The role of DSNs in the evolving NHS

The role of the DSN was first introduced >60 years ago, becoming more common in the 1980s. Initially responsible for general diabetes care, it has developed into one of diversification and a high degree of specialism delivering skills that include:

• The planning and delivery of structured patient education programmes. 
• Insulin pump therapy/continuous blood glucose monitoring. 
• Multidisciplinary working in clinics for people with specific diabetes complications (e.g. kidney disease). 
• Specialised expertise in the management of inpatient diabetes care. 
• Cardiovascular risk management. 
• Independent prescribing. 

The DSN can form a key link between the wide range of healthcare professionals involved in the management and people with diabetes. With the advent of cost-saving initiatives in the NHS, the DSN’s contribution to the vital function of enabling people with diabetes to self-manage effectively in turn enables DSNs to become involved in the management of other people who require specialist management or input.

With the current focus on delivering care closer to home and the increasing prevalence of integrated community-based services, it is essential that commissioners can clearly appreciate the value that the DSN can bring to improving outcomes for people with diabetes, while providing a key educational role to healthcare providers in a cost-effective manner. 

The White Paper Equity and Excellence: Liberating the NHS (Department of Health [DH], 2010) and the subsequent Health and Social Care Bill (DH, 2011) present the new model of commissioning to be implemented. This new, evolving NHS does not necessarily support the continued development and consistent use of specialist services; indeed, the proposed reforms risk a greater reduction in specialist skills through the potential fragmentation of services, as well as the risk that specialist expertise and input is not made a fundamental part of the commissioning process. 

If the DSN role is to survive and flourish in the evolving, new NHS, DSNs must able to make clear the exact difference they bring and be specific about the service they can deliver. In addition, commissioners must to be able to recognise the skills and competencies needed to deliver the desired services, and the DSN must be able to demonstrate that they are working at the necessary competence level for the role (NHS Employers, 2004; TREND-UK, 2011). This is going to be a challenge when there are currently 172 different titles used by nurses delivering diabetes services, as reported in a recent survey conducted by Diabetes UK (2011). This survey highlighted several areas of concern for the future.  

Disappointingly, only 593 DSNs responded to the online and postal survey. Many (47%) of these worked solely in the acute care setting. An alarming statistic was that 40% of DSNs are due to retire in the next 10 years. If the DSN role is to continue to develop and play a major part in the delivery of high-quality diabetes services, it is essential that there is detailed, current information about the function of the DSN workforce and the impact of the role on patient care and the development of services. 

Conclusion
Times are changing swiftly and the DSN has to be adaptable and prepared for this change. The role has constantly developed over the last 50 years and DSNs must now, more than ever, be able to demonstrate their worth, and they need to be aware of current political agendas and be able to speak the language of commissioners. The provision of robust data that can detail the difference they have made to care by, for example, the avoidance of admissions, improved use of resources and improved patient outcomes, is of paramount importance. The new, evolving NHS poses many challenges to the DSN and new skills and partnerships have to be developed urgently if the role is to survive into the future.