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Should insulin initiation take place in primary care?

Heidi Brown
RGN DiPProfPract DNCert
Diabetes Nurse Specialist
Worthing & Southlands Hospitals NHS Trust

As a result of the General Medical Services (GMS) contract, National Service Framework (NSF) and National Institute for Clinical Excellence (NICE) guidelines, much tighter control of diabetes is now strived for. Patients with type 2 diabetes are being initiated onto insulin therapy at a much earlier stage of their disease. Historically this has taken place in secondary care. However, without extra resources it is unlikely that secondary care can continue to cope with the extra demands placed upon its services as more patients are referred for transfer onto insulin therapy. This article considers how insulin transfer may, with the correct infrastructures and support in place, take place in primary care.
The Department of Health believes that implementation of the GMS contract (begun in April 2004) will see many more patients accessing an improved health service provided by their GP. The contract proposes that the more NHS work GPs undertake, the higher their rewards will be. Under the terms of the GMS contract a proportion of practice funding will be linked to a quality performance rating based on a points scoring system. Diabetes management is a key quality indicator within this scheme.(1)
The necessity for maintaining strict glycaemic control in patients with type 2 diabetes was demonstrated by the United Kingdom Prospective Diabetes Study.(2) As a result, patients with type 2 diabetes are urged to maintain strict glycaemic control, determined by a HbA(1c) of 7% or less. The new GMS contract states that if 50% of patients reach a HbA(1c) target of 7.4% or less, then maximum payment for this target is achieved.
In the author's area of practice, patients with type 2 diabetes on maximum oral hypoglycaemic agents who are unable to maintain a HbA(1c) at a level of less than 7.5% are treated with insulin, either in combination with oral hypoglycaemic agents or alone. Insulin initiation has historically taken place in secondary care. However, if increased referrals for initiation of insulin therapy swamp secondary care, delaying treatment with insulin for patients, then it could be considered logical that insulin initiation take place in primary care. From a patient perspective this would mean treatment and education received locally by practitioners they already know.
It has been suggested that this could create opportunities for practice nurses, as they will have a key role to play in helping practices meet the targets of the GMS contract.(3) However, this requires intensive education and follow-up of patients by telephone for titration of insulin doses. This would not be possible without an expansion in the support available to primary care from diabetes specialist nurses (DSNs). The Royal College of Nursing has published extensive guidance to starting insulin treatment.(4) As well as asserting that this must be "within the scope of your professional practice", advice is given to seek help and supervision from a DSN.
Primary care trusts (PCTs) are required to implement self-management programmes for key chronic disease groups, including diabetes, by 2007.(5) If able, people starting insulin should be aiming for self-management, but this cannot happen without effective education. According to the NSF: "The provision of information, education and psychological support that facilitates self-management is the cornerstone of diabetes care."(6) A lack of funding has been shown to have led to difficulties with implementing the NSF for diabetes,(7) yet no provision has been made for secondary care to cope with the extra demands for staff education and potential increase in patient referral generated by the GMS contract. In many areas, education for health professionals is currently based in secondary care, although the existing courses in diabetes may not have sufficient places to cover the potential influx of extra demands placed upon them. In the author's area of practice, new DSN posts have been appointed by the PCT. One of the aims of these posts will be to upskill practice nurses through them working alongside DSNs.
To be able to perform insulin initiation successfully in primary care, "the primary health care team must have the confidence to deliver that care and the patient must feel confident in their team".
Historically this has been performed on a one-to-one basis. Richmond asks, where do overloaded staff find the time to take on this extra work and initiate insulin therapy in their surgeries?(9) Erskine et al found that initiating insulin treatment in groups actually trebled patient contact time, thus being an efficient use of resources.(10) Research and experience have uncovered many benefits of group teaching when designing and planning educational strategies to transfer treatment from oral agents to insulin. Groups allow people the chance to share experiences, reduce misconceptions and learn from the questions that other group members may ask, as well as being an effective vehicle for information giving by healthcare professionals. The benefits to patients of initiating insulin in groups have also been described by Hill and Gillroy.(11) My own area of practice has successfully initiated patients onto insulin in groups for over two years and found this to be an excellent use of resources, as well as improving patient outcomes and quality of life.
Insulin initiation has already been successfully performed in primary care. Richmond describes a "Starting patients on insulin course" that was set up and run by DSNs for any practice nurses and GPs who were carrying out insulin initiation within their own practices.(9) The course was evaluated as benefiting patients, practice nurses, GPs and DSNs.
Once issues such as upskilling practitioners have been addressed, organising a room with sufficient space to take a group and installing the infrastructures required to run a group successfully must be addressed. Administrative and IT support will be needed to invite and recall patients. Systems must be in place to allow patients to be able to opt out of group sessions if this does not suit their needs. Clear guidelines for referral into a group must be in place so that only appropriate referrals are made and accepted. Access to ongoing support and education must be put in place, so patients can successfully manage their own insulin dose adjustments and practitioners can review the efficacy of their teaching. Clearly, where initiation of insulin takes place is not the issue, providing that the infrastructure that keeps patients safe is.
Many studies have taken place into the best way to organise education sessions for transferring patients onto insulin. This is generally broken down into three stages:

