“Diabetes care should be excellent, safe and affordable, and boundaries that hinder effective collaborative working between health professionals should be removed”. So states the Commissioning Without Walls document (NHS Diabetes, 2009). The following article, describing the work of the dietetic service in Bradford, encapsulates the vision of effective commissioning in providing good care, convenient for home, using a clear, well-organised system, providing prompt expert advice (by telephone helpline and drop-in sessions) and provided across boundaries and specialties. The traditional role of the dietitian sitting in the diabetes outpatient clinic is a world away from the varied roles that are expected today.
Being affordable yet still maintaining (or ideally improving) quality will be an increasing challenge in an NHS with limited resources. The number of people with diabetes has increased from 1.4 to 2.5 million since 1996, and is predicted to reach 4 million by 2025 (Diabetes UK, 2009). The use of group sessions and education, such as the X-PERT diabetes programme, uses economies of scale to increase capacity (by seeing more people in a short period of time), yet giving each individual more time, than they would have in individual clinic appointments.
In my area, the community dietetic service also uses band 4 health educators to facilitate group discussions in communities to deliver simple healthy eating messages. These are particularly useful for reaching our south Asian population, for whom the traditional clinic model may not be appropriate. The groups are delivered in Urdu, in the Asian community using Asian foods and cooking demonstrations, providing a local, culturally appropriate, low-cost service.
There has been a significant increase in the past few years in the choice of medications for controlling blood glucose. Diabetes is a clinical area of high expenditure, growing at a higher rate than for any other clinical area. Between 2002 and 2008, the number of diabetes items prescribed in England had increased by 73.3% and the total cost had risen by 93.2% (NHS Information Centre, 2009).
Type 2 diabetes is a progressive condition and will therefore require an increasing number of tablets to control blood glucose and blood pressure. However, the foundation for treating type 2 diabetes remains the adoption of a healthy lifestyle (NICE, 2009), particularly to reduce weight and improve insulin sensitivity and slow the progression of the condition. An effective, accessible, culturally relevant dietetic service is essential for supporting people with type 2 diabetes, to reduce insulin resistance and delay the need for more tablets or insulin, which will have an impact on prescribing costs.
Living healthily with diabetes is everybody’s business, and the Bradford dietetic team have an important role in educating others to incorporate dietary advice into their work. This includes giving talks, producing a regular diabetes bulletin, and developing shared guidelines and written and audio resources. This gives a standardised approach across the area so that everyone is giving the same advice.
The dietetic service supports a person with diabetes throughout their diabetes journey, across primary and secondary care – from the education group for the newly diagnosed, ongoing education through the X-PERT programme, weight management clinics, through to events like starting insulin, planning pregnancy, and with complications (such as restricted diets for people with severe renal failure or PEG feeds following stroke).
Weight management and healthy lifestyle support will become increasingly important in those identified with impaired glucose tolerance, to delay development of diabetes and slow the diabetes epidemic. Managing capacity, maintaining quality, providing choice yet closer to home will be a challenge, but should drive the development of novel ways of working.