Diabetes service delivery: opportunity for innovation

The first Journal of Diabetes Nursing service delivery supplement focused on the NSF Implementation Strategy and opportunities for change (Da Costa, 2003). It is interesting to reflect how, 6 months on, these opportunities remain, as does the major obstacle to turning them into reality: lack of allocated funding. Within this resource-constrained context of care, the focus of this supplement is on opportunities for innovation, specifically nurse-led initiatives. The articles published in the supplement demonstrated a response to current political pressures (the NSF for Diabetes) and the tradition of flexibility, adaptability and leadership in diabetes nursing across many competencies.

Given the increasing demand for diabetes care, some innovations may help us provide better care for more people, but we must ensure such changes to services are sustainable, and do not create more (although different) problems. This is where taking a systems approach is essential, as it encourages decision taking within a much broader context, rather than in isolation (O’Connor and McDermott, 1997). Sometimes quick fixes cause more problems in the future.

The articles in the current supplement are about the outcomes and processes of establishing innovative DSN posts. Alison McHoy from Worthing describes an inpatient DSN post which is directly linked to achieving Standard 8 of the NSF for Diabetes (DoH, 2001) in our hospital trust. The inability to achieve Standard 8 and Standard 7 was revealed during an analysis of secondary care services in 2002. A business case was produced, and the post was funded for 1 year (until April 2004) through pharmaceutical sponsorship. We are currently negotiating for this to become a substantive post.

Debbie Hicks takes a broader perspective, sharing innovations that she has led during her many years as a DSN in Hull. These include developing specialist nurse-led clinics and diabetes integrated care pathways, education using e-learning strategies, and redesigning the DSN team to include attachment to individual PCTs.

Benefits and risks of nursing innovations
Some of the benefits of the above initiatives include increasing patient access to specialist services, reducing duplication of services, and responding to specific client needs. However, it is pertinent to consider the flip side of these, and other nursing innovations. 

There is a risk that nurses take on initiatives better suited to other professionals, adopting a ‘polyfiller’ approach, where a gap in the service is seen, and a nurse attempts to fill it, not always considering whether it is a nursing role, or if it should be filled. Another risk is ‘super-specialisation’; DSNs who provide only specialist expertise and do not support their patients’ other diabetes needs, generating instead yet more appointments. Several of these new roles were presented at Diabetes UK in 2002, and in all cases, non-attendance rates were higher than in other clinics. 

There are two things to consider here: patients’ views on our innovations and workforce issues. Do we have the nursing resources to support super-specialist DSNs, and do our patients want extra appointments? Who will provide the other aspects of diabetes nursing?

Conclusion
Whilst innovations may be nurse-led, they need to be owned by the team and/or stakeholders, and should be appropriate within the context of local diabetes needs in order to succeed. A systems approach encourages this ownership, ensures any innovation fits strategically with involved organisations and prevents duplication of any of our limited resources.