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How to establish a multidisciplinary community diabetes team

Dr Simon Ramsden on how GPs stepped up to the challenge set by their new turnaround PCT chief executive to bring diabetes care into the community

Dr Simon Ramsden on how GPs stepped up to the challenge set by their new turnaround PCT chief executive to bring diabetes care into the community

Three years ago a new chief executive, Andrew Kenworthy, took charge of the PCT and introduced a turnaround strategy.

In his previous role as chief executive for a Northern PCT he had become aware of a number of effective community-based diabetes services. He wanted to bring the same standard of care to patients living in the borough of Kensington and Chelsea.

He made it clear that this service was going to happen within six months and that there were to be ‘no excuses'. I was given the task of making this happen when he asked me to become the diabetes lead for the Kensington and Chelsea PBC group – and that challenge has led to the successful launch of a community diabetes team.

Five years ago, diabetes care in Notting Hill was typical of the picture nationwide. Care of type 2 diabetes patients varied from practice to practice.

There was an absolute divide between primary and secondary care and the condition was considered the preserve of the specialists at the Chelsea and Westminster Hospital and St Mary's Hospital in Paddington. A community diabetes service was unheard of.

41187763Back in 2003, the North Kensington GP locality group received £40,000 from Kensington and Chelsea PCT to pay for a specialist diabetes nurse based at a local health centre – but it was a disaster.

The nurse was professionally isolated and had no peer support. She left after four months. Looking back the PCT management, the diabetes steering group and the GPs were naive and didn't realised we needed to put structures in place to support her.

At this time, I was a member of the PCT's diabetes steering group, which was set up to develop a multidisciplinary diabetes service and help bridge the divide between primary and secondary care. Unfortunately, by this time the PCT was in financial deficit and new initiatives were put on hold.

Shifting diabetes care into the community

The current PBC group is made up of 43 practices, responsible for some 170,000 patients, and it has been very keen to see a community diabetes service introduced. But staff working in the hospital sector believed they already had a good diabetes centre and, quite naturally, felt that responsibility for diabetes should remain there. It was the commitment of the GPs and the drive of the PCT chief executive that helped to change their opinion.

We focused on getting the message across that type 2 diabetes is a primary care condition that should be addressed in the community with no loss of quality.

An audit of secondary care referrals had already been carried out by the PCT's original diabetes steering group, which found that half of all referrals for type 2 diabetes could easily be managed in primary care with suitable community diabetes service support.

Meanwhile, the introduction of Payment by Results created an imperative for the PCT to control secondary care referrals and avoid the danger of spiralling costs. These factors helped us gain support for the new service from consultants and our peers.

There were a number of questions to address to get the service started, such as where the clinics would be situated and who would pass the referrals on to the nurses. But we had learned from experience to take a multidisciplinary team approach and to recruit staff with experience of high-quality diabetes care.

It took just six months to launch the service in October 2007. Start-up costs were low – about £11,000 – because we were using facilities at existing community clinics. To deliver the service, the PCT employed two specialist diabetes nurses, a dietician, a podiatrist, administrative staff and a diabetes education assistant.

The service is aimed at providing care to patients with type 2 diabetes, from regular annual checks through to initiating insulin therapy. Secondary care remains responsible for those with complex type 2, type 1 or pregnancy-associated diabetes.

Initially we estimated that about 3,000 new patients with type 2 diabetes would be referred to the service, which runs from three health centres in North and South Kensington. Cases where GPs need input from a specialist nurse or dietician, patients with existing or difficult-to-manage conditions and those who need conversion to insulin are also referred to the service.

We are currently in the process of collating the exact referral figures.

The multidisciplinary team also helps to promote the service, visiting practices to talk about how it works and the importance of diabetes education.

Creating awareness

Of course, you can't just tell GPs what to do and expect them to do it – you have to talk to practices about the value of the service. The PBC group looks at how many referrals are now coming from different practices and encourages those that haven't used the service to take advantage of what it can offer. The group plans to visit all the surgeries in the PCT twice a year to promote the service.

Inevitably, there are some surgeries that show little interest – the GPs there have always referred to hospitals and are reluctant to change.

But when we visit we explain that the quality of what we're offering is as good as, if not better than, what they've been used to. And to increase patient awareness we make sure members of our team attend diabetes days at practices to let people know how the service can help them. Promoting what we do is essential – if we stop, we'll fail. We're getting there, but it's definitely a work in progress.

Hampered by data

The service is saving the PCT money – as to how much, this is difficult to say as we've only been running for five months. We're also hampered by the data we receive on referrals to secondary care collated under the heading of endocrinology. We know diabetes referrals are a significant part of this but it's hard to tease out exact figures.

It is likely that the service is reducing referrals to secondary care by 20% so far – our original target was 50%. Given that a first visit to a consultant costs about £241 and follow-ups cost about £81, we expect the service to make savings.

Again, we are in the process of assessing these savings, which will depend on the uptake of the service by GPs, but early results are encouraging.

Benefits to staff and patients

Much easier to pin down, however, are benefits the service is bringing to practices, staff and, crucially, patients. Practices now have access to an accessible, easy-to-use service with short waiting times – one to two weeks compared with the previous eight-week wait.

The team has gelled together well and they enjoy their work. After the early departure of our first nurse specialist in diabetes, we recognised it was important to set up links with secondary care. Members of the team, often the diabetes specialist nurses, sit in on the secondary care diabetes clinics once a week to discuss cases.

It's great to have access to advice from a diabetes consultant and to know their expertise is readily available when you have a query. And secondary care staff are giving the service their full support.

Patients get a quality-assured service that's quick, responsive and close to where they live, and staff tell us they seem happy to use it.

Any problems with quality will be dealt with – unlike before when it was assumed everything was fine, even though there were no service guarantees. We adhere to the national standards of diabetes care and if we fall short we'll remedy it.

Setting up a multidisciplinary diabetes team requires equal commitment from both PBC group and PCT. Planning how the service is supported is essential, and that includes secretarial and admin support.

Now that we've rolled the service out to the north and south of the borough we'd like to expand. We have been approached by neighbouring PBC groups interested in our service.

We'd also like to develop the skills of our nurses and conduct two-thirds of all diabetes care in the community. We began in a conservative way – it's better to do that and get things right. But now we're looking to go further.

Dr Simon Ramsden is a GP in Notting Hill, west London

Dr Simon Ramsden: 'Five years ago there was an absolute divide between primary and secondary care.' Dr Simon Ramsden Diabetes leaflet 60-second summary

Our message was that type 2 diabetes is a primary care condition managed in the community

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