£573 million is spent on diabetes inpatient admissions every year in the UK. Erin Dean reports on how nurses can help to reduce this bill
We have much to do
SUMMARY
Most healthcare professionals are aware of the challenge the NHS is facing when it comes to caring for people with diabetes. But the scale of the problem set out in a new report is staggering. According to the Joint British Diabetes Societies for Inpatient Care report, Admissions Avoidance and Diabetes (tinyurl.com/qf4g9nn), there are three million people in the UK diagnosed with diabetes and a further 850,000 estimated to have undiagnosed type 2 diabetes. One in six patients in hospital has diabetes. The report urges the NHS to ensure that people can access well co-ordinated and good quality care. It points out that poor care, as well as being harmful to people’s health, puts an increasing strain on NHS finances, with the extra bed days needed by diabetes patients already costing an estimated £573 million per year. Many patients end up repeatedly going into hospital with a wide range of complications related to poorly managed diabetes. These include conditions that are costly to the NHS and have a devastating effect on quality of life, including amputation of limbs and renal, stroke and heart problems. Rates of re-admission
What is diabetes? Type 1 diabetes develops when the insulin-producing cells in the body have been destroyed and the body is unable to produce any insulin. It accounts for about 10 per cent of all adults with diabetes and is treated by daily insulin injections, a healthy diet and regular physical activity. It can develop at any age but usually appears before the age of 40. Type 2 diabetes typically appears in people over the age of 40, though in South Asian people, who are at greater risk, it often appears from the age of 25. It accounts for between 85 and 90 per cent of all people with diabetes and is treated with a healthy diet and increased physical activity. Medication and/or insulin are often required. Type 2 diabetes develops when the insulin-producing cells in the body are unable to produce enough insulin or when the insulin that is produced does not work properly.
One in six hospital beds is now filled by a patient with diabetes. Integration between primary, community and acute services and improved access to specialist nurses are vital. Some innovative specialist nursing teams are reducing hospital admissions by educating clinicians and patients in diabetes management and providing expert advice. Author Erin Dean is a freelance journalist
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within 28 days for people with diabetes are 59 per cent higher than those without the condition. Angus Forbes, professor of diabetes nursing at the Florence Nightingale School of Nursing and Midwifery, says that while many diabetes patients are, inevitably, at increased risk of admission, opportunities to keep them out of hospital are being missed. ‘The average admission age of a person with diabetes into hospital is 76, so it is predominantly older people. We know admissions are caused by complications, increasing prevalence in older frail people and multiple comorbidities. But there is often a failure of primary care to be able to recognise high-risk patients and implement interventions at this level to stop admissions.’
A recurrent theme in the report is the importance of prompt access to specialist care for patients with urgent or complex issues. For example, GPs, practice nurses and community nurses need to be able to access specialist advice when caring for a patient who has a foot ulcer or is struggling to control his or her blood glucose levels. It also urges NHS commissioners to recruit and train sufficient numbers of diabetes specialist nurses (DSNs) in the hospital and community. Unfortunately, the evidence suggests that specialist nurses are an increasingly rare resource. A Diabetes UK workforce survey published in 2011 found that 43 per cent of posts were unfilled due to cost savings at trusts. It also found that one fifth of DSNs were due to retire by 2016. Meanwhile, the National Diabetes Inpatient Audit for 2012, published last June, found that almost one third of hospitals did not have an inpatient DSN.
Specialist wards
Siobhan Pender, a DSN for Guy’s and St Thomas’ NHS Foundation Trust and a member of the RCN diabetes nursing forum, says the sheer number of patients can overwhelm specialist services. ‘There are so many patients with diabetes who are scattered throughout the hospital. There needs to be a debate on whether specialised diabetes wards should be reintroduced, so that we would know where the high-risk patients are, and that the nurses there are skilled and experienced in diabetes care.’
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Ms Pender warns that the major reorganisation in the NHS in England, which has seen primary care trusts replaced by GP-led commissioning groups, is increasing fragmentation of services and making a difficult situation worse. ‘We used to have links between secondary and community colleagues, but this has been split by the changes to commissioning. The problem is making sure that someone is following up patients who come in and out of hospital when you are not all in the same team. It is concerning that the whole idea of integration does not seem to be happening.’
Decision making
those with type 2 diabetes who are not managing their blood glucose levels on medication and need to go onto insulin, people suffering from frequent hypoglycaemic episodes and people with mental health or learning difficulties. The team has ten whole-time equivalent DSNs, along with the diabetes care technicians, administrative staff, a dietitian and podiatrist, and support from a medical consultant. Ms Joynson says: ‘If we can help people manage their diabetes themselves, it can have benefits for years, as people have this condition for life.’
