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Seamless care: Are we meeting the challenge?

Vivien Aldridge

In a recent report from Dr Sue Roberts and the National Diabetes Support Team (Roberts, 2005) the effect of the National Service Framework (NSF) for diabetes is examined, two years after the implementation was announced (Department of Health, 2003). The report is very easy to read and has three key themes: patient centred care, working together and support for service delivery. Reading through the report caused me to reflect on local issues. We have a very active network and two very vocal and lively patient champions. The network has brought together the four local primary care trusts (PCTs), and the secondary care provider. All disciplines, including senior management, are represented and the patient champions keep everyone focused. Strategy and planning are discussed; some of the debates could only be described as ‘lively’. As we continue to meet we will hopefully become more effective as a group. The greatest output to date has been the jointly produced guidelines for diabetes management locally.

Following on from this we are at the end of the first year of the new General Medical Services (nGMS) contract (British Medical Association, 2003). See the following article from Jill Hill in Birmingham, who discusses in detail the impact of nGMS on diabetes care in general. The year-end has seen me examining local data. How were we as a PCT fairing? Was our retinal screening programme on target? Did our patients have access to adequate foot screening? Were the clinical indicators showing specific areas that needed more input?

Looking at the audit data was interesting. In the past 12 months our diabetes population has grown by approximately 10%; this may be an inflated figure due to better recording within the practices but at last we have an accurate picture of the size of the situation. Retinal screening has reached 83% of our target population and 79% of the patients have received a detailed foot screening. Ninety-eight of the identified population had a record of their blood pressure being recorded in the previous 1 months, but of those people only 68% had a blood pressure of less than 145/85 mmHg. A little work is required there but we know from UKPDS data that management of blood pressure is just as important as glycaemic control in people with diabetes (UKPDS Study Group, 1998). We can use the results gained to discuss with colleagues where more input is needed. These data should make us feel a little more comfortable that we are providing a structured service but we are still not reaching all of our population and the numbers needing screening and care will continue to rise.

An issue which really interests me is that of a fully integrated service between primary and secondary care. Again, this fits with the NSF report where Dr Roberts talks of working differently. I was recently fortunate enough to hear Dr Melanie Davies speaking about the modernisation of diabetes services in Leicestershire. There the acute service, historically three different services based in the three acute provider hospitals, has amalgamated. The six PCTs are all provided with a service led by the same team using a joint philosophy and using shared guidelines and care pathways. The six PCTs are committed to working together, and have a joint vision of how the service should function. Funding for projects has been identified and secured; this is never easy, but more likely to succeed if everyone has the same vision. Three of the PCTs have appointed diabetes nurses linked to the acute service, again showing a commitment to the service.

I think that we are living in exhausting but exciting times. Management of diabetes remains a huge challenge to all who work in healthcare but especially those who choose to specialise in diabetes. Care standards will be driven onwards and upwards by initiatives such as the NSF and the nGMS contract. We must all adapt and learn from the models which are emerging and above all we must remain committed to lifelong learning, for both patients and ourselves, and so continue to raise the standards of care for all people living with diabetes.

In a recent report from Dr Sue Roberts and the National Diabetes Support Team (Roberts, 2005) the effect of the National Service Framework (NSF) for diabetes is examined, two years after the implementation was announced (Department of Health, 2003). The report is very easy to read and has three key themes: patient centred care, working together and support for service delivery. Reading through the report caused me to reflect on local issues. We have a very active network and two very vocal and lively patient champions. The network has brought together the four local primary care trusts (PCTs), and the secondary care provider. All disciplines, including senior management, are represented and the patient champions keep everyone focused. Strategy and planning are discussed; some of the debates could only be described as ‘lively’. As we continue to meet we will hopefully become more effective as a group. The greatest output to date has been the jointly produced guidelines for diabetes management locally.

Following on from this we are at the end of the first year of the new General Medical Services (nGMS) contract (British Medical Association, 2003). See the following article from Jill Hill in Birmingham, who discusses in detail the impact of nGMS on diabetes care in general. The year-end has seen me examining local data. How were we as a PCT fairing? Was our retinal screening programme on target? Did our patients have access to adequate foot screening? Were the clinical indicators showing specific areas that needed more input?

Looking at the audit data was interesting. In the past 12 months our diabetes population has grown by approximately 10%; this may be an inflated figure due to better recording within the practices but at last we have an accurate picture of the size of the situation. Retinal screening has reached 83% of our target population and 79% of the patients have received a detailed foot screening. Ninety-eight of the identified population had a record of their blood pressure being recorded in the previous 1 months, but of those people only 68% had a blood pressure of less than 145/85 mmHg. A little work is required there but we know from UKPDS data that management of blood pressure is just as important as glycaemic control in people with diabetes (UKPDS Study Group, 1998). We can use the results gained to discuss with colleagues where more input is needed. These data should make us feel a little more comfortable that we are providing a structured service but we are still not reaching all of our population and the numbers needing screening and care will continue to rise.

An issue which really interests me is that of a fully integrated service between primary and secondary care. Again, this fits with the NSF report where Dr Roberts talks of working differently. I was recently fortunate enough to hear Dr Melanie Davies speaking about the modernisation of diabetes services in Leicestershire. There the acute service, historically three different services based in the three acute provider hospitals, has amalgamated. The six PCTs are all provided with a service led by the same team using a joint philosophy and using shared guidelines and care pathways. The six PCTs are committed to working together, and have a joint vision of how the service should function. Funding for projects has been identified and secured; this is never easy, but more likely to succeed if everyone has the same vision. Three of the PCTs have appointed diabetes nurses linked to the acute service, again showing a commitment to the service.

I think that we are living in exhausting but exciting times. Management of diabetes remains a huge challenge to all who work in healthcare but especially those who choose to specialise in diabetes. Care standards will be driven onwards and upwards by initiatives such as the NSF and the nGMS contract. We must all adapt and learn from the models which are emerging and above all we must remain committed to lifelong learning, for both patients and ourselves, and so continue to raise the standards of care for all people living with diabetes.

REFERENCES:

British Medical Association (2003) New General Medical Services Contract. BMA, London
Department of Health (2003) National Service Framework for Diabetes: Delivery strategy. DoH, London
Roberts S (2005) Improving Diabetes Services – the NSF Two Years On. DoH, London
United Kingdom Prospective Diabetes Study Group (1998) Tight blood pressure control and risk of macro vascular and micro vascular complications in Type 2 diabetes. (UKPDS 38) British Medical Journal 317(7160): 703–13

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