Effective joined up working is crucial for people with diabetes. By getting involved in the commissioning project nurses were able to shape service design
Caroline Rollings, MBA, Specialist Community Practitioner, RGN, is lead nurse and partner, Newport Pagnell Medical Centre, diabetes team manager, NHS Milton Keynes, and health:mk board member.
Rollings C (2010) Using nurse-led clinical commissioning to improve services for patients with diabetes. Nursing Times; 106: 33, early online publication.
Diabetes services in Milton Keynes were being duplicated and a need to coordinate services in local primary care settings was identified. This article explores how nurse-led clinical commissioning is improving services for patients with diabetes in the area.
It examines the practical challenges of the service redesign, how personalised care planning for people with diabetes can improve quality of care, and the benefits for nurses of becoming involved in clinical commissioning.
Keywords: Clinical, Commissioning, Care planning, Diabetes
- This article has been double-blind peer reviewed
- Advice for setting up a new service:
- Review the current situation to understand the needs of the local population and what you want to achieve from the programme;
- Involve service users, nurses and other healthcare professionals from the outset;
- Make the service as integrated as possible to minimise duplication;
- Ensure you have the right data from your primary care trust to support your bid;
- Set aside time for strategic and operational planning to develop a robust agenda.
The government white paper Equity and Excellence: Liberating the NHS says the responsibility for commissioning services should lie with the healthcare professionals “closest to patients: GPs and their practice teams working in consortia” (Department of Health, 2010).
It is recognised that nurses are often best placed as sources of ideas for innovative service improvement; clinical commissioning gives them the opportunity to take on lead roles in commissioning services as part of GP consortia. Many are already experienced in redesigning patient pathways and local services through practice based commissioning, and this is particularly true for services helping those with long term conditions.
This article explores the development and implementation of a nurse-led clinical commissioning project to coordinate the care of patients with diabetes.
In 2008 there was a lack of effective joined up working in diabetes care in Milton Keynes. The service consisted largely of one GP with a special interest in diabetes practising locally, along with diabetes specialist nurses working in outpatient clinics and the community, plus other healthcare professionals providing training for clinicians and people with diabetes.
A practice based commissioning project was set up in September 2008 which included a team of 10 multidisciplinary diabetes healthcare professionals:
- A GP;
- A practice nurse with a special interest in diabetes;
- Two acute care consultants;
- A community diabetes nurse specialist;
- Two diabetes specialist nurses;
- Specialist administration support and an administrative manager.
The project was supported by health:mk (www.healthmk.org), a local GP-led commissioning organisation working in partnership with Quality:MK, a local quality improvement programme which works to establish a whole system approach to improving healthcare in Milton Keynes (www.qualitymk.nhs.uk).
The project identified the need to better coordinate diabetes services and set up a holistic team to improve the quality of patient services and reduce costs. Key stakeholders worked together through a local “task and finish” group (set up as a temporary measure to overcome any risks or bottlenecks when changing service delivery) to design a new model of diabetes care.
Led by a public health consultant, the group recommended replacing existing routine services with a community based programme to bring care out of hospitals and closer to people’s homes.
The plans shaped a service specification for a new intermediate diabetes service and the programme also ensured that professional development was provided in an evidence based, coordinated way.
The Milton Keynes Diabetes Interim Team also worked with NHS Diabetes to identify how care planning could be offered to people with diabetes. This workstream already demonstrates the priorities set out in the NHS white paper to give patients a greater say and more choice in the healthcare they receive.
The clinical commissioning group now works together on several areas:
- Introducing care planning to GP practices across Milton Keynes and supporting implementation and rollout;
- Supporting practices to increase Quality and Outcomes Framework (QOF) scores in diabetes care;
- Working closely with GP practices that initiate and manage the care and support of people whose diabetes is treated with insulin;
- Delivering the Warwick University Certificate in Diabetes Care course;
- Running multidisciplinary training for diabetes care, including diabetes training for healthcare assistants and insulin initiation/management;
- Managing education and support programmes for people with type 2 diabetes.
The work is funded through an ongoing specific allocation set aside by the PCT in 2008. Commissioners from the PCT and health:mk jointly oversee the team’s progress against their objectives.
The team felt it was crucial that primary care professionals work with acute care specialists to improve services. Half a day a week of consultant time was arranged to support the team, and the consultants take part in the team’s strategic planning to assess future requirements and service provisions. They also visit local practices to discuss ongoing options for improving diabetes care.
