Diabetes education for practice nurses must improve

Given the increased emphasis on treating Type 2 diabetes in primary care, and the massive projected increase in the incidence of this complex condition, diabetes training must be made compulsory for primary care staff says Diabetes UK

There are 3.2 million people in the UK diagnosed with diabetes and that figure is projected to rise to 5 million by 2025. But despite the fact that 1 in 17 people in the UK is estimated to have diabetes, Diabetes UK has significant concerns that Clinical Commissioning Groups (CCGs) do not fund diabetes education for their healthcare professionals and therefore care is being provided by staff who may not have a good level of knowledge about this complex condition.

Diabetes already costs the NHS an incredible amount of money – in 2010-11 UK NHS spending on diabetes was estimated at nearly £10 billion – 10% of the total NHS budget. However, 80% of this diabetes budget currently goes into managing avoidable complications such as blindness and amputations. Better management and understanding of the condition by healthcare professionals has great potential to reduce these costs and improve care provided to people. Yet there is currently no single agreed national framework that would ensure diabetes-specific training is provided to all staff across the NHS.

There is growing evidence that people with diabetes may not be seeing healthcare professionals with the necessary knowledge of their condition. For example, practice nurses trained to deliver the X-PERT Diabetes structured education programme reported that their prior knowledge in the lifestyle management of Type 2 diabetes was inadequate and outdated.¹ Similarly, patients with Type 1 diabetes who had undertaken DAFNE (Dose Adjustment For Normal Eating) reported primary care and inpatient hospital staff as lacking the required level of skills, leading to sometimes incorrect advice.²

Clearly NHS money needs to be invested wisely throughout the UK to help ensure that healthcare staff who treat people with diabetes have the right training, skills, knowledge and attitudes that are conducive to quality care. The current provision of such training is patchy and is dependent on the differing priorities of local health commissioners.

SURVEY

According to a survey by Diabetes UK, 60% of Clinical Commissioning Groups (CCGs) in England do not fund specific diabetes education for their healthcare professionals.

In addition, two out of three CCGs do not have a formal, written policy on diabetes education and almost half of CCGs do not assign time for their healthcare professionals to undertake diabetes-related education, training or development. Of the 56% that do, only a quarter allow dieticians and podiatrists to take time out for diabetes education, despite these specialisms providing essential support to people to help reduce life-changing complications such as amputation.

These statistics are backed up by a survey of 143 users of ‘Diabetes in Healthcare’, an e-learning programme developed by Diabetes UK and Bupa aimed at healthcare professionals who are not diabetes specialists. Half of respondents had received no previous diabetes training, yet after completing the Diabetes UK and Bupa course, 80% said their knowledge and understanding of the condition had increased. Crucially, the same percentage felt more confident in supporting people with diabetes.

Management of diabetes care can be complex, often requiring high levels of knowledge and skills in order to provide high quality and safe care. Sound diabetes education for healthcare professionals can be the launch pad for effective clinical management and positive patient experiences.

While Diabetes UK appreciates that some CCGs are setting examples of good practice in diabetes training provision, the majority should seek to improve the quality and consistency of diabetes training provided to their GPs, nurses and other professionals. Most importantly this will help them improve health outcomes for patients within the financial constraints set by their budget.

To help ensure the standard of diabetes care is high throughout the UK, we are calling for the implementation of an agreed competency framework. This would provide clear guidance for the NHS, from GP practices to large hospitals, to help identify which staff should receive diabetes training and how and when training should be provided. The framework will support both healthcare professionals and those who commission services, by ensuring that all healthcare professionals can demonstrate an appropriate level of care.

We know that many CCGs feel the same. In response to our survey one CCG noted the value of having some form of standardisation of provision: ‘Standardisation would be ideal across the UK and may reduce the variation of care for people with diabetes. I would like to see the competencies set for practice nurses in a number of LTCs including diabetes with primary care responsible for ensuring that these are met.’

