Alison M. Johnson, BSc (Hons), RN, PGC (Health Econ).
Diabetes and Coronary Heart Disease, Project Co-ordinator, Chorley and South Ribble Primary Care Trust, Croston, Preston, LancashireThe incidence of diabetes mellitus is increasing and morbidity associated with its complications costs the NHS more than 10% of its annual budget (Cradock, 1997). One of the priority areas in The Health of the Nation targets is the reduction of morbidity and mortality related to diabetes and its complications (DoH, 1992).
The incidence of diabetes mellitus is increasing and morbidity associated with its complications costs the NHS more than 10% of its annual budget (Cradock, 1997). One of the priority areas in The Health of the Nation targets is the reduction of morbidity and mortality related to diabetes and its complications (DoH, 1992).
Diabetes staff at Lancashire's Chorley and South Ribble Primary Care Trust (PCT) obtained funding from the North-West Education Consortium to undertake a one-year project to develop services to improve the care of people with diabetes using a clinical governance framework.
We planned to gain experience of the clinical governance process within the trust using the diabetes framework. By doing so we hoped to raise awareness of clinical governance among health-care professionals in primary care especially in relation to diabetes care. We knew that it was also particularly important to gauge the feelings of users of diabetes services (Callaghan and Williams, 1994). The main aims of the project were to:
- Identify existing skills and expertise relating to diabetes within primary care
- Reduce inequalities in provision and quality of diabetes care across primary and secondary care
- Assess existing services against agreed standards to identify practice, training and development needs
- Provide appropriate training to relevant staff including PGEA (postgraduate education allowance) sessions, ENB courses, training by diabetic specialist nurses and mentorship
- Develop a patient education and empowerment programme, working with the Community Health Council, local diabetes groups and other professionals involved in caring for people with type 2 diabetes
- Gain experience of the trust's clinical governance process using the diabetes framework.
Secondary aims were to clarify the roles of various professional groups across primary and secondary care and to encourage co-operation and collaboration. Agreement was needed on which services should be provided within primary care and to develop local standards, guidelines and audit criteria for provision of those services. To do this, it was necessary to identify the need for additional resources, such as laboratory tests, equipment, a dietitian and podiatry services.
Three key areas addressed by the project were:
- A base-line review of current skills and services across primary and secondary care using semi-structured interviews with the primary health-care team, as well as health-care professionals and managers across primary and secondary care
- A questionnaire-based patient satisfaction survey targeting approximately half the patients with diabetes within the trust. This was followed by six patient focus groups to obtain more in-depth feedback from patients, relatives and carers
- A clinical audit of diabetes care incorporating the key elements of the annual review agreed as best practice. Due to time limitations this element of the project is not included in this paper.
A multidisciplinary steering group was formed with representation from primary and secondary care. The group included: GPs, practice nurses, diabetes specialist nurses, community nurses, a consultant diabetologist, dietitians, podiatrists and pharmacy advisers. The clinical and organisational standards of care to be used as the benchmarks for the project were those contained within the local guidelines, Good Practice in Shared Care for Patients with Diabetes Mellitus (Chorley and South Ribble Primary Care Trust, 2000) and the diabetes service development handbook (North-West Regional Diabetes Development Group, 1996). A summary of the structured model of care for diabetes included in the handbook is shown in Box 1.
Delivery of care
In the majority of GP practices (29 out of 34), practice nurses had a significant role to play in delivering diabetes care. Box 2 provides a breakdown of the methods of care delivery.
It was identified that patient information literature tended to come from pharmaceutical companies and was of variable quality and availability. The necessity for a consistent and reliable approach to the provision of written information for patients and their relatives/carers was therefore considered to be an important issue.
Confusion over and variation in the delivery of shared care sometimes resulted in duplication of effort and resources in primary and secondary care. Some patients with diabetes, particularly those controlling their condition by diet only, were not adequately monitored. According to both staff and patients, communication between the hospital and the practices was often slow, inadequate and sometimes nonexistent. Better communication and co-ordination was required between the hospital and GP practice to prevent duplication of work and to ensure everyone understood the model of care for each patient and who was responsible for which aspect of monitoring and care.
