Practical solution to support delivery of primary care led diabetes services

In addition to the National Service Framework, the National Institute for Clinical Excellence (NICE) has published guidance on various aspects of diabetes management, from glycaemic control to cardiovascular risk reduction and management of eye, renal and foot disease (NICE, 2002a; NICE, 2002b; NICE, 2002c; NICE, 2002d; and NICE, 2004). There have also been a number of appraisals of new treatments for diabetes, including the glitazones and basal insulin analogues (NICE, 2003a; NICE, 2002e). As well as guidance on these very medical aspects of diabetes management, NICE has also reviewed the importance of offering structured patient education (NICE, 2003b). This plethora of guidance can often be bewildering to healthcare professionals in both primary and secondary care.

Our aims
We therefore set out with the aim of providing a user friendly resource that summarised good clinical practice and was consistent with national guidance, but in a format that included useful local information and was customised to the needs of patients in our locality.

Our approach
Leicestershire has one of the largest diabetes services in the UK, with a population of approximately 1 million; of whom 93 000 are of Indo-Asian origin. The population is served by six primary care trusts (Figure 1) comprising approximately 144 GP practices, all of which are predominantly served by the specialist service located within the University Hospitals of Leicester (UHL). Clinics are undertaken within both the Leicester hospitals themselves and by specialists going out to a network of community hospitals across the county.

A health needs assessment carried out in 2002/03 for people with diabetes in Leicester, Leicestershire and Rutland confirmed national findings that:

• The prevalence of diabetes is high and rising.
• A large number of cases of type 2 diabetes remain undiagnosed.
• There are population groups in whom the risk of diabetes and its complications are considerably higher (e.g. the Indo- Asian population).
• Demographic and social features of the local population, such as numbers of elderly and ethnicity influence the size of the problem in individual areas.

The rapid increase in obesity, a sedentary lifestyle and improvements in screening is leading to a significant rise in the number of people requiring treatment. In Leicestershire this could be approximately 50 000 by the year 2010 (Diabetes Strategy for Leicestershire and Rutland, unpublished observations).

A baseline assessment for diabetes service provision in primary care is essential because it is estimated that 75% of patients with type 2 diabetes are cared for solely by primary care (Pearce et al, 2000). Assessment of service provision is vital to establish current levels of service and to enable the development of models of care relevant to the needs of the local population.

We developed an audit tool to evaluate baseline diabetes services in Eastern Leicester Primary Care Trust (ELPCT), which serves a population of 180 000. with an estimated South-Asian population of 50% (Farooqi A et al, 2003). We carried out a 60-minute semi-structured interview with key members of the primary healthcare team in all 33 practices. This baseline audit covered areas such as:

• Whether a diabetes register was present 
• The estimated number of people with diabetes
• Whether there were dedicated diabetes clinics 
• The number of practice nurse hours 
• Whether training was undertaken by practice staff
• Whether structured education was provided to people with diabetes 
• Whether the practice undertook initiation of insulin therapy
• The time allocated for annual review and follow-up 
• The care of housebound people with diabetes
• Whether the practice was participating in clinical audit 
• What sort of equipment and local practice protocols were available
• The ease of access to support from other healthcare professionals, such as dietetics, podiatry and referral to secondary care.

Findings of baseline audit
The key findings are summarised in Figure 2. The estimated prevalence of diabetes in 2002 was 5000. The baseline audit identified 6895 (3.8%) people with diabetes.

Following this baseline assessment, the ELPCT used a number of quality co- ordinators to update the registers across the PCT. This extensive exercise revealed that there are approximately 11 000 people with diabetes within the ELPCT, giving a prevalence of diabetes nearer to 6%. Within this PCT, one practice alone has 1500 people with diabetes (Farooqi et al, 2003).

Building a comprehensive package for good practice
From the results of the baseline audit it is evident that a comprehensive package and team approach is required to meet the varying needs of the ELPCT. It was important to build on existing models of good practice but at the same time meet the needs of those practices struggling to provide high quality diabetes care.

University Hospitals of Leicester and the Primary Care Trust worked collaboratively to identify and resource a model to meet these needs. The overall package was called JEWEL, an acronym for Joint Education With Eastern Leicester; Figure 3 lists some of key components of the initiative.

A simple practice resource pack is one aspect of this model, and contains information to support all practices. Focus groups for healthcare professionals were held for them to contribute to the contents, and the PCT Diabetes Implementation Group agreed the final format, with patient input. A non- promotional educational grant acquired from a pharmaceutical company was used to resource and produce the 33 packs (Figure 4).

The box (a portable rigid plastic case) includes essential information on how to access specialist and primary care based diabetes services specific to the PCT. There are also guidelines and algorithms for the management of diabetes, including diagnosis and screening, management of complications, blood glucose, lipids and blood pressure management, which are all consistent with NICE and NSF recommendations (NICE, 2002c).

Figure 5 gives an example of one of these guidelines. These guidelines and algorithms were agreed across the healthcare community and are part of the Leicestershire-wide strategy for diabetes services. They are included in a laminated A4 format to ensure ease of use. Within the pack there are two folders containing samples of recommended patient information leaflets covering general diabetes information and dietary advice. For each sample information leaflet, there is information about availability, suppliers and costs. Diabetes UK leaflets in relevant languages and locally produced booklets were also included.

Education groups for the newly diagnosed and those with established diabetes have been organised and are run within the local community. Details on how to refer patients and the format of these educational sessions are all part of the pack. In addition there is information on useful websites, journals and book lists to support healthcare professional development. A CD Rom is also included that contains all of the information in the pack so that additional copies can be reproduced or loaded onto the practice’s computer system. The pack was launched at ELPCT’s protected learning time event where there were formal presentations by the team, and open discussion on the use of this resource.

After 3 months, practice visits were made to evaluate any benefits or difficulties with the pack to allow revision before the pack was used in other PCTs.

Conclusion
In conclusion, the NSF for Diabetes has a remit to address inequalities in the provision of healthcare. In Leicestershire we have developed a practice resource pack as a way of beginning to tackle these issues. Ongoing evaluation has demonstrated that this pack is effective in supporting primary care staff to deliver the standardised approach. The pack is currently being rolled out to all practices in Leicestershire. This roll-out is being co-ordinated via the NSF Programme Board for Diabetes, with clinical leads for each PCT having the responsibility to ensure that the contents of the pack meet the needs of their local health community by consulting their local implementation group for diabetes. We will continue to evaluate this intervention and make further recommendations to the local implementation team for future developments.