For this editorial I am taking the opportunity to share with you the outcome of a service development I discussed in my first editorial for this Journal (Down, 2018). Due to the huge demand on our district nursing (DN) colleagues for visits to administer insulin to housebound patients, I took the concept of GP virtual clinics and developed them within our DN teams across the county. Somerset is a large county with a high proportion of older people with diabetes. At the start of this service development, the DN service was having to provide 300 visits per day for insulin administration.
Virtual clinics, in this instance, involves DN hubs meeting with myself on a regular basis to allow for the discussion and review of all the patients they attend for insulin injections. For each patient, we review their daily glycaemic control and their recent HbA1c, weight, renal function and frailty status. With these factors and an understanding of the patient’s current situation, an assessment is made and individualised targets for glycaemic levels and HbA1c are set. Following each patient assessment, if a change of insulin regimen is made, the GP is informed and requested to alter the patient’s repeat prescription. A new insulin passport is also given to the DNs to leave with the patient.
In the first year of these virtual clinics starting, I withdrew insulin therapy altogether in 23 patients. For some of these, oral diabetes therapies (mainly the dipeptidyl peptidase-4 inhibitor class) were started in place of insulin. For many patients their insulin regimen was either twice-daily NPH or twice-daily mixed insulin. Where clinically appropriate, based mainly but not wholly on frailty status, I switched this regimen from a twice- to a once-daily regimen, predominantly opting for a biosimilar basal insulin.
Staggeringly, once the captured data from the first round of visits to all the DN hubs were reviewed, we found that the daily visit rate was reduced from 300 to 166 visits. In the 23 patients who had their insulin stopped and the 121 who switched to a once-daily insulin regimen, repeat HbA1c checks showed maintained target levels without hypoglycaemia.
A reduction of 134 visits per day, 365 days per year, equates to a huge cost reduction to a service at capacity, and this scheme has also provided the opportunity to set appropriate glycaemic targets on an individual basis to minimise the risk of both hypo- and hyperglycaemia for the patients.
The greatest learning and reflection for me was the simplicity of the idea and the enthusiasm with which the DN teams took to the virtual clinics. Given that this service development came at a time of unsustainable demand, the DN teams attended the clinics with a positive attitude and all of the relevant patient details that I had requested in order to review each case. To see each DN team member grow in confidence and knowledge was incredibly rewarding. The feedback from the teams was exceptional and reflected what I had seen in terms of their increased understanding of managing diabetes in frail elderly patients.
As with any positive idea, this service development has led to an increasing demand. As I had only initially offered one DN virtual clinic per month across the county, it is clear that more frequent reviews are necessary in each area. The DN teams are in contact with the community DSN service to ask for reviews on new patients or if the clinical picture for an existing patient changes in between the planned virtual clinic for that area.
The whole diabetes service is undergoing a redesign in Somerset, and I am proud to say that the DN virtual clinics have been highlighted as an integral part of this evolving service. Discussions are currently underway with regard to the actual cost savings this development has shown to date, and regarding how this saving can be best utilised to ensure the DSN team can continue to offer this invaluable service.
For me, this is a clear demonstration of how innovative thinking and cross-team working can unlock huge potential cost savings and, at the same time, provide quality individualised patient care.