Response to “DSNs are value for money – fact!”

Debbie Hicks pointed out in the previous issue that “DSNs are value for money – fact!”, so it is all the more puzzling that their numbers are declining as trusts up and down the country freeze DSN posts in an attempt to cut costs (Hicks, 2012). Is this yet another example of a fiscal “fix” but one with seriously detrimental long-term consequences?

I write from a practice-nursing perspective having worked in that discipline for the past 18 years. In her editorial, Debbie acknowledges that there are many practice nurses who provide excellent diabetes care but still need to be able to refer more complex cases on to a DSN. I absolutely agree with this and share her concern over who we will turn to for support if the DSN numbers continue to fall.

Like many practice nurses, I have a particular interest in diabetes and have expanded my knowledge and expertise in this clinical area, whilst retaining my generalist role. Over the past decade, there has been a shift in diabetes services from hospital settings into the community, driven by the rising prevalence of diabetes and the need to reduce costs. Indeed, there is evidence to suggest that approximately 85% of the interventions for treating diabetes occur in general practice settings (MODEL Group, 2007).

An increasing number of practice nurses are providing a high level of diabetes care, many of whom have completed accredited courses at a diploma level (or higher). However, huge disparity still exists in the quality of care delivered and the knowledge and skills of those delivering that care. It is to be hoped that those making independent and autonomous decisions about care are able to do so safely, though currently no statutory training is required. Some might argue that the Quality and Outcomes Framework (QOF) provides adequate measures of care quality and standards and, whilst I agree that it is likely to have raised the baseline, not everything that counts can be counted and what is easily measured is not necessarily important. Patient empowerment is a key focus of Department of Health policy yet where is this addressed within the QOF?

General practice nursing covers a broad range of skills and we cannot expect to be experts across numerous clinical specialities. Those of us who have expanded our role in diabetes care offer the advantage of easier access, decreased distance to travel, established relationships and access to complete medical records. However, we must recognise our limitations and refer to specialist teams as necessary. I often call my DSN colleagues to discuss the management of more complex cases and have found their support invaluable. Despite undertaking advanced education in the management of insulin, this aspect of diabetes care is very much more an art than a science, and one in which the DSN is the true expert. To be proficient in the management of insulin, you have to be dealing with sufficient numbers on a regular basis and this simply may not be realistic for most practice nurses (or indeed for some GPs).

Many practice nurses work in relative isolation with limited opportunity to meet and discuss clinical issues or specific cases. Equally, there may not be colleagues with expertise or interest in diabetes. Access to external specialist support and advice is vital. Whilst practice nurses may have advanced knowledge of the condition and specialist skills, they cannot be expected to possess the depth of knowledge or experience of the DSN. If we are to cope with an increasing prevalence of diabetes, the number of nurses with appropriate skills in diabetes care needs to rise not fall.