THE ORGANISATION AND DELIVERY OF OPTIMAL DIABETES CARE

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CHAPTER 7 THE ORGANISATION AND DELIVERY OF OPTIMAL DIABETES CARE

Background to the changing organisation of diabetes services 186
Components of optimal organisation within primary care 189
Delivering high-quality care to older patients with type 2 diabetes 196
The newly diagnosed patient 198
The periodic review: What should it contain? 201
Referrals outside the primary healthcare team 201
Measuring performance: Audit 202

OVERVIEW

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.

BACKGROUND TO THE CHANGING ORGANISATION OF DIABETES SERVICES

INTRODUCTION

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.

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.

National Service Frameworks for Diabetes

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 first stage, published in 2001, listed 12 “standards” that define the areas of care that will need to be delivered (see Appendix 2), of which eight are relevant to type 2 diabetes management in primary care (DoH 2002). Text in this book that is specific to these standards is indicated by a box in the margin in which the numbers of the relevant standards are given.
• The second stage, published in 2003 set out a strategic framework on how the NHS would implement the NSF standards over a 10-year programme (uncosted) (DoH 2003).

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:

• Foot care (Hutchinson et al 2000, McIntosh et al 2003).
• Retinopathy (NICE 2002a, Hutchinson et al 2001).
• 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).
• Blood glucose management (NICE 2002c, McIntosh et al 2002b).

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:

• The American Diabetes Association (ADA) publishes comprehensive and referenced clinical practice recommendations, updated annually and available on its website (ADA 2007).
• The Scottish Intercollegiate Guidelines Network (SIGN) published its own excellent authoritative guidelines in 2001, reviewed in 2005 (SIGN 2005).

New General Medical Services (GMS) contract

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).

The diabetes team

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.

NHS reorganisation and policy documents

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.

Evaluation of service delivery of diabetes care

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).

Patient experience

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 http://www.gpaq.info/), reflect upon it and produce an action plan.

AIMS

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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

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

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Attention to the following guiding principles should enhance this autonomy:

• Type 2 diabetes is a progressive disease that requires regular and staged changes in therapy. Patients must not be made to feel guilty or at fault when these changes occur.
• Treatment plans should be “negotiated” and attempt to incorporate the patient’s own chosen goals. Other issues in a patient’s life may affect the priority given to these diabetes-related goals.
• Interventions should aim to promote and maintain improved self-care behaviour and to maximise freedom and flexibility in the patient’s life.
• Where possible, patients should be encouraged to adjust their treatment and be supported in this. Patients will need to know the actual values and the significance of any tests. This requires the professional to identify and address each patient’s educational needs. If patients are allowed to make decisions, then they should be allowed, without stigmatisation, to make mistakes from which each patient and the professional can learn.
• The professional should aim to earn and maintain each patient’s respect. Solid evidence, where available, should support any guidance given.
• A balance needs to be struck between keeping things as simple as possible and recognising that diabetes is not a simple disease.
• Patients have the right to make choices that may ultimately cause them harm.

PRIMARY HEALTHCARE TEAM PERSONNEL

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Education 8

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:

• Podiatrists
• Dieticians
• Psychologists
• Pharmacists, particularly for medicines management, which may reduce HbA1c results (Choe et al 2005)
• Informatics staff
• Opticians
• Diabetes specialist nurses.

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

• The active leadership of a GP or a practice nurse with a particular interest in diabetes is likely to provide the necessary driving force within the team.
• Members of the practice involved in any activity require sufficient and updated knowledge and skills to undertake these tasks. Training needs should be identified by appraisals, audit, questionnaires and patient feedback. Training may be obtained from a variety of sources, such as attendance at specific courses, observation of specialist colleagues or clinics, distance learning, self-directed reading, or in-house. Current educational practice suggests all team members should have a personal learning plan.
• Non-medical members of the team play an important role. With adequate training and safeguards, nurses should be able to prescribe changes in therapy according to an agreed protocol; this enables a prompt and more effective response to problems and a greater likelihood that the individual patient’s goals will be achieved.
• Good working relationships with others involved in diabetes care outside the practice, both in health and in other services (e.g. social), will facilitate each patient’s access to and a more seamless movement between the available agencies that best address each particular need.
• All team members should be committed to ensuring equitable access and care to patients of all ethnic and cultural backgrounds.

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.

ADMINISTRATIVE STRUCTURES AND PROCESSES

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The following should enhance the delivery of quality diabetes care in practices:

1. An accurate up-to-date diabetic register for recall, management and audit, with a named person responsible for maintaining it. All team members should notify the register when made aware of a newly diagnosed or registered diabetic. Practices should also consider setting up a parallel register of those at higher risk of developing diabetes (in particular those with IGT), for recall to be screened regularly.
2. An evidenced-based protocol

Related posts:

LIVING WITH DIABETES DIABETES COMPLICATIONS WHAT IS TYPE 2 DIABETES MELLITUS? GLYCAEMIC CONTROL REDUCING CARDIOVASCULAR RISK LIFESTYLE