THE ORGANISATION AND DELIVERY OF OPTIMAL DIABETES CARE

Published on 03/04/2015 by admin

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CHAPTER 7 THE ORGANISATION AND DELIVERY OF OPTIMAL DIABETES CARE

BACKGROUND TO THE CHANGING ORGANISATION OF DIABETES SERVICES

GOVERNMENT POLICIES AND NHS CHANGES

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.

Authoritative guidelines

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:

Renal care (NICE 2002b, McIntosh et al 2002c). However, this is being superseded by the NSF for chronic kidney disease, part 2 published in 2005 (DH Renal NSF Team 2005).
Lipids management (McIntosh et al 2002a), but now superseded by 2005 guidance from the Joint British Societies, which includes all relevant cardiovascular risk factors (Wood et al 2005) and the 2006 NICE technology appraisal on statins (NICE 2006).
Blood pressure management (Hutchinson et al 2002). These were superseded by separate guidelines from NICE (North of England Hypertension Guideline Development Group 2004) and the British Hypertension Society (Williams et al 2004), updated by a single NICE/BHS guideline in 2006 (NICE 2006a).

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.

Other authoritative guidelines for the management of diabetes are now readily available from:

AIMS

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.

TABLE 7.1 Suggested aims for diabetes care

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

COMPONENTS OF OPTIMAL ORGANISATION WITHIN PRIMARY CARE

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”:

ACTIVE PARTICIPATION OF DIABETIC PATIENTS IN THEIR CARE

If professionals respect their patients’ autonomy, then patients are more likely to be able to act as the main managers of their chronic disease.

Attention to the following guiding principles should enhance this autonomy:

PRIMARY HEALTHCARE TEAM PERSONNEL

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:

The following points may inform how members of the primary healthcare team can deliver diabetes care more effectively:

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.