Challenge is the catalyst for innovation and evolvement: Let’s embrace it!

It is with great enthusiasm, if not a little trepidation, that I sit here and pen my first editorial as Editor-in-Chief. It is a position that I had never considered would be part of my career plan; however, since being invited to take on the role, my excitement has grown beyond measure, not least because this coincides with the journal’s move to an online platform, and the endless possibilities for evolvement.

I have been very fortunate in my career to have worked closely with both Debbie Hicks and Maggie Watkinson, my predecessors. I have always been inspired by their editorials, which have discussed both challenges to us as a workforce, while also being  great advocates for the massively important role that specialising in diabetes care can offer. I hope my input to the journal continues to inspire.

So while considering the theme for my first musing, I was repeatedly drawn to one recent challenge that my DSN team in Somerset have been facing. This is the increasing number of people with diabetes who require the support of our district nursing (DN) colleagues to administer their insulin. Somerset is a large rural county with a high proportion of older people with diabetes. Our diabetes team has worked closely with DN colleagues over recent years to manage demand. This has included supporting the training of Band 4 practitioners to administer insulin, providing regular link nurse training for DN teams and selecting a member of our own DSN team to focus on closer working with DNs and care homes.

Despite these developments, however, in the days leading up to the Christmas break, our service was overloaded with referrals to develop individualised pragmatic insulin regimens for frail older patients, many of whom would require the DN teams to provide that care. I know that Somerset is not unique in this increasing demand. It appears, from constant media reports, that the whole of the NHS is at “tipping point”. Out of these situations, services have a duty of care to constantly review, adapt and evolve to ensure the safest care is provided.

In response to the increasing referral rate, we developed the concept of “virtual clinics”, with hubs of DNs. Virtual clinics are becoming more common across primary care and involve local diabetologists and DSNs attending practices to provide education and individual virtual patient reviews. 

Taking this concept, patients who require DN insulin administration were discussed with the DSN and the insulin regimens reviewed. The setting also afforded the facility to review any recent results, for example, HbA_1c, weight and renal results. Additionally, the conversation with the DNs allowed for a team approach to establishing the patient’s individualised glycaemic target, while taking account of their social factors, mental health issues and any comorbidities. From these discussions, individual pragmatic regimens were prescribed, with patient safety being the main goal.

The format of these clinics allows for wider discussion and a learning environment, with an increase in knowledge and confidence with regards to insulin and insulin safety. The feedback from the early clinics was very positive, with a vast improvement in communication between our teams. We have collected data to demonstrate how, by use of pragmatic regimens, we have reduced the numbers of visits to some patients, while increasing visits to others. Overall, there has been a reduction in visits needed.

The challenge outlined by Alan Sinclair in his recent short report (Sinclair, 2018) and the financial constraints within which we find ourselves, can form the catalyst for innovation and service evolvement. It is this ability to transform services that keeps me as enthusiastic about diabetes care today as it did when I started in 1989.

And so my first editorial is complete. I hope it has been both a worthwhile read. As I said, I am excited about our journey into the digital world and the potential to evolve the journal to meet the needs of our readers. Watch out for our exciting new website!