CHAPTER 7 THE ORGANISATION AND DELIVERY OF OPTIMAL DIABETES CARE
Although the focus of the primary health care team rests with its patients and local community, the delivery of good care is strongly influenced by a larger framework – government policy and the organisation in which the team works. A better understanding of this framework should help teams to organise the best possible delivery of diabetes care within the available resources.
In October 1989, government health departments and patients’ organisations from across Europe, under the aegis of the World Health Organization (WHO) and the International Diabetes Federation (IDF), agreed upon a series of recommendations for diabetes care to be implemented. Called the St Vincent Declaration, this set out goals and targets for improved effective care (WHO/IDF 1990, Krans et al 1992). Subsequent initiatives in the UK have built upon this landmark declaration.
Current government health policy aims to deliver an improved quality of service to individual patients and to the whole population (DoH 1998). General practitioners’ (GPs) contracts with the National Health Service (NHS) now reflect the government’s intention to support and reward improved quality of care in various areas, including diabetes. In order to address the increasing prevalence of the condition, to take account of greater evidence for and availability for effective interventions, and to meet local patient needs, the organisation of diabetes services needs to adopt an integrated approach between primary, secondary and community care.
Government policy to improve the delivery of care throughout the NHS to patients with diabetes is set out in the National Service Framework (NSF) for Diabetes. Its stated aim is to “make the best practice already offered in some places the norm”. This NSF was published in two stages:
The National Institute of Clinical Excellence (NICE) was established as an independent organisation (although government funded) in 1999 to provide guidance on new and existing technologies and to develop clinical guidelines and audit tools. In April 2005, NICE joined with the Health Development Agency to become the new National Institute for Health and Clinical Excellence (still known as NICE). NICE has published technology appraisals on medication (glitazones, long-acting insulin analogues), delivery systems (insulin pump therapy) and patient education models.
The National Clinical Guideline for type 2 diabetes consists of six inter-related guidelines, developed by a multi-professional, multi-agency collaboration with the support of NICE. These guidelines (with regular updating) aim to provide clinical practice recommendations (with the supporting evidence) for healthcare professionals in the following key areas:
It is arguable that NICE guidance has not always been set out clearly and that some recommendations are inconsistent with its own stated targets, other current authoritative guidance and the results of research. Professionals need to consider this information, but should be prepared to exercise their best clinical judgement to act in the patient’s best interests.
Since the implementation of the new GMS contract (between an individual general practice and its primary care trust) in 2004, some of general practitioners’ annual income is “performance related”: derived from practices achieving points in the Quality and Outcomes Framework (QOF), which covers a range of clinical, organisational and “patient experience” indicators. The contents and payment stages of the QOF are reviewed and revised on a 2-yearly cycle. For the 2006–2008 cycle, Appendix 3 lists and describes the indicators that are relevant to the delivery of care to diabetics. These are not only the disease-specific indicators, but are also relevant to other clinical and organisational areas.
Performance data from the first year (2004–2005) of QOF showed that, for diabetes, practices across the country achieved, on average with some variations, about 94% of the maximum points available (Khunti 2006, National Diabetes Support Team 2006b).
Some GPs can also become a GP with a special interest (GPwSI) in diabetes, following suitable approved training. GPsWIs are expected not only to provide higher-quality disease management, but also to act as “clinical leads” whose roles may include monitoring the implementation of NSF guidelines, coordinating local service developments, and linking with secondary and community care.
The importance of other team members in delivering care must not be forgotten. The Primary Care Diabetes Society was created to represent GPs, GPwSIs, practice nurses and clinical assistants who are involved with diabetes. Practice nurses often take a leading role. Some have become nurse practitioners and have taken a supplementary nurse-prescribing course to allow them to make changes to treatments within the context of practice protocols. Primary care diabetes specialist nurses (DSNs), based in the community and funded by PCTs, have advanced skills to support and deliver care across the community.
The NHS continues to undergo changes in its organisation. Many of these changes affect how diabetes care is delivered. Government policy has been to reform the delivery of care in the community, particularly with the significant injection of funding into the NHS. A series of policy documents (available on the DoH website) have been published that outline the direction of this reform process. Among these are the new White Paper “Your Health, Your Care, Your Say: a new direction for community services” published in 2006, covering all aspects of the care people need in the community and their own homes (DoH 2006).
The introduction of practice-based commissioning (PBC) may alter radically in some districts the delivery of diabetes care: although quality assurance remains central, implementation of cost management may result in care and resources being shifted from secondary care into the community, possibly into new “frameworks” (National Diabetes Support Team 2006c). Bearing in mind the high proportion of QOF points achieved, practices will probably continue to manage most of their diabetics, but delivery of care for more “complex” individuals or problems may change.
The aim of the Healthcare Commission is to promote improvement in the quality of health care and public health in England and Wales. The Commission is committed to annual assessments of the performance of NHS organisations, including components of the diabetes services. A fact sheet summarises this activity (National Diabetes Support Team 2006a).
As part of the QOF, practices are now expected to undertake an annual patient survey, using one of two approved tools (Improving Practice Questionnaire [IPQ], online at www.cfep.co.uk, or General Practice Assessment Questionnaire [GPAQ], online at www.gpaq.info/), reflect upon it and produce an action plan.
The delivery of high-quality care to type 2 diabetic patients in primary care requires that their needs are identified clearly and correctly, and that the available resources are used optimally to address these needs. Better outcomes are more likely to result if the delivery of care respects and complements the goals chosen by the patient. Patients should be regarded as the main managers of their disease. Diabetics who understand their disease are more likely to have similar aims to those of a caring professional. Table 7.1 summarises a professional’s perspective of suitable aims for the care of individual patients with diabetes.
|Ensure the earliest possible detection of the disease|
|Abolish symptoms of the disease|
|Achieve optimal blood glucose control, avoiding extremes of hypoglycaemia and hyperglycaemia|
|Prevent or delay, and provide early treatment of diabetes complications|
|Minimise the risk and impact of cardiovascular disease|
|Enable patients to play the fullest possible role in the management of their disease, by providing suitable education and psychological support, maximising self-reliance|
Effective delivery of care to diabetics has relied traditionally upon the three Rs of chronic disease management: Registration, Recall and regular Review. “Multifaceted” interventions (such as individualised goal-setting with patients and suitable education) improve the performance of both the practitioners and the organisation, with better outcome measurements of such parameters as blood pressure and glycated haemoglobin (Olivarus et al 2001, Renders et al 2001). A successful “recipe” for diabetes care needs to contain the appropriate “ingredients”:
The delivery of diabetes care is a “team effort” with the different members of the primary healthcare team each playing an important role. In most practices, GPs and practice nurses will deliver most of the first-line clinical care with administrative and/or reception staff providing the organisational back-up. However, an increasing number of practices have employed or access other professionals:
Chapter 6 of the Diabetes NSF Delivery Strategy (DoH 2002) outlines issues that relate to workforce planning and development. Although directed more at a district level, the document and its references may be relevant to how individual practices might manage their own personnel.