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Delivering the NSF for diabetes: our experiences

Sara Da Costa
BSc(Hons) DipN(Lond) FETC RGN
Nurse Consultant in Diabetes
Worthing & Southlands Hospitals NHS Trust
Visiting Fellow
University of Brighton
E:sara.da-costa@ wash.nhs.uk

The purpose of this article is to share the experiences of collaboration between primary and secondary care clinicians and managers before and after the publication of the National Service Framework for Diabetes: Standards and Delivery Strategy.(1,2) The rationale and background of our initial collaboration will be discussed, as well as the purpose and development of the group and our preparation for the NSF. The influence of both the local and national political context will be highlighted throughout the ­article, as changes in healthcare do not exist in ­isolation and may be the cause of, or response to,
other ­initiatives.

National and political context
The purpose of the NSFs is to raise standards and promote equality of access and provision of services nationally. They have a 10-year lifecycle and have identified short-, medium- and long-term targets and milestones. They are chosen and informed by research and audit. The Diabetes NSF was preceded by the Audit Commission's review of diabetes services, which demonstrated the variation in quality and resources for diabetes services.(3)
There have been several NSFs before the one for diabetes (eg, coronary heart disease, cancer and mental health), and the majority have had some funds attached. This NSF is different from its predecessors in two ways: it did not have any ringfenced monies for standard achievement, and it was also released late in two parts.(1,2) These differences have had a significant impact on diabetes services, which must be improved through ­efficiency and effectiveness within current resources.
This challenge is unsurprising as the theme of "new ways of working" to improve patient care is implicit within both The NHS Plan and Shifting the Balance of Power.(4,5) The latter document established primary care trusts (PCTs) and strategic health authorities (SHAs) and emphasised working across organisations and professions, breaking down professional boundaries and leadership by clinicians. Interestingly, our collaboration, which began in 1999, consisted of these same themes, because they were the practical way of improving diabetes care for our population.

Local context
In late 1999, I, along with other clinicians, presented papers at a national conference on the barriers to effective working in a changing NHS. From this meeting, Lilly Diabetes Care developed a project to facilitate collaboration between primary and secondary care. This initiative arose because lack of communication and shared vision had been identified as one of the major barriers to improving services. We became one of the pilot sites for this project, and Lilly provided a facilitator to organise meetings. This project became a catalyst for action; generally we had good working relationships with our GPs and in particular our practice nurses, with whom we had a history of providing education and clinical support. Our group consisted of enthusiastic clinicians from both primary and secondary care who wanted to work more collaboratively and improve patient care and better use services, avoiding duplication and gaps in provision. The group consisted of specialist, district and practice nurses, consultants and GPs, and a primary care manager.
The benefit of facilitation was that it enabled us to establish a shared vision, determine outcomes and a process to achieve them, capture action points and generally keep us to the matter in hand. This was needed as it was very easy to be sidetracked and carried away with enthusiasm! It also provided the administration essential to the success of this project; minutes were taken and shared and resources to improve our skills provided.
The meetings were successful in that we identified three main areas of work: providing education specifically for primary care colleagues; producing a care pathway; and communicating our progress. Leads for each topic were chosen by the group, the remaining members were divided among the three groups, and other colleagues were co-opted as required.
I led the education group, as I was module leader for diploma and degree modules at Brighton University and had also provided informal study days for nursing colleagues. With the support of Lilly, I produced a five-module course aimed at enabling behaviour change of clinicians and patients on a range of topics.
To pilot this, seven practice nurses and one GP attended five half-day sessions and evaluated the project. Overall this was seen as relevant to their needs, enabling them to do things differently and giving them the confidence to support more widely their patients' diabetes care. This pilot course was evaluated at other pilot sites and was finally developed by Lilly into "Dialog", an education programme available on CD. Developing the course was relatively easy, but providing ongoing resources to teach it was not. I initially agreed to provide the time for the pilot, but I found I could not continue with this commitment. Therefore, despite its success, the programme was not repeated, although it had a form and content that could be adjusted and used in the future. These limitations were important learning for us as a group.
The care pathway was led by our consultant diabetologist and clarified both the content and process of care for patients at different stages of their diabetes journey, such as at diagnosis (type 1 or type 2), when pregnant and when experiencing complications. Treatment regimens and who to refer to were also included. It was produced on hard copy and on the hospital and primary care intranet. What was not realised was that, as it did not include any variance tracking, it was not a pathway but a protocol. Variance tracking identifies when the care pathway is not followed and why. Therefore this documentation was added.
Our progress as a group needed to be communicated to colleagues, and this was managed by the third group, using hospital and GP newsletters and fora. That enabled feedback and ownership outside of the group. The primary care manager utilised her networks and resources to effectively lead this group.
By the end of the project, we collectively felt we had learnt together and started to put our vision of collaborative care in place, and it was decided that, once the diabetes NSF standards were published (see Box 1 for summary of NSF diabetes standards), we, as a multiprofessional and cross-organisational group, would become the core NSF implementation group, co-opting others as necessary. On reflection the project was successful, our collaboration was recognised by the Audit Commission as a "site of best practice", and our experience was accessible on their website.

