of developing diabetes. Some of the events held this year include two for Asian Womens groups, an African- Caribbean event, three events for adults with learning difficulties, three events for Ramadan, one for our Turkish Community and a library event as well as an event at a local Job Centre
Level 3: Education and training for healthcare professionals
As care is provided within primary care the Diabetes Nursing team also works to ensure that the GPs and practice nurses are able to access appropriate further training and support. They work in collaboration with local diabetes experts to organise the Primary Care Diabetes Course. The course can be accessed free of charge to all staff working for the PCT and takes place twice a year. The course provides a comprehensive 6 day programme for the primary care multidisciplinary team. There has been positive feedback from participants and resulted in an increase in skill levels and confidence. There is also a 2 day insulin management course focuses on supporting General Practitioners and Practice Nurses to update knowledge and skills in this area. It is currently run twice a year and is both oversubscribed and well evaluated.
Level 4: Acute centres for management of complex diabetes problems
Management of acute diabetes problems and highly complex cases, for example, care for children with diabetes, antenatal services, joint renal services, emergency fast track services for foot, acute condition of diabetes, treatment challenges in Type 1 or Type 2 and retinopathy post screening rapid access.
People with Type 2 diabetes who are currently being cared for in acute care and who met an agreed criteria, are repatriated back to their GP practice to receive their ongoing diabetes care as appropriate. To date over 972 people with diabetes have been repatriated back to the Primary Care setting.
Project Aims
The aim of the service was to deliver quality care by developing a comprehensive and equitable diabetes service for all people with diabetes in the locality that is both person centred and evidence based. It included shifting the care of stable people with Type 1 and Type 2 diabetes from acute to primary care as outlined in a systematic and safe way to ensure that best outcomes are obtained.
Evaluation
Recent figures have shown that using the processes outlined, we are seeing 90% of diabetes related referrals in the Primary setting and 10% of people with diabetes require care in the acute setting.
A total of 972 (and rising) people with diabetes have been repatriated back to primary care.
A patient satisfaction survey has indicated that people with diabetes are happy with diabetes services that are provided in the PCT.
We are currently undertaking a clinical outcomes audit, the results of this are expected in Spring/ Summer 2009
Learning
The service redesign would not have been successful without the strong commitment and close collaboration between the acute care and primary care diabetes team. It is necessary to have a multi disciplinary working group to monitor and take the work forward and ensure ownership and accountability by all stakeholders. A comprehensive diabetes service needs all professionals to take on the work that is appropriate for their skills and expertise in order to deliver high quality and cost effective care for people with diabetes across the PCT. It is also critical that the PCT is committed to support continued service improvement and allows the primary care diabetes team the scope to provide what is needed as well as to develop services in the future.
The importance of making arrangements to involve and consult services users and local communities in service planning and operation, as well as in the development of proposals for changes is essential. The benefits of user involvement are significant as the real involvement improve services by finding out what priorities people with diabetes have and this lead to better targeting of resources and planning. Also the engagement with service users is likely to reduce complaints and ensure the service is responsive.