On 11 March 2004, Health Secretary John Reid announced plans to radically alter the way that chronic disease, including diabetes, is managed in England (DoH, 2004a). A total of 28 case-management demonstration sites will be set up, one in each strategic health authority area. Specialist teams will provide advice, care and treatment for chronic disease which aim to cut hospital admissions (and thereby costs) and provide care to at- risk groups nearer home. A ‘whole systems’ approach will be encouraged and will involve healthcare and social care, voluntary groups and local initiatives.
Chronic disease accounts for around 80% of GP consultations and will be the leading cause of disability by 2020 (DoH, 2004b). It will also become the most expensive problem for healthcare systems. People who have more than one condition are likely to require complex care; diabetes, frequently involves co-morbidities due to its complications.
John Reid’s plan links into the new General Medical Services (nGMS) contract and its associated Quality Outcomes Framework (QOF). From 1 April 2004, general practices will receive financial incentives if they can demonstrate higher quality care assessed through a range of quality indicators. Good diabetes care can attract considerable additional funds into general practice if we get it right. So what does it all mean for DSNs?
The new GMS contract
The nGMS contract (DoH, 2004c) provides a complete shake up for primary care. For the first time funding is linked to the whole practice performance instead of being based on individual GP’s lists. Local schemes will be agreed for Personal Medical Services (PMS) practices which have control of their finances already, initially through pilot sites and now as a permanent feature. There are three streams of funding:
- Essential services. (‘Must do’ for all practices, includes chronic disease management at a level determined by the practice).
- Additional services. (Optional services which practices can opt out of… but at a cost).
- Enhanced services (Optional. Essential or additional services, but delivered to a higher standard. Targets may be locally or nationally set, e.g. enhanced care of the homeless. Diabetes may be an enhanced service if high quality care can be demonstrated through agreed goals).
Changes will also be made to out of hours provision. Diabetes care is an essential service for all practices to provide but they may opt out of some other areas (additional services) such as maternity services or minor surgery. Alternatively, practices may be more likely to go for a higher quality service that attracts additional funding through the Quality and Outcomes Framework (Table 1). The higher quality payments rely on practices agreeing targets for the 18 quality indicators and achieving them through audit. The minimum they can opt for is 25% of their patients on their diabetes registers meeting the targets but success in reaching the higher levels shown will attract higher funding.
DSNs may find themselves increasingly involved in holistic care and advising on managing the whole patient rather than blood glucose control. There will be scope to enhance skills in clinical management of hypertension, CHD and stroke prevention, but also in education and training of primary care staff and medicines management, working with PCTs. Points literally do mean prizes in the nGMS and diabetes and its associated conditions accounts for the majority of those available. (Figure 1, Table 2).
Practices will agree the level they expect to attain towards the 18 Quality Indicators (Table 2) with the minimum level to attract funding being set at 25%. Higher percentages attract higher funding. For instance, if Practice A expects to achieve 90% of the patients on their diabetes register to have a blood pressure of 145/85 mmHg or less in a 15 month period they will be awarded the full 17 points at DM 12 and the commensurate funding. Practice B may expect to achieve 50% of its diabetes patients to have HbA1c levels of 7.4% or less and would be awarded funding for 16 points (DM6). The maximum of 50% here is set to be realistic and may rise in the future as practices demonstrate their ability to reach these levels. Accurate recording, and sharing, of data will be very important.
Out of hours service
The out of hours service is changing too (as can be seem in Table 3). Services from 1830–0800 on weekdays, the whole of weekends and bank holidays will become the responsibility of the PCT. The question is, who is going to provide the diabetes out of hours care? DSNs would be well advised to start working with PCTs on forthcoming arrangements; diabetes care needs to be provided when GPs are not available, and practice nurses are generally not available at those times too. New schemes will have to be implemented.
Potential for nurses
However, it is not about counting the points. Patient care is the essence of the nGMS. The new contract focuses on getting systems right through new ways of working. In the future nurses will be able to run practices. They will win contracts to provide a service. They will forge multiprofessional partnerships and can even form limited companies. GPs might employ specialist nurses to provide a total service for their practice, and PCTs may do likewise across a larger area. There will be fewer boundaries to care and a move to a patient-centred approach.
Chronic disease management
The DoH (DoH, 2004b) lists components of chronic disease management that can be applied to diabetes care (Table 4). Each are discussed in turn below:
1. Information Technology
GPs will be keen to work with DSNs to ensure that data is shared between primary and secondary care. Data will be collected on the total practice register. Information that is not recorded equates with loss of income to practices.
2. Identifying patients
As outlined in the NSF for Diabetes (DoH, 2002) diabetes registers are to be used to effectively, call and recall everybody on them. Community staff are likely to need more support with training and managing at risk patients.
DSNs may want to expand their role in high risk patients.
Targets cannot be met without the participation of people with diabetes and their carers. Patient held records facilitate the sharing of information and encourage active participation in self-care. DSNs should be in the vanguard of encouraging this process.
5. Case-manager and coordinator
These roles will be the key to success and could become roles for the DSN.
6. The team approach
Roles are evolving to meet the new systems. Healthcare assistants increasingly work in diabetes care, technicians assist with annual reviews and roving teams link primary and secondary care. Examples of role redesign have been highlighted by the Modernisation Agency (2002).
7. Integrating expertise
Practice nurses will need education and clinical training to achieve targets in HbA1c and blood pressure. Community nurses will welcome support in achieving the same goals for the housebound, elderly or those in care. The DSN could perhaps become the linchpin.
8. Integrating care
DSNs should be involved in discussions with PCTs introducing ‘whole systems’ approaches to diabetes care involving health, social care, voluntary bodies and local initiatives in their plans.
9. Minimise visits and admissions
DSNs will increasingly be required in the community to work with patients, healthcare professionals and allied bodies (community pharmacists, podiatrists) to provide accessible care to people with diabetes. GP visits and admissions to hospital could be lessened through this approach.
10. Care setting
This links into minimising visits and admissions, with patient-centred care becoming the norm.
Prevention of diabetes
Prevention of diabetes should not be neglected. Type 2 diabetes accounts for 75–80% of all cases of diabetes and can largely be prevented through lifestyle changes (BDA, 1996). DSNs should be working with other agencies to promote good health in their local population. Improvements in health now will lead to benefits in the future.
New systems of chronic disease management and the nGMS contract are further shifting the focus of diabetes care into the community. DSNs may wish to re-examine their role in the light of these new ways of working and may take the opportunity to redesign the service, working with PCTs, acute trusts and other bodies to provide an integrated service responsive to local patient need. Figure 2 provides useful information sources.
Comment on a notable recent paper. Trends in the incidence of hospitalisation for diabetic foot disease.
10 Mar 2023