Nurses and commissioning
Clinical commissioning is about empowering local GP practices and primary care professionals to commission services and achieve better healthcare and health outcomes for the local population. By getting involved in commissioning projects, nurses have the opportunity to have more power in shaping patient care and service decision making.
The nurses involved in the programme felt able to exercise increased responsibility and have the autonomy to make decisions about services that directly affect their patients. The care planning programme has allowed them to get closer to patients and understand what support they need to self-manage their condition.
It has proved to be a rewarding way to work with patients and there have been clear benefits in nurses getting involved in commissioning decisions. For example, frontline nurses know where savings can be made and how efficient pathways benefit patients.
Senior team members have developed new management skills, including stakeholder management, and new experience including working on a national basis and sharing the work of the team at healthcare conferences.
However, staff did need some training to feel confident and knowledgeable enough to deliver the service. A two-part care planning course, run over six months, has been implemented by Successful Diabetes, a company that provides products and services for people with diabetes (www.successfuldiabetes.com).
Care planning involves a complete change of mindset for some healthcare professionals. The key to success is ensuring it is based on joint decision making between the healthcare professional and the person with diabetes.
Some clinicians felt they were already care planning effectively in their diabetes consultations, but the training helped them to identify further consultation skills to enable even greater patient empowerment.
Integrating technology so information sharing is made as simple as possible has been a challenge. The aim is to have shared IT systems to make the transfer of information easier and allow the sharing of information between acute and primary care, but this integration can be costly to implement.
The programme also required significant effort from GP practices. The enhanced care planning service has meant that practices now offer two appointments instead of one. Patients see a healthcare assistant first to complete their metrics (such as blood, urine and lifestyle status) and foot assessment. The results and explanations are then sent to the patient to form the basis of a more focused appointment with the practice nurse.
Each practice has been supplied with a set of resources ensuring consistent, quality information for healthcare professionals and people with diabetes.
Patient and service benefits
Anecdotally patients have responded well to the care planning service, saying they feel able to open up about their concerns as part of shared decision making.
At a care planning appointment one patient felt able to express his fears for the first time about going blind. To reassure him, his practice was able to respond to his individual needs and set up more regular eye checks and appointments with an optician who understood the needs of people with diabetes.
Another young male patient was determined to manage his diabetes through exercise and diet alone. But after his first cycle of care planning he realised that medication would be the best option for him. By being part of the decision making process, this patient was able to take part in his treatment plan and was able to agree with the GP’s recommendation.
Patient behaviour has taken some time to change, but as they start to see the benefits of the programme patients are becoming more engaged. They have begun to appreciate the need to have their HbA1c levels checked at the appropriate clinical intervals so they can access the most effective care when they need it.
There is also a strong belief in the team that nurses are able to take a lead and provide care in a way that suits patients, particularly as care planning allows them to treat patients much more holistically.
The team is working with the PCT to measure the programme’s success through audit measures. It is crucial that this analysis includes more than just the number of care plans agreed and reflects the level of support, confidence and involvement in decisions that people need to help them self-care more effectively.
The team is involved in The Diabetes Year of Care programme, a partnership initiative between the DH, Diabetes UK, The Health Foundation and NHS Diabetes, which aims to learn how routine care can be designed and commissioned to provide a personalised approach for people with long term conditions. The programme is using a specially adapted Consultation Quality Index (CQI) questionnaire as part of a national programme examining the success of care planning in people with diabetes.
After a care planning consultation, each patient is asked to complete a two part questionnaire. The first part looks at how the patient felt about the consultations and the second examines whether the consultation helped them understand their condition better and make changes to improve their health and wellbeing. Early results are expected in 2010.
The programme is still in its infancy but 18 out of 27 practices in Milton Keynes are now offering diabetes care planning in this way. Work shadowing is taking place so healthcare professionals can learn best practice from others, there is more inter-practice working and the team is already spreading the benefits of care planning to other parts of NHS Milton Keynes. The district nursing team in Newport Pagnell is about to embark on a programme of care planning and Woodhill prison is looking at adopting the same approach.
As well as improving personalised care for patients, the team believes the programme will prove cost effective in the long term, outweighing any initial set up costs.
- In 2008 a community nurse led diabetes service was set up to coordinate services and bring them closer to patients.
- The service has allowed nurses to become more involved in decision making and service design.
- Research is being carried out to measure the quality of the care planning process and to find out if patients are seeing a benefit.
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Department of Health (2010) Equity and Excellence: Liberating the NHS. London: DH. tinyurl.com/equity-excellence
Department of Health(2009) Supporting People with Long-term Conditions: Commissioning Personalised Care Planning. London: DH.