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Diabetes: bridging the primary/secondary care gap

Julie Williams
BSc SRN HV NPDip CPT
Nurse Practitioner
General Practice
Lee House Surgery
Danbury Chelmsford, Essex
Nurse Representative
Maldon and South Chelmsford PCT
E:julie@cloudcroft. freeserve.co.uk

Landmark research in the last few years - the Diabetes Control and Complications Trial and the UK Prospective Diabetes Study(1,2) - have significantly changed the clinical management of diabetes. This is particularly true of people with type 2 diabetes, where the need to achieve tight control to avoid complications has been demonstrated. This has resulted in the need to convert more patients to insulin.
In view of the imminent publication of the NSF for Diabetes, Maldon and South Chelmsford PCT, a small PCT covering 84,000 patients in rural Essex, undertook a baseline assessment of diabetes care in general practice in 2001/2. They found marked differences in both the provision and quality of care given. A few practices provided a comprehensive service, including annual reviews of people with both type 1 and type 2 diabetes and converting patients to insulin, while others provided only a very basic service to patients with type 2 diabetes. The audit also revealed a need for additional education because only a few of the nurses had had any specialist training in diabetes. Only one practice had the equipment and expertise required for a full examination of the diabetic foot. It was also evident that there were inaccuracies in the practice diabetic registers compared with the register maintained by the acute trust, so some patients were slipping through the net.
The Local Modernisation Review (LMR) for diabetes involving acute trusts and PCTs across North Essex was produced about the same time. This showed that there was an increased risk to the delivery of care due to both the increasing numbers of people being diagnosed with diabetes and those needing conversion to insulin. This was confirmed at a meeting of local PCTs and our local acute trust, Mid Essex Hospitals Trust, where the pressure on the acute trust was highlighted. The number of patients referred to the local diabetes team was increasing - in fact, the numbers needing to start insulin therapy increased by 11% in one year. The results of implementation of the NSF for Diabetes are likely to further inflate these figures.

The diabetes strategy
After meetings with the acute trust diabetes team, Maldon and South Chelmsford PCT decided that it needed to produce a strategy to optimise treatment in the community, which would relieve pressure on the acute trust and provide treatment to patients nearer to their homes. We also wanted to encourage more practices to instigate insulin therapy themselves.

Key points of the strategy
Hospital-based services  The hospital would continue to see patients with specialist needs, including those with significant complications, those newly diagnosed with type 1 diabetes, children and pregnant women.
Diabetic intermediate care centre The local community hospital, now run by the PCT, was already running an outreach clinic staffed by a diabetologist from the acute trust and a GP clinical assistant. This would continue and would manage patients with unresolved poor glycaemic control or other problems. It would also carry out annual reviews of patients where this was not available in the practice.
Nurse-run diabetes clinic  The PCT had already approved the appointment of a diabetes specialist nurse, and it was envisioned that she would run a clinic alongside the consultant clinic. She would undertake conversions to insulin as well as supporting the practices and community staff initiating insulin in the community.
GP practice GPs would opt to become a level 1 or level 2 provider. Both levels would need to meet minimum requirements of care. This would include diagnosis, classification, recording, initial support of patient, ongoing care, recall, screening and audit. There would be a requirement for the GP and practice nurse to undergo appropriate training and attend ­regular updates.
Level 1 providers One GP and nurse from each practice to attend three half-day education sessions run by the local diabetes care team and attend an annual update. A per-capita payment would be made for each comprehensive annual review undertaken over and above the chronic disease management payment.
Level 2 providers These would undertake the routine care of people with type 1 and 2 diabetes, including adjustment of insulin and the decision to convert to insulin. Insulin conversion would be facilitated/ supported by the diabetes specialist nurse until the GP/nurse was confident. A GP and nurse from each practice would be required to attend the nationally recognised Warwick Certificate in Diabetes Care course or equivalent. A higher per-capita payment would be paid to these practices, again in addition to the chronic disease management payment.
Warwick Diabetes Course Two clinicians, a GP and a nurse would attend the Warwick Leaders Course to enable them to facilitate the course locally. Locum payments would be available for GPs and nurses attending the course and the course fees paid by the PCT.
This strategy had the support and approval of the acute trust diabetes team, who agreed to participate in the Warwick Course. The strategy was presented to the practices at a multidisciplinary education evening. It produced a mixed reception! Many felt that they were already providing a good service and that there was no need for additional training. In particular, nurses who had undergone the ENB 928 felt that this was being undervalued.
 
Implementation of the strategy

Warwick Course

In spite of the reservations, 12 clinicians were recruited for the course, including GPs, district nurses, practice nurses and a podiatrist, and 11 completed the course. The course relied strongly on input from secondary care. This included the two diabetes consultants, the diabetes specialist nurses and the diabetes dietician as well as a local podiatrist, GP and ophthalmologist. The course was well received by all, particularly as it concentrated on the management of diabetes, and all participants, GPs and nurses, agreed that they had learned a lot. It is to be repeated this year.
An optional extra day was also organised with the support of one of the drug representatives, which specifically focused on converting people with type 2 diabetes to insulin and adjusting insulin levels.
Due to the financial constraints on balancing the PCT's budget, the amounts paid to level 1 and 2 ­practices had to be reduced, but a one-off payment for each patient started on insulin in the community was agreed. With the new GMS contract the quality points will supersede these payments.

Diabetes specialist nurse
Our diabetes specialist nurse was appointed in March this year. She has been able to gain a great deal of experience since then by working with the diabetes specialist nurses in the acute trust in their patient education and insulin conversion clinics, and has received a great deal of support from them. She has also been able to work with the diabetologist in the outreach clinic within the PCT.
Things have really moved on in the PCT since her appointment:

  • The nurse-run diabetes clinic has just started, with patients being referred by the diabetologist in the first instance. He is available to offer advice when needed.
  • She has visited most of the practices to update the baseline audit and explain her role.
  • Part of the PCT diabetes specialist nurse's remit was to provide education, and the first patient group education session has taken place and ­subsequent sessions will be held monthly.
  • Educational sessions have been run for home care staff and district nurses, and one is planned for ­practice nurses.
  • Visits to residential and nursing homes have ­commenced.
  • A contract is being finalised for the provision of blood glucose monitors for use in surgeries and by district nurses.
  • She is working with Equip (Education and Quality in Primary Care Across Essex) to develop a ­protocol for insulin conversion in GP surgeries.

Joint working across acute, primary and community services as well as specialist services has helped to clarify the care pathways for patients with diabetes and will ensure equity of quality care. All of this work has been done with the support and help of the acute trust, and it remains a regular source of advice. Working closely with secondary care to help solve the problem of the rapidly increasing numbers of patients with diabetes has been beneficial in improving cooperation and communication, as well as giving both primary care and the acute trust health professionals a better understanding of the constraints and difficulties faced by their colleagues.

References

  1. The Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med 1993;329:683-9.
  2. UK Prospective Diabetes Study Group. Intensive blood glucose control compared with conventional treatment and the risk of complication in patients with type 2 diabetes. Lancet 1998;352:837-53, 854-65.

Resources
The NSF for Diabetes
W:www.doh.gov.uk/nsf/diabetes/