Preventing Complications Enabling Primary Care to Walk the Talk'

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Preventing ComplicationsEnabling Primary Care to
Walk the Talk.

• Paul Dromgoole
• Diabetes Specialist Nurse / Lecturer in Diabetes

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is it about enabling or is it about
partnerships?
personally I think its about the latter.
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its also about not re-inventing the wheel
and about selling what we do well!!
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SSCDS SheffieldSpecialist Support for
Community Diabetes Services
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SSCDS SheffieldSpecialist Support for
Community Diabetes Services

• Susan Beveridge highlights a pilot project within
  6 GP surgeries in Sheffield, supporting
  management of patients in primary care who would
  traditionally have attended secondary care
  services.
• Support included 2 hourly meetings lt3 monthly
  between the practice team, Hospital Consultant,
  DSN and Community Nurse to discuss patients care
  and management issues.
• There has been specific agreement on which
  patients will be seen by the hospital clinic
  which by the practice team.
• The innovative feature of this model is the
  development of a supportive relationship between
  a specialist team and a primary care team.
• Benefits to Primary care increased specialist
  care support
• Benefits to secondary care less time on more
  routine issues.
• Contact Susan.Beveridge_at_STH.NHS.UK

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Highlands - Wick

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Highlands Practice Nurse - diabetes specific
degree level course

• Its a case of WATCH THIS SPACE!!
• However Gillian Teft and colleagues have for some
  years been running very successful diabetes
  courses specifically aimed at practice nurses.
• They are now in the process of getting these
  modules accredited at degree level.
• and the great things is it will be website
  based so accessible from anywhere!
• Personally if its anything like the pic, Id
  rather attend!
• Contact gillian.teft_at_haht.scot.nhs.uk

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Rotherham

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RotherhamCommunity diabetes link nurse scheme

• Fiona Smith from Rotherham reports on a community
  diabetes link nurse scheme set up in Rotherham
  PCT.
• One link nurse per health centre. 18 Health
  Centres in PCT each covering 2-3 GP practices.
  Total of 41 Practices.
• Link nurses attend 2 monthly meetings / updates.
• They then act as a resource for other team
  members.
• They develop guidelines for insulin device
  assessment, diabetes review for the housebound
  person, hypoglycaemia prevention / management.
• Works really well!
• Contact fiona.smith_at_rotherhampct.nhs.uk

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Tayside Regional Diabetes Network NHS site

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A web-based system of care to support Tayside MCN

• Managed Clinical Networks are described as
  Linked groups of health professionals and
  organisations from primary, secondary and
  tertiary care, working in a coordinated manner,
  unconstrained by existing professional and
  administrative boundaries to ensure equitable
  provision of high quality clinically effective
  services
• Scottish Office DOH 1998
• This website doubles as an information resource
  and a live clinical database to allow seamless
  diabetes care and record keeping in Tayside.
• Note for some time patients have had one local
  identifyer a community Health Index (CHI)
  number.
• Much of the site is secure but its still worth
  a look.
• www.diabetes-healthnet.ac.uk/
• Further info Diabetes and Primary Care. Vol 15
  No1 2003

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East Cambridgeshire and fenland PCT
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East Cambridgeshire and fenland PCT

• This is a very large rural area with huge
  travelling distances for patients attending
  specialist care.
• Distances also impact on the ease of staff to
  update their knowledge and skills by sitting in
  on specialist care clinics.
• 17 surgeries covered and the emphasis is on case
  based learning.
• The Facilitator does NOT run the clinic really
  important to avoid deskilling!
• T2s on insulin looked after in General Practice
  and increasing numbers of people with T1
• Care pathways currently being put together across
  the SHA
• Some initial sensitivity from some GPs about
  confidentiality and big brother
• Contact helen.hollern_at_eastcambsandfenland-pct.nhs
  .uk

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South Cambridgeshire PCT
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South Cambridgeshire PCTJoint primary care
diabetes clinics.

• Diabetes Facilitator / GP / PN run joint diabetes
  clinic for those people with more complex
  issues.
• These patients traditionally being referred on to
  secondary specialist care.
• T2 insulin starts are also now undertaken in GP
  Practice
• These joint clinic also serve to upskill primary
  care in diabetes management principles.
• South Cambridgeshire PCT covers both city and
  rural area so supporting locality based clinic
  can prevent long trips to specialist services.
• Contact Mary Collins Diabetes Facilitator 01223
  245151

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Bradford
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Bradford Primary Care Diabetes Nurse supporting
General Practice

• Sheree addresses a particular issue for the inner
  city single-handed GP surgery.
• Some 50 of practices within her patch are
  single-handed.
• This necessitates GPs being very much
  generalists in a time when they are being asked
  to achieve more and more in specific health
  fields.
• Project focused on supporting inexperienced PNs
  and introducing structured call, recall and
  record keeping.
• GP incentives!
• She has demonstrated an increase in structured
  care delivery for people with diabetes from 55
  to 80 in 16 month period.
• Contact Sheree.margerison_at_bradford.nhs.uk

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Birmingham
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Birmingham Overcoming language problems

• Jill reports on this new service established
  Oct 03 addressing
• A large, predominantly non-English speaking South
  Asian population (Urdu).
• Large number of single-handed GPs
• Huge lists of 70-120 patients in a morning
  clinic!
• Solution
• Asian link worker performing community centre
  based diabetes education for newly diagnosed T2
• Asian speaking DSN addressing problematic
  glycaemic control.
• Installation of the Insulin for Life programme
• Upskilling of local pharmacists
• Contact Jill.hill_at_easternbirminghampct.nhs.uk

