Effective team work can improve the care of older people with diabetes

Diabetes is the most common long-term metabolic condition affecting older people (Sinclair, 2009). The prevalence of this condition increases with age; an estimated one in 20 people aged 65 years has diabetes. This frequency rises to one in five in those aged 85 years. Among people living in residential and care homes, an estimated one in four has diabetes (NHS Diabetes, 2011). 

The number of people surviving to ages >80 years is predicted to continue to rise (Department of Health [DH], 2001). Older people now represent the largest sector of the diabetes population (Sinclair, 2009). 

With this increasing life-expectancy and an aging population, leading to a rising number of older people with diabetes, the demand for diabetes services can only increase. However, in the present economic climate of financial cuts, it cannot be expected that funding will increase to meet service demands; therefore, all service developments and new strategies will have to be planned within current resources. 

One approach involves collaborative working among members of multidisciplinary teams in primary and secondary care. Diabetes services for older people should be commissioned jointly by health and social care (NHS Diabetes, 2010). The advantages of this strategy for people with diabetes and healthcare providers would be the development of more effective, integrated and supportive services, which could enable a coherent approach to complex cross-agency situations. 

Team working
Health care is often provided by “teams”; however, a team is more than a group of people working together. Katzenbach and Smith (1992) recognised that an effective team has complementary skills with members committed to achieving a common goal and taking personal responsibility for achieving that goal. Mohrman et al (1995) suggest that how team members interact with one another influences their ability to achieve their goals. Both descriptions acknowledge the importance of team members being mutually accountable for the way they collaborate with each other to achieve their goal.

Teams Without Walls: The Value of Medical Innovation and Leadership (Royal College of Physicians [RCP] et al, 2008) is a collaborative project to enable the provision of care closer to home by means of primary and specialist healthcare providers to reduce the complications of diabetes. The description of a healthcare team by Xyrichis and Ream (2008) as two or more healthcare professionals with complementary backgrounds and skills who are able to assess, plan and evaluate patient care could fit into the integrated care plan described in the RCP et al (2008) document. More recent publications have suggested that multidisciplinary team work across the health and social care interface can improve care.

Commissioning Diabetes Without Walls (NHS Diabetes, 2009) is a collaborative framework of commissioning guidelines for providing quality care for all people with diabetes. It proposes a closer partnership between health and social care. Services commissioned jointly between health and social care will require an integrated care pathway with the person with diabetes at the centre of it. Communication between the two care providers will need to be developed at a local level to enable effective working together to plan and deliver services. Integrated services have the potential to improve the quality of the care, reduce duplication and avoid omissions, thus providing a safer, more cost-effective service for older people with diabetes.

Team work could provide holistic care encompassing the needs of the person with diabetes, where the healthcare team can ensure that treatment is optimised to provide medications at a time suited to both the individual and social carers. Social carers can ensure the person with diabetes has regular meals at the correct times. These measures could reduce both the acute and chronic complications of diabetes.

Benefits of team work
In a surgical setting in four UK hospitals, research by Borrill et al (2001) demonstrated the benefits of effective team work to patients, organisations and staff. Staff were more innovative working together to provide quality care, reducing the number of hospital admissions, enhancing patient satisfaction and reducing mortality rates. Clinical care was improved with reduced error rates. Staff retention rates increased. Together, these changes led to reduced service costs. This research demonstrated how team work can make a significant contribution to effectiveness and innovation in healthcare delivery. The greater the number of professional groups represented in the team, the higher the levels of innovation in patient care (Borrill et al, 2001). Therefore, effective team work has the potential to improve the quality of care and clinical governance.

Diabetes care should be individualised with people with diabetes and their carers involved in making decisions about care. Commissioning Diabetes Without Walls (NHS Diabetes, 2009) recognises that providing services to those in residential care is crucial to ensure quality care, as people living in residential care homes may not have access to the same level of care that is available to others (Diabetes UK, 2010). This group of people with diabetes are more frail, have a higher prevalence of comorbidities and have more frequent hospital visits than their counterparts living independently. People unable to attend their GP surgeries may be denied their annual reviews, screening and access to specialist care, putting them at increased risk of complications. In older people with diabetes it may be more important to avoid the acute complications of diabetes, such as hypoglycaemia and symptomatic hyperglycaemia, and manage the effects of any existing complications than to prevent long-term complications.

