A recent comment piece by Sonya Smith, a DSN at the Royal Wolverhampton NHS Trust (Smith, 2014) discusses the plight of community DSNs and I sympathise wholeheartedly. DSN numbers are falling, vacant posts remain unfilled, posts are being downgraded and some DSNs are being taken away from their diabetes work to perform more general nursing duties. There is also little time for professional development.
It is really important that these issues are raised and I agree that DSNs need to provide evidence of their role value and cost efficiency. I did, however, take exception to the suggestion, apparently based on anecdotal evidence from people with diabetes, that, “…practice nurses lack expertise and time, with care given in a dictatorial manner”. Without doubt, diabetes knowledge and skills amongst practice nurses is hugely variable, but I would argue that the same is true for DSNs. There is currently no recognised or accredited DSN qualification.
Role characteristics, including diabetes knowledge and expertise, approachability, partnership working, accessibility and a holistic approach to care planning are not exclusive to specialist nurses; practice nurses are just as likely to possess these attributes.
Sonya Smith refers to a report in The Guardian (Andalo, 2012) where, she writes, “it is suggested that practice nurses do not possess the skills, or have the time required, to deliver the care identified by patients”. Having read the article myself, the journalist actually states, “…while it is common for GP practice nurses to manage diabetic patients whose condition is stable, they often lack the in-depth knowledge to take on those patients whose diabetes is more unpredictable or complex.” Surely this illustrates the complementary roles of primary and secondary care?
The role of practice nurses has changed immeasurably in the 20 years I have been in practice and as levels of responsibility have expanded, practice nurses have acquired specialist skills in certain areas. In most practices there is a practice nurse who leads on diabetes and most will have undertaken diabetes-specific training at diploma level or higher. Of course, specialist skills do not make you a specialist, but neither does the word “specialist” in a job title guarantee a more advanced level of practice, particularly where there is no formal accreditation for the role.
Arguably, because diabetes is multi-factorial and associated with many comorbidities, the more diverse knowledge and skills of the generalist may be an advantage. A key element of general practice is continuity of care. We are able to establish long-term relationships with our patients and, in my experience, this is something people with diabetes value. It is also invaluable to the clinician assessing patients’ holistic needs.
Over the past decade, there has been immense pressure on practice nurses to ensure that the “QOF boxes are ticked” but I do believe that most practice nurses rose to this challenge and have not allowed this to compromise the support and personalised care they offer their patients.
A shift of diabetes care to primary care does not inevitably lead to the demise of the DSN. Of course, there will be some shared competencies, but also there will be elements specific to each of the two roles. DSNs have to evaluate their role in the context of what is being successfully delivered by their practice nurses.
Rather than compete with one another we should be working together. Across the country, there are shining examples of specialist teams working alongside general practice colleagues to ensure patients are seen by the right person, in the right place, at the right time. For one such example, see Kar (2012).
The quality of diabetes care delivered by many practice nurses should not be underestimated or undervalued. I sincerely hope that we can find a way to work together in peace and harmony for the benefit of people with diabetes.
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