Super Six
Another successful model of diabetes care introduced in Portsmouth and South East Hampshire appears to be reducing unnecessary admissions. In the Super Six approach, an integrated, multidisciplinary, community-based specialist team works in partnership with colleagues across primary and secondary care. The community team supports the care of newly diagnosed people with diabetes, as well as those requiring ongoing follow up, unless they fall into
DANIEL MITCHELL
The report says that primary care practitioners should have access to a diabetes specialist team to which they can refer when deciding if a patient requires admission to
hospital. Access to blood ketone testing will identify those patients with type 1 diabetes at risk of diabetic ketoacidosis needing hospital admission and those who can be managed at home. This approach is used by Staffordshire and Stoke-on-Trent Partnership NHS Trust’s community diabetes team, which offers rapid access to specialist staff. Community DSN and team lead Jane Joynson says that as well as providing a service through clinics, the team has a daily on-call DSN for patients and healthcare professionals in need of advice. ‘The DSNs on this rota are very responsive and give avoiding admission a priority,’ she says. ‘They will provide advice over the phone, go out and see the patient, or send out the diabetes care technician to check ketone levels.’ The service sees people in need of specialist care, such as
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The 15 diabetes healthcare essentials Diabetes UK lists 15 healthcare essentials for people with diabetes. These include the nine care processes that NICE says all people with diabetes should receive annually: An HbA1c blood test should be administered at least once a year.
1 2 3 4 5 6 7 8 9 10 11 12 13 14
SUPERSTOCK
15
Blood pressure should be measured once a year or more often. There should be an annual check of blood fats such as cholesterol. An eye screen should be given each year to check for signs of retinopathy. The feet’s skin, circulation and nerve supply should be checked annually. There should be a urine protein test and blood test every year. An annual weight check and waist measurement should be undertaken. Patients should be supported on how to quit smoking, as diabetes increases the risk of heart disease and stroke. Care planning should be individually tailored for every person with diabetes. Patients should attend an education course to help them to understand and manage their diabetes. Children with diabetes should receive care from specialist paediatric teams. Inpatients should receive high-quality care from specialists. Women with diabetes planning to have a baby should get information and specialist care. People with diabetes should see specialist healthcare professionals to help them manage their diabetes. Emotional and psychological support should be provided.
Find out more at tiny.cc/DiabetesUK_ 15checklist Read an RCN resource on diabetes www.rcn.org.uk/development/ practice/diabetes
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categories that remain with the secondary care team, such as pregnant women, adolescents, and people requiring renal dialysis. The aim is to boost the knowledge and self-management of diabetes through education programmes for clinicians and patients. This approach has led to 90 per cent of patients being discharged from secondary care back to primary care. Research suggests more than £90,000 a year is being saved on secondary care appointments. In the fi rst 12 months, there was an 18 per cent reduction in episodes of diabetic ketoacidosis and a 16 per cent fall in hypoglycaemic admissions.
Theresa Smyth, nurse consultant in diabetes at University Hospitals Birmingham NHS Foundation Trust, says nurses can help improve care by ensuring that patients go on these types of courses if they are available. ‘Structured education can prevent admissions by reducing the numbers of patients experiencing hypos and diabetic ketoacidosis,’ she says. ‘It can help patients to know what to do when they are unwell.’ Unfortunately, an education in diabetes is not an option for most patients. Data from the National Diabetes Audit, published in November, found that less than
IT IS UNACCEPTABLE THAT WE HAVE A POSTCODE LOTTERY Gwen Hall, a DSN who works for the Solent NHS Trust, says primary care staff feel supported by specialists. ‘If there is a complex patient, we see them with the GP or district nurse so that while we are helping the patient, we are also upskilling the staff. It works really well for patients as the continuity of care is there with the staff that they normally see. There is also a consultant on call from 5.30pm to 7pm at the end of a phone if a practice nurse or GP needs to discuss a patient.’
Self-management
Two well known schemes to give patients confi dence when managing their condition are dose adjustment for normal eating (DAFNE), which teaches people with type 1 diabetes to adjust their insulin injections to fi t their lifestyles, and diabetes education and self-management for ongoing and newly diagnosed (DESMOND), which is for those with type 2 diabetes.
14 per cent of people newly diagnosed with the condition were offered the chance to attend a structured course. Another problem is that patients often do not receive basic health checks that show how well they are managing their complex conditions and fl ag up issues requiring attention. The National Institute for Health and Care Excellence sets out nine checks that people with diabetes should have every year, including tests of eyes, feet and blood glucose levels. However, the National Diabetes Audit revealed large regional differences in how good the NHS is at carrying out these checks. When the inpatient admission report was published, Diabetes UK chief executive Barbara Young called it ‘a clarion call to improve the care standards people with diabetes get, right from the moment they are diagnosed with the condition’. She added: ‘It is unacceptable that we have a postcode lottery, where one of the biggest predictors for how likely someone with diabetes is to end up in hospital is where they live’ NS
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