The critical nature of education was summed up by one CCG who commented that it was, ‘absolutely essential to provide education to HCPs or the tidal wave of diabetes-related disease just can’t be tackled in the modern NHS.’

From the beginning of a patient’s diabetes journey, it is vital that healthcare professionals recognise the seriousness of the condition. We know that nowhere near enough people are receiving the NICE recommended care processes. Local standards of care and outcomes vary widely between CCGs and this demonstrates how big improvements can be made in the delivery of the NICE nationally agreed standards. According to the latest National Diabetes Audit, in the best performing CCG area 78% of people with diabetes received all eight of the vital checks that are measured, but in the worst CCG area only 30.4% of people with diabetes received them. Likewise, there was a significant regional variation between the number of diabetes patients achieving all three treatment targets for blood glucose, blood pressure and cholesterol. This ranged from 27.8% to 48% across CCGs. Diabetes UK urges each CCG to review the performance of its services in achieving the NICE recommended care processes and outcome measures and put in place an action plan for improvement. A wealth of data is available through national diabetes audits, but we still lack meaningful information about the quality of diabetes care provided by general practice. It is vital that the new NHS structures obtain and use such data to provide effective diabetes care everywhere.

COMPULSORY TRAINING

Given the increased emphasis on treating Type 2 diabetes in primary care, diabetes training must be made compulsory for primary care staff.

At the moment, every five years, licensed doctors practising medicine in the UK have to demonstrate that they are fit to practise and their knowledge and skills are up to date. This revalidation process will soon be a three-yearly requirement for practising nurses. Individual healthcare professionals are also responsible for their own generic ongoing education, known as Continual Professional Development (CPD).

Yet for non-diabetes specialists, such as those working in primary care, general ward staff or nursing staff in residential care homes, the current system does not provide training or assess skills in the specific area of diabetes.

FREE e-LEARNING

The importance of healthcare professionals having knowledge of diabetes is why we are calling for a national competency framework and also why we have developed, in partnership with Bupa, the ‘Diabetes in Healthcare’ e-learning programme.

‘Diabetes in Healthcare’ from Bupa and Diabetes UK is a free, introductory online programme aimed at healthcare professionals who are not diabetes specialists. Written by Diabetes UK’s team of clinicians and diabetes specialists, the Royal College of Nursing-accredited course covers both Type 1 and Type 2 diabetes. It includes expert information on how the condition is diagnosed, treated and monitored, and symptoms to look out for in those who may have diabetes but are yet to be diagnosed.

With the current changes in the NHS structures in England, and the potential for greater variation in the types of ‘qualified provider’, staff need to be shown to be competent and named/accredited or recognised as such. The education and validation of skills needs to be consistently delivered in terms of both quality and quantity. To address this need, Diabetes UK recommends that all NHS organisations prioritise healthcare professional education, training and competency through the implementation of a National Diabetes Competency Framework and a phased approach to delivery.

Widespread healthcare professional education in diabetes can only mean better outcomes for people living with this condition, and could save money in the long-term, as it will help staff understand the need for early intervention and how to prevent complications caused by diabetes.

Education of healthcare professionals is just one aspect of improving diabetes care – but it is a crucial lynch-pin. Radical improvement in the commitment to provision of education for healthcare professionals needs to take place so that people with diabetes can be given the best possible advice and support so they can successfully self-manage their condition and enable them to lead long and healthy lives.

The Diabetes In Healthcare e-learning programmes can be accessed free of charge at www.diabetesinhealthcare.co.uk

REFERENCES

1. Finn S. Worcestershire Diabetes Structured Education Programmes Pilot Report. Self Care Programmes Manager, Worcestershire PCT: January 2013

2. Snow R, Humphrey C, Sandall J. What happens when patients know more than their doctors? Experiences of health interactions after diabetes patient education: a qualitative patient-led study. BMJ Open 2013;3e003583. Doi:10.1136/bmjopen-2013-003583