It was felt that co-ordination and communication between the hospital and community services needed to be improved, particularly when diabetic patients are discharged from hospital. This was particularly relevant in the evenings and during weekends and bank holidays, when specialist advice and support is difficult to obtain. The alternative was the on-call GP or the accident-and-emergency department (A&E), which was not always considered satisfactory or appropriate.
Inequality of access to dietetic services meant that some patients had significant support while others had very little or none at all. Overall, the level of dietetic input was well below the Diabetes UK (2001) recommendation of two-and-a-half hours per year. In addition, the waiting time standards for new referrals to be seen by a dietitian (four weeks from date of referral) were not being met in hospital or in the community.
The annual foot check was sometimes undertaken by a podiatrist and sometimes by a practice nurse and/or GP. Some practices indicated that they would like the podiatrist to undertake all annual foot checks, while others saw this as duplication of work already done by the practice. An agreed standard of monitoring was therefore necessary. Clear referral and access pathways were needed, along with clearer communication channels to avoid duplication of services. The waiting time for podiatry referral could be several weeks, which was considered too long.
In 29 practices, practice nurses provided most of the monitoring and care of diabetes, although only 10 of the nurses had been formally trained in the area. In 14 practices, the nurses had no formal diabetes-related qualification and in five practices they were studying for the ENB 928 in diabetes nursing. Eleven out of the 14 practice nurses without a formal qualification had attended diabetic updates or seminars within the previous two years. All the practice nurses involved in diabetes care expressed an interest in regular updates/seminars and nine of them were interested in obtaining a formal qualification. Seven practice nurses said that they would undertake a diabetic qualification if their involvement in diabetes care was increased.
Diabetic specialist nurses
Primary care staff felt that diabetic specialist nurses provided a useful and effective service when involved with patients but were often difficult to contact by telephone due to other work commitments. GPs, practice nurses and district nurses proposed linking a nurse specialist to a particular practice, resulting in better communication and an improved service for patients.
The specialist nurse team felt there was a misconception by primary care staff that they provided an emergency service. Although home visits were often requested by GPs, patients were encouraged to attend the hospital out-patient department for review. This was felt to be more beneficial by the hospital team as key resources were available, such as monitoring equipment, information booklets and dietetic advice. However, if the patient was unable to attend, then a home visit would be arranged.
Although patients were encouraged to attend hospital to see a specialist nurse, this was not always possible due to the lack of a consulting room.
The specialist nurses already provided group education sessions for patients who were newly diagnosed and were considering developing other sessions to reduce workload, such as group sessions for people changing from tablets to insulin. However, the main stumbling block was an appropriate venue in which to hold sessions.
It was clear that further discussion and clarification of the role of the diabetes nurse specialist in community care was necessary.
The role of the district nurse was felt to be to:
- Educate newly diagnosed diabetes patients on how to manage and monitor their treatment and care
- Administer insulin and support pregnant women who had developed diabetes
- Administer insulin and/or treatment and care to older patients who were ill or lived alone and had diabetes-related complications, such as peripheral vascular disease, visual impairment or had experienced a stroke.
District nurses reinforced the views of GPs and practice nurses that co-ordination and communication between the hospital and community services needed to be improved. Particular problems had followed changes in insulin regimens and with patients who had been discharged over weekend and bank holidays. District nurses confirmed that advice and support regarding diabetic care was difficult to obtain in the evening and at weekends.
Taking the patient's point of view into account is a recent development (Hart, 1996). A key element of the project was developing an education and empowerment programme for people with diabetes. A patient survey and six patient-and-relative focus groups were conducted to establish the following information:
- What level of care and monitoring patients were receiving
- Patient satisfaction with their care
- Levels of patient information, education and involvement
- The views of relatives and carers
- Areas about which patients would like more information
- Suggestions for improvements in care.
