Key learning points:
– The challenges: time, money and skills
– The need for more ‘joined-up’, long-term planning
– Models of integrated care – the way forward
Until recent years, the vast majority of diabetes care was conducted in secondary care, but the first GP mini-clinics were established as far back as 1971.1
Following the publication of the National Service Framework (NSF) for diabetes standards in 20012 and the delivery strategy3 in 2003, provision moved from predominantly hospital-based clinics, into the community.
Shortly after this, in 2004,4 with the introduction of the new GP contract, care changed yet again, and the Quality and Outcomes Framework (QOF) was introduced. This is a ‘pay for performance’ programme, offering incentives to general practice5 for meeting targets in care provision. QOF specifies nine care processes (see table), to be undertaken in diabetes care. The NSF, the new GP contract and QOF were moves to standardise care.
Previously, diabetes ‘mini-clinics’ consisted of one-stop shops where patients were reviewed by a nurse, a podiatrist, a dietician and then their GP. Today, the majority of diabetes management is delivered by nurses of varying levels. They run clinics to provide support and monitoring, covering everything once seen in the one-stop shop; but they also work towards QOF targets. It is estimated that primary care provides 75%5 of all diabetes management.
Time constraints often impose restrictions on what can be done in an annual review, but the review should ideally cover all aspects of the nine care processes.
And the diabetes population continues to grow rapidly. According to Diabetes UK6 there are now four million people in the UK living with diabetes and 549,000 people who are not yet diagnosed. Approximately 700 people a day are being diagnosed, which is one person every two minutes. How can primary care rise to the challenge of reaching such a rapidly expanding population?
Nurses now provide the care that was previously provided by dieticians and podiatrists. However, training is necessary, which may require time out of the surgery. It is becoming increasingly hard for nurses to access the necessary training, as practice managers may be reluctant to lose nurse appointments. Also, there may be costs involved.
How can nurses deliver care without the skills and competencies required? There are online courses that practice nurses can access, and a number of journals that help update nurses. Some drug manufacturers sponsor educational events in localities, often in evenings and at no cost to the participants.
Nurse prescribing has been an asset, as nurses can then work without so much reliance on medical colleagues. Managing the cost of prescribing is one of the fastest growing challenges. There is an expansive range of medications available for managing diabetes, but many prove costly in the short term. When it comes to deciding on a drug, the pressure can be intense, as clinical commissioning groups (CCGs) may impose restrictions. Incentives are produced to convince clinicians to use certain medications, to try to cut prescribing costs, and the clinician must select one that they believe will be most effective for their patient. Often this imposition reduces spending in the short term, but doesn’t necessarily deliver the best outcomes.
If the prescribed medication produces unpleasant side-effects, the drug may not be taken as prescribed or even at all, which is financially costly and clinically ineffective. It is estimated that £300 million of prescribed medicines are thrown away each year.7 This is often compounded by the difficulty in engaging people with their condition. Diabetes UK reminds us that one in seven beds in hospitals are occupied by someone with diabetes; 135 diabetes-related amputations are carried out every week. This could diminish if patients received the most effective drug at the right time and were supported to take it.
The move to provide more services in primary care has brought care delivery closer to home, in an environment that is familiar to patients such as a local GP surgery. Patients are more likely to know the clinician, and hopefully receive greater continuity of care.
It was envisioned that nurse-led clinics would offer patients organised and systematically delivered care, but this is not always the reality. Diabetes is complex, and in order to manage care effectively, practice nurses need regular updates and training as well as sufficient clinic time and appointments.
Specialist support is vital in keeping general practice competent and able to manage their diabetes population. There is no way that practice nurses today can run all the chronic disease clinics necessary, and stay abreast of all the changes in diabetes care. There is a real need for backup from intermediate and specialist diabetes teams. DSNs and diabetologists bring a depth of knowledge that enables the primary care team to concentrate on delivering routine care and working towards QOF targets.
