The diabetes service delivery supplements of 2003 had as their focus opportunities for innovation and change, and identified several nurse-led initiatives. Many of these were prompted by the National Service Framework for Diabetes (2001), which along with the UKPDS (2000) and NICE (www.nice.org.uk), are the basis of the new General Medical Services (GMS) contract.
Implications for specialist services
This new contract, effective from April 2004, has the potential to impact upon both primary and secondary care diabetes services, and is therefore, the theme of this supplement.
Heidi Brown, currently a diabetes specialist nurse, although previously a practice and district nurse, considers the implications of the new GMS contract for specialist services in which she is based. She highlights the context and rationale for these changes, and gives some examples and learning points from several pilot schemes. She illustrates the resource hungry nature of these changes, and the need for specialist care to reconfigure services to provide support from primary care colleagues. She also identifies the need for specialist care to perform a baseline assessment of their services, so that any increase in demand can be seen and monitored, and discussions undertaken as to how to resource it.
Out with the old, in with the new
Vivien Aldridge (Diabetes Nurse and Project Facilitator, Broadland PCT) considers the differences between the old contract and this new contract. She discusses the change from salaried doctors with a list of patients to the new GMS contract, which is now between the primary care organisation and the practice. This means that patients are registered to the practice itself, rather than to individual doctor’s lists. She also identifies the three funding streams for the contract, which are the global sum, quality rewards, and enhanced services payments. Vivien also highlights the opportunities for nurses to lead diabetes care service changes.
Challenges for secondary care
There appear to be several challenges facing secondary or specialist care. One is the need to support primary care colleagues in terms of increasing their skills, and finding the resources to do this so that patient care is not compromised. Without additional resources, how will this be managed? Will it mean taking clinicians from their clinics, and thus increasing waiting times for appointments? This will result in financial penalties when these times are breached, so secondary care would want to avoid this. Will it mean more patients being referred to secondary care, in order for the boxes to be ticked? This would be fine if the funding followed the patients to specialist care, but that appears unlikely.
Increased collaboration or increased division?
Whilst there are opportunities, there is a real risk that primary and secondary care will be more divided due to these financial flows, and that providing best care will be a casualty. Many nurses and other clinicians have invested in collaborative working over many years, so I suggest we build on these positives, and provide systems and processes which will be of more benefit to our patients than box ticking alone.
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