Bringing specialist diabetes care to primary care

It is well recognised that cardiovascular risk management and good glycaemic control are central to diabetes care (Stratton et al, 2000; Gaede et al, 2003). However, risk reduction is frequently not optimised in many people with diabetes for a number of reasons, including clinical inertia (Voorham et al, 2008) and poor adherence with treatment plans (Osterberg and Blaschke, 2005).

Even in the authors’ practice, which was achieving full quality points for diabetes care, 10% of patients had three or more modifiable risk factors above recommended targets (HbA1c <7.5% [<58 mmol/mol]; blood pressure <130/80 mmHg; total cholesterol <4 mmol/L and LDL-cholesterol <2 mmol/L) (NICE, 2009), and were therefore considered at high risk for developing macro- and microvascular complications.

In this practice, the traditional “one size fits all” approach to care frustrated both patients and healthcare professionals, and there was a strong desire to provide person- centred care close to home, with particular emphasis on reaching those who previously had not fully engaged with their diabetes management delivered at the GP practice or the secondary care provider.

Aim
The aim of the project was to evaluate the effects of providing specialist diabetes care to a hard-to-reach cohort of high-risk people with complex diabetes in an already high- achieving general practice.

Method
Fifty people attended an initial joint consultation with a dedicated DSN and specialist GP team at the practice. Follow-up was arranged – either joint or individual consultations with the DSN or specialist GP dependent on the person’s needs. Time was invested in building collaborative relationships through effective communication and partnership working, to engage the patient in developing and negotiating their own personal care plans.

Motivational interviewing encouraged patients to take an active part in decision- making and goal setting. Individually tailored education, supporting behaviour change and self-care, together with improved treatment adherence and evidence-based pharmacological interventions, were used to achieve individually agreed targets. Particular effort was made to ensure patients attended for follow-up, including the use of telephone consultations. As a result, the quality of the care improved, and inappropriate referrals to secondary care were reduced.

Results
Mean HbA_1c reduced by 1.1% (12 mmol/ mol) and blood pressure by 16/4 mmHg.

Those with total cholesterol within target rose from 42% to 70% and LDL-cholesterol from 31% to 51%. Structured patient feedback revealed high satisfaction with consultation time, care close to home and joint consultations with the DSN and GP, resulting in consistent advice being given.

On average, a patient attended two joint and two single appointments with the patient journey costing less than half that of equivalent secondary care attendances.

Conclusions
This transferable, novel model for delivering personalised, complex care demonstrates improved outcomes can be achieved in primary care. Furthermore, this pilot study has shown that using a variety of consultation strategies and approaches to care can improve risk factors in those who are often difficult to engage.