Team work could identify the education that is required by staff working in residential care homes and of community nurses – which may be provided by DSNs – to improve care and reduce complications occurring in this vulnerable group. In some areas, DSNs are visiting residential care homes to identify and review the people with diabetes. Care and treatments are reviewed and a management plan is put in place for each resident. Carers also have contact details for the DSNs so that they can access advice about caring for their residents, which can reduce the number of hospital admissions for diabetes-related conditions. Educational input includes both opportunist and structured education both for people with diabetes and for health carers.

Networking – the opportunity of making and developing connections with other healthcare professionals and care workers to share information – can be a benefit to older people. Individual members may each bring differing experiences and skills to the team; they may also bring different networks. 

Older people with diabetes are cared for by a variety of people: diabetologists, district nurses, DSNs, GPs, podiatrists and practice nurses. Good communication between these professionals and the older person with diabetes can lead to better insight into the individual’s life, thus helping to plan and provide the best individualised care for that person. This can reduce duplication, improve quality of care for people with diabetes and increase patient satisfaction. It also provides an opportunity for team members to learn together. 

Good team work also improves staff retention as stress levels are reduced (Borrill and West, 2002). As the reputation of a quality team spreads, staff recruitment becomes easier as candidates are keen to join a progressive team.

Elements of effective team
Borrill and West (2002) found that effective team members showed respect towards their colleagues, had clear objectives, shared a common goal and had a clear vision of where they were going and what they wanted to achieve within agreed timescales. Their emphasis was on quality care. They communicated well between themselves and with other teams. Good leadership has been identified as the principal prerequisite for effective team work (Wedderburn-Tate, 1999).

Team working has been recognised as not one skill but a range of skills that may not all be possessed by each team member. A strength in one member can counter a weakness in another, provided conflict is managed and channelled to provide a learning experience (Haynes, 2003). An effective team can share learning, thus providing a safe environment for developing new skills. Differing values among team members need to be recognised as neither right nor wrong, but different and these differences should be respected (Wedderburn-Tate, 1999). Giving and receiving effective feedback is a component of a successful team. It is important to celebrate successes and significant occasions within teams, thereby recognising the contributions of the members.

Life cycle of a team
Tuckman (1965) described the four stages through which any team develops as forming, storming, norming and performing. A new team forms then progresses into the storming stage, in which there may be jostling of ideas and conflict. Storming is followed by the norming stage in which a team culture has developed with members knowing how one another works. It is only once the team has developed through this stage that performing occurs and the outcomes of the task are achieved.

Disadvantages of teams
There are also disadvantages to team working, the main one being the long time it takes to nurture the team and individual team members and to provide ongoing support for the team. The team may also become isolated from the organisation and lose sight of the organisation’s objectives (Mullins, 2010). This may occur when there is a lack of alignment between the team’s and the organisation’s objectives. Where teams do not have clear aims and processes, people with diabetes may receive conflicting advice, which is not conducive to quality care.

Conclusion
Care providers can deliver a high-quality service for older people with diabetes by involving them in the planning of services. Listening to people with diabetes, identifying the barriers and problems in current systems, and working collaboratively to make things better, could improve the healthcare experience of older people with diabetes through better coordination (Wedderburn-Tate, 1999). Specialist teams need to ensure the infrastructure of systems and processes are in place so that older people with diabetes are seen by the right person, in the right place and at the right time.

The need for effective multidisciplinary team work within increasingly complex health and social care environments has been recommended in Commissioning Diabetes Without Walls (NHS Diabetes, 2009). While anticipating the publication of further documents, White Papers and guidance as the Government makes its mark on the country, healthcare professionals must remain focused on providing quality care to older people with diabetes. As the spending cuts take effect, healthcare providers must make best use of diminishing resources and work collaboratively with colleagues in social care. 

Older people with diabetes require care that is more effective by reducing duplication and omissions through good team work, which improves communication, sets a clear goal and provides a good environment for members to learn from each other. These benefits can be achieved under good leadership, but they take time and nurturing to be accomplished.