I met Poppy today. She is a Medical Detection Dog (see hypoalertdogs.co.uk for more information). Her owner, Philippa, has long-standing diabetes and Poppy warns her of impending hypoglycaemia in time to take appropriate action. Without Poppy, Philippa would have frequent, severe hypoglycaemic episodes. This is a good example of care tailored very specifically to one person and her needs.
Equity and Excellence: Liberating the NHS (Department of Health, 2010), the NHS White Paper preceding the Health and Social Care Bill going through the parliamentary process at present, states: “We want the principle of ‘shared decision-making’ to become the norm: no decision about me without me.” The Paper goes on to say that there is evidence to suggest that involving people in their care and treatment “improves their health outcomes, boosts their satisfaction with services received, and increases not just their knowledge and understanding of their health status but also their adherence to a chosen treatment” .
As doctors we are trained to focus on each individual person and his or her needs (and the General Medical Contract requires that we do so). But commissioners have to provide appropriate care for a group of people with a particular health problem in a way that addresses their individual needs and makes optimal use of currently limited resources. While people may have some shared needs (for example, many need advice on healthy lifestyle, diet, weight management, exercise, not smoking and limiting alcohol), evidence-based diabetes care is condition specific. Communal interventions need to be tailored to the individual, for example reducing insulin dose when starting an exercise programme.
The Year of Care programme (NHS Diabetes, 2011a), led by Dr Sue Roberts, aims to assess how to redesign and commission routine care for people with long-term conditions: “The Year of Care approach puts people with long-term conditions firmly in the driving seat of their care and supports them to self-manage”. Care planning (making routine consultations between clinicians and people with long-term conditions truly collaborative) and commissioning (identifying local services required by people with long-term conditions to self-manage) are central to this personalised care (NHS Diabetes, 2011a). The Year of Care is a real “no decision about me, without me” process.
Other areas of commissioning that also put patients at the centre of their care are often forgotten. NICE has published guidance on adherence to medication (Nunes et al, 2009) – we spend hours painstakingly working out how to adjust medication that the individual is not taking! It might be helpful if commissioning recognised this.
NHS Diabetes (2011b) has published commissioning guidance for PCTs. This states that: “Any person living with diabetes will expect to find services that meet their individual needs, give them the best clinical outcomes, and help them to manage their own condition in the most effective way to keep them healthy and happy in their daily lives”. The guidance also emphasises the importance of feedback from effective monitoring to inform the commissioning process. Commissioners should ensure user involvement – perhaps via Diabetes UK (2011).
The commissioning guidance is being adapted for GP consortia. Individual GP practice reports or dashboards are in development, allowing both the practices and the Consortium of which they are a part to monitor outcomes linked to the NICE Quality Standard for Diabetes (NICE, 2011). This important document was published on 31 March. The Quality Standard will guide GP consortia about outcomes to be delivered by their providers – and, in turn, the NHS Commissioning Board will be able to assess the consortia’s performance via the Quality Standard. The National Diabetes Information Service is a publication partner and will supply many of the metrics required by clinicians and commissioners to monitor outcomes.