What is currently driving change in diabetes care?

I am sure you will agree that many local/national initiatives are driving changes in diabetes service delivery. The speed of these changes and the reasons for the changes are on the increase. This supplement reflects this by discussing two major changes in care: the transfer of specialist secondary care based nursing services to primary care; and the setting up of GPs with a special interest (GPwSI) services.

Influenced by Government recommendations to shift from secondary- to primary-care-led services (Department of Health, 2001), such service redesign, with the establishment of new roles and responsibilities, is becoming more common. In addition, local capacity issues, where specialist services are overwhelmed with referrals, leading to increased waiting times which, in turn, increase patient risk, highlight the fact that the traditional system of delivering care is not sustainable, and must change.

The first article in the supplement, written by two newly appointed primary care diabetes specialist nurses (DSNs), Carole Dempsey and Alison McHoy, discusses the transfer of specialist nursing services into primary care from secondary care. The vision driving this change was one of integrated diabetes care, which was owned and developed by local stakeholders. The authors discuss how this was managed and marketed, both internally and externally. The rationale for their redesign can be summarised as follows.

• An increasing diabetes population.
• Increasing waiting lists for specialist nurses, due to outpatient capacity being exceeded.
• Increasing numbers of GP visits and hospital admissions while patients wait for appointments.
• Increasingly inappropriate referrals to DSNs.

This DSN team proposed two potential solutions: to pilot a DSN-run clinic in primary care, and to produce referral criteria. The feasibility of these proposals, and patient, clinician and practice satisfaction was audited against 10 standards (see Table 1, page 300), and demonstrated positive outcomes. This, along with the potential to use the model as a means of moving more chronic conditions into primary care, enabled primary care trust support and substantive funding for the two primary care DSN posts.

The second article, by Gill Freeman, considers the many factors contributing to evolving secondary care services, in particular increased waiting times, the need to triage patients more effectively to reduce referrals and to manage the increasing numbers of patients being initiated to insulin. She identifies how there is expert knowledge regarding diabetes in primary care, and discusses the development of intermediate diabetes services to manage these issues effectively, especially the establishment of GPwSIs, working collaboratively with DSNs. This fits with wishes of patients, who often prefer care closer to home.