This site is intended for health professionals only

How the diabetes NSF impacts on primary care

Sara Da Costa
MBA BSc(Hons) DipN(Lond) FETC RGN
Nurse Consultant in Diabetes
Worthing & Southlands Hospitals NHS Trust

While the Diabetes National Service Framework Standards, published in 2001,(1) provided the content for changes in diabetes management, it was the Delivery Strategy,(2) published in 2003, which provided the timescales for this change. Over the past three years, the political context has also imposed new targets (such as the GMS contract(3)) and new models of care (managed care), which in turn will impact upon diabetes services. This article explores how some of these politically driven changes influence diabetes care and services.
It feels like a lifetime ago that the Diabetes NSF was finally published. It was long awaited, but, unlike previous NSFs, short on cash. However, it did identify the content of good diabetes care and 12 standards to be achieved by 2013, while the delivery strategy determined timescales for the short-term priorities. The rationale for an NSF in diabetes was cost (to the individual, the NHS, and society as a whole), the variability of resources causing a postcode lottery of care, and few outcome measures, or an outcome focus. All aspects of the care system were affected - primary, secondary and tertiary.
Therefore the main aims of the NSF were to develop supported self-care, improve the partnership between the person and their carers, and develop equitable services that meet individuals' needs. This requires integration across disciplines and services that are outcomes orientated. The 12 standards are not problems occurring in primary or secondary care alone, but in all care, and as such are a collective problem, or opportunity. As with all chronic diseases, diabetes management should disregard such artificial barriers and use a systems approach.
Many recommendations in diabetes in the past (such as the St Vincent's declaration in 19894) have been notable not for any lack of content, but for lack of implementation. However, timescales do focus the attention, particularly when, like all NSF targets, they influence the Healthcare Commission (formerly Commission for Health Improvement) and star ratings.
While all standards need to be achieved by 2013, the NSF Delivery Strategy has identified the following targets to be implemented by 2006:

  • A systematic eye screening programme for 80% of all people with diabetes, increasing to 100% by 2007.
  • Setting up of diabetes registers.
  • Setting up of systematic treatment regimes.
  • Provision of education and advice.

The revenue funding for this is said to come from the PCT baseline allocations to enable progress to be made in delivering local priorities across the standards. However, the delivery strategy moved beyond short-term targets, and made clear that a broader service review was necessary, by recommending local diabetes networks with clinical champions, and the appointment of network managers.(*)
*Once again, money was not ring-fenced to set up these systems; finally, one-year funding for network managers has just been released via Strategic Health Authorities and allocated to local PCTs.
The strategy also suggested a local skills profile of those involved in the care of people with diabetes, the establishment of education and training programmes, and a baseline assessment against the 12 NSF standards. Plans to achieve the standards were also required, incorporating local and national audit. In many areas of England, strategic health authorities (SHAs) requested these assessments to benchmark and assess progress, and ultimately to inform the Department of Health. This starts to illustrate how the diabetes NSF does not stand in isolation, but influences, and is influenced by, other factors, which will now be discussed.
I believe that when one considers an area of clinical care and services, such as diabetes, it is useful to consider what other political influences have or could have an impact on the patient's journey and outcomes. This immediately forces you to consider the context of the care you give, and if you can see it as a system, rather than in isolation, it may help you plan service changes that fit with your organisation's targets and priorities. To illustrate this, I have identified some major political agendas that impact upon diabetes. These are:

  • The National Institute for Clinical Excellence (NICE).
  • Nurse-led care.
  • The shift to primary care.
  • The GMS contract.
  • Managed care.
  • Chronic disease management/long-term ­conditions (LTCs).

NICE
NICE specifically impacts upon diabetes care via clinical guidelines and technology appraisals. There is a significant difference between the two: the first is to inform practice, while the second is a "must do". Examples of the former include the management of type 2 diabetes, renal disease and blood pressure, lipids and blood glucose. Examples of the latter include guidance on insulin glargine and insulin pumps. Again, there are no specific monies allocated, other than those already in the baselines for NICE implementation, so there are competing demands to release money to fund these "must dos".

Nurse-led care
Shifting the Balance of Power(5) enabled many of the changes described in the NHS Plan(6) and formed the current structure of PCTs and Strategic Health Authorities. It emphasised that within NHS trusts there should be greater responsibility placed on clinical teams, with a focus on patient-centred care shifted closer to the patient's home.
Nurse-led care has been a common theme in healthcare since the Labour government came to power, and in diabetes many initiatives are either nurse-led or nurse-coordinated. The majority of diabetes care is provided by practice nurses and specialist nurses, and this is both an economic and efficient solution to the needs of people with chronic disease, who require more than a medical model of care. The model proposed later as a way forward acknowledges this reality.