The survey and focus groups identified a number of key areas where patients and their relatives felt care could be improved:
Professional knowledge and education - It was felt that all health-care professionals should have a good basic knowledge of diabetes.
Practice-based care - Well-organised, supportive diabetes care should be available at the local general practice, with good and speedy access to hospital services when needed. This was felt to provide a more rounded approach, and allowed the development of a good relationship between the patient and the practice team. However, this was only the case if the GP and practice nurse were skilled and knowledgeable in diabetes management and care.
Standards of care - Patients wanted better knowledge and awareness of the standards of care they should expect, and on the health professional's level of expertise. They also wanted an improvement in the consistency of care provided in all areas of diabetes management, including early diagnosis and initial management and support.
Hospital care - A number of areas were identified as requiring improvement. These included:
- Communication - particularly with regard to feedback of results and patient involvement
- Reducing waiting times for nurse specialists
- Doctors seen at hospital appointments were often different at each visit; patients felt this resulted in discontinuous, inconsistent care. It was felt that seeing the same doctor would promote the development of a relationship and understanding of the patient and reduce the likelihood of the doctor repeating basic information at every visit.
Support services - Several improvements were necessary to reflect patient needs:
- Access to podiatry and foot-care; screening to be improved and standardised
- An efficient, user-friendly appointment system
- Access to dietitians to be more consistent
- An increase in the availability of home monitoring and support for elderly and disabled people
- Improvement in ease and frequency of access to care and support in primary and secondary areas, including more flexible clinic opening times.
Information and education - The importance of providing patients and relatives with consistent and comprehensive information, allowing them to ask questions and offering opportunities for further discussion was made clear. Key issues included:
- The need for comprehensive verbal and written information at the time of diagnosis and updates covering a range of topics
- The need for better provision and sharing of written and verbal information, including: appropriate targeting and staging; consistency; use of patient-friendly language; access to a local resource centre; including relatives and carers; health professionals offering information; and newsletters
- Better information, advice and support on self-monitoring equipment, needles, insulin pens and so on, including prescription and payment advice.
Patients as partners - Patients felt they were not always believed and trusted by their doctor if their diabetes or weight were not under proper control. The sharing of information with patients and discussion of their condition and progress needs to be improved, to promote ownership and partnership in care (Wikblad, 1996). Patients should be treated as individuals and be able to negotiate and discuss issues relevant to their life and their care.
Communication and support - Patients often felt 'in shock' on diagnosis and needed a one-to-one chat with an appropriate professional and regular follow-up to continue the education process. The way information-giving and education was carried out was seen to be very important, to allow time for discussion and questions. This linked very closely with the relationship between the person with diabetes and his or her doctor or nurse. Vulnerable times for patients, when they felt more support was needed, was on diagnosis and when treatment changed, for example, when moving from diet to tablets or tablets to insulin therapy (Wikblad, 1996). Patients also reinforced the view that communication between the hospital and GP was sometimes poor, which could lead to confusion and loss of confidence in the system.
Issues and action
Issues identified following completion of the project are listed in Box 3. Box 4 lists some of the action taken to address these issues. Multidisciplinary postgraduate sessions have been set up to encourage feedback on the project findings and a multiprofessional education programme has been linked to the delivery of good practice and practice/personal development plans. In addition, a number of practice nurses received financial backing to enable them to undertake formal diabetes courses.
A considerable amount has been achieved by the project and the project steering group continues to work to ensure that the work continues. Over the next six months, the project will be formally evaluated to assess whether its objectives have been achieved and whether the changes and developments initiated have improved services and outcomes for patients with type 2 diabetes.
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Cradock, S. (1997)Clinical update: prevention and management of diabetes in the community. Health Visitor 70: 2, 75-76.
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Hart, M. (1996)Incorporating outpatient perceptions into definitions of quality. Journal of Advanced Nursing 24: 6, 1234-1240.
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Wikblad, K.F. (1996)Patient perspectives of diabetes care and education. Journal of Advanced Nursing 16: 7, 837-844.