Delivery of diabetes care is changing… and so it should. The numbers of people with diabetes, particularly type 2, are increasing in epidemic proportions. We need new ways of working within limited resources to tackle the problem.
The new joint position statement (Diabetes UK et al, 2007) states that ‘moving more ongoing care out of hospitals into the community can be positive, as long as people with diabetes continue to have access to the skills and facilities they need’. In the best cases primary care teams work together with their secondary care colleagues to gain the knowledge and skills required to provide a high-quality service involving people with diabetes in their own management. Much has been made of ‘choice’ in health care and in many cases the voice of those with diabetes goes unheard. They have no choice. It appears some blanket letters informing people that their follow-up care is to be moved are being sent: a practice that should be unacceptable. Diabetes UK et al (2007) confirm that: ‘evidence is emerging that the redesign of diabetes services is being implemented in some areas through cutting specialist diabetes services’.
Historically, before the 1990 GP Contract, people with diabetes were referred to specialist teams for review when problems arose. For example, insulin initiation was considered difficult, time consuming and required specialist skills not available in primary care. However, the system today is capable of becoming divisive due to NHS reforms. Those in secondary care feel their specialist skills are not given the significance they deserve while GPs are encouraged to cut back on referrals and manage people with long-term conditions in the practice. The previously unbelievable has happened in a few centres: specialist nurses employed in secondary care teams have faced redundancy due to the changing patterns of care while others have adapted and work with practices through employment in primary care or as part of an intermediate service funded by PCTs or equivalent. Many are feeling devalued due to Agenda for Change and what is seen as a backdoor method of cutting salaries in a system that was supposed to create uniformity and reward for skills.
Practice nurses have responded to the challenge of working in new ways and acquiring new skills – the results of the QOF amply demonstrate that. Pressure on them to take on a more specialist role without providing the resources to do so results in anxiety and lack of confidence at a time when the individual with diabetes needs reassurance (Sanderson et al, 2007). People with diabetes need time and easy access to support at times of change; particularly if insulin is required. Many practices do not have sufficient numbers of people with diabetes for the practice nurse to become proficient in insulin initiation and management and it is imperative to continue to provide specialist nursing care. Some are finding none available.
Much importance has been put on empowerment of people with diabetes and on structured education to underpin it (DoH, 2001; NICE, 2003). The average GP practice does not have the capacity to devote the time and expertise needed to meet NICE criteria. Courses such as DESMOND and X-PERT benefit from specialist nursing input and may help bridge any primary–secondary care gap, assisting people with diabetes in their choice of where and when to receive their care.
Health professionals only see a person with diabetes for 2–3 hours in a year. More resources are needed to cope with the increasing numbers of people being diagnosed. This is not the time for uncertainty in diabetes specialist nursing.