Meeting the educational needs of primary care practitioners: MERIT

Enfield Primary Care Trust is one of the five North London PCTs. According to data taken from the Enfield Observatory (www.enfield-observatory.org.uk [accessed 16.07.2007]) it had a population of 280 000 in 2004. There is also a large population of people aged <14 years and >74 years in comparison to the rest of London. The combined number of people in these two groups is estimated to increase by 10 000 by 2011. Enfield PCT has a population that is 60% Caucasian and 40% diverse ethnic minorities with the top five non-English languages being Turkish, Greek, Bengali, Somali and Gujarat.

Average life expectancy at birth is good in Enfield, being higher than the national average for men (Enfield men: 77.0 years; rest of England: 76.5 years). Women can expect to live, on average, as long as anywhere else in England (Enfield women: 81.0 years; rest of England 81.0 years). The population of people with diabetes is approximately 14 000 with the highest prevalence in any practice being 6.4% (QOF database, 2006). Enfield has 63 general practices with 135 GPs in three locations: Edmonton, Enfield North and Southgate.

Action plan
A common theme to emerge from the audit was a lack of knowledge, skills and confidence in insulin management. Owing to the growing number of people with type 2 diabetes moving onto insulin therapy, this was a growing concern for our GPs and practice nurses (PNs), especially as people with type 2 diabetes are starting to be discharged from acute care to their general practice for routine care (Hicks and McAuley, 2006).

As our understanding of diabetes evolves and the number of people with this condition increases, in the authors’ experiences the implementation of more intensive diabetes treatment regimens (including those involving insulin) is becoming increasingly common in primary care practices. Accordingly, new and extended skill sets are required in primary care. 

In response to the concerns of practice staff and the identified skills gap, rather than starting from scratch and developing their own education programme, the authors explored various options of ‘off-the-shelf’ healthcare professional diabetes education programmes. The two programmes reviewed were the ‘Insulin for Life’ (IFL) programme developed by Sanofi-Aventis and the Meeting Educational Requirements, Improving Treatment (MERIT) programme developed by Novo Nordisk Ltd.

IFL
Piloted in 2003, the IFL course was developed to assist primary care healthcare professionals in managing insulin initiation in type 2 diabetes. The educational programme, which also deals with diabetes awareness and optimal management, was developed by the Warwick Diabetes Care Team at the University of Warwick. There is an additional section of the course in which GPs and PNs are able to qualify for a ‘statement of extended practice’ certificate. This verifies that they are able to practically implement the skills learned as part of IFL. 

The course covers the following areas:

• insulin types
• combination therapies (for example, use with 
• oral hypoglycaemic agents)
• dosing and dose adjustment
• risk management 
• injection technique
• delivery devices.

MERIT
The overall aim of the MERIT programme is to support the use of insulin treatment in primary care.

The MERIT programme is based around the skills required for effective diabetes care, as listed in the National Diabetes Workforce Competence Framework Guide (www.skillsforhealth.org.uk [accessed 16.07.2007]). The Diabetes Competence Framework covers the many diverse aspects of diabetes care; the MERIT programme aims to provide the skills and knowledge required for some of the competencies that involve the use of insulin. 

The course consists of a number of modules targeting some of the units outlined in the Skills for Heath competence framework (see Table 1). 

• Each module will be delivered by a secondary care diabetes specialist or a diabetes specialist nurse.
• Each module will focus on practical advice and will encourage interaction between the participants and tutor.
• Primary care practices will be presented with details of the course and invited to attend.

If a practice wants to take part in the course, their specific training needs will be identified through the use of a questionnaire to assess what elements of diabetes care the practice already provides and what areas they feel they need to develop. The course will then be tailored to address these specific needs within the time available for training. 

The MERIT modules are accredited by the Royal College of Nursing (RCN). This means that they are deemed by the RCN to be capable of impacting positively on nursing, nurses or the environment of care, and have been assessed to meet the RCN’s exacting and well-respected standards for education.

The course is not biased towards Novo Nordisk products. However, as part of the MERIT programme, Novo Nordisk provide support in the form of PowerPoint presentations and handouts for each module, help towards organising venues for the workshops, and help with delivering the module if required. They will also arrange help with catering if needed.

Programme selection
At the time of reviewing potential insulin management tools available for use in primary care, the IFL programme was discounted as it only involved training in insulin initiation. The Enfield diabetes nursing team did not want to focus exclusively on insulin initiation but wanted to concentrate on the effective management of those people with type 2 diabetes already on insulin therapy. However, the new IFL programme now includes information on insulin management as well as insulin initiation.