The GMS contract
The GMS contract, although relating to primary care targets, impacts on specialist care as well, because diabetes works in a healthcare system. This fact is often overlooked and has led to more patients being referred to specialist care so that these targets can be achieved. The outcome is that specialist care is overwhelmed, no additional resources are being funded to meet these demands, and yet, if targets are achieved, GP practices will be paid. Money is not following the patient journey. Similarly, practice nurses have increased caseloads to achieve targets, and prescribing costs have increased. The concern here is that while this outcome focus can hit the target, it often misses the person. Slavish targets forget the individual and can cause patient harm by too tight control and the increased risk of hypoglycaemia, particularly in elderly people.

Managed care
Managed care also impacts on diabetes because it is another group of nurses whose focus is on the group of people who have repeated admissions, and by acting as gatekeepers and working across organisational silos their aim is to connect care and keep these people out of hospital. There is much overlap between their own, district nurse and specialist nurses caseloads, so the challenge will be to ensure that duplication is avoided  and resources are best used, which will require ongoing ­communication. Practice nurses may also be involved.

Chronic disease management
Chronic disease management (LTC is now the preferred usage) has become a Department of Health focus because of cost and bed usage. Approximately 60% of people have an LTC, and these conditions are the cause of 80% of all GP consultations. In addition to this, there is a public service agreement that by 2008 the number of emergency bed days will be reduced by 5%. Most areas now have chronic disease management boards, whose aim is to build upon NSFs, integrate specialist networks, engage clinicians and develop new roles or change existing roles. Diabetes is often a priority area, because of the rising population.

Collaboration
So, how does knowing some of the factors that impact on how we can deliver diabetes care help us as nurses? I believe it demonstrates that, to achieve targets, system changes, resource issues and so on, collaboration is key. Neither primary nor specialist care can do it alone, and the more new models incorporate these political agendas, the greater should be their chance of successful adoption. Leadership and an owned vision are also crucial. The following can illustrate these points.
Our vision for integrated diabetes nursing has been informed by patients and primary care colleagues. It has been led by myself, the diabetes NSF workforce group, the chronic disease management board and specialist care, and further developed in primary and specialist care.
It proposes locality-responsible diabetes specialist nurses (DSNs), who will manage and coordinate patient care across primary and specialist care settings, by providing DSN clinics within practices, group education for patients, training and upskilling of clinicians, and systematic treatment regimes. The current organisation of care in our locality is demonstrated in Figure 1. This shows how the DSNs are located within the specialist diabetes centre, with variable practice support and education given to the practices in our three localities. The vision proposes an integrated nursing service, which, in addition to the clinical and educational support identified earlier, would also be a resource within the locality and thus be able to provide proactive care equitably across our health community. This is not resource-neutral and will require investment with two DSNs funded from year one and a third from year two.

[[NIP21_fig1_42]]

The first phase of this proposal has already been successfully piloted with a DSN clinic based in one of the practices, where earlier specialist intervention has enabled greater choice of therapies, treatment and lifestyle review and change, and a systematic treatment plan. Additional benefits include the practice nurse increasing her learning by collaborating in all clinics with the DSN. This has enabled improvements in care and patients requesting this specialist care closer to home. It has also given specialist care a greater insight into practice issues, joined up the diabetes service and reduced waiting times for specialist review. Understandably, other practices are requesting similar support, and we are now able to identify through this pilot what their commitment needs to be in terms of protected time, space, personnel and documentation to ensure similar success.
So, returning to the original challenge of identifying the influences, including the NSF, on diabetes care, one can see that this vision ticks all of these political boxes.
It enables GMS targets to be achieved, incorporates NICE guidelines into practice, is nurse-led and has shifted specialist care into primary care. It is also synergistic with managed care, as the DSNs will be a resource to this group of clinicians and work with them to avoid fragmentation and duplication of services. We hope that this strategic fit will enable the business case for this proposal to be successful in securing future funding. Whatever happens, our philosophy of nurse collaboration will continue, as this is a real opportunity to improve diabetes care.

(*) Once againn, money was not ring-fenced to set up these systems; finally, one-yea funding for network managers has just been released via Strategic Health Authorities and allocated to local PCTs.

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. Chamberlain-Webber J. What does the GMS contract mean? Prof Nurse 2004;19:14-17.
  4. British Diabetic Association/ Department of Health. Report of the St Vincent Taskforce for diabetes. London: BDA; 1995.
  5. Department of Health. Shifting the balance of power. London: HMSO; 2001.
  6. Department of Health. The NHS plan. London: HMSO; 2000.

Resources
Department of Health
W:www.dh.gov.uk