  • Initial preparation - covering the start of insulin treatment, including topics such as injection technique, the timing of injections in relation to food, hypo/hyperglycaemia,storage and disposal of supplies, and driving regulations.
  • Using insulin - covering topics needed within the first few weeks of starting insulin, such as insulin dose adjustment and the effects of alcohol, diet exercise and sickness.
  • Ongoing education - covering the progression of the disease, how to reduce the risk of developing possible long-term complications, and including subjects such as travel advice.

In my practice, as well as the course described by Richmond, patients are encouraged to adjust their own insulin doses with support from literature provided at the group sessions and from weekly phone calls to a DSN. This works well in a secondary care DSN team as the telephone triage system is always manned by an experienced DSN. However, in many GP surgeries, one practice nurse will have experience of insulin dose titration. If this person is away or leaves, the onus for dose adjustment problems may then fall back on already overworked GPs, or be put through to DSNs in secondary care, fragmenting care for the patient.
As can be seen from the literature, if practices in primary care want to initiate insulin therapy, then they can build on existing models of good practice and education. However, scrutiny and meeting of their own resource needs are vital to put educational and support packages in place. Ongoing evaluation of these packages will be essential to ensure that NSF and NICE guidelines and standards are met. Resources must allow for the ongoing support and education that patients will continue to need while undergoing treatment with insulin. It is vital and has been demonstrated that patients need to be empowered to self-manage their insulin therapy. The number of patients requiring insulin is growing, but resources are not increasing to match. Close working relationships must be built with secondary care to enable upskilling of practitioners and sharing of information. If this does not happen, patients may be put at risk of developing complications associated with diabetes as they wait to benefit from treatment with insulin.

References

  1. Department of Health. Investing in general practice. The New General Medical Services contract. 2003. Available from URL: http://www.dh.gov.uk/assetRoot/04/07/19/67/04071967.pdf
  2. UK 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. Lancet 1998;352:837-53.
  3. Hall G. New systems of care: what are the implications for DSNs? J Diabetes Nurs 2004;8(4):132-6.
  4. Royal College of Nursing. Starting insulin treatment in adults with type 2 diabetes. London: RCN; 2003.
  5. Department of Health. National Service Framework for diabetes standards. London: DH; 2001.
  6. Department of Health. National Service Framework for diabetes. London: DH; 2002.
  7. DaCosta S. The new GMS contract: old news or new opportunities? J Diabetes Nurs 2004;3(3):98.
  8. Freeman G. Insulin in primary care: educating patients and healthcare professionals. Diabetes Primary Care 2004;6:26.
  9. Richmond J. Insulin initiation: who should do it and who could do it? Diabetes Primary Care 2004;6:27.
  10. Erskine PJ, Idris I, Daly H, Scott AR. Treatment satisfaction and metabolic outcome in patients with type 2 diabetes starting insulin: one to one vs group therapy. Practical Diabetes Int 2003;20:243-6.
  11. Hill J, Gilroy J. Using group education sessions to start patients on insulin. J Diabetes Nurs 2002;6(4):104-8.

Resources
National Institute for Clinical Excellence
W:www.nice.org.uk

National Service Framework for Diabetes
W:www.dh.gov.uk/Policy and Guidance/HealthandSocialCare topics/Diabetes/fs/en

Further Reading
Management of type 2 diabetes - blood glucose.
London: National Institute for Clinical Excellence; 2002