The Super Six Model of Care,8 which was introduced in Portsmouth by the diabetes team at Queen Alexandra’s Hospital, has sought to address some of the issues highlighted earlier. This was triggered in 2009 by the recognition that something had to change in the way Portsmouth’s diabetes population was managed.
As a result of many discussions with the various stakeholders, the Super Six model was born in November 2011. This model seeks to keep certain, more complex categories of diabetes care, with the secondary care specialist, while the majority of the remaining diabetes population is managed in primary care with specialist nurses and diabetes consultants providing regular support and education.
Having worked in a Portsmouth GP surgery, this author can testify to the success of this venture. A diabetes specialist nurse (DSN) was accessible for advice or support by phone or in person any weekday during standard working hours, and the consultant team answered calls for emergency advice in the early evening. A diabetes consultant and specialist nurse visited the practice twice yearly to upskill the team in any necessary areas. A real sense of joint working developed. It was no longer a question of ‘us in primary care and ‘them’ in secondary care. And there were regular educational network meetings in the evenings for all involved.
Where additional training was needed, the specialist team offered this informally as hands-on learning. They were also available to provide expert advice when primary care teams were unsure how to proceed. The MERIT9 course was made available for practice nurses and GPs, to equip them to better manage their patients.
This model overcomes the difficulty of referring from one team to the other, as all came under the same umbrella.
Another model of care is the intermediate care team of diabetologists, GPs with special interests and specialist nurses. This type of service has been commissioned by the Surrey Downs CCG, and the service is run by Kingston Hospital. General practices receive regular visits from members of the DSN team at tier 2 level. They work alongside the practice nurses, often running separate clinics to help those whose diabetes is more complex. For the more specialist and complex care, tier 3 multi-disciplinary clinics are run fortnightly in several of the local community hospitals, keeping the care close to home, with DSN, diabetes specialist, podiatrist and dietician. These include insulin pump clinics and specialist input for people with poorly controlled diabetes or multiple co-morbidities.
Other models of integrated care are being developed and used in various parts of the UK. Some may prove more effective than others. In 201410 these included projects in Derby, North West London, Wolverhampton and Leicester. Others will be developing, with elements of the models already in existence. Diabetes care is growing and developing in general practice, so the challenges will only increase. To maintain the level of care, GPs and nurses need education and resources. Drug manufacturers should not be demonised, as they are a valuable source of education and support. There must be enough appointments at appropriate times, so that problems and poor control are not overlooked.
Primary care needs specialist support, in whatever model is appropriate, so that those with more complex needs can have them adequately met. The problem of prescribing costs will not go away but there needs to be more joined up perspective on this, and consideration of long-term outcomes, in order to deal with this and other costly issues.
1. Thorn PA, Russell RG. Diabetes Clinics Today and Tomorrow: Mini-Clinics in General Practice. British Medical Journal 1973;2(5865):534-536.
2. Department of Health. National Service Framework for Diabetes: Standards. Department of Health, 2001.
3. Department of Health. National Service Framework for Diabetes: Delivery Strategy. Department of Health, 2003
4. The National Health Service. (General Medical Services Contracts) Regulations. England National Health Service, 2004.
5. Gadsby R. What has QoF ever done for diabetes? Practical Diabetes International 2009a;26:314-315.
6. Diabetes UK. Facts and Stats. Diabetes UK, 2015.
7. B Hazell, R Robson. Pharmaceutical Waste reduction in the NHS. NHS England One, 2015.
8. Partha Kar. The Super Six Model: Integrating diabetes care across Portsmouth and south-east Hampshire. Diabetes and Primary Care 2012;14(5):277-283.
9. Hicks D, McAuley K. Meeting the Educaitonal needs of primary care practitioners: MERIT. Journal of Diabetes Nursing 2007;11(7):271-275.
10. Diabetes UK. Improving the delivery of Adult Diabetes Care through integration: sharing Experience and Learning. Diabetes UK, 2014.