While the prevalence of type 2 diabetes is increasing, the population of the UK is ageing. Education and support is becoming more important than ever before. As primary care continues to lean towards aggressive treatment of diabetes to prevent long-term complications, it is inevitable that there will be an increase in the number of older people who require insulin as part of their diabetes management.
Equality in diabetes care
How can we ensure that there is equality in diabetes care for our ageing population? Liberating the talents is a Department of Health document that aims to help PCTs and nurses to deliver a standard of diabetes care fit for the 21st century (DoH 2002b). This document states that ‘change is needed’ and ‘with an ageing population and chronic illness increasing, prevention becomes more important’.
The NHS plan is of great relevance to the treatment of type 2 diabetes (DoH, 2000), and with the subsequent publication of the NSF for Diabetes it is time to address how we can improve standards of diabetes care for our ageing population. The plan outlined in Figure 1 can be used as a basis to initiate the thought process of who will need to be involved at a local level (DoH, 2002b).
The Nottingham project
A model of care for people with diabetes has been piloted by the Nottingham City PCT over the last 2 years. The vision is to develop an integrated diabetes service that is responsive to the needs of all people with diabetes within the primary care setting.
The Nottingham project team has developed a close working relationship with local primary healthcare teams in order to standardise patient-centred care. The project nurse is an experienced diabetes nurse who has been involved with the diabetes management plan of many housebound older people. This has included joint visits with district nursing teams to empower people in their own homes. Examples of the role of the project nurse are seen in Table 1.
Involving the social services team of home-care workers who visit housebound people has been helpful. The social services are a workforce who, when educated to a basic standard of diabetes knowledge, can continually reinforce diabetes education to older people with diabetes and their families.
In the early days of the Nottingham project, the project nurse developed a basic education programme for the home-care team. This covered information about diabetes, treatments and situation-specific material. A group education session was used to present this information and discuss some of the situations that the home-care team may come across when visiting people with diabetes in their own homes.
Deakin and Littley (2001) found that an educational package for care-home staff increased the knowledge of staff and improved the quality of care of people with diabetes, up to a year after intervention.
Standard 10 of the NSF for Diabetes is ‘detection and management of long term complications’ (DoH, 2002a). This standard states that all people with diabetes will receive regular checks for long-term complications. We need to have a system in place where a designated group will take responsibility for the recording and assessment of the findings of these regular checks. In Nottingham City PCT, the Nottingham Diabetes Guidelines for the Management of Diabetes are used to assist in the management and recording of the annual assessment of people with diabetes, including the housebound.
Current practice is that the work is undertaken by district nurses, practice nurses who do home visits, or the hospital-based diabetes service (in which case, the elderly person with diabetes may have to be transported to their appointment for annual review). The latter can cause problems and time-wasting for the person with diabetes, who has to wait for transport on outward and return visits.
The vision is to take a team approach so that the individual is reviewed either at home or in their local practice if they are able to visit it.
Including older people with diabetes in their own diabetes care
Support groups have been set up in Nottingham City PCT as a way of including older people with diabetes in their diabetes care. Formed completely by older people with diabetes, there are now three of these patient support groups, and they are increasing in numbers of people attending.
The support groups provide the opportunity for members to meet on a monthly basis in a relaxed atmosphere close to their own homes (usually within walking distance). The groups often develop into informal teaching sessions with people discussing their own experiences of living with diabetes. The project nurse attends meetings periodically to offer support and structured education about diabetes and its management. Health centres within the area actively advertise the groups, and suggest that people go along and meet others with the same condition Figure 2 shows examples of advertising material used. The support groups can be a particularly useful resource for people who have been recently diagnosed with diabetes and who may feel alone in their lack of understanding of the condition. Figure 3 shows a practice-based education session in action. It is hoped that in the near future provision will be made for those people who cannot easily travel alone, so they too may have access to this support.
Practice-based education for older people with diabetes should provide the following: annual updating for existing patients; information, education and support for people newly diagnosed with type 2 diabetes; and an adequate support mechanism for people who are commencing insulin treatment. There should be liaison between primary care colleagues, general practitioners, district nurses, practice nurses, dietitians, podiatrists, community pharmacists and the administration staff.
What do patients want?
In order to effectively deliver care for older people with diabetes (who may also be housebound), we need to establish what they see as best practice.
Older people with diabetes confirm that they are happy to be seen at their local practices. Pooley et al (2001) interviewed people with type 2 diabetes and health professionals who deliver the care. They explored issues that they perceived as being central to the effective management of diabetes, primarily within a primary care setting. Five concepts were found to be key: the importance of having sufficient time in consultations; continuity of care; opportunities to ask questions; the extent to which people feel they are listened to; and each individual’s experience of life with diabetes.
Education for people with type 2 diabetes cannot be age restricted and unequal in quality. We need to raise the profile of diabetes within the general public, as well as among people with the condition. Strategies are needed to reduce the risk of developing type 2 diabetes in the population as a whole, and to reduce the inequalities in diabetes care and education (DoH, 2001).