Bridget Turner

Delivering person centred care in long term conditions

Transforming care for people with long term conditions, including support for self management, requires comprehensive reform of health systems largely geared to provide acute care. Simon Eaton, Sue Roberts, and Bridget Turner explore the barriers to change, arguing that the success of new approaches will depend on whole system change and strong leadership

The fifth UK paediatric diabetes services survey: meeting guidelines and recommendations?

Aim To assess the provision of UK paediatric and adolescent diabetes services and examine changes in service delivery since 2002. Method Questionnaires were sent to the lead paediatric consultant from all paediatric and adolescent diabetes services (n=205). Questions were based on National Institute for Health and Clinical Excellence and Scottish Intercollegiate Guidelines recommendations for diabetes care in childhood. Results were analysed using parametric and non-parametric tests. Results 129 Services (63%) returned questionnaires involving 220 clinics. Staffing has improved and 98% of consultants have a special interest in diabetes (89%, 2002). In 88% of services, the diabetes specialist nurse worked solely in paediatric diabetes (53%, 2002). Only 21% of clinics have a psychological professional integrated within the diabetes team (20%, 2002). Over 94% of services offered support with intensive insulin regimens causing problems at school for 36% of services. Almost all services offer annual microvascular screening (98–100%) but transitional care was variable; only 76% of services have specific local protocols for transition and 21% organise transfer by letter only. Conclusion Paediatric and adolescent diabetes services are rising to the challenge of providing high-quality care despite rising prevalence and increasingly complex insulin regimes. Services have improved in a number of key areas but serious deficiencies remain.

Diabetes specialist nurses and role evolvement: a survey by Diabetes UK and ABCD of specialist diabetes services 2007

Aims  To review the working practices of UK diabetes specialist nurses (DSNs), specific clinical roles, and to examine changes since 2000.

A national survey of the current state of screening services for diabetic retinopathy: ABCD-diabetes UK survey of specialist diabetes services 2006.

The main aims were to ascertain the progress made in the implementation of retinal screening services and to explore any barriers or difficulties faced by the programmes. The survey focused on all the essential elements for retinal screening, including assessment and treatment of screen‐positive cases. Eighty‐five per cent of screening programmes have a coordinated screening service and 73% of these felt that they have made significant progress. Eighty‐five per cent of screening units use ‘call and recall’ for appointments and 73.5% of programmes follow the National Screening Committee (NSC) guidance. Although many units worked closely with ophthalmology, further assessment and management of screen‐positive patients was a cause for concern. The fast‐track referral system, to ensure timely and appropriate care, has been difficult to engineer by several programmes. This is demonstrated by 48% of programmes having waiting lists for patients identified as needing further assessment and treatment for retinopathy. Ophthalmology service for people with diabetic retinopathy was provided by a dedicated ophthalmologist in 89.4% of the programmes. Sixty‐six per cent of the programmes reported inadequate resources to sustain a high‐quality service, while 26% highlighted the lack of infrastructure and 49% lacked information technology (IT) support. In conclusion, progress has been made towards establishing a national screening programme for diabetic retinopathy by individual screening units, with a number of programmes providing a structured retinal screening service. However, programmes face difficulties with resource allocation and compliance with Quality Assurance (QA) standards, especially those which apply to ophthalmology and IT support. Screening programmes need to be resourced adequately to ensure comprehensive coverage and compliance with QA.

Commissioning specialist diabetes services for adults with diabetes: summary of a Diabetes UK Task and Finish Group report

Diabet. Med. 28, 1494–1500 (2011)

Diabetes UK funded surveys of the structural provision of primary care diabetes services in the UK

Aim To describe diabetes service provision in primary care in the UK.

Association of British Clinical Diabetologists (ABCD) and Diabetes-UK survey of specialist diabetes services in the UK, 2006. 1. The consultant physician perspective

Aims  To identify the views and working practices of consultant diabetologists in the UK in 2006–2007, the current provision of specialist services, and to examine changes since 2000.

Putting feet first -- national guidance at last.

