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The National Service Framework for Diabetes

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VOL: 98, ISSUE: 19, PAGE NO: 59

Mary Burden, RGN, MPH, is nurse consultant in diabetes, Heart of Birmingham Teaching Primary Care Trust, and sits on the Long-Term Condition Care Group Workforce Team and the Implementation Group for the Diabetes National Service Framework

The 10-year NHS plan has far-reaching policies that will change the balance of power in the health service. Patients, instead of being passive recipients of health professionals' interventions, will be active participants in their own care. Saving Lives: Our Healthier Nation (Department of Health, 1999) has focused on public health initiatives, heralding interventions that affect communities rather than just individuals. Diabetes lends itself to this approach, and self-management skills have long been advocated. Indeed, R.D. Lawrence, who formed the British Diabetic Association with H.G. Wells nearly 70 years ago, described how the person with diabetes needed to be their own 'physician, dietitian and laboratory' (Lawrence, 1955).

The 10-year NHS plan has far-reaching policies that will change the balance of power in the health service. Patients, instead of being passive recipients of health professionals' interventions, will be active participants in their own care. Saving Lives: Our Healthier Nation (Department of Health, 1999) has focused on public health initiatives, heralding interventions that affect communities rather than just individuals. Diabetes lends itself to this approach, and self-management skills have long been advocated. Indeed, R.D. Lawrence, who formed the British Diabetic Association with H.G. Wells nearly 70 years ago, described how the person with diabetes needed to be their own 'physician, dietitian and laboratory' (Lawrence, 1955).

National standards for England to improve the care of people with diabetes were published on December 14, 2001 (Department of Health, 2001). It is the first part of a new care blueprint for people with diabetes and covers standards, rationales, key interventions and the implications for planning services. The second part of the National Service Framework for Diabetes - the delivery strategy - will be published in summer 2002 and implemented from April 2003. An implementation group has been set up to advise the government on how these standards will be carried out. Their recommendations will be based on comments received from people with diabetes, their carers and relevant organisations.

Why do we need an NSF for diabetes?
In England there are more than 1.3million people diagnosed with diabetes and approximately as many again in whom the condition has not been identified. Two landmark studies (Diabetes Control and Complications Trial Research Group, 1993; UK Prospective Diabetes Study, 1998) clearly showed that complications such as retinopathy, neuropathy, nephropathy and the increased risks of coronary artery disease and stroke, peripheral vascular disease, cataracts and depression can be prevented or the disease progress delayed. What is needed is improved glycaemic control, 'normal' blood pressure and lipid levels, the prevention of microvascular complications and an improvement in the quality of life as well as the reduction of risk factors, such as stopping smoking, to avoid heart disease and stroke. Furthermore, national inequalities need to be removed as annual population data clearly shows the inequalities of outcomes in diabetes care. Examples include wide variations in amputation rates (Global Lower Extremity Study Group, 2000), visual loss and renal disease.

The needs of the population also vary according to ethnic origin, with black and ethnic minority groups having high rates of diabetes. Ten percent of the white population over 65 years has diabetes (Croxson et al, 1991), compared with over 25% of Asian people over 65 (Costa et al, 1991). While the risk of diabetes increases with age, the Asian population develops diabetes at an earlier age and needs more treatments to maintain diabetes control (Burden et al, 2000). The prevalence of diabetes is increased in areas of high socio-economic disadvantage (Connolly et al, 2000), yet resource allocation for diabetes does not usually reflect these differences.

Socially disadvantaged people are less likely to be treated with insulin, suggesting a lower priority on preventative care in type 2 diabetes. More men get diabetes (Khunti et al, 1999), and there are big geographic variations in the rates of complications. If the best care and best outcomes can be achieved for everyone we know that the benefits for the individual are improved quality of life, increased life expectancy, decreased risk of coronary heart disease and stroke, renal failure, lower limb amputation and visual impairment. This impacts on the NHS and on society in general because at least 10% of hospital in-patients are people with diabetes (Currie et al, 1997), and more than 8% of NHS resources goes towards diabetes care, with over 80% of this going on the complications of diabetes (King's Fund Policy Institute, 1996). Diabetes also increases the length of hospital stays and there are increased social care costs.