The team decided to explore MERIT module 2 – ‘Helping people with type 2 diabetes to continue on insulin therapy’ – further. All the modules within the MERIT programme are linked to the Skills for Health competencies that ensure consistency with other nationally accepted tools, including An Integrated Career & Competency Framework for Diabetes Nursing (the Diabetes Nursing Strategy Group, 2005).

Implementation
The Enfield diabetes team developed a business case to support the provision of insulin management workshops for our practice teams using MERIT module 2. The case was presented to the Professional Executive Committee of Enfield PCT and outlined the resources required as well as detailing the potential benefits not only to local healthcare professionals (HCP) but also for people with diabetes on insulin therapy.

The business case was successful; the Professional Executive Committee was impressed by the quality of the package and was reassured by the guarantee that the programme was non-promotional. All insulins and injection devices available on prescription, regardless of manufacturer, were discussed during the delivery of the module. The Professional Executive Committee did make one recommendation: that the Enfield diabetes team should maintain control of the programme at all times. 

The course organisers had a short discussion with a few interested GPs and PNs as to how best to deliver the programme given they are involved in busy practices. The general consensus was that given enough notice, they would be able to get other practice colleagues to cover the leave required. They advised us that the ideal timing for such a programme would be a shortened day to allow the evening surgery to be unaffected by the training.

The authors decided on a programme commencing at 09.00 and concluding at 15.00, on two separate days a month apart. Although the programme is available as a complete package, it is flexible enough to personalise it to the team using it without losing key messages. 

Although the team were already aware from the baseline audit that some practices were keener than others to undertake insulin management workshops, a letter was sent to every GP in each of our 63 practices advising of dates available for training and what the workshops would involve. It was made very clear in all correspondence that the programme was aimed at practice teams and that both a GP and a PN needed to attend together, not individually. Each team had to be able to attend both days to secure a place on the programme. The authors also sent out a learning needs analysis form to gauge whether or not it was necessary to alter any elements of the course in order to ensure that practitioners were given all the required information for insulin management.

Each day of the programme is a mixture of taught theory, discussion and practical workshops. As it is mainly the diabetes nursing team delivering the sessions, with some support from the local Novo Nordisk clinical support nurse, real clinical cases are used to illustrate the key messages from each session. See Boxes 1 and 2 for the programme details of module 2.

Evaluation of MERIT programme in May 2006
Enfield PCT completed two MERIT programmes in 2006 and a third was held in June and July 2007. In total, 18 practices have been engaged. There is already a waiting list for the next programme, which will run in the autumn of 2007. 

Tables 2 and 3 and Box 3 show some of the feedback received from the courses run in 2006. Additionally, of the ten practice nurses who participated, eight said the course met 100% of their expectations and all said that the duration of the course was ‘just right’. Among the nine GPs who participated, the feedback on meeting expectations and length of the course was similar to that given by the nurses.

The first time the programme was run, a conference venue was hired and all refreshments including lunch were included. This worked very well, but was viewed as an unnecessary cost. The next time the course was run, it was held at the Enfield DSN base, which houses a large meeting room.

Conclusion
Now that more people with diabetes are being cared for by their general practice teams, it is crucial that their care team has access to effective tools to help them increase not only their knowledge and skills, but also their confidence in caring for those people with diabetes on insulin therapy. It is our experience that the MERIT programme’s second module, ‘Helping people with type 2 diabetes to continue on insulin therapy’, assists specialist diabetes teams to share the information required to increase the knowledge and skills of the primary care practitioners in order for them to manage insulin therapy confidently and effectively in the primary care setting.

With an ever-increasing workload, it is a great help to have the presentations and handouts provided by the sponsor for the MERIT programme to use for each workshop. The support of the sponsor’s local representative is also greatly appreciated as they are able to provide help with demonstration and teaching materials. Other pharmaceutical companies that market insulin are also helpful in providing their demonstration devices for use during the programme.

Interestingly, Enfield PCT found that going through such an educational process also develops a support network for those practices undergoing skills training. They have time during the workshops to get to know each other in an informal environment. The practice teams also get to know the DSN team and feel more able to contact them should a problem arise in the future. It has also been noticed that owing to the social side of the workshops, communication has improved between the primary care diabetes team and the practice teams: everyone now has a face to match a voice and communication is much easier when making contact regarding a patient query. Overall, the experience of the Enfield diabetes nursing team was that the MERIT course provided a win–win situation.