Seamless care? Who cares?

At the 2008 Diabetes UK Annual Professional Conference in Glasgow, much disquiet was expressed with regard to nursing, and medical, roles in diabetes care. I was fortunate to be awarded the honour of giving the Mary MacKinnon lecture during which I prompted a spontaneous cheer, I suspect from the nurses, when I suggested I would welcome the time when nurses are financially rewarded for providing diabetes care as the GPs are now through the Quality and Outcomes Framework. The shift of diabetes care into the primary care sector has happened rapidly, and it is upon nurses that much of the brunt has fallen.

In the following article, Jill Hill describes how her team have tackled the changing emphasis in her locality by building bridges between secondary, intermediate and primary care, in line with Kaiser Permanente principles. But it wasn’t easy. Diabetes ‘care’ may be mistaken for box ticking as we strive to meet NHS targets and, even in Jill and her colleagues’ excellent setup, unachievable targets were initially set. The right person in the right place at the right time is the Kaiser Permanente mantra and is, indeed, what we should all be striving towards.

And where is the voice of the person with diabetes when services are being redesigned in areas less well organised than Jill’s? Is it always in the patient’s best interests to be discharged from a specialist service they have confidence in to a less specialist service? The leading UK diabetes bodies do not think so. In their recently published joint position statement (Diabetes UK et al, 2007) they abhor the use of ‘block transfers’ of groups of individuals from secondary to primary care and changes to the system undertaken too hastily, without proper consultation or in a divisive manner. Where discharging works best is where, as described in Jill’s article, health professionals and others work in partnership with people with diabetes, with the provision of relevant education for all.

But it is not only the transfer of patients that causes concern. Transferring highly experienced specialist nurses from their traditional secondary care role into an intermediate or primary care service has its own implications. I never thought I would see the day when a specialist nurse would be made redundant, but it is happening. It appears that NHS reforms that are intended to improve patient care can, in some cases, drive a wedge between those who should be working together. But, commissioners can use integrated care to improve clinical outcomes, patient involvement and effective use of expertise – all of which make up seamless care.

The Diabetes Commissioning Toolkit (DoH, 2006) offers a chance for service review. Changes to local services should be developed and implemented through collaboration with specialist services, general practice teams, people with diabetes and their carers, and be based on competency. Challenges remain to improve services that support self-care and reduce variations in outcomes, as reported by the Healthcare Commission (2007) and National Diabetes Audit (The Information Centre, 2006).

Nationality has a bearing on diabetes care too. QOF data have demonstrated improvements in diabetes care across the UK; but how the service is tackled is very different. The commissioning process, and who buys what service, is blamed for aiding the primary–secondary care split. England has it in the form of practice-based commissioning, which is proving slow to get going; Wales and Northern Ireland have commissioning; while Scotland has no current plans for commissioning, which was evident at the 2008 Diabetes UK Annual Professional Conference. Diabetes nurses, and doctors, from primary and secondary care were happy to confirm that barriers did not exist to them working together and that ‘seamless care’ was truly happening.

I welcome the insight provided by the following article into how improvements can be made where there is a will to do so.