The principles underpinning the standards of the NSF for Diabetes (Table 1) are that they should be person-centred and developed in partnership with people with diabetes. They should be equitable, delivered by services which are integrated and work together and they should be oriented towards outcomes so that we know the changes in delivery of care that have been undertaken have actually led to benefits for people with diabetes.

What the NSF for Diabetes means for nurses
The NSF should ensure that all nurses, wherever they work, know and can practise at least the basics of diabetes care. The implementation group will be making recommendations about how the standards will be delivered so that, based on this, nurses will be able to plan their service to suit their local situation and population. There will need to be an increasing involvement of the communities and individuals in the management of care, so that informed patients make beneficial changes to their lifestyle and know how to respond to diabetic emergencies, such as hypoglycaemia and hyperglycaemia, and when suffering an intercurrent illness, such as influenza.

Some nurses are not confident about managing diabetes and seem happy to leave the person with diabetes to self-manage. But nurses do have a role in ensuring that patients can make healthy choices and improve the quality of their life by avoiding diabetic complications. Nurses will need to be trained and confident so that they can advise and support people with diabetes to self-manage. Importantly, nurses also need to know the sources of information and support that already exist so that their patients can access them.

The expert patient pilot interventions are in place (Department of Health, 1999), and the results will be used to make people with diabetes the main driver in their care. Lay tutors have also been appointed to provide appropriate education but they will need teaching and support themselves from knowledgeable health professionals.

Some nurses have felt in the past that it adversely affected the quality of life (QOL) of people with type 2 diabetes to be prescribed insulin, but the evidence from QOL studies from the UK Prospective Diabetes Study (1999) showed that the various treatments for diabetes did not adversely affect QOL but that treatment for complications and hypoglycaemia did.

Some diabetes specialists choose a particular treatment regimen and only offer their patients this option, rather than offer them choices in treatments that may suit their lifestyle and work patterns more flexibly. This means the treatment regimen needs to suit the patient, rather that the patient suit the treatment regimen. With self-management skills people with diabetes will have real choices and be aware of what is needed to maintain health.

Nurses need to support people with diabetes and to inform them of some of the 'good news' stories of recent diabetes research, rather than focus on the horror stories of complications. Positive messages to deliver include the following:

- The 'diabetic diet' is not different from anyone else's; it is a healthy diet and one that all members of the public should be following;

- Diabetic complications can be prevented or slowed;

- Treatments can be adapted to suit an individual's lifestyle.

Barriers
The main barriers facing the successful implementation of the standards include a lack of understanding about what actually happens to a person's body who has diabetes, the different types of diabetes, effective prevention strategies, different treatments and the importance of blood glucose control, blood pressure and lipids. Training and education will be imperative for health professionals and people with diabetes and their carers alike: nurses are likely to be key people to provide this.

Conclusion
Glycated haemoglobin (HbA1c) has been around since the late 1970s and is known to predict diabetic complications and indicate when treatments are inadequate. Yet most patient education materials do not mention it and many nurses do not give enough information to patients so they understand the importance of this test. This is just one example of how practice will need to change. The targets for improving diabetes care are ambitious but achievable. It is hoped that in 10 years:

- Fewer people will develop diabetes;

- People with diabetes are identified earlier;

- People with diabetes will have greater control;

- People with diabetes will develop fewer complications;

- The complications that do occur will be identified and treated at an earlier stage;

- When people with diabetes are admitted to hospital they will receive effective care;

- Women with diabetes and those who develop diabetes during pregnancy will have healthier pregnancies and healthy babies.

Nurses can help to bring these improved outcomes into the realm of normal good practice and make sure they are available to all people with diabetes. They can play their part by accessing the delivery strategies when they are published in the summer and putting the standards into practice.n

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