Data from Partha Kar - Curated by EPG Health - Last updated 07 April 2017
It’s an ever present debate...who is best suited to deliver the optimal diabetes care...is it the acute trust? Is it primary care? Is it the nurses? Is it the doctors? In the intensified, white hot debate, two fundamentals get sidestepped; firstly the patients, who in the most, ask to be seen on time by one who is qualified, irrespective of their badge, and secondly; the immaterial parochial debate fuelled by different Trusts and organisations - when actually, in Britain, we all are employed by one organisation - the NHS.
Diabetes care has always been a source of debate amongst policy-makers in England. In one way, it epitomises a pathology which juxtaposes within acute settings, long term conditions, primary care settings with its reach touching on multiple other pathologies, thereby intrinsically entwining Diabetes within the myriad multiple providers and healthcare of the NHS.
What's the role of the specialist?
Taking a step back, away from the debate of ownership, the first primary aim must be to identify where the role of a specialist is paramount in the diabetes journey of the patient. It is not arrogance, but an appreciation of specialist training which should allow this discussion to happen without any prejudice.
There are areas of diabetes care which can only be delivered within an acute Trust (e.g. inpatient diabetes care) or needs multiple expertise (e.g. antenatal diabetes needing an obstetrician, a Diabetologist, a midwife, etc.) or higher training (e.g. Insulin Pumps) Appreciably, the number or definition of such services may differ slightly, depending on local expertise in primary care, relationships, willingness of multiple providers to work together, etc., but it should not vary hugely if one thinks of it from a patient point of view.
A fundamental part of any commissioning is never to lose sight of the fact that the hospital is a part of the community; not a separate entity. It's a part and parcel of the patient’s journey with their pathology, so segregating that into a different component rarely (if ever) works.
The rest of diabetes care can indeed be managed in primary care, though one must be cautious of the relevance and application of that statement. Over the years, primary care have been asked to do more for little extra and it would be wise not to repeat the mistakes of the past. Herein lies the vast opportunity for diabetes specialists to think broadly, work innovatively and perhaps make a huge difference to diabetes care.
So what does "education and support" mean? It's not about simply doing didactic teaching or holding workshops which, although an important part of the whole process, is only but a part. A bigger role is to be flexible to the daily needs of primary care. One of the fundamentals of a community team is education and thereby one needs to avoid the temptation of "case holding". If the community team is going to engage in one-to-one reviews then those patients or even primary care benefit little, apart from the convenience, in some instances, of the location being closer to the patient’s home. However, the principle is not different from those patients going to the hospital. They are still seen by a specialist on their own, a letter of communication is done and the learning experience from that for the primary care staff is variable.
New technology: how can it be used in Diabetes care?
On the other hand, if the role of the community team is to be available for the GP surgeries as and when needed, apart from scheduled visits, then the scenario is completely different. The "flexibility" to discuss any case within 24 hours or less, either by email, phone or Skype, acts as a constant source of support, reassurance and education for primary care staff, while the planned visits could involve reviews of patients at GP surgeries with the primary care staff sitting in (or leading with the specialist team acting as a consult), dedicated sessions looking at the basics of diabetes care, such as the Nine care process or even review of medicine use within the surgery, tackling areas of evidence-based medicine, NICE guidelines, etc. The possibilities of these roles are endless and indeed education has to be the way to up-skilling primary care to tackle the increasing complexity of patients with diabetes, if we want them to be managed in primary care better.
"We are the change that we seek"
With an ever-shrinking financial margin and the continued increase in diabetes prevalence, there is no doubt there is a big need to change the paradigm of diabetes care. The capacity of finances is perhaps not available to stick to the traditional model of diabetes care, nor should there be any more reticence to tackle the variations within primary or secondary care, as highlighted by the National Diabetes audit
In the oft-quoted words of Obama "Change will not come if we wait for another person or for another time. We are the change that we seek". There is a broader debate as to whether that is applicable for the NHS as a whole, but for sure, there is no debate that the time for change in diabetes care is now and it is up to the present generation to make it happen.