Success of a community MDT in diabetes management

In Barking and Dagenham, 9305 individuals (6.12% of total population) had a diagnosis of diabetes in 2011; this prevalence is greater than the England average of 5.50% (NHS Information Centre, 2011). The higher prevalence of diabetes in deprived areas is well documented in the literature. This is further compounded by poor health behaviours (e.g. higher than average prevalence of smoking and obesity) among the population. These factors have contributed to difficulties in achieving good glycaemic control in this area. 

According to the 2007 Managing Diabetes, Improving Services for People with Diabetes report (Healthcare Commission, 2007), the overall performance in diabetes care in Barking and Dagenham did not meet “minimum requirements” or “reasonable expectations of patients and the public”. In this diabetes service review undertaken by the Healthcare Commission, all 152 new primary care trusts (PCTs) participated. They rated 78.3% of London strategic health authority PCTs as “fair”, 11.2% as “good”, 8.6% as “weak” and 1.9% as excellent.

The Integrated Diabetes Service
The Integrated Diabetes Service (IDS)was introduced in 2008 as an intervention to manage the care of high-risk people with diabetes in the community. The model is based on the principles of a comprehensive, integrated service providing a seamless care pathway between primary, specialist and secondary care services.  It ensures fast and efficient processing of referrals from several community-based sources (e.g. GPs, practice nurses, community matrons, integrated care teams and podiatrists) for advice and management planning, and facilitates increased specialist input into primary care settings. 

The current team structure is one consultant endocrinologist, one nurse consultant, three GPs with special interest (GPSIs), four DSNs, two specialist dietitians, one psychologist, two podiatrists and one healthcare assistant. The consultant endocrinologist provides the vital link between the  primary and secondary care pathways. The entire team come together for a 4-hour session once a week (the complex care clinic) to provide comprehensive care to people with poorly controlled diabetes, often with complex psychosocial and physical comorbidities.The complex care clinic enables access to a high-quality multidisciplinary team (MDT) in a community setting, in a single appointment. This ensures that there is no unnecessary gap or duplication in service provision between primary and secondary care. As a community-based, easily accessible service, the IDS is envisaged to reduce interpractice variability in the borough.

Pilot audit
We randomly selected 20 patients who were seen in the complex care clinic during July and August 2010. One patient with type 1 diabetes was excluded; the remaining 19 had type 2 diabetes and were included. All patients received some input from the MDT.

We compared the average HbA_1c level and weight for the period 2009/2010 (the preceding 2 years) with the most recent recordings in 2011. We found improvements, with an average HbA_1c level reduction of 0.6 percentage points (6.6 mmol/mol) and average weight reduction of 1.18 kg.

Conclusion
The service is still in its infancy and the wider, long-term impact on diabetes care in Barking and Dagenham is yet to emerge.However, our pilot audit shows that the provision of MDT input, covering all of the bio-psycho-social aspects of diabetes care can afford better glycaemic control and improved metabolic profile for people with poor diabetes control.