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Diabetes care: the developing community role

Eileen Padmore
RN RM RHV MHSc BA
Diabetes Specialist Nurse
Leeds Teaching Hospital Trust

The 12 standards emphasise the enhanced role of primary care teams in managing the disorder, which is essential given the projected worldwide diabetes epidemic with its huge cost implications.(1-3) It is no longer thought to be appropriate or possible for most patients to be seen in secondary care.(4)

The necessity of prevention at various stages, including primary prevention for type 2 patients and earlier detection in this group, is paramount. Constructing care pathways across organisational and professional boundaries to achieve integrated primary and secondary care underpins the entire document. Empowering patients to become active in managing their diabetes is emphasised.

In some standards, primary care teams are seen as having a role to play in areas where care has been traditionally devolved to specialist secondary care teams. For example, standards 5 and 6 state there is a need to agree, implement and audit protocols for "the initial assessment and care of children and young people presenting with diabetes - these should be implemented in all healthcare settings where people with newly diagnosed diabetes are present", such as general practice and NHS Direct.

Where are we now?
The Audit Commission found considerable variations in the availability and quality of diabetes services throughout England and Wales.(4) It reported:

  • Lack of educational opportunities for patients and relatives, resulting in an inability to effectively selfmanage their healthcare.
  • Unnecessary duplication of care management.
  • Poor communication and integration, particularly between primary and secondary care.
  • Inadequate recording and follow up of data.A Diabetes UK report also raised vital concerns:5
  • The annual cost of diabetes to the NHS is around £5.2 billion.
  • 75% of people with the highest risk of developing diabetes are unaware of that risk.
  • More than one-third and as many as one-half of people with diabetes had developed long-term complications by the time they were diagnosed.

Nursing roles and responsibilities
The two groups of nurses most involved with diabetes are practice nurses (PNs) and diabetes specialist nurses (DSNs). The former have a generalist function, even when taking the lead for diabetes in the practice; the time spent on contact with diabetes patients forming only a small part of the total workload. Alternatively, diabetes specialist nurses spend all their time in diabetes care, some even specialising further in areas such as paediatrics, adolescence, the frail elderly, pregnancy, renal or foot problems.

A national Delphi study that explored PN and DSN understandings of each other's current and future roles in the care of people with type 2 diabetes, identified high levels of agreement with regard to the care of patients.6 The factors inhibiting care were also a focus for agreement by the two groups of nurses, reflecting similar findings to those of the Audit Commission.(4)

The fact that both PNs and DSNs placed value on each other's roles and agreed that there were differences in specific areas of service provision was a positive finding. There is recognition of the possibility of PNs having a special interest in diabetes, although this remains a relatively small part of their work. The differentiation between this type of involvement and that of a diabetes specialist nurse with constant clinical experience in diabetes care was emphasised.

The study also identified areas of discordance both within and between individual nurse groups, mainly relating to the professional responsibilities and the likely outcomes of devolving care into the community. Addressing these issues is likely to be important in the successful future nursing management of type 2 patients in primary care.

Contribution of practice nurses
The evidence base for the potential to reduce the costly and debilitating long-term complications of diabetes is indisputable, as demonstrated by major multicentre trials with both type 1 and type 2 patients.(7-8) However, the NSF diabetes standards take this further, with standards 1 and 2 respectively devoted to primary prevention and earlier detection of type 2 diabetes.(1)

PNs are crucial to this new emphasis in care, based as they are in GP practices with access to databases covering the majority of the UK population. The 12 standards indicate the key tasks to be:

  • Targeting at risk groups in the general population (eg, ethnic minorities, obese, those with a family history).
  • Health promotion strategies.
  • Increasing the awareness of the symptoms and signs of diabetes in both health professionals and the general population.
  • Follow-up of those with known impaired glucose regulation and gestational diabetes.
  • Collaborative patient/carer education tailored to individual need.
  • Risk factor reduction strategies in the diagnosed.
  • Earlier recognition of diabetes in children and young people as well as collaboration with specialist teams in their care.
  • Reduction and management of hypo- and hyperglycaemic events through education and support.
  • Preconceptual counselling.
  • Detection and management of long-term complications.

There will need to be good working relationships and communication between PNs and diabetes specialist teams in order to deliver this comprehensive programme of care effectively.
 