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Diabetes NSF standards
The diabetes NSF standards were published in December 2001, and in the spring of 2002 the NSF implementation group convened with additional members from other disciplines (dietetics, podiatry, paediatrics) to determine a process for achieving them.
Secondary care performed a gap analysis - reviewing current practice against the 12 standards and providing strategies to achieve these standards. They also identified resource implications and challenged and audited current practice and service design - could we do things differently to be more effective and efficient?
We used a number of modernisation techniques, process mapping our outpatient and DSN (diabetes specialist nurse) referrals, and establishing the demand profiles for our telephone triage and ward referrals. For the first time we began to understand the bottlenecks and demand fluctuations for our services. We also identified inaccuracies in the hospital computer systems - an audit in two directorates revealed that the computer system was showing only 50% of all patients with diabetes on these wards. Hence we could not rely on the system to identify where our diabetic patients were. This was reported to our IT department, and the situation is slowly improving. We also used clinical incidents to demonstrate the need for more hospital nurse and doctor education.
As there was no funding to improve these problems, we looked at new ways of working. By cancelling a specialist nurse clinic, we could provide group insulin transfer sessions and also a fast-track emergency DSN clinic. By realising we could not achieve standards 7 and 8, we subsequently obtained pharmaceutical funding to sponsor an inpatient nurse for a year (commenced February 2002).
Despite these changes, the group recognised that they are not enough to improve care. This review revealed that there are insufficient skilled professionals in our health community to deliver care to all who need it, when they need it. We agreed that we need to educate both professionals and patients to enable health behaviour change, and that we also need greater patient involvement in service review and psychology support.

Diabetes implementation strategy
This provided priorities and timescales lacking from the standards. By 2006, PCTs will have systematic eye screening and treatment programmes, as well as updated registers used as a basis for systematic treatment regimens in line with the NSF standards.(1)
To consider these implications, the group organised an away day, inviting colleagues from secondary and primary care and representatives from the Department of Health and SHA. We prioritised our local needs, which included reviewing and developing the care pathway, as well as funding a network manager to coordinate the group's activities and monitor progress against standards. We also obtained support for ongoing care pathway review and development.
The SHA required a baseline assessment of diabetes services and a costed action plan by September 2003. As chair of the NSF implementation group, I collaborated with the public health department to produce this. This action plan now forms the basis of our diabetes priorities for local delivery plans, and we are awaiting feedback.

Successes and difficulties
Through our collaboration we now have increased understanding and respect between primary and secondary care, particularly regarding our roles in care. Also, guidelines and evidence change rapidly, so information reflecting this is valued. Becoming a nurse ­consultant was timely, as it has provided some leadership and the ability to work in new areas in both ­primary and secondary care.
However, difficulties remain. In particular, the lack of funding for diabetes means that this group has insufficient administrative support (seen as part of the network manager role, hence its priority), and a lack of monitoring structures or processes to determine progress against the NSF targets and timescales. As the delivery strategy states, more staff will be needed, but there is no money to invest in them.(2) We are clear where they are needed, but there is a risk that we will all become so demoralised with our increased workload and feeling that we are getting nowhere that our collaboration will falter.

Future steps
To reduce that risk, we have decided to form subgroups to enable more focus on specific topics without extra meetings. These subgroups are in IT, workforce and training, retinopathy, care pathways and prescribing. These groups will incorporate the action points from the baseline assessment, form terms of reference and establish chairs to report back to the main group on a quarterly basis. Again, these subgroups are multiprofessional and cross- organisational, and additional members will be co-opted onto groups as required.

Conclusion
Our background of collaboration has helped us work well in difficult local and political circumstances and has built a good foundation for the future. Linking any decisions with organisational goals, priorities and other political and professional initiatives has been essential. This process could be used as a model for chronic disease management.
If we do not collaborate there are huge risks - for our patients and for our services. There are also risks of secondary care becoming marginalised, which will disbenefit inpatients and compromise their care, and this will become the bottleneck for diabetes care. If we do not manage diabetes care well in hospital, as stated in standards 7 and 8, we will directly affect patient outcomes and achievement of the goals of the new GMS contract. But more than that, patients want diabetes care from experienced clinicians, where and when they need it, and generally do not consider the financial or strategic distinction between primary and secondary care.
I believe that collaboration can stop these barriers from preventing patients getting the care they deserve.

Practice pointers

  • Practice nurses have a huge potential role in influencing diabetes strategy and care as they manage the majority of diabetes in primary care
  • If practice nurses collaborate with their ­secondary care nursing colleagues, they can share ideas, identify gaps and plan solutions together
  • Practice nurses should use diabetes specialist nurses as a resource to help them plan care for patients, and also to provide ongoing education for their practice
  • This may need formalising in a business case, but it would ­identify the education needs of practice nurses and support them in their practice

References

  1. Department of Health. National Service Framework for diabetes: ­standards. London: HMSO; 2001.
  2. Department of Health. National Service Framework for diabetes: delivery strategy. London: HMSO; 2003.
  3. Audit Commission. Testing times: a review of diabetes services in England and Wales. London: Audit Commission; 2000.
  4. Department of Health. The NHS plan: a plan for investment, a plan for reform. London: HMSO; 2000.
  5. Department of Health. Shifting the balance of power. London: HMSO; 2001.

Resources
NSF for Diabetes
W:www.doh.gov.uk/nsf
Audit Commission
W:www.audit-commission.gov.uk