Working together to deliver a local model of care
Specialist diabetes teams can best fulfil their potential when functioning in a complementary fashion to other parts of the healthcare system. Commissioners must ensure the delivery of services for their population that meets local health needs, and monitor the quality of those services and outcomes. Multidisciplinary primary care teams have a fundamental role in the prevention and identification of diabetes as well as in routine care at a level that fits with their competencies. This role will often include active case management of patients with multiple conditions.
Multidisciplinary diabetes teams
Specialists involved in the delivery of diabetes care must work in multidisciplinary teams for care to be truly effective. They should have received extensive training accredited at a national level. Specialist teams should comprise physicians, nurses, podiatrists, dietitians and clinical psychologists, who will also collaborate with many other specialists who might be incorporated into the team.
Specialist teams provide direct care for people with diabetes with complex needs that cannot be met within the skill competencies of the general practice team. Examples include:
- People newly diagnosed with Type 1 diabetes.
- People with Type 1 diabetes (for carbohydrate counting and/or the use of insulin pumps/or continuous blood glucose monitoring).
- Children with diabetes.
- Pregnant women and those planning a pregnancy.
- Patients with significant and ongoing cardiovascular or peripheral vascular disease.
- Young patients with diabetes of an undefined nature.
- Patients with active foot ulcers or uncontrolled neuropathic pain.
- Patients with diabetes and renal disease or retinopathy requiring active management or complex monitoring.
- People whose risk factors for complications have been unsuccessfully controlled in primary care.
- Patients with recurrent hypoglycaemia.
- Patients with neuropathy, especially autonomic neuropathy.
- Inpatient care.
Co-ordination across the whole system of diabetes care
Specialists will also often have a coordinating and facilitating role for some of the population-wide services, such as education and training or surveillance for complications.
Education and training
The role of specialist teams in developing and maintaining the skills of other care teams is significant. As the local experts, they play a key part in advising commissioners and the leadership of other organisations. Specialists also have a significant role in training and supporting the development of expertise in those providing ongoing diabetes care in the community.
Specialist teams may be based in hospitals or community settings, but will need to provide care, support and education in all locations for the local population. In some teams key members focus on different aspects of the service. In those areas where they must also focus on community-based care, community specialist jobs have been created. The medical components of specialist care cannot feasibly be delivered and led by a single consultant diabetologist as part of a multidisciplinary team for the size of population served by most CCGs, even with the support of GPs with a special interest and the other professions.
One of the key challenges for many specialist teams, particularly those based in hospitals, is that they may be serving a number of commissioners and populations with differing requirements or models of care. Local clinical diabetes networks, consisting of those working in primary and community diabetes services, specialist diabetes care, social care and people with diabetes, should be the mechanism for partners to work together to agree and define local care models and systems, and advise commissioners and providers on service availability and monitoring across all parts of the UK.
This information is taken from the 2010 Diabetes UK Task and Finish Group report,Commissioning specialist diabetes service for adults with diabetes (Word, 8MB)