Nurse prescribing in diabetes care
In a Department of Health (DoH) press release in May 2001, nurses working with chronic diseases such as diabetes were recommended for supplementary prescribing.(9-10) Thus the recent consultation on the extension to nurse prescribing with the proposed new formulary of 200 additional Prescription Only Medicines was not directly relevant to nurses wishing to prescribe for diabetes management as it related specifically to independent prescribers.(11)

The use of Patient Group Directions (PGDs) in diabetes management is also questionable. The Health Service guidance circular on PGDs states that "The majority of clinical care should be provided on an individual, patient specific basis".(12) The Royal College of Nursing guidance on PGDs interprets this to mean "homogenous" patient groups such as those requiring immunisations, contraceptive services or treatments for minor injuries.(13)

The ideal method of pres ascribing for nurses working in diabetes is seen by the DoH supplementary prescribing, a consultation document for which was released in April 2002.(14) In the final Crown Report, these prescribers - referred to as dependent prescribers - were seen as being "responsible for the continuing care of patients who have been clinically assessed by an independent prescriber. This continuing care may include prescribing … and will be consistent with individual treatment plans."(10) Pending the consultation exercise and subsequent evaluation, it is not clear how this will work in practice.

A useful guidance document on the generic clinical competencies required for nurse prescribing has been produced by the National Prescribing Centre.(15)

Conclusion
The nature of diabetes is such that it may be susceptible to primary prevention. Patient-empowering motivational and educational strategies are an essential part of treatment. The condition requires earlier detection and subsequent intensive management with multiple medication, combination therapies and earlier initiation of insulin in type 2 diabetes.
The future role of the practice nurse in diabetes management will be that of a facilitator of community care. There will be a need to work with people with diabetes in the context of their families and communities in collaboration with specialist diabetes teams and other care providers to ensure effective, culturally sensitive, local diabetes care.

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References

  1. Department of Health. National Service Framework for Diabetes: Standards. Draft consultative document. London: Department of Health; 2001.
  2. Amos AF, McCarty DJ, Zimmet P. The rising global burden of diabetes and its complications. Diabet Med 1997;14(suppl):Sl-85.
  3. Currie CJ, et al. NHS acute sector expenditure for diabetes: the present, the future and excess in-patient cost of care. Diabet Med 1997;14:686-92.
  4. Audit Commission. Testing Times. Oxford: Audit Commission Publications; 2000. p. 100-1.
  5. Diabetes UK. Too many too late. London: Diabetes UK; 2001. p. 3-5.
  6. Peters J, et al. What role do nurses play in type 2 diabetes care: a Delphi study. J Adv Nurs 2001;34:179-88.
  7. 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;329:977-86.
  8. UK Prospective Diabetes Study Group. Intensive blood glucose control with sulphonylureas and insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes. Lancet 1998;352:837-53.
  9. Department of Health. Patients to get quicker access to medicines. London: Department of Health; 2001.
  10. Department of Health. Review of Prescribing, Supply and Administration of Medicines. Final Report. London: Department of Health, 1999.
  11. Medicines Control Agency. Extended prescribing of prescription only medicines (POMs) by independent nurse prescribers. London: MCA; 2001.
  12. Department of Health. Patient Group Directions (HSC 2000/26). London: Department of Health; 2000.
  13. Royal College of Nursing. Patient Group Directions Guidance and Information. London: Royal College of Nursing; 2000.
  14. Department of Health. Proposals for supplementary prescribing by nurses and pharmacists and proposed amendments to the Prescription Only Medicines (human use) Order 1997. London; DoH; 2002.
  15. National Prescribing Centre. Maintaining Competency in Prescribing. Liverpool: NPC; 2001.

Resources
Royal College of Nursing
Diabetes Nursing Forum
c/o Anne Elliott RCN, 5th floor
20 Cavendish Square, London W1M 0AB
T:020 7647 3734
F:020 7647 3430
E:anne.elliott@rcn.org.uk
W:www.rcn.org.uk
Diabetes UK
T:020 7323 1531
Helpline:020 7636 6112
W:www.diabetes.org.uk
Diabetes Research and Wellness Foundation
T:023 92 637 808
W:www.diabetes
wellnessnet.org.uk