The GIRFT return on investment tool and the role of diabetes inpatient specialist nurses

Diabetes inpatient specialist nurses (DISNs) are essential for enhancing the quality of care for inpatients with diabetes. They significantly improve patient safety through education, medication management and multidisciplinary collaboration.

Impact on patient care

Studies have demonstrated that, through their in-depth knowledge and specialist understanding of diabetes, DISNs contribute to improved glycaemic control (Flanagan et al, 2009; Kyi et al, 2019; Akiboye et al, 2020; 2021; Rayman et al, 2024). Consequently, instances of hyperglycaemia and hypoglycaemia, which are associated with serious adverse outcomes (such as infections and poor wound healing) are reduced in hospitals. Furthermore, DISNs play a critical role in managing acute metabolic complications, like diabetic ketoacidosis and hyperosmolar hyperglycaemic state.

Insulin is one of the three most high-risk medications in hospitals. If incorrectly prescribed, prepared or administered, it can lead to severe harm or death. The presence of DISNs helps to mitigate insulin and other medication errors. They educate staff, oversee insulin management, promote self-management among patients and handle complex cases. Their multidisciplinary patient-centred approach supports healthcare professionals in delivering best practices and reducing variability in diabetes care, ultimately improving patient outcomes. 

Their involvement has also been shown to reduce the average length of hospital stays by 1–2 days. By educating patients on self-management and early recognition of dysglycaemia, and providing support to those at high-risk post-discharge, DISNs help prevent post-discharge complications and reduce readmissions.

Adapting to complexity in care

In recent years, inpatient diabetes care has become more complex, with the increasing use of advanced technologies (such as subcutaneous insulin pumps, wearable glucose sensors and hybrid closed-loop systems) and new diabetes medications. DISNs provide vital support for inpatients with diabetes on the use of these innovations, where general ward staff may not be familiar with their use. DISNs also update colleagues on the use of newer medications, like SGLT2 inhibitors, which require special management during acute illnesses and prior to elective surgeries.

The National Diabetes Inpatient Audit (NaDIA) revealed a rise in the percentage of hospital beds occupied by people with diabetes, increasing from 14% in 2009 to 19% in 2019, with some trusts exceeding 30% (NHS Digital, 2020). The current figure is unknown, as there has been no recent NaDIA, but reports suggest that it may be in the region of 25%. As patients with diabetes live longer, many present with multiple comorbidities, particularly severe frailty, further complicating their inpatient care.

The importance of staffing

Given these challenges and the clear benefits of employing them, it is crucial for hospitals to have an appropriate number of DISNs to meet their caseloads. The Getting It Right First Time (GIRFT) programme, an NHS England initiative, aims to improve treatment and care by reducing unwarranted variation in health services, and recommending best practices. The 2020 GIRFT national report for diabetes emphasised the critical role of DISNs in inpatient care and highlighted the significant variation in staffing across the country, particularly the lack of weekend DISN services in most trusts (Rayman and Kar, 2020).

To address this, NHS England provided transformation funds to increase DISN numbers, though these funds were time limited. Recent GIRFT reviews have indicated that, while some posts were secured, others were lost when central funding ceased.

Return on investment tool

In response, the GIRFT team developed an easy-to-use return on investment (ROI) tool to illustrate the potential cost benefits of DISNs and to help diabetes teams make a strong case for necessary staffing. The tool uses data from the Joint British Diabetes Societies (JBDS) and NaDIA to calculate the number of DISNs required for a 7-day service, factoring in the number of inpatient beds and the percentage of patients with diabetes needing DISN support (NHS Digital, 2020; Dashora et al, 2023). The tool estimates employment costs for DISNs, alongside associated bed days saved and other financial notional opportunities, such as reduced readmissions linked to increasing the DISN workforce in a trust. 

Users of the tool receive an ROI figure for their provider demonstrating the notional financial benefits of investment, with around 2.5 being the average in England. This indicates that for every £100,000 invested, there’s a potential financial opportunity of £250,000. This figure does not account for the additional benefits of improved patient experience, reduced harm and, potentially, lower litigation costs.

The tool has been co-badged by the Association of British Clinical Diabetologists and Diabetes UK, and has received positive feedback from diabetes teams. Since its launch in May 2024, there has been strong interest.

The ROI tool can be accessed by anyone with an NHS email address on the GIRFT Future NHS web site: https://bit.ly/3AHCPWE

Conclusion

As inpatient diabetes care grows more complex, the support of DISNs is essential for ensuring safe and effective treatment. Hospitals must adequately resource their DISN teams to enhance patient care and reduce the risks associated with poor diabetes management. The GIRFT ROI tool serves as a valuable resource for trusts, helping advocate for well-resourced inpatient diabetes services. Collaboration among organisations like GIRFT, NHS England, Diabetes UK, ABCD, JBDS and the DISN UK Group is vital to ensure that inpatient diabetes care receives the necessary resources, leading to improved patient experiences and reduced harm.