Identify at-risk groups to cut diabetes admissions

Practice nurses could play a major role in keeping patients with diabetes out of hospital by targeting people at risk of developing the condition, an expert working group has suggested.

This is one of eight recommendations in a report by a Primary Care Diabetes Society (PCDS) working group that investigated the rate of hospital admissions for people with diabetes, and attempted to identify why people with diabetes were more likely to be admitted.¹

PCDS committee member Dr Paul Downie said: 'As an organisation, PCDS are constantly striving to support primary care professionals to deliver high-quality clinically effective care, to improve the lives of people living with diabetes. This project has enabled us to come together with our secondary and emergency care colleagues and work in partnership on this critical challenge in diabetes care: how to negate the trend of high hospital admission rates among those living with diabetes.'

People with diabetes are more likely to be admitted to hospital and have longer stays than people of the same age without the condition.

£25 MILLION A DAY

It has been estimated that the NHS spends approximately £25 million a day on treating people with diabetes, and the cost of inpatient care for people with diabetes is more than £2 billion a year - which equates to 11% of NHS inpatient care expenditure.²

Poorly managed diabetes can lead to complications, including amputation, kidney disease, stroke, heart disease, depression and blindness, which increase the chances of a person needing hospital admission five-fold. Over half of people diagnosed with type 2 diabetes already show signs of complications at the point of diagnosis, but early diagnosis and treatment can reduce the risk of complications.

In its report, the PCDS working group assessed current clinical practices and recommended a range of strategies to avoid hospital admission. A key recommendation is to proactively target 'at risk' groups.

The report suggests GP practices should be incentivised by a Quality and Outcomes Framework (QOF) indicator to establish a register of patients in a pre-diabetic state: those with impaired glucose regulation (IGR); impaired glucose tolerance (IGT); impaired fasting glycaemia (IFG) or gestational diabetes.

These at-risk patients should be referred to appropriate structured education programmes and advised on lifestyle management techniques.

A QOF indicator would not only help incentivise GPs but would also raise awareness among practice nurses and other practice staff of the importance of targeting at-risk groups.

The working group also calls on GPs and practice nurses to develop strategies to identify vulnerable and hard-to-reach groups who are more susceptible to complications in order to support them to manage their diabetes and keep them out of hospital. Hard to reach groups include patients in deprived communities and those with mental health, alcohol or drug misuse problems who have a poor or non existent relationship with their GP or practice nurse.

Another vulnerable group are older people with diabetes living in care homes, particularly in the private sector, who do not have access to regular contact with a diabetes specialist. The working group noted that diabetes care provided in care homes is often not appropriate and that care workers should be given more support to ensure that specialist diabetes care is available where necessary.

Local strategies should be developed to encourage healthcare professionals, including practice nurses, to develop outreach services for patients who are housebound or in care homes.

The report also says it is important that practice nurses and other primary healthcare professionals publicise structured patient education programmes to ensure people with diabetes are aware of them and are able to access the resources.

Other recommendations address the need for ambulance services to refer patients following an acute episode of hypoglycaemia to an appropriate primary or secondary care professional.

Both PCTs and ambulance trusts are urged to address issues of patient consent and clinical access to patient records across the NHS to help healthcare professionals, whether they are a GP, practice nurse, diabetes specialist nurse, paramedic or diabetologist, to administer care while fully informed of the patient's history.

SPECIALIST CARE

The report also calls for specialist diabetes care to be made available in all PCTs and for closer working relationships in multidisciplinary teams to be developed across commissioning groups.

The working group raises concerns over delivery of diabetes care in the new NHS. They say that GP commissioning will be an effective way of managing resources for short-term procedures but commissioning for chronic care could be at risk. They warn that it will essential for GP practices and secondary care to work together. It recommends that healthcare professionals make more effort to network with one another.

Claire Rowell, senior community diabetes specialist nurse at Berkshire Healthcare Foundation Trust, welcomed the idea of introducing QOF points to incentivise practices to target people with pre-diabetes. She said: 'This is a really good idea but we also need more resources in general practice to help these patients. The problem is once the practice nurse has identified these patients and put them on a register what do they do with them? Diabetes education programmes such as DESMOND get very booked up and if nurses provide the required intensive lifestyle advice in the practice it means they have to contact all these patients at least once a week. It is not a cheap option.'

CLEAR NEED

Dr Roger Gadsby, a Nuneaton GP and associate clinical professor at Warwick Medical School, and a member of the PCDS working group, said: 'All practices make decisions about how they feel it's best to spend money on improving their patient care. I've never had any difficulties in convincing my partners to spend money in improving services to patients with diabetes. Getting people with pre-diabetes screened and making sure they get the right interventions has not been a difficult argument to win. This is because the clinical need is very clear.The fact that the interventions work is also very clear.'

Dr Gadsby said there were a number of other areas in the report that would be of interest to practice nurses. 'We addressed issues about hypoglycaemia - in particular identifying hypoglycaemia in patients who may not realise they're having hypoglycaemic episodes and issues around making sure that significant hypoglycaemic events are recorded and appropriately followed up.

'There are also concerns around the care of people who are housebound and in nursing and care homes that may have a knock-on involvement for the practice. This report is about providing good quality care for people with diabetes.'

NHS Diabetes Director Anna Morton said there was an urgent need to help reduce hospital admissions for people with diabetes. 'Unnecessary hospital admissions and lengths of stay not only increase costs, but more importantly they cause great distress for patients,' she said.