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Developing community diabetes services

Mary MacKinnon
MMedSci RGN
Senior Lecturer Centre for Primary Health Care Studies
University of Warwick
Director of Education
Warwick Diabetes Care

To proceed with the implementation of the National Service Framework (NSF) for Diabetes from April 2002, new and changing roles of healthcare professionals will need to be developed to manage the emerging epidemic of diabetes. Certain evidence-based key issues highlighted in the Executive Summary of a new Diabetes UK Report(1) are:

  • More than one-third and as many as half of ­people with diabetes are developing complications by the time they are diagnosed.
  • 75% of people at the highest risk of developing diabetes are unaware of that risk.
  • Diabetes costs the NHS £5.2 billion a year.

The Audit Commission highlighted the following problems:(2)

  • Lack of educational opportunities for people with diabetes and their families to take responsibility for and manage their own health care.
  • Considerable variation in diabetes services.
  • Duplication in care management.
  • Inadequate care provision.
  • Inadequate recording and follow-up of data.
  • Poor communication between primary and ­secondary care and between the healthcare ­professionals involved.
  • Diabetes care insufficiently integrated or coordinated in many districts.

Nurses involved in diabetes care
The nurses most involved with the 1.4 million people diagnosed with diabetes are practice nurses and diabetes specialist nurses. Their understanding of their own current and future roles and their perception of each other's current and future roles in the care of people with type 2 diabetes have been investigated and recently reported following a national Delphi study.(3) In the study the following areas were identified as impacting upon the role of nurses managing type 2 diabetes care in the community:

  • Safe and effective nursing.
  • The practice nurse's and diabetes specialist nurse's contributions.
  • Evidence-based factors that facilitate or inhibit care.
  • Continuing professional development.
  • Continuing changes in the NHS.

The study identified high levels of agreement by participating practice and diabetes nurses regarding the care of people with type 2 diabetes. The factors that inhibit care were also largely agreed upon by the two groups of nurses and reflected the same findings as identified by the Audit Commission. Both practice and diabetes nurses valued each other's roles but agreed that there were differences in several areas of care provision. This was an important finding as it recognised that practice nurses (like GPs) might have a special interest in diabetes but this was mainly a relatively small part of their work. However, diabetes specialist nurses were constantly engaged in this area.

Current role and responsibilities of the ­practice nurse in diabetes care
Recommendations for the management of diabetes care5 have provided the background for the provision of services by the primary care team. The practice nurse may be involved in all or some of the following:

  • Screening.
  • Confirmation and support at diagnosis.
  • Recall and follow-up.
  • Regular review and education.
  • Identification of risk factors for long-term ­complications.
  • Surveillance/detection of long-term complications.
  • Annual review.
  • Appropriate referral.
  • Clinical audit.

Integrated diabetes care
"In the management of diabetes, the provision of care should aim to be organised and individual to the person concerned. During the lifetime of a person with diabetes, care is provided by the primary care team, a specialist team, or both. The appropriate care provider will change according to the progress of the condition, the need for optimum management and the wishes of the person with diabetes."(5)

The evolving role of the practice nurse in ­integrated diabetes care
The evidence is now available from extensive clinical trials in types 1 and 2 diabetes that intensive management and control of blood glucose and blood pressure levels reduces the morbidity and mortality associated with the long-term complications of diabetes.(6,7)
The progressive nature of diabetes now requires progressive treatment and intensive management with multiple medications, combination therapies and increased use of insulin in type 2 diabetes.
The practice nurse's role in the future will be as a facilitator of diabetes healthcare in the community, working with people with diabetes, their families, other care providers and across boundaries to ensure the provision of locally supportive and culturally sensitive integrated diabetes care.

References

  1. Diabetes UK Report. Too many too late. A report from Diabetes UK, the charity for people with diabetes. London: Diabetes UK; 2001. p. 3-5.
  2. Audit Commission National Report. Testing times - a review of diabetes services in England and Wales. Oxford: Audit Commission Publications; 2000.
  3. Peters J, Hutchinson A, MacKinnon M, et al. What role do nurses play in Type 2 diabetes care: a Delphi study.J Adv Nurs 2001;34(2):179-88.
  4. British Diabetic Association Report. Recommendations for the management of diabetes in primary care. London: British Diabetic Association; 1997.
  5. The Diabetes Control and Complications Trial Research Group. The effect of intensive treatment on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med 1993;329:977-86.
  6. United Kingdom Prospective Diabetes Study (UKPDS) Group. Intensive blood glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS33). Lancet 1998;352:837-53.
  7. MacKinnon M. Providing diabetes care in general practice; a practical guide for the primary care team. 3rd edn. London: Class Publishing; 1998.