The APPG for Diabetes investigation into diabetes care, with the aim of improving standards and reducing variation held its third meeting on 20th July. The Group heard from a range of healthcare professionals (HCP) involved in the care of people with diabetes. HCPs face a number of pressures when caring for those with a complex condition such as diabetes: limited time, varying knowledge and different processes depending on the environment they work in.
The HCPs speaking included a consultant in diabetes and endocrinology, a diabetes specialist nurse, a pharmacist, a dietician and a podiatrist with each focusing on challenges they face and potential solutions to these challenges.
Ruth Miller, Lead Diabetes Nurse at Pool Hospital NHS Foundation Trust, spoke on how to improve diabetes inpatient outcomes by introducing training for all patient facing staff, which, she said, could improve the management of diabetes in hospitals. Ruth discussed the development of her ‘Diabetes 10 Point Training Programme’ – the so-called ‘speed dating of the diabetes education world’ – which teaches ten core competencies and basic skills to manage patients with diabetes and which has already been used to train a wide range of patient facing staff including those not familiar with the care processes for diabetes. Importantly, the training was designed be adapted and used in different hospital and community settings around the country, is not costly, is quick and can be complemented with other diabetes education modules.
Dr Karunakaren Vithian, consultant in diabetes and endocrinology at Colchester University Hospital NHS Foundation Trust and Clinical lead for diabetes integrated service in North East Essex diabetes service (NEEDS) told how North East Essex was a low spending, low performing area; it was not achieving the eight care processes that Dr Vithian described as the ‘bread and butter of the basics that every person with diabetes should be measures on.’
In 2013 the CCG group for Dr Vithian’s area ambitiously redesigned diabetes services from scratch. Dr Vithian describe this as ‘a liberating experience allowing them a blank canvas on which to paint the new diabetes service’.
The new North East Essex Diabetes Service (NEEDS) strategy was a three legged model.
- Patients at the centre
- Specialist diabetes care teams
- Primary care data extraction to assess how well practices were achieving the eight care processes.
The benefit of this has been that surgeries are able to use the data to develop a bespoke care plan. Initial results showed that before the new NEEDS strategy the percentage of patients achieving the eight care processes was 40%, this increased to 60.3% in March 2015 and had reached 68.3% by December 2015.
Using the example of NEEDS, he concluded that despite financial and staffing constraints within the NHS it is possible to improve care, with clear leadership and buy-in from key stakeholders to work together, there will be a momentum to improve diabetes care and reduce variation.
Rosemary Plum, Chief Officer of Leicestershire Independent Pharmacy Federation, explained the role of pharmacy as one to complement diabetes services of other HCPs, not as an alternative to them.
Pharmacists are under-utilised in the management of people with diabetes; community pharmacy has the highest repeat footfall of any healthcare provider with pharmacy as some patients’ only regular contact with a HCP.
Rosemary highlighted the SIMPLE: Stop Smoking, Insulin, Monitoring, Pharmacotherapy, Lifestyle and Education scheme which provides a framework to maximise the benefit of a pharmacy medicines use review. It’s designed to improve quality of life, medication adherence and to identify poor diabetes control and is already being delivered by some community pharmacists for people with long-term respiratory conditions, with successful patient outcomes.
On average, 38% of inpatients with diabetes in England experience a medication error while in hospital. This is an area needs improvement and hospital pharmacists can help. Principal Pharmacist, Elizabeth Hackett, confirmed how a pharmacy-led, diabetes in-reach service halved the length of stay for elective patients with diabetes from four to two days.
Anita Beckwith, Dietitian at King’s College Hospital and National DAFNE Educator UK presentation focused on diet for diabetes management for people with Type 1 diabetes.
Anita explained that one of the national challenges facing dieticians in the UK is the competing with diet advice – i.e. from the food industry or celebrity chefs – that may be incorrect for the patient. Structured education is offered in a variety of education programmes; from an afternoon to a five day course for people with both Type 1 and Type 2 diabetes. However both locally and nationally take-up of a DAFNE courses by people with Type 1 diabetes is low.
Two key barriers to take-up:
- Child care
- Flexibility with employers to attend the courses.
Online course content is available however feedback from patients suggested that DAFNE is best delivered in a course like manner as patients feel more supported. DAFNE is now looking at how to address psychological issues around diabetes management at hypo-unawareness restoration as a standard part of the care pathway.
Alex Harrington, Podiatrist at Gloucestershire Care Services NHS Trust, opened with an example of a familiar situation she encounters: the person she met had not been to see a podiatrist for some time and their foot had become ulcerated despite being seen by numerous other HCPs.
Alex explained that currently podiatry services deliver reactive care, rather than proactively preventing problems. In Gloucestershire the CCG pulled together all providers and stakeholders in a Foot Care Project Group that looked at clinical pathways, self-management, prevention and HCP education to improve services in the area.
The Gloucestershire CCG worked with Irene M. Stratton, Honorary Associate Professor and Senior Statistician and posed the question: ‘Can clinical information from primary care help identify those at risk of foot ulceration?’
The Foot Care Project Group worked to see if routinely collected data from GP surgeries could help understand and identify who was at risk. Modelling was designed with acceptable sensitivity and specificity to help identify those at high risk of developing diabetes related foot problems.
There are concerns regarding the number of podiatry students taking up the profession and the age of those graduating being older that the average newly qualified HCP, heightened given the need for a bigger podiatry workforce.
Following the discussion, Jonathan Valabhji noted with optimism how the direction of the investigation in terms of addressing the areas that can make the biggest positive impact on diabetes care reflects that of the NHS Five Year Forward View.