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The NSF for diabetes: a primary care review

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

The last part of the Diabetes National Service Framework - the Delivery Strategy - has finally been published, providing a framework for implementing the NSF standards over the next 10 years and shifting the responsibility for providing quality diabetic care to primary care organisations (PCOs). While less prescriptive than previous NSFs, it has a more realistic timeframe - only two targets are set for implementation by 2006, with the other standards to be met by 2013.

The first year
In the first year the priority will be on building the capacity to deliver the standards within the next 10 years. The strategy recommends the setting up of a diabetes network of local leaders, managers, clinical diabetic specialists from both primary and secondary care, and patient representatives to work across traditional boundaries. The aim of this network is to lead on integrating care and improving patient experience, leading to improved clinical outcomes in a cost-effective and equitable service. It is hoped that this network will include all the primary care organisations (PCOs) covered by one secondary care provider and will include local leaders, network managers, a clinical champion and a patients' champion.
This appears to me to be similar to the Local Diabetic Service Advisory Groups (LDSAGs) that have already been set up in many areas, but the role of the clinical champion is unclear. The Department of Health will also appoint a National Clinical Director for Diabetes to provide national leadership and support. Again I feel it is unclear how this will work when responsibilities have been devolved to PCOs.
Suggested work in the first year includes a baseline assessment of local diabetic services to underpin the development of a plan to implement the strategy. An important part of this assessment will be the workforce profile of staff involved in diabetic care. This is ­necessary to inform the development of training and education programmes. PCOs will also be expected to participate in audits at both local and national level. Changes will be supported by the NHS Modernisation Agency, and the Department of Health is developing rapid learning sites where networks will be set up quickly so that ­experiences can be shared between PCOs.

The next three years
The Delivery Strategy has set only two targets:

  • 80% of diabetic patients are to be offered ­screening for diabetic retinopathy by 2006, with 100% being screened by 2007.
  • Practice-based diabetic registers and structured treatment regimens are to be in place by 2006, and are to include appropriate lifestyle advice and a recall system.

Some finance will be available for the capital costs of retinal screening, but this will have a huge impact on resources, both human and financial, to reach the 100% target. At present retinal screening is fragmented - very different systems are in place in different parts of the country, and as yet there is no consensus on the best method of screening.(1)
In many areas practice-based diabetes registers are already up and running with protocols in place. Where this has not happened it should not be too difficult to introduce, especially following the experience of setting up coronary heart disease (CHD) registers. It is suggested that priority should be given to patients with coronary heart disease and diabetes, to those with the greatest risk of complications and to newly diagnosed patients, with an emphasis on lifestyle advice. It is recommended that each patient should have an individual care plan with personally held diabetic records and a named contact to help them obtain the most appropriate care. The strategy warns that, while self-care is encouraged, people with diabetes should not be forced to take more responsibility than they are happy with.
The document stresses that education is an important factor in quality care and should be structured, lifelong and in line with the NICE guidelines, linking where possible with the "Expert Patient's Programme".

The next 10 years
Over the next 10 years a framework must be in place to deliver all the remaining standards in the NSF, with local plans reflecting local priorities. PCOs will be expected to set themselves measurable targets that will result in improved quality of care. Changes cannot all be made at once, and the delivery strategy recommends prioritising patients with poorly managed diabetes and the groups most at risk of developing diabetes. Prevention should be an important part of the framework, with work continuing on schemes such as smoking cessation and the "Healthy Schools Programme".
The document acknowledges that better liaison between primary and secondary care will need to be developed to provide seamless care with protocols and guidelines covering both areas. There should be clear guidelines on referral criteria, the management of long-term complications and fast-track access to specialist care.
One of the aims of the NSF is to reduce inequalities, but I think it is unfortunate that no national performance indicators have been set. This means that, as PCOs are setting their own targets, differences between localities could persist.
Nationally, progress will be monitored under The NHS Plan and be subject to review by the Commission for Healthcare Audit and Inspection (CHAI). Structures must be in place to ensure that the public and patients are involved in the monitoring. Monitoring at local level will be the responsibility of PCO clinical governance.