New guidance on the specialist management of foot disease was launched on 12 June 2009 at a packed meeting in London, which was co-hosted by Diabetes UK and NHS Diabetes. It is based on the report of a Diabetes UK multidisciplinary Task and Finish group which met during 2008–2009. This group addressed for the first time the need to improve the structure and quality of foot care in hospitals [1,2]. A written reply from the office of the Secretary of State for Health to Norman Lamb MP on 17 June 2009 stated that this guidance would assist local NHS organizations in commissioning a comprehensive service for people with diabetes in accordance with best practice [3]. The origins of the report lie in the frequently poor, and occasionally very poor, quality of care offered to users, both in the community and in hospitals. At a user group discussion held in Manchester in 2008, the following comments were representative of those volunteered: ‘They never changed my bandages’; ‘Really scary because you think you are going to lose your leg’; ‘I felt people were not explaining things fully’; ‘There seems to be a general lack of awareness’; ‘It was atrocious really’ (W. Jeffcoate, L. Stuart, B. Turner, unpubl. data). The reasons for the quality of care being so low derive from professionals having an historical lack of interest in the subject (and the resultant lack of basic knowledge and clinical skills), compounded by lack of the definition of the minimum standard of care required and the lack of awareness of the need for change. The failure of many hospital doctors (and nurses) to even consider the foot and the extent to which it might be at risk of ulceration, or to examine it when it is already known to be affected, is commonplace. This is a particular issue in renal units, where foot disease is so common and is so often the factor which presages major amputation and ⁄ or death. Although there are some examples where services are excellent, these are probably the exception rather than the rule. Podiatrists tend to work in isolation from other healthcare professionals and many hospitals have no podiatry input at all. It is not surprising, therefore, that the quality of care of foot disease is generally poor. It is currently estimated that some 100 people in the UK lose a limb through diabetes each week and many of these are preventable. All people with diabetes should have their feet examined by a competent healthcare professional at least annually [4–6] and those who are at increased risk (as a result of neuropathy, peripheral arterial disease, deformity, other incapacity or a history of previous problems) should be seen more frequently [4,5]. It is also agreed that every person with new disease of the foot should have access to early expert assessment, either in hospitals or the community, within one working day [4,5], because longer ulcer duration at first specialist review is associated with an adverse outcome [7,8]. However, while Quality and Outcomes Framework (QOF) returns indicate that the frequency of annual foot screening in the community is steadily rising, newly occurring foot disease is often not referred for early expert assessment. In contrast, it will usually be managed by staff in primary care or emergency departments who do not have the necessary skills, and who may place heavy reliance on the often wrongly repeated prescription of poorly chosenantibiotic regimens,andtheselectionofheavilypromoted dressing products of unproven efficacy. The problem is that few towns have established systems for enabling early expert assessment and only a minority of hospitals have the designated multidisciplinary team which is known to be needed for optimal care. Even where specialist services exist, they may be limited to a weekly outpatient service and may be isolated from other clinical areas (such as Accident and Emergency departments and dialysis units) where foot disease frequently presents. However, the new guidance now specifies that every trust providing specialist care of diabetes must have a designated multidisciplinary team for the management of foot disease. The identity of this team should be known and it should be accessible within one working day to advise and support, and, when appropriate, to take over, the management of patients with foot disease. The guidance also specifies that each hospital trust must have protocols in place for the assessment of risk of new ulcers developing in people admitted with other disease, together with strategies to minimize it. Over 10% of all inpatients in acute trusts in theUK have pressure sores and half of these are in people with diabetes [9]. Those who are responsible for the patient at the time that they develop pressure sores in acute hospital beds are often unaware of the extent of the suffering caused, and its cost, because long-term care is taken over by others. The introduction of these new standards is of potentially enormous significance for people with, or at risk of, foot disease. It has already been shown that the implementation of coordinated care can reduce the incidence of major amputation over fourfold [10,11] and, if this can be done, then it should be done, and done at once. The required investment is minimal and the barriers posed by traditional professional attitudes and inappropriate political pressure to decentralize expert care should be swept aside. What is needed is close integration and effective communication between generalists and specialist teams, between primary and secondary care, and different groups of healthcare professionals. Implementation of the new guidance will now follow three strands: communication, skills training and assessment of the effectiveness of care, and the Correspondence to: W Jeffcoate, Nottingham University Hospitals Trust, City Hospital Campus, Hucknall Road, Nottingham, NG5 1PB. E-mail: wjeffcoate@futu.co.uk DIABETICMedicine

Competency frameworks in diabetes

The quality, skills and attitudes of staff working in the healthcare system are central to multidisciplinary learning and working, and to the delivery of the quality of care patients expect. Patients want to know that the staff supporting them have the right knowledge and attitudes to work in partnership, particularly for conditions such as diabetes where 95% of all care is delivered by the person with diabetes themselves. With the current changes in the NHS structures in England, and the potential for greater variation in the types of ‘qualified provider’, along with the recent scandal at Mid‐Staffordshire Hospital, staff need to be shown to be competent and named/accredited or recognized as such. This will help to restore faith in an increasingly devolved delivery structure. The education and validation of competency needs to be consistently delivered and assured to ensure standards are maintained for different roles and disciplines across each UK nation. Diabetes UK recommends that all NHS organizations prioritize healthcare professional education, training and competency through the implementation of a National Diabetes Competency Framework and the phased approach to delivery to address this need.

A decade in diabetes specialist services, 2000 to 2011, in England: the views of consultant diabetologists and diabetes specialist nurses amidst persistent healthcare delivery change

To assess the impact of continual major National Health Service reorganization on commissioning, organizational and delivery arrangements for secondary care diabetes services. To explore how consultant diabetologists and diabetes specialist nurses perceive the issues facing diabetes specialist services in 2011 and how these have changed in the preceding decade.