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Bridlington

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Foot assessment service for elderly housebound

• Bridlington East coast of Yorkshire. Area with
  a high elderly population.
• Health Care Assistant with a District Nursing
  background trained-up to undertake foot
  assessment using dÖppler, monofilament and tuning
  fork.
• Referrals for housebound people with diabetes
  taken from GPs and PNs.
• Thereafter patient followed up as seen
  appropriate.
• Reports to GP but can refer direct to Diabetes
  Foot Clinic.
• HCA also works in the foot clinic which assists
  Clinical Supervision and appreciation of MDT
  roles.
• Contact mhairi.meldrum_at_herch-tr.nhs.uk

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www.yorkshirediabetes.com York
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Yorkwww.yorkshirediabetes.com

• Set up some 3 years ago Yorkshire diabetes
  aimed to pool diabetes information and move
  away from re-inventing the wheel.
• Contents include Prescribing codes pen and
  glucose meter guides reporting to MHRA on-line
  NICE, SIGN and other guidelines educational
  leaflets useful links children and young adult
  page news and forthcoming events.
• Recently added sharing best practice page
  weblog
• Its even more than about Yorkshire!
• Hit count currently around 150,000 per year.
• Contact moira.digby_at_york.nhs.com
• paul.dromgoole_at_york.nhs.uk

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Diabetes Educational Needs -Cardiff
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Diabetes Educational Needs Analysis Cardiff Vale

• Diabetes NSF The challenge for diabetes teams
  is to identify the interventions that will best
  support the needs of primary care teams.
• This project considered what means of educational
  support from specialist care, a group of 76 GP
  surgeries might prefer.
• Questionnaires detailing proposed options were
  sent out.
• Semi-structured interviews were arranged to
  clarify findings.
• The findings were fed back to the 4 localities
  that lead practice in Cardiff have been accepted
  by LDSAG and LHB and now forms a consensus
  diabetes educational model in Cardiff.
• This approach to an educational strategy clearly
  identified preferred methods of information
  giving.

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Diabetes Educational Needs Analysis Cardiff Vale

• Since then has been submitted to the Welsh
  Assembly for funding.
• Funding applied for
• DSNs x4, Dietitians x4, Podiatrists x4,
  Full-time Clinical Psychologist, 0.5 wte admin
  support. Ongoing funding for courses. This
  amounts to some 450,000
• Part-funding at least is guaranteed.
• GP surgeries (PNs GPs) strongly favoured
  practiced based learning. The DSN was identified
  as a core support individual in this programme.
• Contact Maire.Davies_at_cardiffandvale.wales.nhs.uk

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The Glasgow Project

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The Glasgow Project
Care of Type 2 Diabetes
Primary Care
Secondary Care
Diabetes diagnosed
Assessment and Education
Hospital services Poor control Complications High
risk
Primary Care Network Practice Services /
Community Services GPs, PNs, Dietitians,
Podiatrists, DSNs, Pharmacists, hospital
outreach.
Open access eye screening
Shared Diabetes Clinical Information System
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The Glasgow ProjectModelled on Birmingham
Ladywood

• Rebuilding the service.
• Project Management Consultant recruited initially
• Project sponsored by Greater Glasgow Diabetes
  Health Improvement Planning Board.
• Phased implementation initially South Glasgow
• 3 levels. Phased introduction
• Key stakeholders inc. Diabetes UK involved from
  day 1
• Financial incentives for GPs to become involved.
• Cost 9 mill. over 5 years.
• gt 500 HCPs received Uni accredited diabetes
  training
• In a way its perhaps what wed all like to do
• Contact Jenny.Ackland_at_glacomen.scot.nhs.uk or
  www.glasgowdiabetes.org/right

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National Diabetes Facilitators Group

• The National Diabetes Facilitators Group (NDFG)
  was set up in 1995 to support diabetes
  facilitators by creating a national network and
  arranging meetings for members to share their
  experience and innovations.
• Document A way forward Primary Care Led
  Facilitation in Diabetes Care Oct 2000 available
  on their website. www.diabetesfacilitators.com
• Presently revising their Creating Partnerships
  course
• Chair Gill Freeman 0161 419 5048
• Email gillian.freeman_at_stockport-tr.nwest.nhs.uk

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Some commonalities within these schemes

• Its about joined-up services
• Its about care occurring where its most
  appropriate.
• Its about adequate and appropriate training to
  allow this care to happen.
• Its about recording care and outcomes and
  evaluating whether it works.
• Its about access to specialist help when its
  required.
• Its about care which is focused on local need.

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Some commonalities within these schemes

• Its also about not changing for changing sake.
• Assessing where we are now where we would like
  to be how we might get there and what resources
  do we require.
• Its also about looking at the stakeholders who
  will help it happen, who will allow it to happen
  and who might oppose it.
• Its also about having a vision and enthusing
  others to come on board.
• Its also about learning from what each other is
  doing and not reinventing the wheel!

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Remember lets sell what we do well!
Apologies if you are not on this tour - theres
simply so much going on!
As you look around its quite staggering the
innovation, enthusiasm and commitment we offer.
Thank you!