Implications for primary care
Nurses in primary care will welcome this delivery strategy, but they are already overstretched trying to implement the previous NSFs. The existing workload, together with the increasing number of people with diabetes being diagnosed and the transfer of patients from secondary care, will further increase the burden for these staff. The concern will be whether there are sufficient human and financial resources to meet the challenge.
It is disappointing that no ringfenced funds have been made available to finance the delivery of diabetes services. The assumption is made in the document that funds made available in the baseline allocations to PCOs will be available to implement the strategy. Unfortunately, the demands on PCO finances already exceed the funding available, with most PCOs having an overspend on their drug budgets, so finding money for the NSF is going to be difficult.
Finance will be needed for extra doctors, nurses, dieticians and podiatrists, and there are already severe recruitment problems. This problem is likely to be further intensified by the large number of community and primary care staff due to retire in the next 10 years. Optimising treatment for control of blood pressure and blood glucose is also likely to have implications for the drug budget. Practices will need extra time to set up and verify the registers and extra appointment time for both nurses and doctors to give the required structured quality care to the increasing number of people with diabetes. District nurses will also need increased resources as more patients are put on insulin. The challenging opportunity for new initiatives to provide equity of care to housebound patients with diabetes and those in nursing homes may also stretch practice and district nurse resources. Education and training is also crucial to the successful implementation of the NSF and will involve locum cover. All of these factors have financial implications.
The Diabetes NSF will give nurses an excellent opportunity to develop new roles as nurse consultants and diabetes nurse specialists within PCOs and practices. It will also give nurses the chance to use their hard- fought-for extended nurse prescribing.
Most of the increasing day-to-day workload will fall on practices, and extra staff will be needed, but it is already difficult to recruit both nurses and GPs, particularly in rural areas. Innovative schemes such as practice nurse apprenticeships will need to be considered to attract more nurses into primary care. Singlehanded practitioners will be at a disadvantage because it is difficult for one doctor or nurse to have up-to-date expertise in the management of all chronic diseases. I think new initiatives such as the sharing of specialist nurses between small practices could help in this respect.
Many practices already provide well-structured care in diabetic clinics run by skilled and knowledgeable staff. As the number of people diagnosed with diabetes increases, additional staff will be required and will need to be trained. The demand for training courses is likely to exceed the number of places available, and, as often happens, those in most need are least likely to attend, partly due to lack of locum cover. Skills for Health are developing a competence framework for professionals working with diabetes. This is due in autumn 2003 and should help to identify those in most need of training. I have some concerns that there will not be enough suitably qualified people to teach on these training programmes.
The strategy states that PCO or practice diabetes protocols will need to be in line with NICE guidelines, but I feel that some of these guidelines appear ­
overambitious and will be impossible to meet. For example, checking HbA(1c) routinely every three to six months will put extra strain on practices and the laboratory services as well as appearing to take control away from patients and medicalising their condition.
In theory, patient-held records seem to be a good idea, but in practice they tend to get lost or forgotten and the paperwork for each consultation is complicated by this duplication. This situation may improve and become more practical with the introduction of electronic smart cards. Patient-held individual treatment plans and targets may be a better option in the short term. Help may be at hand as the Department of Health is to look at personal diabetic records and report on best practice in the autumn.
One thing the NSF does not address is the identification of undiagnosed patients with diabetes. There are no guidelines on those most at risk or the best screening methods. Without identifying these patients we shall not be able to accurately forecast future needs.
The vision of this NSF is excellent; it will be welcomed by both health professionals and people with diabetes and should result in improved quality of care and a corresponding reduction in morbidity and mortality. However, the concern remains as to whether the resources will be available to meet the demands of this wide-ranging programme.

Reference

  1. Razvi FM, Illahi W, Ryder REJ. Is digital retinal imaging alone sufficient as a screening tool for diabetic­ ­retinopathy? Pract Diab Int 2002;19(8):240-4.

Resources
NSF for Diabetes Delivery Strategy
Available on the Department of Health website
W:www.doh.gov.uk/nsf/diabetes/

An interprofessional resource pack to support learning and development at practice and PCT level in ­delivering the NSF  is available on the National Primary and Care Trust Development Team Website
W:www.natpact.nhs.uk

National Institute for Clinical Excellence (NICE)
W:www.nice.org.uk

NHS Modernisation Agency
W:www.modernnhs.nhs.uk

The Expert Patient's Programme
W:www.lmca.demon.co.uk/ docs/expert.htm

Healthy Schools Programme
W:www.wiredfor health.gov.uk/healthy/healint.html

Skills for Health
W:www.skillsfor health.org.uk/intro.asp