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Blood, sweat and tears, and a whole lot of funding

In NiP 37 Lubna Kerr described a research project in Lothian that examined the effect of culturally-sensitive education on the diabetic control of patients who came from an ethnic minority background. The results were so impressive that it was decided to expand the project into an actual service. This is her story …

Lubna Kerr
BSc(Hons) MPharm PhD
Pharmacist
Metabolic Unit
Western General Hospital
Edinburgh

The original project was conducted four years ago and would sit well within the realms of the upcoming Race Relations Amendment Act. The benefits to all parties were soon recognised. However, I had to make a difficult decision - I had been seconded from my hospital job to do the research project, and although the secondment had been extended for six months, I could not extend it any more. I thought I would try to do both jobs part-time, but this didn't work out as I just wasn't able to put the time and effort into trying to develop the service that was required.
I eventually decided to take the plunge and I gave up my permanent, stable clinical pharmacy job to continue with the development of the ethnic minority diabetes service, which needed a lot more work. I had decided quite naively to take the risk and move out of my comfort zone and tackle the challenges that this new world could throw at me. In reality, looking back there was no choice. I had loved what I was doing from day one. I felt needed and I knew that these people needed more education and help in diabetes. I felt as if it was my turn to give something back to the community who had looked after my family so well when we had come here 40 years ago.

Four years later
Four years later I have no regrets. The service is now fully operational covering the whole of Lothian from Dunbar to Armadale and patients from a wide range of ethnic minority backgrounds. I have had highs and lows, ups and downs, good and bad days, but I have loved it. The challenges have come from every direction and profession. However, the knowledge, experience and negotiating skills that I have gained from this experience have been priceless. While the objectives were definitely not all "SMART" (specific, measurable, achievable, realistic, timely), the adventure has been tremendously interesting and exciting.
So how did I do it and who helped me along the way? It was achieved by a combination of blood, sweat, tears, hard work, time, persistence, persuasion and belief. I totally and utterly believed in what I was doing and that's what kept me going in my darkest days, as well as the great physical and moral support I received from some highly valued health professionals.
There were many things to do all at the same time: inform; educate; design a process and deliver the service; all in two days a week. Not to mention the F-word - funding.
The first thing to do was to tell people about the project, a marketing job. As I sit within the managed clinical network for diabetes I was aware of the structure of the community set-up. There were 80 local healthcare cooperatives (LHCCs) in Lothian at that time and each had their own very different structure unbeknown to me. Which one should I tackle first? The only thing was to go to the area that had the highest number of ethnic minority patients, but that proved to be a problem. Ethnicity was not recorded by many practices so we had no idea where the largest populations were. We had to use census data and local knowledge.
However, before I could speak to any clinician I had to have a process in place that would allow patients to be referred. Once this process was designed and a referral form produced I was able to go and see GPs and practice nurses to let them know about the new service that they would be able to access. However, I was still working in South East LHCC and still had patients to see and exercise classes to run and now funding to find for my own post. 
Knowledge is power as they say, but when I came to work with another LHCC, having knowledge of how the first LHCC worked did not help me at all, and I had to start the whole process again: find out who I had to meet, when, where, what groups did they have, who was their lead GP, was there a diabetes interest group and did they have regular meetings? Could I see one group that would cover all the people I needed to see? No, that would have been too easy. So in every LHCC I would need to go and see at least two different groups of health professionals, and sometimes more. All the people who were involved in providing the patients with diabetes care needed to be seen. This involved GPs, practice nurses, dietitians, podiatrists and pharmacists. I often thought to myself: when was I going to see another patient? when would I get my allocated days off? and who would I need to approach for my next bit of funding?

Education and information
Slowly but surely all the LHCCs were seen. However, as this service was being developed and changed the same LHCCs needed to be kept informed and so the process of education and information continued. During the past four years there has been another reorganisation in the health structure and the LHCCs have become community health partnerships (CHPs) and local health partnerships (LHPs). Panic struck me at the thought of restarting the whole marketing process again, but luckily there have not been many significant changes to the set-up that would affect my service. We now have a regular referral form for health professionals to use that covers all of Lothian. The new GP contract has added extra importance to the monitoring of diabetes patients and I now see the demand for the service growing daily. I have had well over 200 patients referred to me over the past three years. I see the patients at a location that suits them and provide them with education and advice about diabetes. Being a pharmacist I am able to conduct a tailored medication review, which is essential to ensure compliance. I know the geography and roads of Lothian much better than I used to and I am getting to be an expert at negotiating all the backroads to get to patients in time.
Cookery classes are now held once a year with a dietitian. The exercise classes are still held in the same sports centre. The project has been nominated for and won a few different awards and it's great to know that my peers and colleagues in the wider medical field appreciate the work that we have been doing in Lothian.

Three-in-one clinic
To overcome this tremendous time spent travelling and to provide a more comprehensive service, another pilot project was initiated that would enable these services to be developed. This new service, an outreach diabetic clinic held in a sports centre, was called the three-in-one clinic, because it offered three therapies (traditional, complementary and exercise) in the one clinic. This consisted of a conventional medical approach where the diabetes nurse specialist (DSN) measured the patients BP, cholesterol, HbA1c, and weight and waist circumference. The bilingual pharmacist conducted a medication review. The patients then had the opportunity to access relaxation therapies such as head and neck massage, reiki, shiatsu or reflexology.  Each patient was allowed at least two of these therapies. The patient was also able to exercise following the clinic. This clinic has been very well received by the women as many of them had never experienced any form of relaxation therapies and definitely not reiki or shiatsu. The clinic has a great buzz about it and the therapists have commented that there is a lot of energy in the room. We are halfway through our project and so far the results look very promising.

Conclusion
This service would never have worked had it not been for the great team of people who all helped in delivering the service. The DSNs, practice nurses, GPs, consultants, pharmacists, managers and other health professionals have all played a great role in ensuring that this service became a success and I am grateful to them all. This was a team effort and without these people I would never have managed to get the service up and running.
All of these services were underpinned by the fact that I needed to find funding that would allow me to continue to work for the NHS. I am very grateful to Takeda and Novo Nordisk for their funding to allow this service to develop. Thanks also to the Pfizer Charitable foundation that allowed many of the services to expand into the community.
Recently the whole service was awarded the DAWN Award (Diabetes Awareness Wishes and Needs), a global competition involving 23 countries. This was for services that catered for the hard-to-reach communities. The award was presented in Cape Town at the International Diabetes Federation (IDF) conference. This was a very fitting stage for a sometimes turbulent, but always positive service. It is now up to Lothian health board to ensure that this service continues and is available to all those who need it.

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